HEMME Approach To Lumbopelvic Disorders

HEMME APPROACH TO
LUMBOPELVIC
DISORDERS
ii
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v
HEMME APPROACH to
LUMBOPELVIC DISORDERS
Copyright, David H. Leflet, 2005

Revised 2011
All rights reserved
Published by HEMME APPROACH PUBLICATIONS

502 Armstrong Street
Bonifay, Florida 32425
(850) 547-9320
The author grants permission to photocopy a limited

portion of this manual for personal use. Beyond this
consent, no portion of this manual may be reproduced or
copied in any form without written permission from the
author, who can be reached by contacting the publisher.
Although the author has made every effort to ensure the

accuracy of the information herein, medical science is
progressive, theories change with time, and experts often
disagree. Practitioners are advised to consult appropriate
information sources if they have questions concerning the
information or principles presented in this manual.
It is the responsibility of the practitioner to determine the

appropriateness of any principle or technique in terms of
personal competency, scope of practice, or relevant laws.
Written medical opinions are the best way to resolve any
questions that relate to whether soft-tissue therapy is
indicated or contraindicated, and written legal opinions
are the best way to resolve any questions concerning law.

vi
PREFACE
This book addresses a complex problem and one of the major causes
of permanent disability: common (nonspecific) low back pain. After years
of effort by the medical profession, common low back pain—which is not
caused by disease or major trauma—remains a medical crisis that continues
to spiral out of control because of high costs and low success rates.
Back pain was a 20th-century medical disaster and the legacy

reverberates into the new millennium….We can only diagnose
definite pathology in about 15% of patients with back pain….Most
back pain is benign and non-specific and all the serious problems
put together are probably less than 5%.—Dr. Gordon Waddell
Voluminous literature on the problems of the low back has been

written in recent decades with impairment primarily related to the disc
of the spine and thus all studies and treatment protocols have been so
directed….However, the results have been disappointing.—Dr. Rene
Cailliet
Conservative care commends itself, when properly carried out, as the

only kind of treatment that will be needed for 99% of your back pain
patients.—Dr. Arthur White
Common (nonspecific) low back pain is not a disease because exact

origins are unknown and the signs and symptoms are inconsistent. Diseases
are characterized by a known pathogenesis and the signs and symptoms are
consistent. When viewed objectively, common low back pain is a symptom,
not a disease, and the symptom (back pain) is usually caused by soft-tissue
impairments or mechanical dysfunctions that affect lumbopelvic rhythm.
HEMME Approach is a systems-theory method for simplifying and
solving complex problems, such as common low back pain, by using logic
and feedback from patients. The recommendations offered in this book are
based on clinical experience, evidence-based research, and common sense.
This book offers a cost-effective approach for treating common low
back pain. What makes this book unique is the way knowledge from many
different health care fields has been pulled together to create an amazingly
simple treatment protocol for millions of people who suffer repeatedly from
nonspecific (common) low back pain and help them live a normal life.

vii
For people with nonspecific LBP, stooping over may not be painful,
but trying to stand erect after being stooped over may cause severe pain.
You cannot stand erect until the pelvis tilts forward into a neutral position—
anterior superior iliac spines and posterior superior iliac spines on the same
horizontal line—and the pelvis cannot tilt forward if abnormal tension from
the gluteus maximus prevents anterior tilt. Besides the pain caused by
stretching a tight gluteus maximus, there may also be pain from stretching a
tight psoas or from compressing the facet joints or the lumbosacral joint.
Even though understanding lumbopelvic rhythm is critical when you
try to predict, treat, or prevent nonspecific low back pain, the real challenge
is trying to understand the factors that disrupt lumbopelvic rhythm.
Muscle imbalances disrupt lumbopelvic rhythm more than any other
cause, and the muscles that are usually involved are the psoas (iliopsoas),
hamstrings, gluteus maximus, and multifidus. Other muscles that may be
involved are the gluteus medius, rectus femoris, soleus, and piriformis.
The psoas can be difficult to treat unless you realize that it can flex or
extend the lumbar spine, depending on the angle of the trunk. This property
is called inversion of function. The psoas may increase lumbar kyphosis
when the trunk is flexed or increase lumbar lordosis when the trunk is erect.
Although the hamstrings and gluteus maximus are often treated as a
single unit because they are both hip extensors, if the lumbar spine cannot
achieve neutral lordosis because the pelvis will not tilt forward into a neutral
position, the hamstrings may be stretched and weak and the gluteus maximus
may be short, tight, and weak. If you stretch both hip extensors, you may
abnormally lengthen the hamstrings and make them even weaker.
If the multifidus is overstressed while the lumbar spine is trying to
achieve neutral lordosis, it often becomes weak because of hypertonicity,
pain, or disuse atrophy. Without specific intervention, such as manipulation
or exercise, the multifidus seldom improves and it may get worse. A muscle
that has far less effect on LBP than the multifidus is the rectus abdominis,
and this muscle usually gets much more attention than the multifidus.
The four goals when treating nonspecific LBP are (1) reduce pain, (2)
promote healing, (3) restore function, and (4) prevent LBP. Even if more
people understood how to treat nonspecific LBP, which is more of a
lumbopelvic problem than a low-back problem, the health care system in the
US makes effective treatment difficult. Most people need a treatment plan
that includes education, medication, modalities, manipulation, and exercise.
If insurance barriers prevent people from getting the treatments they need,
LBP will continue to be an escalating problem and a medical disaster.

viii
The central concept that makes this book unique is the strong belief
that correcting muscle imbalances is a safer and more effective way to treat
nonspecific LBP than trying to correct unproven or insignificant discogenic
abnormalities. If the discogenic approach was more effective, nonspecific
LBP would not continue to be an escalating problem that reduces the quality
of life for most patients because of pain, disability, and loss of income.
Even though muscle imbalances can be caused by many factors, such
as external trauma, poor use of body mechanics when lifting, or repetitive
strain, the most common cause appears to be a decrease in neuromuscular
efficiency that starts at age 30. This corresponds with the peak range for
nonspecific LBP, which is 30 to 50 years of age.
Decreases in neuromuscular efficiency can be caused by (1) less
contractile strength in muscle fibers, (2) inappropriate recruitment patterns,
(3) weak facilitation, (4) slow reciprocal inhibition, (5) inefficient metabolic
reactions that increase the risk of fatigue or cramps, (6) a loss of flexibility
that increases the risk of microtrauma and hypertonicity, or (7) a decrease in
general fitness that results from inactivity or improper diet.
After they occur, decreases in neuromuscular efficiency set the stage
for internal microtrauma or macrotrauma that leads to inflammation, reflex
spasm, and a loss of mobility. What complicates the problem when dealing
with lumbopelvic disorders is that spinal movement depends on a complex
interaction between the lumbar spine and the pelvis called lumbopelvic
rhythm. If this rhythm is disrupted because pain inhibition or reflex spasm
prevents the necessary movements that are part of the rhythm, the lumbar
spine and the pelvis will not interact properly and the likely outcome will be
additional inflammation, reflex spasm, and loss of mobility, which can
trigger a cycle of trauma, inflammation, reflex spasm, and loss of mobility.
Were it not for the mystique surrounding the intervertebral disk, more
physicians would recognize and acknowledge the obvious parallels between
scapulohumeral rhythm and lumbopelvic rhythm. After you recognize the
similarities, it requires very little imagination to realize that the treatment
options for nonspecific LBP might be similar to the treatment options for
nonspecific neck and shoulder problems.
Another similarity between nonspecific neck and shoulder pain and
nonspecific LBP is the body’s ability to perpetuate pain and disability long
after the events that interfered with scapulohumeral rhythm or lumbopelvic
rhythm have been resolved. In both cases, pain and disability will probably
continue unless specific treatments are used to correct muscle imbalances
that disrupt the rhythmic interactions between interrelated body parts.

ix
A working theory is a combination of research, observation, logic,
common sense, and speculation, which is sometimes the best you can do
when there is not enough high-quality research to justify an evidence-based
conclusion. The pain and disability associated with nonspecific LBP and the
scarcity of effective treatments justify the need for a working theory that
explains the mechanisms that perpetuate nonspecific LBP and proposes a
treatment protocol based on an understanding of these mechanisms.
Regardless of what triggers an episode of nonspecific LBP, most
episodes are characterized by one or more lumbopelvic muscle imbalances
that cause a defect in lumbopelvic rhythm. The most common defect occurs
when a person tries to stand erect after sitting or being stooped over and the
pelvis cannot change from a posterior-tilt position to a neutral position. For
the pelvis to achieve a neutral position, there must be enough anterior pelvic
tilt for the lumbar spine to regain neutral (normal) lordosis.
The two main factors that usually prevent the pelvis from reaching a
neutral position are abnormal tension from the psoas and gluteus maximus.
The abnormal tension from these muscles increases lumbar compression,
which affects the facet (zygapophyseal) joints and the lumbosacral joint, and
tension from the psoas may increase anterior shear.
It is interesting to note that after people with nonspecific LBP manage
to overcome the pain and stand erect after sitting or being stooped over, it is
common to see their mobility dramatically improve after they stretch by
raising their arms overhead and then walk for several minutes. Apparently
the pelvic movement that causes the most pain is somewhere between a
posterior position and a neutral position. Possible reasons for this pain are
(1) lumbar compression with anterior shear, (2) stretching or compressing
hypertonic muscles, (3) tension on muscle attachments, or (4) a downward
displacement of the sacrum that stretches sacral ligaments.
If the pain is too great when attempting to stand erect after being
stooped over, the person may return to a stooped-over position, which tends
to reduce pain in the same way that being in a fetal position reduces pain. If
the psoas is abnormally short, tight, and painful, one or both feet may be
laterally rotated while a person is stooped over to keep the psoas slack.
If muscle imbalances cause or perpetuate defects in lumbopelvic
rhythm that cause or perpetuate LBP, correcting muscle imbalances should
be a major part of treatment, which is why a large percentage of this book
focuses on locating, correcting, and preventing muscle imbalances.
Dave Leflet, MS, LMT, CFL

x
TABLE OF CONTENTS
INTRODUCTION ....................................................................................... 1
Fallacies Relating to Low Back Pain ....................................................... 2
(1) Bed Rest........................................................................................ 2
(2) Degenerative Changes .................................................................. 3
(3) Surgery ......................................................................................... 4
(4) Flexibility ..................................................................................... 5
(5) Strength ........................................................................................ 6
(6) Abdominal Exercises .................................................................... 7
(7) Posture .......................................................................................... 8
(8) Leg Length ................................................................................... 9
(9) Nerve and Disc Involvement ........................................................ 10
(10) Activity and Pain .......................................................................... 12
Muscle Imbalance .................................................................................... 13
Sacral Dysfunction ................................................................................... 16
Epidemiology ........................................................................................... 18
Lumbopelvic Rhythm .............................................................................. 19
Lumbopelvic Dysfunction ....................................................................... 21
Lateral Pelvic Shift................................................................................... 25
Pain Cycles: Pain-Spasm-Edema-Pain ................................................... 26
Treating Common (Nonspecific) Low Back Pain ................................... 27
Expectations ............................................................................................. 29
The Challenge .......................................................................................... 30
Factors that Trigger or Perpetuate Nonspecific Low Back Pain ........... 31
International Guidelines ........................................................................... 32
CHAPTER HIGHLIGHTS .......................................................................... 33
HEMME APPROACH ................................................................................ 34

HEMMEGON ............................................................................................... 36
SOAP to SOAPIE ........................................................................................ 38
Quick Conversion Guide ............................................................................. 38
HISTORY .................................................................................................... 40
Bedside Manner ....................................................................................... 41

xi
TABLE OF CONTENTS CONTINUED
EVALUATION............................................................................................ 46
Major Muscles or Muscle Groups ........................................................... 46
Muscles or Muscle Groups: Description ................................................ 48
Prone Position........................................................................................ 48
Right or Left Lateral Recumbent Position ............................................ 51
Supine Position ...................................................................................... 52
Multifidus and Transversus Abdominis................................................... 54
Illustrations............................................................................................... 55
Muscles or Muscle Groups ................................................................ 55
Muscle Groups by Members ............................................................. 56
Muscles and Muscle Groups Arranged by Functions ..................... 56
Posterior Hip.......................................................................................... 57
Anterior Hip........................................................................................... 58
Posterior Torso ...................................................................................... 59
Posterior Limb ....................................................................................... 60
Lateral Limb .......................................................................................... 61
Anterior Limb ........................................................................................ 62
Posterior Thorax .................................................................................... 63
Lateral Midsection ................................................................................. 64
Evaluating Low Back Pain....................................................................... 65
Level I Evaluation ................................................................................. 66
Four Classic Methods of Evaluation ................................................. 66
(1) Palpation ................................................................................... 66
(2) Observation............................................................................... 67
(3) Auscultation .............................................................................. 67
(4) Percussion ................................................................................. 68
A SPARKLE...................................................................................... 68
(A) Antalgic Gait or Posture ........................................................... 68
(S) Spasm (Hypertonicity) ............................................................. 69
(P) Pain or Tenderness ................................................................... 71
(A) Asymmetry or Posture .............................................................. 72
(R) Range-of-Motion (ROM) Loss ................................................. 75
(K) Kyphotic Increase ..................................................................... 75
(L) Lordotic Decrease ..................................................................... 75
(E) External Rotation ...................................................................... 76

xii
Level II Evaluation ................................................................................ 76

Eight-Step Evaluation Protocol ......................................................... 77
Lateral Pelvic Shift ........................................................................ 77
Modified Sit-up.............................................................................. 77
Double Leg Curl ............................................................................ 78
Single Leg Lift ............................................................................... 78
Trunk Rotation ............................................................................... 79
Chest Lift with Extension Push-up ................................................ 79
Reverse Leg Lift ............................................................................ 80
Chair Stretch .................................................................................. 80
Level III Evaluation............................................................................... 82
Muscle Testing .................................................................................. 82
Major Muscles or Muscle Groups: Muscle Testing ...................... 88
Straight Leg Raising Test .................................................................. 91
Gluteal-Drop Test .............................................................................. 92
Sacral-Integrity Testing ..................................................................... 93
Spinal-Flexion Testing ...................................................................... 95
Malingering Tests .............................................................................. 96
ALTERNATIVES........................................................................................ 98
MODALITIES ............................................................................................. 100

Cryotherapy .............................................................................................. 100
Ice Massage Method for Treating Trigger Points ................................. 104
Ice Pressure Method for Treating Trigger Points .................................. 104
Thermotherapy ......................................................................................... 105
Cold or Heat ............................................................................................. 107
Cryostretch or Thermostretch .................................................................. 109
Contrast Bath or Cryokinetics.................................................................. 110
Hot-to-Cold Stretch .................................................................................. 111
Deep Heat (Ultrasound) ........................................................................... 111
Basic Protocol .......................................................................................... 112
Heat-Induced or Cold-Induced Pain ........................................................ 112
Effects of Cold or Heat .......................................................................... 113
Vibration .................................................................................................. 114

xiii
MANIPULATION ....................................................................................... 117

The Principles of Soft-Tissue Therapy .................................................... 119
Soft-Tissue Therapy ................................................................................. 121
Compensatory Stress ................................................................................ 124
Adaptive Shortening ................................................................................ 125
General Background ................................................................................ 126
Balancing Muscles ................................................................................... 127
TRIGGER POINT THERAPY ........................................................................ 131
Deep Sliding Pressure (DSP) ................................................................ 139
Multifidus Triangle................................................................................ 141
Ligamentous Trigger Points .................................................................. 141
Self-Treatment ....................................................................................... 142
Major Muscles or Muscle Groups: Trigger Point Zones ..................... 143
NEUROMUSCULAR THERAPY .................................................................... 146
Inhibition ............................................................................................... 149
Proprioceptive Inhibition .................................................................... 150
Post-Isometric Relaxation (Inhibition) ............................................... 151
Reciprocal Inhibition .......................................................................... 151
Stretching to Reset Proprioceptors ........................................................ 152
Positional Release.................................................................................. 153
Gliding Strokes in Neuromuscular Therapy ......................................... 153
Facilitation ............................................................................................. 154
Activation of the Stretch Reflex ........................................................ 154
Repeated Contractions ....................................................................... 154
Muscle Palpation ................................................................................... 155
CONNECTIVE TISSUE THERAPY ................................................................ 156
Thixotropy ............................................................................................. 157
Hysteresis .............................................................................................. 157
Creep...................................................................................................... 158
Adhesions .............................................................................................. 158
Skin Rolling ........................................................................................... 159
Skin Pulling ........................................................................................... 160
Cross-Fiber Friction .............................................................................. 161
Layers .................................................................................................... 163
Special Stretching Techniques .............................................................. 163

xiv
RANGE-OF-MOTION STRETCHING ............................................................ 164
Indirect (Functional) Techniques .......................................................... 165
Mechanics of Stretching ........................................................................ 168
Fascial Stretching .................................................................................. 171
Crossover Stretch .................................................................................. 172
Ballistic Stretching ................................................................................ 173
Special Stretching Methods ................................................................... 173
Contraindications to Stretching ............................................................. 175
Neutral Positioning ................................................................................ 175
Aquatic Stretching ................................................................................. 176
Pain Related to Stretching ..................................................................... 177
Therapeutic Stretching .......................................................................... 177
Major Muscles or Muscle Groups: Range-of-Motion Stretching ........ 179
EXERCISE .................................................................................................. 188

Regular and Correct Exercise .................................................................. 189
Exercise Principles ................................................................................... 190
Overload Principle ............................................................................... 192
Intensity Principle ................................................................................ 193
Frequency and Duration Principle ....................................................... 195
Specificity Principle ............................................................................. 195
Training Principle ................................................................................ 196
Exercise and Manipulation ...................................................................... 197
Intervention Exercises .............................................................................. 197
Home Exercises........................................................................................ 199
Eight-Step Exercise Plan.......................................................................... 200
Evaluation-Exercise Movements ............................................................. 203
Perception of Pain .................................................................................... 204
Supplemental Evaluation-Exercise Movements ...................................... 205
Standing Spine-Extension (Multifidus) ............................................... 205
Kneeling Leg-Extension (Multifidus) .................................................. 205
Isometric Hand-to-Knee (Transversus Abdominis) ............................. 206
Forced Expiration (Transversus Abdominis) ....................................... 206
Compliance .............................................................................................. 207
Prevention ................................................................................................ 207
Safe Lifting .............................................................................................. 209
Coping Mechanisms................................................................................. 211
Sleeping .................................................................................................... 212

xv
Smoking and Vibration ............................................................................ 213
Personal Trainers...................................................................................... 213
OBJECTIVES .............................................................................................. 215
CONCLUSION ............................................................................................ 216
APPENDIX 1 ............................................................................................... 217
APPENDIX 2 ............................................................................................... 225
BIBLIOGRAPHY ........................................................................................ 229
GLOSSARY ................................................................................................ 243
INDEX ......................................................................................................... 265
QUIZ ............................................................................................................ 268
So why is back pain, in particular, such a problem? What is

different about it? Part of the problem is that back pain is only
a symptom, not a disease.—Dr. Gordon Waddell
A back pain patient in the United States is five times more

likely to be a surgical candidate than if they were a patient in
England or Scotland.—Robin McKenzie
The best way to treat nonspecific (common) low back pain is

self-treatment, and the most important rule to follow when
using self-treatment is try to stay active. If they help you stay
active, the short-term use of nonprescription pain relievers can
be beneficial. With training, most people can learn how to use
modalities and manipulation for self-treatment.—Dave Leflet

INTRODUCTION
The word disorder means a disturbance of function, structure, or both

that results from internal factors such as genetic defects or external factors
such as macrotrauma, microtrauma, or infection. An idiopathic disorder is a
physical disorder that has no known cause to explain the symptoms.
Common (nonspecific) low back pain is classified as an idiopathic
disorder because the causes are unknown. Since common low back pain is
not caused by a known pathologic agent, (1) it is not classified as a disease
and (2) the people who have it are not considered sick or unhealthy.
A paradigm is a theoretical framework for developing theories or
conducting research. Since the early 1930s, the paradigm for treating low
back pain (LBP) has revolved around the intervertebral disc (disk) and most
research has focused on the disc. The problem with this paradigm is that
using surgery or therapy to alter the structure or function of a disc has not
been very successful. Many patients have more pain after surgery than they
had before surgery, and therapy is time-consuming and usually ineffective.
Rather than build on a failed paradigm, this book will offer a new
paradigm: common LBP is caused by a lumbopelvic disorder (LPD) and the
primary cause for this disorder is a muscle imbalance that interferes with
lumbopelvic rhythm. Even if a muscle imbalance is triggered by a disc
problem, the lumbar spine will not be the only structure affected or the only
structure requiring treatment. Besides affecting the lumbar spine, a muscle
imbalance can affect the pelvic region, upper body, thighs, legs, and feet.
Unlike the old paradigm, which is based on the belief that common
LBP is caused by a spinal disc and treating the disc will solve the problem,
this new paradigm is based on the belief that common LBP is caused by a
lumbopelvic disorder and treating the factors that cause the LPD, such as a
muscle imbalance, will usually solve the problem. Some of the factors that
may cause a muscle imbalance are hypertonicity, pain, or weakness.
LBP has reached near-epidemic proportions in the United States and
is still the most common musculoskeletal complaint seen in clinical practice.
Because of medical bills, disability payments, and lost productivity, LBP is
costing the US about 90 billion dollars per year. Despite the immensity of
the problem, evidence-based research shows that most methods used for
treating common LBP are ineffective or even worse than no treatment.
Besides being conservative, relatively inexpensive, and based on clinical
experience, evidence-based research, and logic, the treatments in this book
are effective because they focus on treating dysfunctions rather than disease.
2
Fallacies Relating to Low Back Pain
Rather than start by explaining what should be done, it might be easier

to start by discussing what should not be done. These ten fallacies are a
good starting point for what you should not do or believe when treating a
lumbopelvic disorder (LPD) that causes low back pain (LBP).
(1) Bed Rest
Fallacy: Bed rest cures common low back pain.
Truth: Activity promotes healing and decreases disability.
A few days of bed rest may help to relieve pain and give hypertonic
muscles time to relax, but too much bed rest can decondition the body and
cause atrophy. Prolonged inactivity decreases muscle strength about 3% per
day and may shorten connective tissues because of contractures. Inactivity
can also reduce circulation and weaken connective tissue or bone.
When joints are immobilized for a long time, fibrofatty connective
tissues proliferate in the joint space and merge with hyaline cartilage. If
proliferation continues, the pressure between the articular contact surfaces
may cause pressure necrosis that liquefies and erodes articular cartilage.
Pressure necrosis reduces the flow of both the synovial fluid that lubricates
the joint and the nutritive fluid that nourishes the joint.
A better approach for treating LBP is continuous passive mobilization
after the inflammatory phase of healing has passed. Continuous passive
mobilization (1) increases the strength or pliability of connective tissue by
improving fiber alignment or breaking adhesions, (2) accelerates metabolite
dispersal by increasing circulation, and (3) stops necrosis by decreasing
abnormal pressure from edema or hypertonicity. Since healing depends on
circulation, mobilization accelerates healing and decreases recovery time.
Once people are capable of continuous active movement, regular
exercise will increase general fitness, stimulate production of synovial fluid,
and reduce joint stiffness. Range-of-motion (ROM) stretching will improve
mobility by (1) breaking adhesions in periarticular tissue, (2) stretching
contractures, (3) reducing spasm, and (4) strengthening weak muscles. The
long-term effects of exercise and ROM stretching are less pain and greater
mobility. Contrary to what many doctors once believed, movement and
physical activity promote healing and decrease disability more than bed rest.

3
(2) Degenerative Changes
Fallacy: Degenerative changes are the main cause for low back pain.
Truth: Soft-tissue injuries appear to be the major cause for low back pain.
There is no strong correlation between the occurrence of common low

back pain and radiologic findings of spinal degeneration. The first episodes
of low back pain usually occur between ages 20 and 40, and the peak range
is between ages 30 and 50. Common LBP after 55 years of age is rare, and
LBP after age 55 is usually caused by a known pathologic entity. Spinal
degeneration starts at about age 40 and becomes progressively worse with
time. It does not respond favorably to surgery and it may be asymptomatic.
The frequency of spondylosis and spinal osteoarthritis is about the
same for people with or without common LBP. Furthermore, many patients
presenting LBP show no signs of spondylosis or spinal osteoarthritis. The
lack of correlation between degenerative changes and lumbar pain indicates
that spondylosis or osteoarthritis is not the main causes for common LBP.
About 70% of all nonspecific LBP patients show major improvement
within 6 weeks with or without treatment, which indicates that muscles or
tendons cause or perpetuate LBP. The normal healing time for strained
muscles or tendons is 6 to 8 weeks and for sprained ligaments is 6 to 12
weeks. The fact that most LBP patients (75%) will still have symptoms one
year after treatment may indicate that therapy was ineffective or incomplete.
The decreases in muscular strength that often start to occur after age
30 may help to explain why people over age 30 have LBP more often than
people under age 30. As strength decreases, the risk of a muscle imbalance
increases. Other factors that may cause a muscle imbalance are poor body
mechanics, poor balance, incoordination, microtrauma, atrophy, or fatigue.
The decreases in spinal flexibility that often start to occur after age 50
may help to explain why LBP is more common before age 50 than after age
50. As the spine becomes less flexible and most people become less active,
the risk of irritating the tissues that cause common LBP—such as muscles,
tendons, ligaments, periosteum, fascia, joints, or discs—tends to decrease.
Decreases in static sacral mobility may also explain why LBP is more
common before age 50 than after age 50. Sacral hypermobility is a known
cause for LBP, and sacral mobility decreases after age 50 because the ridges
and grooves between the sacrum and ilium become rougher, which increases
static friction and makes the ridges and grooves more likely to interlock.

4
(3) Surgery
Fallacy: The only cure for most low back pain is surgery.
Truth: Surgery is appropriate for only a small number of cases.
It is interesting to note that the probability of having back surgery is

40% greater in the United States than in similar countries such as England or
Sweden. Performed on 2% to 4% of all back patients, a discectomy—the
partial or complete excision of an intervertebral disc—is the most common
spinal operation. Back patients who are treated with surgery are at higher
risk of becoming disabled than patients treated by conservative measures,
and disc surgery is more likely to relieve leg pain than back pain.
Although surgery is appropriate in some cases because of progressive
neurological dysfunction or unbearable pain, most people respond favorably
to conservative care. The United States Agency for Health Care Policy and
Research (AHCPR) recommended the following criteria be present to justify
surgery, but vocal opposition prevented implementation of these guidelines.
• sciatica persisting after at least four weeks of conservative care

• sciatica that is both severe and disabling (incapacitating)
• persistent symptoms of sciatica (pain extending below the knee)
(1) without improvement or (2) with progression
• evidence of nerve root compromise (radiculopathy)
In addition to having similar criteria, the North American Spine Society

(NASS) and the American Academy of Orthopaedic Surgeons (AAOS) also
require that an imaging study—such as an abnormal CAT (computerized
axial tomography) or MRI (magnetic resonance imaging) scan—correlate
with the physical signs and distribution of pain.
It appears that only 10% of all back patients treated surgically return
to normal life and most back patients (95% to 99%) should not be operated
on. Although surgery can sometimes work miracles, conservative estimates
place the failure rate for low-back operations at higher than 50%. The
reasons given for these failures include poor diagnosis, technical errors,
complications, and poor patient selection. In one study, 68% of the surgical
candidates who refused or had been denied surgery were substantially better
three years later. Surgical outcomes are rarely this good. Even so, back and
neck operations are the third most common form of surgery in the US.

5
(4) Flexibility
Fallacy: Increasing trunk flexion prevents low back pain.
Truth: Balancing flexibility and stability helps to prevent low back pain.
The belief that increasing trunk flexion prevents low back pain is not
true. Hyperflexion, such as touching the palms to the floor from a standing
position, is more likely to increase rather than decrease LBP. People with
chronic back pain frequently have greater than average trunk flexion when
the body is pain-free, and sometimes even during attacks.
The ranges of motion that usually show the greatest restriction during
episodes of low back pain are lumbar extension, sidebending, and rotation.
Movements that are normal between episodes may become stiff and slightly
restricted just before the onset of LBP. Limited lumbar extension is more
predictive of low back pain than limited sidebending or limited rotation.
One reason increasing flexibility does not prevent LBP is the trade-off
between mobility and stability, which means that increasing flexibility may
decrease stability. If increasing flexibility causes instability, normal or
abnormal movements may generate mechanical stresses that deform tissues
and cause strains, sprains, or tears. The entire low-back mechanism appears
to be most functional when mobility and stability fall within normal limits.
The need for a balance between mobility and stability has therapeutic
implications. The fact that some stretching is often good does not mean that
more stretching is always better. Although most people with low back pain
present a limited ROM in one or more directions and need stretching to
achieve a normal ROM, stretching that increases ROM beyond normal may
cause or increase instability or cause a length-strength disparity between
opposing muscles (muscle imbalance) that disrupts lumbopelvic rhythm.
Hypermobility (too much flexibility) often causes more problems than
hypomobility (too little flexibility). There are many conservative methods
for treating hypomobility, such as neutralizing trigger points, inhibiting
hypertonic muscles, or ROM stretching, but very few conservative methods
for treating hypermobility, such as (1) reducing hypomobility that causes
compensatory hypermobility, (2) strengthening muscles that stabilize joints,
(3) resting hypermobile body parts, or (4) preventing activities that increase
hypermobility. If the sacrum is hypermobile, slouching over and sitting on
the sacrum or using a pelvic belt may reduce pain. Operative methods for
stiffening a joint (arthrodesis) include fusion and internal fixation screws.

6
(5) Strength
Fallacy: Improving strength prevents low back pain.
Truth: Strengthening and balancing muscles helps prevent back pain.
You can be physically strong and still have low back pain. The role of
exercise in terms of reducing the risk of low back pain is not well defined.
While physical fitness, in general, seems to reduce the risk of low back pain,
well-conditioned athletes can suffer from low back pain the same as poorly
conditioned spectators. Though men are statistically stronger than women,
low back pain affects about the same number of men as women.
The best low-back exercise programs are the ones that (1) lengthen
abnormally short muscles, (2) strengthen abnormally weak muscles, and (3)
keep opposing muscles balanced. A bad program increases the risk of low
back pain by injuring tissues or creating a muscle imbalance, which means
the length-strength relationship between opposing muscles changes in a way
that adversely affects their ability to function normally.
Even though regular exercise, such as jogging, strengthens bones by
increasing the storage of calcium and other minerals, increases in bone mass
are not likely to reduce low back pain. While increasing bone hypertrophy
may decrease the risk of fracture, back pain is seldom caused by a fracture.
While high-impact exercises are not recommended for low back fitness, low-
impact exercises that increase aerobic fitness seem to be beneficial.
If regular exercise, on the positive side, strengthens muscles, tendons,
or ligaments and decreases the risk of rupture, on the negative side, it may
cause overuse injuries or chronic fatigue syndrome. Synovial joints, such as
facet (zygapophyseal) joints or sacroiliac joints, are just as prone to overuse
injuries as other synovial joints such as the knee and elbow. Spinal joints
often react to microtrauma and macrotrauma in the same way as peripheral
joints. When either type of joint is injured, hypertonicity (reactive spasm,
muscle guarding, or muscle splinting) often occurs to stabilize the joint, and
muscles that interact with the joint appear weak because of pain inhibition.
An exercise program needs to avoid deconditioning from underuse on
one hand and injuries from overuse on the other. What complicates the
problem for people with LPD is that a muscle imbalance triggered by joint
injury may continue to exist long after the joint injury has healed. Muscles
that often stay out of balance and weak long after the injury that caused the
imbalance has healed are the psoas, multifidus, and transversus abdominis.

7
(6) Abdominal Exercises
Fallacy: Abdominal exercises such as sit-ups prevent low back pain.
Truth: Extensor exercises are just as important as flexor exercises.
Patients with common LBP may have normal flexion strength but test
weak because of pain inhibition or tightness in the gluteals or hamstrings.
Careful examination will often show that the problem is a hip-extensor
restriction more than trunk-flexor weakness. After the hip extensors are
lengthened, patients who tested weak for flexor strength may test normal. If
a muscle is stretched and weak (stretch weakness), test opposing muscles for
abnormal shortness and tightness (high resistance to passive stretch).
If a muscle is weak because of pain inhibition or pain avoidance, treat
the pain. Using digital pressure to neutralize trigger points or tender points
and then stretching the muscle is one way to relieve pain. Mild stretching
can help a stretched muscle regain its normal length and strength.
The belief that sit-ups prevent LBP by increasing inter-abdominal
pressure (air-bag theory) appears to be invalid, and sit-ups may injure a disc
or overstretch the hamstrings and cause stretch weakness. If the hamstrings
are stretched and weak, they need to be strengthened—not stretched. If the
gluteus maximus is short and tight, stretches that isolate the muscle are safer
than sit-ups, which also stretch the other hip extensors at the same time.
There is very little correlation between obesity and low back pain. A
pendulous abdomen may indicate too much fat, weak abdominal muscles, or
that the psoas is too short. A short psoas may cause the trunk to flex
forward, which reduces lumbar lordosis and increases abdominal bulging.
Although patients with LBP often test weak for trunk flexion or have
a pendulous abdomen, trunk-flexion weakness and a bulging abdomen are
more likely to be the effects of having LBP than the cause for having LBP.
Believing that effects are causes often leads to poor therapeutic outcomes.
Sit-ups do not prevent LBP, but increasing the strength or endurance
of a weak multifidus or transversus abdominis might reduce the risk of LBP.
Besides participating in forced expiration, the transversus abdominis
stabilizes the trunk just before rapid (ballistic) arm or leg movements.
Exercises that cause abnormal shortening of the abdominal muscles
may limit trunk extension. If flexion exercises are used to strengthen the
abdominal muscle, extension exercises can be used to help them maintain a
normal length. Exercises that cause a muscle imbalance may increase LBP.

8
(7) Posture
Fallacy: Lumbar lordosis and bad sitting postures cause low back pain.
Truth: Posture is not considered a major cause of low back pain.
Despite the belief that excessive lumbar lordosis causes low back
pain, patients with low back pain are often stooped-over, which increases
thoracic kyphosis and decreases lumbar lordosis. If a stooped-over patient
manages to stand erect, which may be difficult, thoracic kyphosis decreases
and lumbar lordosis increases. If hyperlordosis occurs after someone with
low back pain stands erect, neutral lordosis will usually occur within a short
time. Low-back patients presenting chronic hyperlordosis are rare.
The belief that poor sitting postures cause low back pain is doubtful.
First, since the highest incidence of LBP occurs between ages 30 and 50 and
common LBP is rare after age 55, does this mean that some of these people
had good posture before age 30, poor posture between ages 30 and 50, and
good posture after age 50? Regardless of what causes LBP, there should be
a strong correlation between the causes and the occurrence of LBP.
Second, the fact that low back pain frequently occurs when patients
rise from a sitting position does not justify the belief that poor sitting
postures cause low back pain. The pain is probably caused by stretching
hypertonic muscles that shorten while the patient is sitting. Sitting does not
cause the pain; it allows hypertonic muscles time to shorten. People with
hypertonic muscles can often sit for hours, regardless of posture, without
feeling any low back pain until they rise and try to stand erect. Sitting in a
slouched position will sometimes reduce low back pain.
Patients with LBP should not remain sitting in any one position for a
long time. Changing from one sitting position to another should be frequent
and gradual to keep hypertonic muscles from shortening. Rapid movements
can trigger a stretch reflex that increases tonus in muscles that are already in
a relatively short position and make rising even more difficult. Regardless
of how your posture looks to other people, sitting positions that relieve pain
are good and sitting positions that cause or increase pain are bad.
The belief that obesity makes your posture worse and increases the
risk of LBP is unproven. Even though there is no direct correlation between
obesity and LBP, obesity can adversely affect health and fitness, which may
increase the severity or the frequency of LBP. Extreme obesity can increase
stress on the knees and make lifting or holding heavy objects awkward.

9
(8) Leg Length
Fallacy: Leg-length discrepancies should always be treated.
Truth: Leg-length discrepancies less than 1/2 inch are seldom significant.
Leg-length discrepancies can be functional or anatomic. Functional

discrepancies can result from physical activities that alter the body's posture,
whereas anatomic discrepancies are caused by structural differences. The
most accurate way to measure leg length is by taking an x-ray of the pelvis
and both legs, but leg length can be estimated by measuring the distance
between the anterior superior iliac spine (ASIS) and the medial malleolus.
Even if anatomical leg length is identical, most people will have some
degree of functional leg-length discrepancy because of usage. People with a
history of LBP and symptoms seem to have leg-length discrepancies more
often than people with a history of LBP and no symptoms. If the gluteus
medius or gluteus minimus are stretched or weak, femoral and tibial medial
rotation may cause a leg-length discrepancy.
With the patient supine, applying traction to the short leg may
temporarily lengthen the short leg and give the appearance of equalizing leg
length. With normal activity, the short leg will usually return to its previous
length. Even though "lengthening" the short leg appears to produce no
therapeutic benefits, some patients seem to get relief from the stretch.
There is no good justification for treating differences in leg length or
other defects in lumbar symmetry that are asymptomatic. If the patient does
not experience pain when standing or walking, discrepancies in leg length
are probably not relevant to low back pain.
Careful examination reveals that most bodies are asymmetric and
genuine symmetry is almost atypical. Many people with palpable anomalies
can have healthy spines and no low back pain. In other words, "If it's not
broke, why fix it?" Although some doctors treat leg-length discrepancies as
small as 1/4 inch, differences of less than 1/2 inch are seldom significant.
The body will normally compensate for small differences in leg length with
no adverse effects. Long-distance runners who try to compensate for a leg-
length discrepancy by wearing special shoes often create new problems.
Since a leg-length discrepancy of 1/2 inch has been associated with a
4-degree pelvic tilt and some people with chronic LBP have reported some
relief from wearing a shoe lift, it may be appropriate to try one. For most
people, using a shoe lift is a low-cost, conservative, and low-risk option.

10
(9) Nerve and Disc Involvement
Fallacy: Discogenic problems are the major cause for low back pain.
Truth: Disc problems account for only about 5% of all low back pain.
Since 1934—when Mixter and Barr performed the first spinal surgery
on a herniated disc—orthopedic surgeons who specialize in low back pain
have made the disc the center of attention, and this decision has affected
every health care professional who treats low back pain.
Before the disc was considered the main cause for LBP, surgeons did
not have a good reason for recommending surgery. After the advent of the
disc paradigm, surgeons could tell people that back pain is caused by a disc
and that surgery will stop the pain and stiffness they feel in their back.
Herniated discs account for about 5% of all low back pain. It has also
been shown statistically that documented disc ruptures treated surgically
produce about the same long-term results as similar ruptures left untreated.
Even though a disc may cause LBP, it is not the normal cause.
Whereas pressure on muscles, ligaments, tendons, joint capsules, or
periosteum usually causes pain, pressure on a normal nerve root because of a
disc usually causes weakness, paresthesia, or numbness instead of pain. In
the absence of neurologic signs such as weakness, paresthesia, or numbness,
low back pain is more likely to be somatic pain than radicular pain.
It is also notable that areas of the spine without discs are capable of
producing the same signs and symptoms as areas with discs. The junctions
between the occiput and atlas and between the atlas and axis do not have
discs, yet injuries to these segments produce the same local and radiating
pain as injuries to the lumbar spine.
Since synovial facet joints, unlike discs, are found along the entire
spine, synovial swelling probably accounts for many of the signs and
symptoms attributed to discogenic disorders. These signs and symptoms
include nerve-root irritation (radiculitis), local or radiating pain, paresthesia,
muscle weakness, and sensory or reflex changes.
After the disc became accepted as the main cause for LBP, patients
were usually told that any pain referred to the lower extremities was caused
by a bulging disc or some other disc pathology. Contrary to this belief, it is
now well established that strong irritants injected into tissues other than
discs or nerves contiguous with discs can refer pain to the lower extremities.
Neurogenic pain from the piriformis can extend to the sole of the foot.

11
Trigger points in the lumbar iliocostalis muscle and longissimus
thoracis muscle can refer pain down into the buttocks. Trigger points in the
anterior part of the gluteus minimus can refer pain into the ankle, and trigger
points in the posterior part of this muscle can refer pain into the calf.
Muscles can also refer pain upward from the buttocks. Trigger points
in the gluteus medius can refer pain over the sacrum and into the lowest
lumbar region. The piriformis muscle can refer neurogenic pain upward to
the low back or downward to the thigh, leg, or foot (piriformis syndrome).
This could explain how irritated nociceptors in the gluteal muscles can
produce reflex patterns that cause spasm in the hamstring or the tensor
fasciae latae. Besides muscles, nociceptors are found in joint capsules,
ligaments, perivascular tissue, periosteum, and tendons. According to most
authorities, only the outer layers of an intervertebral disc have nociceptors.
While there may be times when surgery is the best alternative, most
discogenic problems do not require surgery. If a herniated disc triggers a
muscle imbalance that causes low back pain, the muscle imbalance and low
back pain often continue long after the herniated disc has healed.
If a muscle imbalance does occur, the stresses caused by the muscle
imbalance may aggravate existing discogenic problems or cause new ones.
On the other hand, conservative measures that correct a muscle imbalance
will increase the probability that an injured disc will heal and decrease the
probability that an injured disc will need surgical intervention.
According to evidence-based research, x-rays or magnetic resonance
imaging (MRI) have never been able to prove that a bulging disc is causing
low back pain or that the presence of a bulging disc will cause future LBP.
Many patients with highly visible bulging discs are asymptomatic and many
patients with no visible discogenic problems have low back pain.
If lifting injures a disc, the mechanism of injury often involves lifting
while the spine is flexed and rotated; there may be a pop or tearing sensation
followed by a deep, aching discomfort that extends to the foot or toes; and
unilateral leg pain may be worse than back pain. Bending, lifting, or sitting
may exacerbate the pain and standing, walking, lying supine, or being in a
fetal position may relieve the pain. Patients may present palpable spasm
along the paraspinal muscles and spinal flexion may be painful and limited.
When it comes to treating common LBP, it appears that more than 90
percent of the effort is being used to treat something—discs or nerve-root
pain—that is causing less than 10 percent of the problem, which is probably
why at least one prominent medical doctor says that low back pain is a 20th-
century medical disaster (Waddell, 2004).

12
(10) Activity and Pain
Fallacy: Avoid painful activities when you have common low back pain.
Truth: Even if pain is present, try to stay as active as possible.
If you have common LBP, there are two main reasons why working
through the pain is usually better than remaining inactive until the pain is
gone. First, most normal daily activities that are painful are not harmful and
second, activity will increase your tolerance for pain and reduce stiffness.
Low back pain can be very painful, but serious or permanent damage is rare.
Understanding the nature of common LBP, accepting the pain and
inconvenience that results from common low back pain, having a positive
attitude, and trying to stay as active as possible despite the pain will usually
increase your chances of having a rapid recovery.
Focusing on pain avoidance and developing pain behaviors such as
helplessness and constant inactivity will decrease your chances of having a
full recovery. One thing that makes soft-tissue manipulation very effective
is that it helps patients stay active by reducing pain, strengthening weak
muscles, and lengthening abnormally short muscles. After manipulation
prepares patients for activity, exercise can be used to increase strength.
Soft-tissue manipulation strengthens skeletal muscles by decreasing
neurologic inhibition or increasing facilitation, whereas therapeutic exercise
strengthens muscles by increasing neurologic efficiency or increasing mass
(hypertrophy or hyperplasia). If muscles are atrophied from deconditioning,
manipulation without exercise might not restore normal strength. Exercise
may also improve endurance, flexibility, balance, and coordination.
In people with chronic LBP, the superficial paraspinals may atrophy
and the fat percentage may increase. The multifidus may also atrophy, but
the reason could be neurologic inhibition more than disuse. The multifidus
might not regain its normal strength without specific exercises, and failure to
strengthen this muscle may cause future attacks of LBP. If the time since
the last attack is less than 1 week, the probability of future attacks within the
next year is about 75%. Strengthening the multifidus can reduce stress on
the other spinal extensors and lower the risk of future attacks.
Even if it hurts—try to relax. Stress can increase spasm, decrease
motor control, and make back pain worse. Common LBP is not caused by a
serious injury or disease, and the long-term outcomes are usually good.
Doing low-intensity back exercises and deep breathing may help you relax.

13
Muscle Imbalance
A muscle imbalance is a length-strength disparity between opposing

muscles that causes a loss of function. This book is based on the belief that
common LBP is usually caused by irritated tissues and muscle imbalances.
The irritated tissues that cause LBP are muscles, tendons, ligaments,
fascia, periosteum, joint capsules (facet joint or sacroiliac joint), and discs.
Regardless of which tissues are involved, muscle imbalances are normally
much more apparent when common LBP is active than after it stops.
Several factors that cause or perpetuate muscle imbalances are pain,
spasm, weakness, and trigger points. Once created, muscle imbalances can
irritate more tissues, which in turn may generate more muscle imbalances.
Like many dysfunctions related to LBP, muscle imbalances can start cycles.
Muscle imbalances provide the best starting point for evaluating and
treating common LBP for several reasons: (1) there is a strong correlation
between low back pain and the occurrence of muscle imbalances, (2) muscle
imbalances are easier to identify and treat than many of the irritated tissues
that cause LBP, (3) if problems such as a herniated disc are causing LBP,
decreasing the intensity of a muscle imbalance can help injured tissues heal
themselves, (4) correcting muscle imbalances can stop noxious cycles from
starting, and (5) explaining what a muscle imbalance does will help people
understand what causes LBP and give them a way to measure progress.
While there is no foolproof method for finding a muscle imbalance,
most muscle imbalances cause pain, weakness, a limited ROM, and a loss of
function. Pain can be measured by stretching, compressing or contracting the
affected muscles, weakness and ROM can be measured by using muscle
testing, and statements by the patient and observing the patient can help you
measure loss of function—which may not correspond with other findings.
If measurements of pain and weakness do not correspond with loss of
function, the patient’s condition may involve psychological factors as well
as physical factors. Specific testing can be used to separate physiologic
problems from psychogenic problems. Psychological issues such as stress,
fear, anger, depression, or desperation are more likely to be effects that
result from having common low back pain than causes for common LBP.
Muscle imbalances can occur between muscles that sidebend (lateral
flexion), rotate, or flex and extend, but the one that occurs most often during
common LBP is a muscle imbalance between the psoas, strong hip flexors,
and hamstrings, strong hip extensors. The psoas are often short, tight and
weak, and the hamstrings are often stretched, tight, and weak.

14
In most cases: (1) the psoas are short and tight because of spasm and
weak because of tight weakness or pain and (2) the hamstrings are stretched
because of tension from the psoas, tight because of hypertonicity, and weak
because of stretch weakness. If there is a muscle imbalance between the
psoas and hamstrings, the gluteus maximus or rectus abdominis may test
weak and the quadriceps or back extensors may be tender. If the piriformis,
gluteus medius, gluteus minimus, gastrocnemius, and soleus are tender,
these muscles need to be treated shortly after the psoas, hamstrings, gluteus
maximus, rectus abdominis, quadriceps, and back extensors are treated.
Correcting the imbalance between the psoas and the hamstrings may
increase the strength of rectus abdominis and gluteus maximus and reduce
pain in the quadriceps, gastrocnemius, soleus, or gluteus minimus. Muscles
that test weak during episodes of LBP, such as rectus abdominis or gluteus
maximus, often test normal before and after an episode. Gluteus medius and
piriformis usually require specific intervention such as trigger point therapy.
There are different ways to strengthen a muscle: (1) if weakness is
caused by hypertonicity or pain, inhibition may strengthen the muscle, (2) if
weakness is caused by hypotonicity, facilitation may strengthen the muscle,
(3) if weakness is caused by antagonistic muscles that are abnormally short,
lengthening the antagonists may strengthen the agonist, and (4) if weakness
is caused by inactivity and deconditioning, treating soft-tissue impairments,
restoring a normal muscle balance, and exercise may strengthen muscles.
Since a muscle imbalance involves an interaction between opposing
muscles or muscle groups and common LBP involves a complex interaction
between many different muscles, any protocol that limits treatment to only
one or two muscles will probably fail. The term low back pain is probably a
poor choice of words because it seems to imply that treatments for LBP
should not include muscles that are located below the waist.
As modern medicine becomes more specialized, there is much less of
a tendency to treat low back pain as a complex interaction between different
muscles. Orthopaedic surgeons have a tendency to see LBP as a discogenic
problem treatable by surgery, chiropractors have a tendency to see LBP as a
subluxation problem treatable by spinal manipulation, and podiatrists have a
tendency to see LBP as a foot problem treatable by orthotics.
Even though palpation or muscle testing can be used to demonstrate
that most cases of common LBP are characterized by some type of muscle
imbalance, Western medicine seems to ignore myofascial strain as a cause
for common LBP. Using soft-tissue manipulation to optimize the length-
strength relationship between opposing muscles and then using exercise to

15
help muscles maintain a normal length-strength relationship is the most cost-
effective way to treat common LBP. If a new muscle imbalance occurs
during an exercise program or because of the exercise program, soft-tissue
manipulation can be used to correct the muscle imbalance.
If you try to use exercise as a substitute for soft-tissue manipulation,
you are treating the symptoms but not the cause. If an irritated facet joint
causes reactive spasm and muscle guarding, the psoas often becomes
hypertonic and disrupts lumbopelvic rhythm. If therapeutic exercise is used
before the psoas is relaxed by using inhibition and then lengthened by using
ROM stretching, the stress from exercise may damage the psoas or cause
additional joint damage. If trigger points within a muscle are not neutralized
before someone starts an exercise program, the muscle may not function at
full capacity and even a minor strain may increase hypertonicity and
increase the time it takes for the muscle to relax after it contracts.
The fact that most cases of common low back pain involve the same
muscles and the same muscle imbalances does not mean that every case of
common low back pain will be exactly the same. Even though adductors are
less likely to be involved in common LBP than muscles that flex, extend,
sidebend, or rotate, you should palpate and muscle test the adductor muscles
and treat them with appropriate therapy if you find soft-tissue impairments.
Once patients are given the help they need to reduce pain and get their
muscles functioning properly, they need to take responsibility for their own
recovery by avoiding harmful activities, staying physically active, and
learning to cope with LBP. Learning to deal with mental stress because of
pain or discomfort can be just as important as learning to deal with physical
stress because of pain inhibition, weakness, or a limited range of motion.
Why soft-tissue therapy—which is a very-cost-effective way to treat
common low back pain—is not used more often is hard to say, but the main
reason is probably money. Surgery is usually more profitable than manual
medicine, and even if you practice manual medicine, spinal manipulation is
faster and generates more profit than soft-tissue manipulation. Soft-tissue
manipulation also requires more physical effort than spinal manipulation.
Soft-tissue therapy is cost-effective because it reduces the severity of
symptoms, shortens recovery time, restores normal body functions, reduces
the risk of recurrence, and often produces far better results than treatments
that are much more expensive and sometimes harmful. If more practitioners
understood the value of soft-tissue therapy because of its cost-effectiveness,
treating common low back pain would probably be less of a problem than it
is today: disability would be lower and productivity would be higher.

16
Sacral Dysfunction
The sacroiliac joint (SIJ) is one of the most enigmatic joints in the
human body and may hold part of the key as to why nonspecific LBP seems
to peak between ages 30 and 50 and sharply decrease after age 55. Before
the intervertebral disc became the most popular way to explain nonspecific
low back pain, sacroiliac joint dysfunction was thought to be a major cause.
The sacroiliac joint is capable of only a few degrees of motion, and
the mobility of the joint seems to decrease with age. Because of fibrosis and
changes in the surfaces between the sacrum and ilium, the sacroiliac joint
loses most of its static mobility after the fifth decade. This could help
explain why nonspecific LBP seldom occurs after 55 years of age.
Why nonspecific LBP increases after 30 years of age probably relates
more to changes in neuromuscular efficiency than to changes in the SIJ. The
decreases in neuromuscular efficiency that occur after the third decade may
increase the risk of LBP because they increase the risk of having a muscle
imbalance that interferes with lumbopelvic rhythm.
While sacral dysfunctions, such as hypomobility or hypermobility, do
not always cause LBP, hypermobility seems to increase LBP (pregnancy)
and hypomobility seems to decrease LBP (fusing or pinning the sacrum).
Pelvic belts that increase sacral stability by compressing the lower lumbar
spine and pelvis have been demonstrated to reduce LBP during pregnancy.
The decrease in sacral mobility after age 50 may decrease stretching
of the sacral ligaments, which can cause reflex spasm and pain, or it may
create a more level contact surface between the lumbar spine and sacrum.
When sacral movement is normal, the muscles that stabilize the sacrum have
normal tonicity and the ligaments that stabilize the sacrum are not stretched.
If the sacrum is hypermobile: (1) strengthen muscles that stabilize the
sacrum, such as the gluteus maximus, latissimus dorsi, erector spinae, and
biceps femoris and (2) increase the lumbar spine’s ROM if less than normal.
Because of compensatory hypermobility, a limited ROM in the lumbar spine
may force the sacrum to compensate by increasing its own ROM, which is
why increasing lumbar mobility may increase sacral stability. Hypomobility
in the lumbar spine can also increase compression of the lumbosacral joint,
which in turn may increase tension on the sacral ligaments.
Trigger points are often found on or near sacral ligaments, such as the
sacrotuberous or sacrospinous ligament. If the sacrum is hypermobile and
the ligaments with trigger points are stretched or weak, trigger point therapy
will be ineffective unless the ligaments are first shortened and strengthened.

17
Prolotherapy, injecting ligaments with glucose, glycerin, phenol, and
water or other solutions, can shorten stretched ligaments and reduce laxity.
Since fibers from the gluteus maximus, multifidus, and piriformis blend with
the sacrotuberous ligament, prolotherapy may improve muscle balance.
If something irritates the pelvic region and some of the muscles that
stabilize the sacrum become hypertonic and cause hypomobility in one area,
compensatory movements may increase mobility in other areas and cause
hypermobility—which might place abnormal tension on sacral ligaments. If
abnormal tension on ligaments increases hypertonicity (splinting), it may
start a hypertonicity-hypomobility-hypermobility-hypertonicity cycle.
Sacral pain may occur if posterior ligaments, such as the long or short
dorsal, interosseus sacroiliac, sacrospinous or sacrotuberous, are stretched or
weak because of sacral hypermobility. If ligamentous laxity causes sacral
instability, do not use any type of manipulation that lengthens the ligaments.
Besides prolotherapy, standard methods for treating hypermobility are
(1) release tissue restrictions, (2) reduce pain, (3) restore muscle balance,
and (4) strengthen weak muscles with therapeutic exercise. Patients should
be told they need to avoid any activities that increase sacral instability, such
as spinal adjustments or exercises that may stretch sacral ligaments, and they
need to understand that a full recovery may take several months.
The primary muscles that stabilize the sacrum are gluteus maximus,
latissimus dorsi, erector spinae, and biceps femoris, and the secondary
muscles are the internal and external obliques, transversus abdominis,
piriformis, multifidus, and psoas. The cross-like configuration created by
the latissimus dorsi, thoracolumbar fascia, contralateral gluteus maximus,
and iliotibial tract increases sacral and lumbar stability, and contraction of
the gluteus maximus may increase lumbar compression and posterior pelvic
tilt. The obliques and linea alba also form a cross-like configuration.
When people have sacral dysfunctions, hypertonicity and pain in the
gluteus maximus may increase and strength may decrease. The pain may be
greater on one side than on the other. As the sacrum becomes more stable,
hypertonicity and pain will usually decrease and strength will increase. A
similar sequence may occur in other muscles that stabilize the sacrum.
Stress on sacral ligaments may produce sequelae similar to those that
occur after a sprained ankle, such as hypertonicity, muscle splinting, pain
inhibition, pain avoidance, malaligned joint surfaces, subluxation, and joint
dysfunction. Compensatory hypermobility because of a sprained ankle may
cause knee or hip problems, but these problems occur less frequently than
the lumbopelvic problems that occur because of sacral hypermobility.

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Epidemiology
Muscle imbalances and sacral dysfunctions help to explain why the

highest incidence of common low back pain occurs between ages 30 and 50.
If factors that increase with age, such a spinal degeneration, cause low back
pain, you would expect the frequency of low back pain to increase rather
than decrease after 50 years of age. On the contrary, low back pain after age
55 that is not caused by a pathologic entity, such as bone cancer, is rare.
Based on years of scientific research, it is well established that muscle
strength starts to decrease after age 30. Factors that cause a loss of strength
include a decrease in motor units, less muscle mass, a lower concentration of
mitochondrial enzymes, and smaller or fewer muscle fibers. Fast-twitch
muscle fibers decrease at a faster rate than slow-twitch muscle fibers.
While exercise can be used to offset the strength loss that normally
occurs because of aging, opposing muscles will not stay balanced if agonists
and antagonists do not get similar types of exercise. If exercise strengthens
a weak agonist and a lack of exercise weakens a weak antagonist, the two
opposing muscles will not maintain a balance the way they did before aging
weakened both muscles. After age 30, the imbalance between muscles often
becomes greater because of use or disuse. Exercise programs that are not
properly designed may cause a muscle imbalance that decreases function.
An imbalance between opposing muscles because of a difference in
strength often leads to an imbalance because of a difference in length. If a
strong agonist repeatedly overpowers a weak antagonist, the agonist will
tend to shorten and become weak and the antagonist will tend to stretch and
become weak. The antagonist may also stay at the same length and become
weak because of passive stiffness (tightness), which means the muscle has a
higher resistance to passive and active stretch (tension) than normal.
Just as a muscle imbalance will increase the risk of having low back
pain, a loss of sacral mobility will decrease the risk. Factors that cause the
sacrum to lose most of its mobility by age 50 are increased roughness in the
surface of the sacrum that increases friction between the sacrum and the hip
bone (innominate) and increased fibrosis between the sacrum and hip bone.
Ankylosis is the stiffening or fixation of a joint because of a fibrous or
bony union across the joint. While some believe that most sacral joints are
completely ankylosed by age 50, others believe that a major loss of mobility
is common, but complete ankylosis is rare. Since reducing sacral mobility
by using pins or fusion (arthrodesis) has been shown to reduce low back
pain, it seems logical that reaching 50 years of age will have a similar effect.

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Lumbopelvic Rhythm
Lumbopelvic rhythm refers to the lumbar and pelvic movements that

occur between standing erect, full trunk flexion, and standing erect again. If
trunk flexion is 90 degrees, lumbar flexion will produce most of the first 45
degrees and pelvic rotation will produce most of the last 45 degrees. As the
lumbar spine flexes, lordotic curvature will be lost and the lumbar spine will
flatten. Normal trunk flexion is about 80 to 90 degrees. Trunk flexion will
stop when the spine is fully flexed and the pelvis is fully rotated.
As the trunk reaches about 45 degrees flexion, the lumbar spine is
about fully flexed and the trunk is about 75% fully flexed. For the trunk to
achieve full flexion, pelvic tilt will change from neutral to anterior and the
last 25% of trunk flexion will occur because of anterior pelvic rotation.
When returning to an upright posture, the opposite occurs. During the
first 45 degrees, the pelvis derotates and the spine is flexed. During the last
45 degrees, derotation slows and the spine extends. The lumbar spine does
not achieve normal lordosis when standing erect in a neutral position (no
flexion or extension) until the pelvis stops derotating and tilts forward.
When standing at rest, the line of gravity of the trunk is anterior to the
axis of the hip joint and pelvic tilt is slightly anterior. During the initial
stages of trunk flexion, the lumbar spine flexes and pelvic tilt changes from
anterior to posterior. When flexion is viewed from behind, the lumbar spine
should flatten and the pelvis should move toward the examiner.
As the spine flexes forward, posterior translation of the pelvis helps to
keep the body’s center of gravity over the feet. This explains why people
standing with their back against a wall cannot bend over and keep their
balance without stepping forward to reposition their feet under their center
of gravity. As the spine flexes forward and the pelvis moves in a posterior
direction, the body’s center of gravity moves in an anterior direction.
When the gluteus maximus and the hamstring muscles relax enough to
permit elongation, they must also contract eccentrically or isometrically to
control the velocity of forward flexion. The proprioceptive stimuli that
control muscle elongation and deceleration are probably generated by
muscle spindles, Golgi tendon organs, or joint mechanoreceptors, which are
located in the facet joints or their capsules. When the trunk is fully flexed,
ligaments and fascia maintain the trunk's position without muscular activity.
Lumbar flexion continues until the lumbodorsal fascia, facet capsules,
and spinal ligaments—such as the interspinous, supraspinous, and posterior
longitudinal—stretch tight enough to stop further flexion. When the trunk is

20
fully flexed, lumbar flexion and anterior pelvic tilt have reached their full
range of motion and muscular activity ceases (myoelectric silence).
When returning to an upright posture: the pelvis derotates around the
axis of the hip by virtue of gluteal and hamstring contractions and pelvic tilt
changes from anterior at full flexion to posterior during extension and then
slightly anterior when the spine is fully erect. Standing erect will usually
cause an increase in lumbar and cervical lordosis, a decrease in thoracic
flexion, and a slight anterior tilt of the pelvis into neutral position.
The lumbar spine cannot achieve neutral lordosis until the pelvis
completes derotation and the hip extensors relax enough for the pelvis to tilt
slightly forward into a neutral position. If tension in the hamstrings or
gluteus maximus keeps the pelvis from tilting forward, the lumbar spine will
not achieve neutral lordosis and standing erect will be difficult. If the
gluteus maximus is short and tight, tilting the pelvis forward may be painful
because of increased compression and shear at the lumbosacral articulation.
The psoas can interfere with lumbopelvic rhythm in two ways. First,
when attempting to rise from a stooped-over position, excessive tension
from the psoas can interfere with pelvic derotation. Second, after a person is
standing erect, excessive tension from the psoas may increase anterior pelvic
tilt and cause hyperlordosis. If the excessive tension from the psoas is
caused by hypertonicity, tightness, or abnormal shortness—relaxing and
stretching the psoas may help restore normal lumbopelvic rhythm.
If anterior pelvic tilt is excessive and the spine is hyperlordotic, the
abdomen may protrude (pendulous abdomen) until the psoas relaxes. If this
occurs, relaxing and lengthening the psoas will flatten the abdomen more
than strengthening abdominal muscles, such as rectus abdominis. In most
cases, strengthening core stabilizers—the transversus abdominis, internal
obliques, and external obliques—will do more to reduce or prevent
nonspecific LBP than strengthening the rectus abdominis, a trunk flexor.
Muscle imbalances that disrupt lumbopelvic rhythm are the links that
connect spinal and pelvic dysfunctions and help to explain why nonspecific
LBP is often caused by soft-tissue impairments below the waist. Because of
lumbopelvic rhythm and compensatory hypermobility, pelvic hypomobility
may cause spinal hypermobility and spinal hypomobility may cause pelvic
hypermobility. If the hip flexors and hip extensors are both short and tight,
compression of the facet joints when trying to stand erect may cause pain
and reflex spasm in both the flexors and the extensors. If lumbar extension
occurs while the lower spine is rotated, compression on the facet joints will
be even greater than if the lower spine were not rotated during extension.

21
Lumbopelvic Dysfunction
The three structures that usually cause lumbopelvic dysfunctions are

the pelvis—which is formed by the innominate bones (ilium, ischium, and
pubis), the sacrum, the coccyx, and all connecting ligaments—the hips, and
the lumbar spine. Back pain often strikes when someone attempts to stand
up after sitting or being stooped, and most of these attacks relate directly to
lumbopelvic rhythm and rotation or derotation of the pelvis.
Most lumbopelvic dysfunctions involve the relationship between the
L5 facet and the sacrum. The articulation between L5 and the sacrum is
called the lumbosacral spinal joint. The angle between L5 and the sacrum is
called the lumbosacral angle. This angle measures the arc between a
horizontal line and a line parallel to the upper surface of the sacrum. The
optimal arc for this angle is about 30 degrees because a 30-degree forward
tilt creates neutral lordotic curvature when S1 and L5 approximate.
The position of the pelvis is neutral when the anterior superior iliac
spines are in the same horizontal plane and the anterior superior iliac spines
and the pubic symphysis are in the same vertical plane. If the pelvis does
not tilt forward after derotation and locks in a posterior-tilt position, (pelvic-
lockup), the lumbosacral angle will be less than 30 degrees, lumbar lordosis
and possibly extension will be reduced, but lumbar flexion may be normal.
If there is no anterior pelvic tilt and the back is flat, standing stooped
over may be easier than standing erect and trying to stand erect may cause
excessive compression between S1 and L5. If compression irritates tissues,
reflex spasm may decrease pelvic mobility. Full trunk flexion will also be
difficult if the pelvis cannot tilt (rotate) forward after spinal flexion stops.
People may try to compensate for a loss of lumbar lordosis by flexing
the knees and shifting the pelvis forward. This will flatten the back and
make walking difficult. Unlike a sway-back posture, which is characterized
by a weak psoas, a flat-back posture is characterized by an abnormally short
psoas, which may also be weak (tight weakness). Protective spasm because
of inflammation may also cause a loss of lumbar lordosis.
If the pelvis fails to derotate completely because the hip extensors are
tight or abnormally short, the contact surface between L5 and the sacrum
will not be parallel and approximation will cause uneven pressure. Patients
frequently describe this feeling as a "locking" or "catching" in the back.
Lumbosacral joint dysfunction occurs when the sacrum fails to assume its
normal position during flexion or extension and the effects of abnormal
compression cause pain and reflex spasm (guarding or splinting).

22
Because pain from the lumbopelvic region can radiate or be referred
to areas that are remote from the origin of pain, a pelvis that fails to assume
its normal position during or after flexion or extension of the trunk is often
overlooked as one of the main causes for LBP. Any muscle imbalance that
causes abnormal pelvic rotation and interferes with lumbopelvic rhythm has
a strong potential for causing or perpetuating common low back pain.
Muscle imbalances in the lumbopelvic region often create interacting
cycles: (1) if abnormal changes in the length, strength, or tightness of the
psoas, hamstrings, or gluteus maximus interfere with pelvic rotation and
cause tissue trauma, the trauma may cause inflammation or reflex spasm that
can affect the quadratus lumborum or obliques and (2) if unilateral spasm in
the quadratus lumborum or obliques causes a lateral pelvic shift, the
probable outcomes are less mobility, more pain, and more tissue damage,
which in turn may perpetuate or amplify existing cycles or start a new cycle.
These cycles can make common (nonspecific) LBP very difficult to treat.
The two muscle imbalances that are usually associated with common
LBP are a flexion-extension imbalance involving the psoas, hamstring, and
gluteus maximus and a sidebending imbalance involving the psoas,
quadratus lumborum, and obliques. Lateral pelvic shift, sidebending (lateral
flexion) imbalance, may also affect rotation. Since any muscle that causes a
disparity between the length or strength of opposing muscles may cause a
muscle imbalance, you can have many different types of muscle imbalances
and one imbalance may cause or perpetuate other muscle imbalances.
If spasm causes long-term joint compression and changes in contact-
surface symmetry, spinal joints may undergo changes that cause mechanical
or neurologic defects. Theoretically, muscle contractions strong enough to
reduce lumbar mobility may cause a bulging lumbar disc. If this condition is
left untreated, it may lead to surgery that could have been prevented by early
intervention and properly applied conservative care.
Unless the trunk is free-falling, hip extensors contract isometrically
during the initial stages of flexion when the pelvis is stationary, and then
contract eccentrically during the final stages of flexion when the pelvis tilts
forward. If the hip extensors experience microtrauma during trunk flexion,
the forceful contractions needed to derotate the pelvis during extension will
place additional stress on the hip extensors, which may exacerbate existing
trauma. If the hip extensors go into spasm because of trauma, standing fully
erect without pain or loss of lumbar lordosis may not be possible. Working
while stooped over puts continuous stress on the hip extensors, and standing
up after working while stooped over often causes low back pain.

23
That hip extensors are capable of preventing derotation of the hip is
not surprising, considering the large amount of force they generate when
overcoming flexion and lifting heavy objects at the same time. When hip
extensors fail to relax after forcefully contracting to derotate the pelvis, the
force they exert is more than sufficient to lock the pelvis, prevent anterior
pelvic tilt, and keep the sacrum from assuming its normal position.
During lumbar extension, spasm or weakness in the gluteus maximus
increases erector spinae activity. Even though the erector spinae and psoas
can work together contralaterally to stabilize the lower spine, during lumbar
extension, the erector spinae extends the lower spine and the psoas relaxes
(reciprocal inhibition). While the iliocostalis lumborum and longissimus
thoracis are both very strong trunk extensors, these muscles may be injured
because of overload if they try to compensate for weak hip extensors, such
as the hamstrings or gluteus maximus, the largest muscle in the body.
Besides lumbosacral joint dysfunction, there are two other factors that
may cause spasm in the hamstrings or gluteus maximus. The first is a nerve
root irritation between L1 and L5. To prevent painful movement of the
lumbar spine, one or more of the five pairs of lumbar spinal nerves may send
a nerve impulse that causes reflex spasm in the muscles that control
lumbopelvic movement. Reflex spasm splints (stiffens) the affected joints.
Another factor is trauma. The normal sites for low-back muscle tears
are the juncture between the erector spinae group and the common tendon,
which is medial to the posterior superior iliac spines, and the gluteal origin
on the upper part of the iliac bone, which is lateral to the posterior superior
iliac spines. Acute inflammation usually lasts about 24 to 72 hours.
Even though patients may know that they felt something tear loose or
give way in their back, the spasm that occurs because of trauma may not be
apparent for 7 or 8 hours. Once tissues tear, repeating any movement that
caused the initial tearing will aggravate the injury. Muscles are more likely
to tear at or near musculotendinous junctures than near the belly.
Tearing can result from stress on the hamstrings or gluteus maximus
during anterior or posterior pelvic rotation. If these muscles go into spasm
because of trauma and fail to relax when the trunk tries to go from flexion to
an upright position, the pelvis may not tilt forward, lumbar lordosis may be
absent or greatly reduced, and walking may be difficult and painful.
Muscle soreness may occur while heavy lifting is still in progress or
48 hours later. Lifting a heavy object one day and then waking up the next
morning with muscle soreness is very common. This is called delayed-onset
muscle soreness, and the pain may not reach its full intensity for 12 to 48

24
hours. Acute muscle soreness, the pain felt during or shortly after heavy
exertion, is probably caused by trauma and inflammation. Muscle soreness
may also occur after manipulation. Delayed muscle soreness is common,
but acute muscle soreness is rare and may indicate too much force was used.
Muscle soreness from exercise or manipulation is probably caused by
microtrauma, inflammation, ischemia, metabolic insufficiency, chemical
imbalances, or reflex spasm. These same factors may also cause a muscle
imbalance that interferes with lumbopelvic rhythm and causes LBP.
Common LBP is not caused by an injury or a pathogen and the causes
are nonspecific, but microtrauma and inflammation are usually involved.
Since repetitive strain, overuse, and eccentric contractions are known causes
for muscle soreness after exercise, these same factors probably cause LBP.
Recurrences of LBP are often caused by repeating the activities that
caused LBP in the past or not being symptom-free after the last episode. If
trigger points in muscles such as the multifidus or transversus abdominis are
not properly treated, they will increase the probability of future LBP.
Even without treatment, LBP is self-limiting to the extent that most
people can resume normal activities within 6 to 8 weeks. This does not
mean that all functions have returned to normal, and most people report pain
and stiffness after they resume normal activities. What competent treatment
can do is (1) reduce the severity or duration of present or future episodes, (2)
reduce the risk of future episodes, (3) reduce the risk of disability, and (4)
give people who suffer from LBP more control over their lives.
How often sacrum dysfunctions cause LBP is open for debate. As a
weight-bearing mechanism, stopping the sacrum from assuming its normal
position may reduce joint play or make it difficult for the sacrum to attenuate
force or absorb shock, which increases the risk of injury at the L5-S1
juncture. Sacral dysfunctions can also weaken the biceps femoris.
Sacral misalignment can affect capsular or ligamentous tissues. If
compression is greater on one side of the sacrum than on the other, unequal
forces may shorten tissues on the side with greater compression because of
adaptive shortening (slack tissues have a tendency to shorten) and lengthen
tissues on the side with greater tension. Both compression and tension can
irritate tissues and cause mechanical pain, referred pain, or chronic pain.
One key to understanding lumbopelvic disorders is understanding the
relationship between pelvic rotation and lumbopelvic rhythm. If the ROM
for anterior or posterior pelvic tilt is less than normal because of a muscle
imbalance, improper lumbopelvic movements can start pain cycles that
cause or perpetuate LBP until they are stopped by appropriate treatment.

25
Lateral Pelvic Shift
A muscle imbalance between muscles such as the psoas, quadratus

lumborum, internal obliques, external obliques, rectus abdominis, gluteus
medius, erector spinae, or multifidus may cause a lateral pelvic deviation
that moves the pelvis to the right or left of the sagittal midline. This
movement is called lateral pelvic shift and it may cause functional scoliosis,
which tends to diminish during sleep or when hypertonic muscles relax.
A plumb bob dropped from the seventh cervical vertebrae (C7) can be
used to measure lateral pelvic shift. This movement is a combination of
side-gliding and sidebending with some rotation. Lateral pelvic shift is
measured with the shoulders stationary and parallel to the ground. Shifting
the pelvis while keeping the shoulders stationary results in lumbar scoliosis.
Muscles that play a major role in lateral pelvic shift are the psoas and
quadratus lumborum. When the psoas shortens unilaterally: (1) the trunk
flexes and sidebends toward the hip on the short side, (2) the other hip
rotates in a posterior direction, and (3) lateral shift is opposite the short side.
Bilateral psoas shortness flexes the trunk more than unilateral shortness, and
lateral pelvic shift, if it does occur, will be away from the shortest side.
If the eyes and shoulders are fairly level: lateral pelvic shift (LPS)
and sidebending usually occur on opposite sides, lateral lumbar convexity—
and possibly a higher pelvis—will be on the same side as lateral pelvic shift,
and lateral thoracic convexity will be on the same side as sidebending.
When the quadratus lumborum shortens unilaterally: (1) the pelvis is
elevated on the short side, (2) the lumbar spine sidebends to the opposite
side, and (3) lateral pelvic shift is on the short side. A downward pull from
the gluteus medius may lower the pelvis on the side opposite the short side.
Unilateral shortness in the internal obliques, erector spinae, or rectus
abdominis sidebends the spine to the same side, and unilateral shortness in
the external obliques sidebends the spine to the opposite side.
If LPS is caused by unilateral shortness of the psoas, you may be able
to reposition the hip and reduce abnormal lateral curvature (scoliosis) by
having patients sidebend toward the side that has shifted outward while
pushing the hip inward. If LPS is caused by a short quadratus lumborum,
have the patient sidebend away from the side that has shifted outward and
push the hip inward. Reducing hypertonicity before a patient sidebends can
make bending less painful. After lateral pelvic shift has been reduced, have
patients sidebend, rotate the spine, and walk for several minutes. Putting
muscles in a slack position by sitting or stooping may increase LPS.

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Pain Cycles: Pain-Spasm-Edema-Pain
Pain cycles in the lumbopelvic region are similar to pain cycles in the
extremities. Like other synovial joints, the facet joints or the sacrum can be
affected by internal or external forces that strain myofascial tissues, sprain
ligaments, or partially tear musculotendinous insertions. If these structures
become irritated, the joints controlled by these structures may not function
normally because of pain inhibition, edema, loss of joint play, hypertonicity,
weakness, or instability. If the lumbar spine or sacroiliac joint are involved,
lumbopelvic rhythm may be disrupted and cause further irritation.
Common LBP is not limited to the region surrounding the spine. The
typical region for dealing with LBP lies between the lower costal margins
and the gluteal folds, and the smallest region for dealing with a lumbopelvic
disorder (LPD) lies between the base of the skull and the feet. Because of
psychological factors such as stress, the brain may also be affected.
Even though pain, spasm, and edema can serve a useful purpose
during the early phases of trauma by stabilizing injured body parts, the long-
term effects are mostly negative. By increasing tissue tension, compressing
joints, and causing circulatory stasis—pain, spasm, and edema can irritate
surrounding tissues and cause additional pain, spasm, and edema.
The ongoing sequence of pain-spasm-edema followed by more pain,
spasm, and edema is a pain cycle. The physiologic factors that contribute to
this cycle are local ischemia, metabolite retention, and restricted movement.
Once a pain cycle has started, the best way to break the cycle is by reducing
pain and spasm, improving circulation, and restoring tissues to their normal
length and strength. Most pain cycles involve at least two or three muscles.
If a body part loses mobility because of pain, spasm, or edema, other
body parts can be affected. If the lumbar spine loses mobility, the thoracic
spine may compensate by gaining mobility. If the hips lose their ability to
tilt forward, the lumbar spine may use hyperflexion to compensate.
When you treat a pain cycle, treat all body parts that contribute to the
cycle. Even if a patient seems to be functioning normally, palpation often
reveals trigger points or tender areas that the patient was not aware of. Any
muscle, tendon, ligament, or trigger point left untreated can restart the cycle.
The final stage of treating a pain cycle is checking a patient for any
conditions that prevent normal movement. If disuse atrophy occurred, the
patient may need special exercises to help restore aerobic fitness, strength,
muscle endurance, balance, or coordination. Fatigue, poor body mechanics,
or putting hypertonic muscles in a slack position can restart a pain cycle.

27
Treating Common (Nonspecific) Low Back Pain
Common low back pain is often referred to as nonspecific because

medical science is not able to identify the exact causes for common low back
pain. Part of the problem relates to the fact that common low back pain is
caused by more than one factor, and these factors often interact with each
other in unpredictable ways. To complicate the issue, the fitness and
behavior of a low-back-pain victim can affect the course of low back pain. A
physically fit person might recover faster than an unfit person or pain that
has no effect on one person’s activities might totally disable someone else.
There is also a problem with medical specialization and competition.
Doctors who specialize in spinal surgery are often reluctant to recommend
manual therapy. This is unfortunate because common LBP is not a disease
and spinal surgery is rarely the best option for most low-back patients.
Even though most orthopedic surgeons are excellent at determining if
low back pain is being caused by a known pathogenesis, if surgery cannot be
justified—they seldom do more than prescribe medication. Except for the
acute phase of common LBP, muscle relaxants and painkillers have limited
value and the side effects may outweigh the benefits.
Most practitioners who specialize in manual therapy need four skills
that make them effective when treating common LBP: (1) listening skills,
(2) observation skills, (3) palpation skills, and (4) physical skills. Manual
therapy is labor-intensive and often time-consuming, but it often produces
excellent results and has very few negative side effects when used correctly.
The exact causes for common low back pain cannot be identified, but
they are probably related to one or more of the following combinations:
• normal stresses applied to normal tissues—low risk of trauma

• abnormal stresses applied to normal tissues—intermediate risk of trauma
• normal stresses applied to abnormal tissues—intermediate risk of trauma
• abnormal stresses applied to abnormal tissues—high risk of trauma
Since abnormal stresses applied to abnormal tissues are much more

likely to cause common LBP than normal stresses applied to normal tissues,
part of therapy is helping people avoid abnormal stress and the other part is
helping abnormal tissues heal themselves. This means that even if you know
how to treat abnormal tissues and correct soft-tissue impairments, you will
not be effective as a manual therapist unless you learn to communicate with
your patients and motivate them to live a safe and healthy lifestyle.

28
Even if people are physically fit and their muscles are balanced in
terms of length, strength, and tightness, they still run the risk of having low
back pain if abnormal stresses such as repetitive stress (microtrauma) or a
sports injury (macrotrauma) damage tissues. When acting as a teacher, a
manual therapist needs to explain the danger of repetitive-strain injuries and
emphasize the importance of following safety procedures and using good
judgment when dealing with potentially dangerous situations.
On the other hand, abnormal tissues subjected to normal or abnormal
stress may cause low back pain. Athletes and professional dancers often fall
into this category. Despite existing injuries, they do things that expose their
bodies to abnormal stresses and get back pain. Since most of these people
knowingly continue doing things that have caused LBP in the past, physical
skills will probably be of more value than communication skills.
A common failure when treating LBP is not looking for all conditions
that might lead to a recurrence. Regardless of how tissue damage occurs or
whether the damaged tissues are part of a muscle, joint, or disc, LBP will
probably recur if tissue damage triggers a pain cycle and causes a muscle
imbalance that interferes with lumbopelvic rhythm. This is an overview of
the four basic areas a manual therapist will usually need to treat:
1. tissue damage (acute): use modalities to treat inflammation—pain,

redness, swelling, or loss of function—and promote wound healing.
2. pain cycles: use manual therapy and modalities to interrupt pain cycles.
3. muscle imbalance: use manual therapy and exercise to balance muscles
and muscle groups in terms of length, strength, and normal tightness.
4. lumbopelvic rhythm: use manual therapy and exercise to improve
proprioception, balance, coordination, and mobility.
Even though most episodes of nonspecific LBP will be over within 6

to 8 weeks without treatment, if no treatment or improper treatment leaves
any of the above four steps unresolved, LBP will probably recur.
Common LBP resembles a cycle represented by the acronym SPIN,
and a good manual therapist needs to address all four of these areas when
treating people who are suffering from common low back pain:
Stress: internal or external forces that cause microtrauma or macrotrauma

Pain: extreme discomfort that causes pain inhibition or pain avoidance
Immobility: a loss of flexibility, strength, endurance, or coordination
Neurosis: anxiety, fear, depression, or desperation because of LBP

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Expectations
The methods explained in this book for treating common LBP are
very effective, but they do have limitations. First, there is very little you can
do with manual therapy during the acute phase of LBP. Nonsteroidal anti-
inflammatory drugs (NSAIDS), muscle relaxants, and a few modalities such
as thermotherapy or cryotherapy may relieve symptoms, but manual therapy,
such as passive mobilization of an injured body part, should be used very
sparingly until most of the inflammation has subsided.
Contrary to popular belief, continuing ordinary activity as much as
possible will give most people faster symptomatic relief from LBP than
long-term bed rest. Lumbopelvic exercises are not recommended during the
acute phase, but a mild exercise such as walking or swimming can be used
during the subacute phase. Exercise helps people understand how to deal
with pain and shows them they can still perform most normal activities.
During the subacute phase, the first step is using manual therapy to
promote wound healing. Stretching can be used to lengthen abnormally
short tissues and facilitation techniques can be used to strengthen muscles
that are weak because of pain inhibition or neuromuscular inhibition. Cross-
fiber friction can be beneficial when treating tendons or ligaments.
After manual therapy is used to lengthen restricted tissues and to help
muscles operate with greater neurologic efficiency, flexibility exercises can
be used to help tissues maintain their normal length and resistance exercises
can be used to strengthen abnormally weak muscles.
The strengthening process should help maintain a normal balance
between opposing muscles and not increase ROM to the extent that tissues
have a greater than normal ROM. Since too much flexibility may cause
instability, stretching exercises need to be used in moderation. Low-back
exercises are better for treating chronic LBP than acute or subacute LBP.
The line between subacute and chronic is somewhat arbitrary, but
chronic low back pain is often defined as LBP persisting three months or
longer. Manual therapy and exercise therapy are very effective during the
chronic phase, but most drugs should be avoided. Manual therapy is still
needed during the chronic stage because an exercise program will often
create problems that need to be treated by manipulation. Modalities such as
thermotherapy and cryotherapy are often used in conjunction with exercise
programs to improve performance by reducing pain or increasing tissue
extensibility. Exercise without manual therapy puts patients at greater risk
of injury and frequently reduces the effectiveness of exercise programs.

30
The Challenge
The treatment goals for nonspecific LBP include reduce pain, restore
function, encourage movement, make people more resistant to LBP, help
people avoid activities that cause LBP, and describe the warning signs—
such as a loss of lumbar extension—that indicate a need for intervention.
Despite the popularity of using modalities or exercise as independent
forms of therapy, combining modalities and exercise with manipulation is
usually more effective when treating LBP. Modalities can be used to reduce
pain or joint stiffness, manipulation can be used to stretch restricted tissues
or strengthen muscles by reducing pain inhibition or increasing facilitation,
and exercise can be used to stretch restricted tissues or strengthen muscles
by increasing neurologic efficiency or increasing muscle mass.
Soft-tissue therapy is a method for treating soft-tissue impairments—
which are soft-tissue defects or dysfunctions that are characterized by pain,
abnormal ranges of motion, or muscle weakness. Signs and symptoms that
are usually associated with soft-tissue impairments are inflammation, trigger
points, tender points, pain inhibition, pain avoidance, guarding, splinting,
hypertonicity, spasms, cramps, hypotonicity, hypermobility, instability,
hypomobility, adhesions, contractures, weakness, fatigue, and atrophy.
If a soft-tissue impairment in a muscle, tendon, ligament, joint, or disc
causes a muscle imbalance that interferes with lumbopelvic rhythm, LBP
may continue after the events that triggered LBP are no longer active and the
events that triggered LBP may stay active until the mechanical defects in
lumbopelvic rhythm are corrected. Complex lumbopelvic interaction may
explain why the disc paradigm has become so popular. Telling people that
LBP is caused by a disc is easier than trying to explain lumbopelvic rhythm.
Since the peak range of nonspecific LBP is 30 to 50 years of age, if a
disc is the main cause for nonspecific LBP, discogenic problems should start
at about age 30 and end at about age 50, which is not the case. On the other
hand, it is well known that muscle efficiency starts to decrease after age 30
and sacral mobility becomes almost nonexistent after age 50.
Based on the 30-50 rule (factors that cause nonspecific LBP should
increase after age 30 and decrease after age 50), it appears that too many
people focus on the disc and too few people focus on muscles or the sacrum.
Until more people realize that nonspecific LBP is a lumbopelvic problem,
not just a lumbar problem, and that the soft-tissue impairments that cause
LBP can occur below the waist, not just above the waist, it seems likely that
the treatments for nonspecific LBP will continue to be disappointing.

31
FACTORS THAT TRIGGER OR
PERPETUATE NONSPECIFIC
LOW BACK PAIN
Muscle imbalances LBP Factors that can

that perpetuate LBP trigger LBP
Low back pain

and dysfunction Dysfunctional
cause factors or irritated:
such as muscles
Inflammation tendons
Pain inhibition sacroiliac joints
Pain avoidance facet joints
Hypertonicity ligaments
Hypomobility periosteum
Hypotonicity spinal discs
Hypermobility
Stretch weakness
Tight weakness
Tender points
Trigger points
Adhesions
Contractures
Mental stress
Inactivity
Deconditioning
Fatigue
Muscle atrophy
that often create a
muscle imbalance
that perpetuates
low back pain.
Regardless of what triggers an episode of nonspecific LBP, it is hard

to create a healing environment for the lumbopelvic region until you correct
muscle imbalances that interfere with lumbopelvic rhythm.

32
International Guidelines
The information below summarizes some of the basic guidelines for

treating nonspecific LBP that are used in the United Kingdom (UK), New
Zealand, and most European countries. It is doubtful that any country in the
world spends more money on low-back surgery than the United States.
Low back pain is defined as pain or discomfort localized between the
costal margin and the inferior gluteal folds. Leg pain may or may not be
present. Nonspecific (common) low back pain is defined as LBP that is not
caused by a known pathologic entity such as infection, tumor, fracture,
cauda equina syndrome, radicular syndrome, or spondylosis.
International Guidelines for Patients with Common (Nonspecific) LBP
• Exclude serious conditions such as spinal pathology or nerve root pain.

• Prescribe analgesics and muscle relaxants during the acute phase.
• Do not recommend more than a few days of bed rest as a treatment.
• Tell patients to cope with the pain and try to stay as active as possible.
• Recommend a cold pack or local heat for short-term symptomatic relief.
• Consider manual therapy for patients who need additional help for pain.
• Do not recommend specific back exercises until the acute phase is over.
• Explain to patients that common low back pain is not a disease.
• Acknowledge that the pain is real, but not a sign of serious injury.
Acute is normally defined as less than 6 weeks, and manual therapy,

such as passive mobilization, can be used during the acute phase of LBP but
specific back exercises are not recommended during the acute phase. Even
though NSAIDS (nonsteroidal anti-inflammatory drugs) may be used for
pain relief, patients must be told about possible adverse side effects.
Patients also need to understand that what they do to help themselves
will have a major effect on how soon they recover. The first step for most
people is trying to understand that common LBP is not a sign of a serious
injury or disease. A doctor who diagnoses a patient’s condition as common
(nonspecific) LBP should make it clear that (1) most people will have a full
recovery without surgery if they learn to cope with the pain and stay active
and (2) long-term bed rest is not a good option. Even people with sciatica
are usually asymptomatic within 6 months. At some point, patients must
also be told that episodes of common LBP often recur.

33
CHAPTER HIGHLIGHTS
THE FALLACIES AND TRUTHS ABOUT COMMON LOW BACK PAIN
FALLACIES:
• Bed rest cures low back pain.
• Degenerative changes are the main cause for low back pain.
• The only cure for most low back pain is surgery.
• Improving trunk flexion prevents low back pain.
• Improving strength prevents low back pain.
• Abdominal exercises such as sit-ups prevent low back pain.
• Lumbar lordosis and bad sitting postures cause low back pain.
• Leg-length discrepancies should always be treated.
• Discogenic problems are the major cause for low back pain.
• Avoid painful activities when you have common low back pain.
TRUTHS:
• Activity promotes healing and decreases disability.
• Soft-tissue injuries appear to be the major cause for low back pain.
• Surgery is appropriate in only a small number of cases.
• Balancing flexibility and stability helps to prevent low back pain.
• Strengthening and balancing muscles helps to prevent low back pain.
• Trunk-extensor exercises are just as important as trunk-flexor exercises.
• Posture is not considered a major cause of low back pain.
• Leg-length discrepancies of less than 1/2 inch are seldom significant.
• Disc problems account for only about 5% of all low back pain.
• Even if pain is present, try to stay as active as possible.
POSSIBLE CAUSES FOR COMMON LBP INCLUDE IRRITATED:
• Muscles • Periosteum
• Fascia • Sacroiliac joints
• Tendons • Facet joints
• Ligaments • Spinal discs

34
HEMME APPROACH
The HEMME Approach is a logical, conservative, and comprehensive

method for treating patients with soft-tissue impairments. The principles
and techniques in this approach are based on scientific research, empirical
observation, and clinical experience. The acronym HEMME stands for:
These are the five

KEY POINT ¨ HEMME basic steps in the
H HISTORY HEMME Approach,
E EVALUATION and everything in this
book is built around
M MODALITIES this acronym, which
M MANIPULATION is pronounced:
E EXERCISE hem-mē.
More than just a series of steps, HEMME Approach is based on what

system theory refers to as a language model. Language models are used
when complex ideas cannot be formulated mathematically. The purpose of a
language model is to simplify the process of converting knowledge into
action and measuring the results. Language models can be used to (1)
identify problems, (2) collect information, (3) formulate theories, and (4) test
possible solutions by using feedback.
The six connecting steps that hold the model together are:
CONNECTING STEPS
1. ENTER PATIENT 4. OBJECTIVES SATISFIED
2. ALTERNATIVES 5. OBJECTIVES NOT SATISFIED
3. FEEDBACK 6. OUTSIDE INFORMATION
In the model (HEMMEGON), the basic steps HISTORY, EVALUATION,

MODALITIES, MANIPULATION, and EXERCISE are in bold letters and the other
steps are in outline letters. The starting point is titled ENTER PATIENT. Lines
and arrows show which directions of movement are possible within the
model. The steps HISTORY and EVALUATION define the problem and the
steps MODALITIES, MANIPULATION, and EXERCISE define possible solutions.
The next step, ALTERNATIVES, is a link between problems and solutions.
Alternatives should be specifically defined. If modalities, manipula-
tion, or exercise are needed, practitioners should know specifically which
modalities, manipulations, and exercises are needed. Workable plans for

35
therapy should include goals, timetables, and measurable results. If therapy
involves more than one practitioner, responsibilities should be assigned.
The steps MODALITIES, MANIPULATION, and EXERCISE are situated on
one line to emphasize that therapy may include one or more of these three
steps. If modalities and exercise are both used, a normal sequence would be
(1) modalities, (2) manipulation, and (3) exercise.
The next step is FEEDBACK. Positive feedback validates the course of
therapy being followed and negative feedback indicates a need for change.
If feedback is positive, it is often best to continue with the same treatment
until all improvements cease. Even though you can change the activities that
occur during a step or repeat a step, you cannot always skip a step. You
must always take a medical history, and you never start therapy until you do
a physical evaluation. Modalities and exercise can be skipped.
The step for entering new information in the upper left-hand corner of
the HEMMEGON is titled OUTSIDE INFORMATION. Like a living system, the
model can receive and process input from outside sources. When working
with a patient, outside input may come from consultations or test results.
You can exit the system by using FEEDBACK to reach OBJECTIVES
SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives of therapy are not
satisfied, the patient may (1) exit the system or (2) reenter the system. If the
objectives of therapy are satisfied, the patient exits the system.
From the step titled HISTORY you can go directly to OBJECTIVES NOT
SATISFIED or EVALUATION. If contraindications are found, the step titled
OBJECTIVES NOT SATISFIED would be used to exit the model. If soft-tissue
therapy is indicated, the next step is always EVALUATION.
From EVALUATION you can return to HISTORY if more history is
needed or go directly to the steps titled OBJECTIVES NOT SATISFIED or
ALTERNATIVES. OBJECTIVES NOT SATISFIED would be used if therapy is
contraindicated and ALTERNATIVES would be used if therapy is indicated.
A common sequence for therapy is (1) modalities, (2) manipulation,
and (3) exercise. Manipulation can be used without modalities or exercise,
but modalities and exercise are seldom effective without manipulation.
The next step is FEEDBACK. If therapy is successful, OBJECTIVES
SATISFIED can be used to exit the model. If therapy is not successful, you
can use OBJECTIVES NOT SATISFIED to exit the model or you can continue
therapy by repeating any steps connected by lines and arrows. There is no
limit on how many times a patient can reenter the system. Since episodes of
LBP often recur, the same patient may reenter the model many times.

36

37
In the medical field, the most common format used for documentation
is the SOAP notes format. The word SOAP is an acronym that stands for:
SOAP
S Subjective
O Objective
A Assessment
P Plan
The first step in the SOAP format—subjective—refers to information

provided by the patient. The most common topics covered during this step
are the patient’s medical history and the patient’s chief complaint.
The second step in the SOAP format—objective—refers to laboratory
testing or physical evaluation of the patient. The most common forms of
physical evaluation are palpation and orthopedic or neurologic testing.
The third step—assessment—is a mental process that tries to identify
a medical problem based on what was found in the first two steps.
The final step—plan—is where the objectives and the treatment plan
are defined. After you identify the problem, you try to solve the problem.
Like the SOAP format, the HEMME format is problem-oriented. This
means that both formats start with a problem, collect relevant information,
and try to solve the problem. The two main factors that separate the HEMME
format from SOAP are (1) flexibility, and (2) feedback.
The HEMME format is more flexible than SOAP because it allows new
information to enter the system at any time and also allows repeating any
step and skipping some steps. When HEMME is used, only the relevant steps
are shown in the initial, subsequent, or final reports. If soft-tissue therapy is
contraindicated, the only step shown in the initial report would be history.
Unlike SOAP, HEMME treats therapy more like an interactive process
than a series of steps. While both methods can be used to help practitioners
collect, organize, and record medical data, HEMME openly uses feedback to
determine if therapy is effective or ineffective. If therapy is not effective,
you have options such as using outside information or repeating steps.
Whether using HEMME or SOAP, the reason for using documentation
is about the same: improve the quality of patient care by having a logical
and systematic way to monitor and record any significant activity that relates
to the course of therapy. Documentation should include recording your
failures as well as recording your successes.

38
Secondary reasons for documentation include communicating with
other health care professionals, satisfying legal requirements, or giving
health care insurance companies the documentation they need to justify
reimbursement. Documentation can also provide data for medical research
or suggest possible directions for future studies. Regardless of what format
is used, almost every document should be dated and signed by the person
completing the document and then placed in the patient’s medical record.
SOAP to SOAPIE
Because of the limitations that result from using the original SOAP
notes, later versions have two more steps: interventions and evaluation.
The term intervention refers to the actions taken by the practitioner and the
term evaluation refers to an assessment of whether the interventions taken
by the practitioner have been effective. As used in a SOAPIE notes format,
evaluation refers to feedback, not physical evaluation.
When using HEMME or SOAPIE, the final report should explain why a
patient was discharged. The main reasons for discharging patients are (1)
objectives not satisfied because of little or no improvement or (2) objectives
satisfied because the patient recovered. When treating common LBP, a full
recovery usually means the patient regained normal functions and is able to
perform normal daily activities. If patients are released before pain and
other symptoms have been completely resolved, unresolved impairments
such as a weak or hypertonic multifidus, a weak transversus abdominis, or
an abnormally short psoas may cause future episodes of common LBP.
Quick Conversion Guide
HEMME APPROACH QUICK CONVERSION GUIDE

HISTORY converts to Subjective
EVALUATION converts to Objective
ALTERNATIVES converts to Assessment and plan
MODALITIES converts to Interventions
MANIPULATION converts to Interventions
EXERCISE converts to Interventions
FEEDBACK converts to Evaluation
This guide may be helpful if HEMME and SOAPIE are both used.

39
CHAPTER HIGHLIGHTS
FIVE BASIC STEPS IN THE HEMME APPROACH
• HISTORY (medical history)

• EVALUATION (physical evaluation)
• MODALITIES (thermotherapy, cryotherapy, vibration)
• MANIPULATION (soft-tissue manipulation)
• EXERCISE (therapeutic exercise)
SIX STEPS THAT LINK THE FIVE BASIC STEPS TOGETHER
• ENTER PATIENT
• ALTERNATIVES
• FEEDBACK
• OUTSIDE INFORMATION
• OBJECTIVES SATISFIED
• OBJECTIVES NOT SATISFIED
FOUR WAYS TO USE A LANGUAGE MODEL
• Identify the problem.

• Collect information.
• Formulate theories.
• Test possible solutions by using feedback.
BASIC SEQUENCE TO IDENTIFY AND SOLVE PROBLEMS
• HISTORY (identify problem)

• EVALUATION (identify problem)
• MODALITIES (solve problem)
• MANIPULATION (solve problem)
• EXERCISE (solve problem)
• FEEDBACK (validate solution)
• OBJECTIVE SATISFIED (preferred solution)
• OBJECTIVE NOT SATISFIED (possible solution)

40
HISTORY
The first step in the HEMME APPROACH is HISTORY. A medical

history is the systematic collection of information from a patient for the
purpose of (1) identifying contraindications and (2) formulating a treatment
plan. Contraindications are signs, symptoms, or circumstances that make
therapy inadvisable because of the risk. General contraindications to soft-
tissue therapy include fractures, infections, fever, inflammation, thrombosis,
bleeding, and serious malformations or diseases. Signs or symptoms that
usually contraindicate low-back therapy without a physician’s approval are:
• Numbness or weakness without pain Cauda equina

• Spinal deformity with or without pain syndrome as
• Loss of bowel or bladder control indicated by loss
of bowel or
• Saddle (perineum) anesthesia or impotence bladder control
• Radiation of pain or tingling below the knee and saddle
• Unilateral leg pain that is worse than back pain anesthesia is a
medical
• Positive straight leg raising test (sciatic pain) emergency.
• Reduction of patellar or calcaneal reflexes Like rapidly
progressive
• Weakness or numbness in the great toe (hallex)
paresis, cauda
• Weakness of ankle dorsiflexion or dropped foot equina syndrome
• Lateral trunk tilt or severely limited lumbar flexion often requires
surgical
• Constant pain regardless of position or movement intervention.
• Difficulty walking on the toes or on the heels
Other red flags are LBP that becomes progressively worse, LBP
lasting longer than 3 months, LBP in people younger than age 20 or older
than age 55, thoracic pain, a major loss of bone mass or body weight, pelvic
or spinal disease, or a severe and persistent restriction of trunk flexion.
If possible, have patients complete a medical-history form before you
start the physical evaluation. This form will help determine if soft-tissue
therapy is indicated. Most forms ask for information about lifestyle, vital
statistics, general health, past or present diseases, past or present treatments,
and the main reason for seeking treatment (chief complaint). You can also
ask if the patient has any reason to believe manipulation is contraindicated.
If you or the patient believes manipulation might be contraindicated, refer
the patient to a physician who can evaluate the patient’s condition and then
give you written authorization stating that manipulation is indicated.

41
Bedside Manner
Though some practitioners seem to believe that communication skills

are unnecessary, it still appears that having a good bedside manner is a
valuable asset. Patients who like you and trust you are more likely to follow
your recommendations and less likely to get you involved in litigation that is
based on communication failures. The acronym REALISM summarizes the
characteristics that can help you have a good bedside manner.
Rapport: have a friendly smile, firm handshake, cheerful manner.

Empathy: relate to other people’s needs and give them reassurance.
Appearance: let your appearance and equipment show professionalism.
Listening: make eye contact and nod your head to show approval.
Information: help people make intelligent decisions about their health.
Sincerity: show patients that you care about their health and welfare.
Motivation: work hard to give patients the best service that you can.
During the first few minutes of contact, practitioners and patients form
impressions that are very difficult to change after they are formed.
Practitioners evaluate a patient's honesty, intelligence, personality, and
motivation, and patients evaluate the practitioner's competency, attitude,
demeanor, and communication skills. Negative opinions formed by either
party at this time can adversely affect long-term relationships and therapy.
To help establish rapport with patients, practitioners should follow
these five points: (1) present a professional appearance, (2) help the patient
relax by asking nonthreatening questions, (3) never interrupt when patients
try to answer a question, (4) be agreeable, which means never argue, and (5)
smile when appropriate and use humor that reflects high ethical standards.
The importance of eye contact cannot be overstated. After speaking
to a patient for several minutes, look away and try to recall the patient's eye
color. Failure to do so indicates that eye contact was faulty. You can often
communicate more with eye contact and body language than you can with
your voice. Use eye contact when you try to emphasize important points.
Two attitudes that are strongly recommended for health care workers
are (1) sincerity and (2) caring. Other concerns tend to become secondary if
patients believe that practitioners truly care about helping them. As a very
observant person once noted, "Patients don't care how much you know until
they know how much you care."

42
Rapport implies trust, confidence, and cooperation. Once rapport has
been established, review the patient's written history, ask questions about the
questionnaire if necessary, and listen carefully to what the patient says. A
common failing in the health care field is failure to listen. Medical errors
would not be the problem they are today if practitioners listened better.
When conducting an interview, separate the patient from the problem
and focus on the problem. Medical histories are taken to evaluate the
patient's condition and not the patient. For ethical and legal reasons, the
personality of the patient should not be allowed to bias your interview.
After reviewing the patient's medical history form, the examiner
should ask questions requiring more than a "yes or no" answer. Questions
concerning (1) the problem or chief complaint and (2) the quality of past or
present treatment will give the examiner a good place to start.
Open-ended questions about pain, loss of motion, and lifestyle will
further clarify the problem. Almost every patient can provide at least some
information that is useful enough to be recorded as part of the patient's
permanent medical history.
Open-ended Questions for Medical History:
• What is the nature of the problem?

• Are you now under a physician’s care?
• Has this problem been treated before?
• Are you taking any medication?
• What do you think caused the problem?
• Do you have any other medical problems?
• What type of treatments do you think might help?
• How does this problem affect your life?
• Is there anyone else I should talk to about this problem?
• What do you hope to gain from soft-tissue therapy?
The acronym PDQ summarizes the first three questions above:
PDQ
P Problem
D Doctor's care
Q Quality of past treatment

43
Common questions relating specifically to low back pain:
(1) Where is the pain?
Aching, numbness, or tingling that radiates below the knee may

indicate sciatica. Pain or burning that radiates into the groin may
indicate herniated disc disease.
(2) When do you feel the pain?
Unremitting pain that continues night and day is often more serious
than pain that occurs only during the day.
(3) What activities cause pain or give relief?
Pain that occurs for no apparent reason is often more serious than
pain known to be caused by certain activities or postures.
(4) How did the pain start?
Pain that is caused by sudden onset, where the patient is aware of the
cause, will be easier to evaluate than pain caused by insidious onset,
where the patient is not aware of the cause.
Signs or symptoms that may indicate a neoplasm:
1. Pain that does not improve with rest

2. Pain that becomes worse with continued activity
3. Pain that is not improved by changing position
4. Pain without stiffness
5. Pain, heat, swelling, or redness not related to trauma
Signs or symptoms that may indicate hypertonicity or spasm:
1. Pain that improves with rest

2. Pain that improves with continued activity Tightness can result
3. Pain that is relieved by changing positions from neuromuscular,
4. Pain accompanied by joint stiffness connective tissue, or
viscoelastic factors.
5. Painful bands of tightness in a muscle

44
A medical history can be used in several different ways to identify
which tissues are causing pain. (1) Mechanism of injury refers to the nature
of forces that caused the injury and force refers to any action that pushes or
pulls tissues. If you know the mechanism of injury, you know where force
was applied, how much force was applied, and which tissues are probably
affected. (2) Symptoms indicate that a structure, function, or sensation is not
normal. If you know the symptoms, you can extrapolate which tissues are
affected. (3) Disability refers to an incapacity or loss of normal function.
Disability indicates which tissues are probably affected, but the correlation
between disability, tissue damage, and pain is often very poor because of
factors such as personality, cultural differences, insurance, or litigation.
A history may also show if the severity of an injury is consistent with
the forces (stresses) that caused the injury. The risk of severity increases if
factors such as intensity, impulse, frequency, or duration increase. Large
forces (intensity) applied quickly (impulse) and repeatedly (frequency) over
a long time (duration) are more likely to cause severe tissue damage than a
small, single force applied slowly for a short time. Direction is also a factor.
Forces applied at 90 degrees are usually more damaging than forces
applied at less than 90 degrees. When forces are applied at 90 degrees, the
entire force causes compression. When the angle is 45 degrees, 50% causes
compression and 50% causes tension. If the angle is less than 45 degrees,
less than 50% of the force causes compression. When applied to superficial
tissues, compression is more likely to cause damage than tension.
Regardless of what forces are involved, sensitive or fragile tissues,
such as nerve tissue, are more likely to be damaged by force than insensitive
or very durable tissues, such as adipose tissue. For this reason, the nature of
the tissue that becomes the target for the force can also affect severity.
The acronym DID FIT summarizes the factors that affect severity:
Myofascial DID FIT Increasing the

strain caused frequency or
by increasing D Direction of force duration of
the intensity, I Intensity of force spinal flexions,
duration, or with or without
frequency of
D Duration of force an external
stress is one load, greatly
of the major F Frequency of force increases the
causes for risk of having
common LBP.
I Impulse common LBP.
T Target

45
CHAPTER HIGHLIGHTS
THIRTEEN CONTRAINDICATIONS TO SOFT-TISSUE THERAPY
• Numbness or weakness without pain

• Spinal deformity without pain
• Loss of bowel or bladder control
• Saddle (perineum) anesthesia or impotence
• Radiation of pain or tingling below the knee
• Unilateral leg pain that is worse than back pain
• Positive straight leg raising test (sciatic pain)
• Reduction of patellar or calcaneal reflexes
• Weakness or numbness in the great toe (hallex)
• Weakness of ankle dorsiflexion or dropped foot
• Lateral trunk tilt or severely limited lumbar flexion
• Constant pain regardless of position or movement
• Difficulty walking on the toes or on the heels
THE ACRONYM REALISM STANDS FOR
Rapport: have a friendly smile, firm handshake, cheerful manner.

Empathy: relate to other people’s needs and give them reassurance.
Appearance: let your appearance and equipment show professionalism.
Listening: make eye contact and nod your head to show approval.
Information: help people make intelligent decisions about their health.
Sincerity: show patients that you care about their health and welfare.
Motivation: work hard to give patients the best service that you can.
FIVE SIGNS OR SYMPTOMS THAT MAY INDICATE A NEOPLASM
• Pain that does not improve with rest

• Pain that becomes worse with continued activity
• Pain that is not improved by changing position
• Pain without stiffness
• Pain, heat, swelling, or redness not related to trauma

46
EVALUATION
The most common diagnostic procedures used in modern medicine to

evaluate LBP are (1) spinal radiographs, (2) myelography, (3) magnetic
resonance imaging, (4) bone scanning, and (5) discography. Despite their
sophistication, these procedures very seldom identify the causes of low back
pain and they are normally less effective than using provocative palpation or
muscle testing to reproduce the patient's symptoms.
Even though most authorities agree that the causes for common LBP
are difficult or impossible to identify, starting therapy before you physically
evaluate a patient is pointless and dangerous. How can you treat a problem
before you know what the problem is? The reasons for evaluation are (1)
identify impairments or dysfunctions, (2) select the best interventions, (3)
measure the outcomes, and (4) make changes if necessary. Evaluating a
patient’s condition often takes more time than treating the condition.
Major Muscles or Muscle Groups
Low back pain affects many different parts of the body. At least 29
muscles have distal or proximal insertions on the pelvis and influence the
lumbar spine, but only seventeen muscles or muscle groups usually need to
be treated. Muscles that are difficult to locate, isolate, or treat because they
are small or lie deep to other muscles are not included in this group, such as
interspinalis and intertransversarii, which are deep paraspinals, whereas
other deep paraspinals, such as rotatores lumborum and multifidus, have
been included. Because of recent research that shows the importance of this
trunk stabilizer, the transversus abdominis has been included.
If abnormal muscles and normal muscles perform similar functions,
abnormal muscles can sometimes be treated by treating the normal muscles.
Even though the serratus posterior inferior has been implicated as a muscle
that may, on rare occasion, cause residual low back pain, it was not selected
because it works synergistically with the iliocostals, longissimus thoracis,
and quadratus lumborum, which were selected. Treating the three selected
muscles will normally correct any impairments in serratus posterior inferior.
If low back pain continues over the lower ribs after pain in the erector
spinae and quadratus lumborum has been relieved, it would be reasonable at
this point to focus on serratus posterior inferior. By restoring normal
function in the seventeen muscles or muscle groups, practitioners can then
focus on any other muscles that require soft-tissue therapy.

47
Understanding therapeutic principles and functional anatomy is more
efficient than memorizing separate routines for each muscle. The principles
that apply to one muscle can often be applied to muscles that have similar
functions. Principles that apply when treating the piriformis can often be
used when treating other lateral rotators, such as quadratus femoris.
The seventeen basic muscles or muscle groups are arranged according
to clinical positions. The three basic positions are (1) prone position, (2)
lateral recumbent position, and (3) supine position. Low-back evaluations
often begin with the patient prone and end with the patient supine.
Even so, this sequence is optional since most muscles can be treated
with the patient in more than one position. Since trigger point therapy is
normally followed by local or ROM stretching, which is often done with the
patient in a different position, having patients change position during the
therapy is normal. Although not listed as basic positions, standing, sitting,
kneeling on the hands and knees, and other positions can be used as needed.
Since lateral pelvic shift, if present, is usually treated first, the patient
may need to change from a prone position after trigger point therapy to a
standing or lateral recumbent position for stretching. Posterior extensor
muscles, such as the hamstring or gluteus maximus, are usually tested and
treated from a prone position and then stretched from a supine position.
Though muscles are sequenced in this particular order to serve as a
guide, it would be wrong to believe that all patients are the same and one
sequence fits all patients. In reality, routines or protocols should be flexible
enough to allow for change. By understanding the principles of therapy and
muscle function, practitioners will know when to follow a given sequence
and when to deviate. These decisions are normally based on feedback from
the patient, palpation, observation, and muscle testing procedures.
A good evaluator gets a clear, accurate, and unbiased picture of what
is happening before reaching any conclusions. While it may be true that
some muscles are often tight—such as the hamstrings, rectus femoris, tensor
fasciae latae, psoas, piriformis, quadratus lumborum, or erector spinae—and
other muscles are often inhibited—such as the gluteals or abdominals—
never decide a muscle is tight or inhibited until you palpate and muscle test
the muscle. Palpation may reveal tenderness that people were not aware of.
Do not be surprised if even light palpation increases or decreases the
tonicity of a muscle being palpated or if muscle testing strengthens a muscle
that tested weak. The tension or compression caused by palpation or muscle
testing often produces effects that are similar to those produced by therapy.
Palpation often relaxes superficial muscles and allows deeper palpation.

48
Muscles or Muscle Groups: Description
The seventeen muscles or muscle groups listed below are also used to
explain muscle testing on page 88, trigger point zones on page 143, and
ROM stretching on page 179. These muscles are considered major because
they have a major impact on lumbopelvic disorders and nonspecific LBP.
Prone Position The attachments and

actions listed below
reflect the latest
1. GLUTEUS MINIMUS research available.
Action: Abducts, anterior fibers flex and rotate thigh medially, and
posterior fibers extend and rotate thigh laterally.
Origin: Lateral surface of ilium
Insertion: Greater trochanter of femur
Innervation: Branch of superior gluteal nerve
2. GLUTEUS MEDIUS
Action: Abducts and rotates hip medially

Origin: Lateral surface of ilium
Insertion: Greater trochanter of femur
Innervation: Branch of the superior gluteal nerve
3. GLUTEUS MAXIMUS
Action: Extends, abducts, and rotates hip laterally

Origin: Lateral surface of ilium and dorsal surface of sacrum and coccyx
Insertion: Iliotibial track of fascia latae and gluteal ridge of femur
Innervation: Inferior gluteal nerve
4. PIRIFORMIS
Action: Abducts and rotates hip laterally

Origin: Second to fourth sacral vertebrae and sacrosciatic notch of ilium
Insertion: Upper border of greater trochanter of femur
Innervation: Branch of sacral nerve

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5. HAMSTRINGS
SEMIMEMBRANOSUS
Action: Flexes and rotates leg medially, extends hip

Origin: Ischial tuberosity
Insertion: Medial condyle of tibia and lateral condyle of femur
Innervation: Tibial portion of sciatic nerve
SEMITENDINOSUS
Action: flexes and rotates leg medially, extends hip

Origin: Ischial tuberosity
Insertion: Upper part of medial surface of tibia
Innervation: Tibial portion of sciatic nerve
BICEPS FEMORIS
Action: Flexes and rotates leg laterally, extends hip

Origin: Long head—ischial tuberosity and short head—linea aspera
Insertion: Head of fibula and lateral condyle of tibia
Innervation: Tibial and peroneal portions of sciatic nerve
6. PARASPINAL MUSCLES
SUPERFICIAL PARASPINALS (Erector Spinae)
Iliocostalis lumborum
Action: Extends lumbar spine, assists in sidebending (unilateral)

Origin: Iliac crest
Insertion: Angles of lower six or seven ribs.
Innervation: Branches of thoracic and lumbar nerves
Longissimus thoracis
Action: Extends and sidebends (unilateral) thoracic and lumbar spine

Origin: Transverse processes of lumbar and dorsal vertebrae

50
Insertion: Nine or ten lower ribs and all thoracic vertebrae
Innervation: Lumbar and dorsal divisions of spinal nerve
Spinalis thoracis
Action: Extends spinal column

Origin: Spines of upper lumbar and lower thoracic vertebrae
Insertion: Spines of middle and upper thoracic vertebrae
Innervation: Dorsal branches of spinal nerve
DEEP PARASPINALS (Transverse Spinae)
Rotatores lumborum
Action: Extends and rotates spinal column toward opposite side

Origin: Transverse processes of lumbar vertebrae
Insertion: Lamina of next vertebrae above
Innervation: Branches of dorsal divisions of spinal nerve
Multifidus (fills the grooves on both side of the spinous process)
Action: Extends, sidebends, and rotates spinal column

Origin: Iliac spine, sacrum, and upper twenty-four vertebrae
Insertion: Spinous processes of next four vertebrae above
The multifidus runs the entire length of the spine, but the muscle is most
visible in the lumbar region. Pain and spasm can be unilateral or bilateral,
and hypertonicity may cause low-back stiffness in all spinal direction except
rotation. This muscle often remains weak after LBP is gone. There is no
hard evidence based on random-controlled trials, but many patients believe
strengthening the multifidus has helped them reduce or prevent LBP.
Semispinalis thoracis
Action: Extends and rotates spine toward opposite side

Origin: Transverse processes of lower thoracic vertebrae
Insertion: Spines of upper thoracic and lower cervical vertebrae

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7. SOLEUS
Action: Plantar flexes (extends) foot

Origin: Upper shaft of fibula, tendinous arch, and oblique line of tibia
Insertion: Calcaneus by calcaneal (Achilles) tendon
Innervation: Tibial nerve
8. GASTROCNEMIUS
Action: Plantar flexes foot and flexes leg

Origin: External and internal femoral condyles
Insertion: Unites with tendon of soleus to form calcaneal tendon
Innervation: Branches of tibial nerve
9. LATISSIMUS DORSI
Action: Adducts, extends, and rotates humerus medially

Origin: Lower thoracic and lumbar vertebrae, sacrum, and iliac crest
Insertion: Intertubercular groove of humerus
Innervation: Brachial plexus
Because of its connection with the thoracolumbar fascia, stress placed on

the latissimus dorsi affects the gluteus maximus and vice versa.
Right or Left Lateral Recumbent Position
10. QUADRATUS LUMBORUM
Action: Extends (both sides) and sidebends (same side) lumbar spine
Origin: Iliac crest, thoracolumbar fascia, and lower lumbar vertebrae
Insertion: Twelfth rib and upper lumbar vertebrae
Innervation: Branches of 1st and 2nd lumbar and 12th thoracic nerve
11. TENSOR FASCIAE LATAE
Action: Flexes, medially rotates, and abducts hip

Origin: Iliac crest and iliac spine
Insertion: Iliotibial band of fascia latae
Innervation: Branch of superior gluteal nerve

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Supine Position
12. QUADRICEPS FEMORIS
RECTUS FEMORIS
Action: Extends leg and flexes thigh

Origin: Iliac spine and rim of acetabulum
Insertion: Base of patella and tuberosity of tibia
Innervation: Femoral nerve
VASTUS LATERALIS
Action: Extends leg

Origin: Lateral aspects of femur
Insertion: Patella and common tendon of quadriceps femoris
Innervation: Branches of femoral nerve
VASTUS MEDIALIS
Action: Extends leg and draws in patella

Origin: Medial aspect of femur
VASTUS INTERMEDIUS
Action: Extends leg

Origin: Anterior and lateral surfaces of femur
13. RECTUS ABDOMINIS
Action: Compresses abdomen and flexes lumbar vertebrae

Origin: Pubic crest and symphysis
Insertion: Xiphoid process, cartilage of 5th, 6th, and 7th ribs
Innervation: Lower thoracic nerve

53
14. INTERNAL OBLIQUES (OBLIQUUS INTERNUS ABDOMINIS)
Action: Compresses viscera, and flexes, sidebends, and rotates spine

Origin: Iliac crest, inguinal ligament, and lumbar fascia
Insertion: Lower 3 or 4 costal cartilages, linea alba, pubic crest
15. EXTERNAL OBLIQUES (OBLIQUUS EXTERNUS ABDOMINIS)
Action: Compresses viscera and flexes, sidebends, and rotates spine

Origin: Lower eight ribs at costal cartilages
Insertion: Iliac crest, linea alba, and pubic crest
16. ILIOPSOAS
PSOAS MAJOR (The term psoas refers to psoas major and psoas minor.)
Even though they are two separate muscles, the psoas and iliacus are
often referred to as the iliopsoas because they blend with each other.
Action: Flexes trunk and flexes, adducts, and rotates hip laterally
Origin: Last thoracic and all lumbar vertebrae
Insertion: Lesser trochanter of femur
Innervation: Lumbar plexus
PSOAS MINOR
Action: Assists psoas major and flexes trunk

Origin: Last thoracic and 1st lumbar vertebrae
Insertion: Iliac fascia and iliopectineal tuberosity
Innervation: Branch of lumbar nerve
ILIACUS (The iliacus functions in conjunction with the psoas.)
Action: Flexes trunk and flexes and rotates hip laterally

Origin: Margin of iliac fossa and base of sacrum
Insertion: Lesser trochanter of femur

54
A tight psoas may increase or decrease lumbar lordosis. If the trunk is
flexed, a tight psoas can decrease or flatten lumbar lordosis. If the trunk is
erect, a tight psoas can increase lumbar lordosis. The word tight (taut) refers
to a muscle that is more resistant to stretching than normal. Tight muscles,
like hypertonic muscles, are not always abnormally short.
17. TRANSVERSUS ABDOMINIS
Action: Flex thorax, compress or flatten abdomen, participate in forced

expiration, and stabilize spine (cocontracts with multifidus)
Origin: 7th through 12th costal cartilages, thoracolumbar fascia, iliac crest
Insertion: Conjoined tendon of pubis, linea alba through rectus sheath
Innervation: Branches of 7th to 12th intercostal (lower thoracic)
Multifidus and Transversus Abdominis
The transversus abdominis is deeper than the other two layers of the
abdominal wall, the internal and external obliques, and it seems to have a
direct connection with LBP. It appears that trauma or chronic LBP delays
recruitment of the transversus abdominis and prevents the back from being
as stiff or as stable as it should be just before rapid (ballistic) arm or leg
movements. The transversus abdominis stiffens and stabilizes the back by
cocontracting with the multifidus, which increases intra-abdominal pressure
(IAP) and increases tension on the thoracolumbar and anterior fascia.
Just as a muscle imbalance caused by microtrauma, inflammation, or
spasm can interfere with lumbopelvic rhythm, delayed reaction times by the
multifidus or transversus abdominis can interfere with lumbopelvic rhythm.
Since the recruitment of these two muscles seems to be impaired by trauma
or chronic LBP and neither of these two muscles seems to recover without
specific interventions, it seems logical that using manipulation and exercise
to treat these muscles will improve motor control, reduce the risk of
interfering with lumbopelvic rhythm, and reduce or prevent common LBP.
Because of the effects the multifidus and transversus abdominis have
on back stability, pages 205-206 have two supplemental evaluation-exercise
movements for the multifidus (standing spine-extension and kneeling leg-
extension movements) and two for the transversus abdominis (isometric
hand-to-knee and forced-expiration movements). If palpation reveals the
multifidus is atrophied, use manipulation to achieve normal tonicity and then
use exercise to increase neurologic efficiency, mass, and strength.

55
Illustrations
MUSCLES OR MUSCLE GROUPS Pages
1. GLUTEUS MINIMUS ........................................................................ 57
2. GLUTEUS MEDIUS ..................................................................... 57, 60
3. GLUTEUS MAXIMUS .................................................................. 60, 61
4. PIRIFORMIS ........................................................................................ 57
5. HAMSTRINGS............................................................................... 60, 61
6. PARASPINAL MUSCLES .................................................................. 59
7. LATISSIMUS DORSI .................................................................... 63, 64
8. SOLEUS ......................................................................................... 60, 62
9. GASTROCNEMIUS................................................................. 60, 61, 62
10 QUADRATUS LUMBORUM ....................................................... 58, 59
11 TENSOR FASCIAE LATAE ......................................................... 61, 62
12. QUADRICEPS FEMORIS............................................................. 61, 62
13. RECTUS ABDOMINIS ....................................................................... 64
14. INTERNAL OBLIQUES ..................................................................... 64
15. EXTERNAL OBLIQUES .............................................................. 60, 64
16. ILIOPSOAS .................................................................................... 58, 62
17. TRANSVERSUS ABDOMINIS .......................................................... 64

56
MUSCLE GROUPS BY MEMBERS Pages
5. HAMSTRINGS
A. SEMIMEMBRANOSUS ............................................................... 60
B. SEMITENDINOSUS ..................................................................... 60
C. BICEPS FEMORIS .................................................................. 60, 61
6. PARASPINAL MUSCLES (SUPERFICIAL PARASPINALS)

A. ILIOCOSTALIS LUMBORUM .................................................... 59
B. LONGISSIMUS THORACIS ....................................................... 59
C. SPINALIS THORACIS ................................................................. 59

A. RECTUS FEMORIS ................................................................ 61, 62
B. VASTUS LATERALIS............................................................ 61, 62
C. VASTUS MEDIALIS .................................................................... 62
D. VASTUS INTERMEDIUS ............................................................ 62
16. ILIOPSOAS
A. PSOAS MAJOR....................................................................... 58, 62
B. PSOAS MINOR ............................................................................. 58
C. ILIACUS ........................................................................................ 58
Muscles and Muscle Groups Arranged by Functions
• Muscles that control anterior pelvic tilt: psoas, rectus femoris, tensor
fasciae latae, and erector spinae.
• Muscles that control posterior pelvic tilt: hamstrings, gluteus maximus,
rectus abdominis, and the internal and external obliques.
• Muscles that control lateral pelvic tilt: quadratus lumborum, gluteus
medius, tensor fasciae latae, obliques, and erector spinae.
• Muscles that eccentrically control flexion of the trunk: hamstrings,
gluteus maximus, multifidus, quadratus lumborum, and erector spinae.
• Muscles that eccentrically control extension of the trunk: rectus
abdominis, quadriceps, tensor fasciae latae, and psoas.
• Muscles that eccentrically control sidebending of the trunk: quadratus
lumborum, gluteus medius, gluteus minimus, psoas, tensor fasciae latae,
multifidus, internal and external obliques.

57
POSTERIOR HIP
Gluteus minimus (page 48)

Gluteus medius (page 48)
Piriformis (page 48)
Gluteus medius
Gluteus minimus
(hidden below)
Piriformis

58
ANTERIOR HIP
Quadratus lumborum (page 51)

Iliopsoas (page 53)
Quadratus
lumborum
Psoas major
Psoas minor
Iliacus

59
POSTERIOR TORSO
Spinalis thoracis (page 50)

Longissimus thoracis (page 49)
Iliocostalis lumborum (page 49)
Multifidus (page 50)
Quadratus lumborum (page 51)
Spinalis thoracis
Longissimus
thoracis
Iliocostalis
lumborum
Thoracolumbar fascia
Multifidus (lumbar)
(hidden below)
Quadratus
lumborum
You can palpate the
lumbar multifidus,
which is deep to
the erector spinae,
during lumbar
extension and deep
inspiration or during
forced expiration.

60
POSTERIOR LIMB
External obliques (page 53)

Gluteus medius (page 48)
Gluteus maximus (page 48)
Hamstrings group (page 49)
Gastrocnemius (page 51)
Soleus (page 51)
External obliques
Gluteus medius
Gluteus maximus
Semitendinosus
Semimembranosus
Biceps femoris
Gastrocnemius
Soleus

61
LATERAL LIMB
Gluteus maximus (page 48)

Tensor fasciae latae (page 51)
Quadriceps femoris group (page 52)
Hamstrings group (page 49)
Gluteus maximus
Tensor fasciae latae
Rectus femoris
Vastus lateralis
Biceps femoris
Gastrocnemius

62
ANTERIOR LIMB
Tensor fasciae latae (page 51)

Psoas major (page 53)
Quadriceps femoris group (page 52)
Soleus (page 51)
Tensor fasciae latae
Psoas major
Rectus femoris
Vastus intermedius
(hidden below)
Vastus lateralis
Vastus medialis
Gastrocnemius
Soleus

63
POSTERIOR THORAX
Latissimus dorsi (page 51)
Latissimus
dorsi
Thoracolumbar
(lumbodorsal)
fascia

64
LATERAL MIDSECTION
Latissimus dorsi (page 51)

Rectus abdominis (page 52)
External obliques (page 53)
Internal obliques (page 53)
Transversus abdominis (page 54)
Latissimus dorsi
Rectus abdominis
External oblique
Internal oblique
(hidden below)
Transversus abdominis
(hidden below)
Unilateral contraction
of the internal oblique
rotates the spine to the
same side, whereas
unilateral contraction of
the external oblique
rotates the spine to the
opposite side.

65
Evaluating Low Back Pain
Level I Evaluation ............................................................................. 66
A. Four classic forms of evaluation

a. palpation
b. observation
c. auscultation
d. percussion
B. The acronym A SPARKLE:
a. Antalgic gait or posture
b. Spasm
c. Pain or tenderness
d. Asymmetry or posture
e. Range-of-motion loss
f. Kyphotic increase
g. Lordotic decrease
h. External rotation
Level II Evaluation ........................................................................... 76
A. Eight-step evaluation protocol

a. lateral pelvic shift
b. modified sit-up
c. double leg curl
d. single leg lift
e. trunk rotation
f. chest lift with extension push-up
g. reverse leg lift
h. chair stretch
Level III Evaluation .......................................................................... 82
A. Muscle testing
B. Straight leg-raising test
C. Gluteal-drop test
D. Sacral-integrity testing
E. Spinal-flexion testing
F. Malingering tests

66
Level I Evaluation
Level I evaluation, the starting point for doing a physical evaluation,

relies on (1) the four classic forms of evaluation: palpation, observation,
auscultation, and percussion and (2) the phrase A SPARKLE, which stands
for Antalgic gait or posture, Spasm, Pain, Asymmetry, Range-of-motion
loss, Kyphotic increase, Lordotic decrease, and External rotation.
Four Classic Methods of Evaluation
(1) Palpation
In soft-tissue therapy, palpation is the most effective method for

determining the condition of tissues. The types of information collected by
palpation include (1) temperature, (2) moisture, and (3) tissue compliance.
Temperatures above normal indicate vasodilation and temperatures
below normal indicate vasoconstriction or a vascular obstruction. If loss of
function, redness, swelling, and tenderness are present, temperatures above
normal indicate inflammation. If loss of function, tenderness, and ropy or
indurated bands are present, temperatures below normal indicate spasm. In
patients with LBP, the gluteal muscles may exhibit hypothermic zones. The
distribution of hypothermic and hyperthermic zones is usually symmetrical.
Moisture indicates an increase in sudomotor activity because of an
increase in sympathetic nerve activity. Pain is one factor that triggers sweat
glands to increase production of moisture (hyperhidrosis). Patients with
chronic LBP often have areas of hyperactivity that are constantly moist
because of efferent sympathetic activity. If these areas are colder than
normal because of vasomotor activity that causes vasoconstriction, patients
may report cold spots or cold sweat.
Tissue compliance measures tissue tension or resistance to pressure.
Abnormal increases in tissue compliance suggest reactive spasm or splinting
because of pain. These areas often occur as nodules, zones, or bands within
a muscle, and these zones or bands may run the entire length of the muscle.
Factors that increase tissue compliance include (1) spasm, (2) proliferation
of connective tissue, or (3) local edema, which may have a spongy feel.
Unlike temperature, moisture, and tissue compliance—which are
considered largely objective—tender points or trigger points are both
objective and subjective. They involve not only physical finding but also
feedback that relates to the patient's threshold and tolerance for pain.

67
Facilitated spinal segments are usually considered objective findings.
Characterized by a spongy feeling, facilitated segments are often caused by
microtrauma that irritates tissues and causes inflammation. They have a low
threshold for pain and may continue firing nerve impulses after the pressure
is removed. When trigger points facilitate a muscle, areas tend to be hard
and indurated as opposed to soft and boggy. Despite the value of palpation,
most health care practitioners never develop or use palpatory skills.
(2) Observation
The back should be observed when a patient is standing and prone.

Functional scoliosis, which is due to muscle spasm, may be visible when a
patient is standing but not visible when the patient is prone. Structural
scoliosis is visible when a patient is standing or prone. Patients should also
be observed while performing flexion, extension, sidebending, and rotation.
Normal movements are smooth, continuous, and symmetrical. Observation
of eye movements and breathing may indicate pain or psychological stress.
Having patients point to where they feel the pain can be helpful. If a
patient tells you a muscle is tender, it is probably tender. On the other hand,
palpation and muscle testing often reveal areas of pain that were unknown to
the patient because most patients do not palpate their own bodies.
Even if patients identify areas of pain, these may be areas of referred
pain and not the origins of pain. If the origins of pain are in areas of low
sensitivity and the adjacent areas are high sensitivity, people may ignore the
origin and point to adjacent areas where they feel the pain.
Observation can detect atrophy, swelling, or a lack of tonus. In low-
back patients, the contour of erector spinae, gluteals, or multifidus on one
side of the body may be different from the other side. One side could be low
because of atrophy and the opposite side could be high because of spasm or
edema. In the multifidus, medial (deep) fibers may be atrophied and lateral
(superficial) fibers hypertonic. You can use palpation or muscle testing with
observation to differentiate between atrophy, spasm, or edema.
(3) Auscultation
Auscultation is a method of listening for abnormal sounds such as

crepitus or the clicking of a tendon. When aided by a stethoscope (mediate
auscultation), sounds of blood rushing through a vessel (bruits) or sounds of
muscular contraction can be heard.

68
The cracking or popping sound made when joints are distracted or
rotated is not considered diagnostic. These sounds are probably caused by a
vacuum that forms in the joint or release of nitrogen gas. It normally takes
about twenty minutes for the same joint to reset before it can pop again.
(4) Percussion
When dealing with low back pain, percussion is using the fingertips to
tap the body lightly but sharply to determine the nature of underlying
structures. When the spine is flexed, tapping a lumbar spinous process with
the fingers may produce local or radiating pain. Pain that disappears slowly
may indicate a more serious condition than pain that disappears quickly.
Other forms of percussion rely on auditory or tactile feedback.
A SPARKLE
A SPARKLE is an acronym that stands for antalgic gait or posture,

spasm or hypertonicity, pain, asymmetry, range-of-motion loss, kyphotic
increase, lordotic decrease, and external rotation. Almost every case of LBP
is characterized by one or more of these conditions. Abnormal postures do
not necessarily cause LBP, but they usually occur when LBP is present.
A SPARKLE
A Antalgic gait or posture
S Spasm (hypertonicity)
P Pain or tenderness
A Asymmetry or posture
R Range-of-motion loss
K Kyphotic increase
L Lordotic decrease
E External rotation
(A) Antalgic Gait or Posture
Because of pain, low-back patients will guard injured tissues and alter
patterns of movements to avoid pain. Antalgic postures are self-protective
and characterized by hip flexion, lateral rotation, and adduction.

69
Antalgic gaits are characterized by poor muscle recruitment, reduced
lumbar lordosis, and deviations from normal movement patterns. Signs of
defective gait are (1) a lateral trunk list or lateral pelvic shift, (2) a tendency
to place more weight on one leg than the other, (3) abnormal changes in
head or shoulder position, (4) a wider stance than normal, (5) a shorter stride
than normal, and (6) walking with the knees flexed. Movements that cause
pain are executed quickly to minimize pain or avoid instability.
Weakness in the gluteus medius, gluteus maximus, or psoas may
cause characteristic limps. Someone with a gluteus medius weakness will
thrust the thorax laterally toward the weak side to keep the center of gravity
directly over the weak support leg. Someone with a gluteus maximus
weakness will thrust the thorax posteriorly when the lead foot makes contact
with the ground to help the support leg maintain extension. A limp caused
by psoas weakness is characterized by abduction and lateral rotation.
Antalgic posture refers to a stance people use to avoid pain. Patients
with low back pain may stand stooped over with their knees flexed and the
right or left foot externally rotated to increase support and avoid pain.
When rising from a chair, low-back patients often avoid standing erect
until they pause for several seconds or take several steps forward. Problems
with rising from a chair, standing straight, and walking can result from
spasm in the psoas or gluteus medius. Antalgic gaits and postures are
difficult to correct when efforts to avoid pain become habitual and body
structures adaptively change because of functional changes.
(S) Spasm (Hypertonicity)
Even though dictionaries may define spasm as a sudden, involuntary,

violent muscle contraction, in manual medicine, spasm usually means the
presence of persistent and palpable hypertonicity and tenderness. Possible
causes include irritation of nerves that supply the muscle, reflex activity by
proprioceptors, or tearing of the sarcoplasmic reticulum (trauma).
If the sarcoplasmic reticulum tears because of overload or trauma, the
release of ionic calcium triggers a strong interaction between actin and
myosin myofilaments that shortens sarcomeres and causes spasm. If energy
demands because of spasm accelerate metabolism, the result can be local
ischemia that depletes adenosine triphosphate (ATP). Without ATP, the
sarcoplasmic reticulum cannot retrieve ionic calcium and the heads of the
actin and myosin filaments remain locked in spasm. Rigor mortis, the
stiffness that occurs in dead bodies, is also caused by an ATP depletion.

70
If continuous spasm creates hypoxic areas that become chronically
irritated and tense and sensitizing agents, such as histamines or serotonin,
are released because of inflammation, edema may cause ischemia and more
hypoxia. When muscles are in spasm, the musculotendinous junctures are
often more vulnerable to injury than the muscle itself.
Spasms increase tonus and may prevent a muscle from achieving its
normal length. When muscles go into spasm, increasing tension may cause
pain, decreasing tension may reduce pain, and long-term tension may cause
stretch weakness. Painful spasms (cramps) are usually treated by slowly
stretching a muscle and then holding the muscle in a stretched position until
the pain diminishes and normal tonus is restored.
Whereas bone pain tends to be worse at night and unaffected by
movement or rest, muscle pain tends to improve at night and becomes worse
when you get out of bed and less severe if movement continues.
A muscle in spasm is usually more resistant to passive stretching than
normal because of static contractions and weaker than normal because of its
inability to exert normal force. Weakness may be caused by pain inhibition,
pain avoidance, excessive overlapping of actin and myosin myofilaments,
neurologic inefficiency, or atrophy. Although spasm tends to make muscles
and ROMs shorter than normal, length and ROM do not always change.
If spasm causes abnormal shortness: (1) abnormally short hip flexors
can decrease lumbar lordosis when stooped over or increase lumbar lordosis
when standing up and (2) abnormally short hip extensors can decrease trunk
flexion when stooping over or decrease lumbar lordosis when standing up.
If the hip flexors are abnormally short and the hip extensors are weak, it may
be difficult for a person who is stooped over to stand up.
Decreases in lumbar lordosis, trunk flexion, or trunk extension relate
to changes in pelvic tilt. Abnormally short hip flexors, such as the psoas,
increase anterior pelvic tilt. When a person is stooped over, anterior pelvic
tilt encourages the spine to flex forward—which decreases lumbar lordosis.
When the person stands up, anterior pelvic tilt increases lumbar lordosis
because the spine is no longer encouraged to flex forward.
Abnormally short hip extensors, such as biceps femoris, increase
posterior pelvic tilt. This decreases trunk flexion because the pelvis does not
tilt forward after the spine is fully flexed and decreases lumbar lordosis
because the pelvis does not tilt forward after the person is standing up.
Even though spasms can interfere with lumbopelvic rhythm and cause
LBP, soft-tissue therapy can be used to reduce spasms, balance opposing
muscles, improve lumbopelvic rhythm, and reduce nonspecific LBP.

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Once the pelvis is fully flexed, additional efforts to flex the trunk may
cause overstretching of the lumbar spine. When the spine is fully flexed,
spinal extensors become myoelectrically silent. If overstretching causes
trauma, the spinal muscles will have a tendency to contract because of reflex
spasm and cause pain when the tension is released. If these contractions are
very strong, extensors such as the multifidus may go into spasm or cramp.
To avoid dangerous overstretching of muscles, ligaments, and fascia,
passive manipulation should not be used to enhance the effects of gravity if
the trunk is being fully flexed from a sitting or standing position. Under
normal circumstances, flexing your spine and straining to touch your toes is
not a good exercise, and this movement should not be used for evaluation.
(P) Pain or Tenderness
Pain from superficial tissues is usually sharp and precise as compared

with muscle, ligament, or joint pain, which is usually dull and vague. Pain
from skeletal muscles, bone, and superficial periosteum is usually localized
and occurs in the region that surrounds the tissue damage.
Pain can result from chemical or mechanical stimulation. Chemically,
pain is caused by pain-producing substances such as hydrogen or potassium
ions, substance P, histamines, prostaglandins, and serotonin. Mechanically,
pain is caused by internal or external forces that cause tension, compression,
or shear. Pain may also be caused by electrical or thermal stimulation.
While pain can result from either myofascial involvement or joint
problems, stiff joints without abnormal tissue tension are seldom painful.
Except for the sacroiliac joint, which might become painful because of torn
ligaments, most joints can remain asymptomatic unless muscles that cross
the joint have shortened. Lengthening tissues that are abnormally short
because of spasm or fibrosis can relieve pain and restore a normal ROM.
Muscles that are short and tight because of spasm are usually more
elastic than muscles that are short and tight because of fibrosis. While both
types of shortness or tightness respond to ROM stretching, spasms are more
responsive to trigger point therapy and neuromuscular therapy than fibrosis.
When treating painful joints, evaluate the joint’s ROM. If the ROM is
less than normal, try to lengthen the restricted tissues and test again. The
test-treat-retest sequence is usually repeated many times during the course
of therapy because it (1) gives practitioners a way to measure progress and
(2) gives patients a way to see progress. Without tangible signs of progress,
many patients become discouraged and discontinue therapy.

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(A) Asymmetry or Posture
Three of the main factors that affect symmetry are (1) muscles in the
lumbopelvic region that affect posture (stability) or movement (mobility)—
such as psoas, quadratus lumborum, internal obliques, external obliques,
rectus abdominis, hamstrings, and gluteals, (2) normal daily activities, usage
such as work-related or sport-related activities, and (3) handedness, a
tendency to use one hand instead of the other.
Unilateral shortness can affect symmetry in the following ways:
• Psoas shortness: sidebending on the same side.

• Quadratus lumborum shortness: sidebending on the same side
• Internal oblique shortness: sidebending on the same side
• External oblique shortness: sidebending on the opposite side
If unilateral muscle shortness because of hypertonicity causes side-

bending in one direction, sidebending the muscle in the opposite direction
will stretch the muscle. For example, if quadratus lumborum shortens on
one side, it will create a lateral lumbar convexity (scoliosis) on the same side
and a lateral thoracic convexity (scoliosis) on the other side. To stretch the
muscle, sidebend away from the side with a lumbar convexity or put the
patient in a supine position and apply traction to the leg on the same side as
the lumbar convexity. Stretching the shortened quadratus may also lower
the hip and lengthen the leg on the same side, and reduce lateral pelvic shift.
Patients with LBP may bend forward to avoid stretching the psoas,
which will cause further shortening of the muscle on both sides. If psoas
shortness is unilateral, sidebending will be on the short side, sidebending
away from the short side may cause pain, and sidebending toward the short
side is usually painless unless it compresses or stretches irritated tissues.
The multifidus may also affect symmetry. Unilateral shortness may
cause sidebending on the same (ipsilateral) side and rotation to the opposite
(contralateral) side. The short side is frequently hypertonic and tender.
Asymmetry may suggest what muscles are involved, but the complex
interplay between muscles makes it difficult to formulate simple rules that
cover all scenarios. As a starting point, theorize that excessive asymmetry
probably indicates a muscle imbalance and then use palpation and muscle
testing to identify which muscles are involved. Factors that contribute to a
muscle imbalance include (1) pain, (2) hypertonicity, (3) hypotonicity, (4)
weakness, (5) abnormally long muscles, and (6) abnormally short muscles.

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If asymmetry falls within normal limits, postures are non-fatiguing
and painless. During therapy, asymmetry may change from abnormal in one
direction to abnormal in the opposite direction and the areas that are painful
may change. Completely symmetrical postures are almost nonexistent.
When a LBP patient is standing erect or lying supine, contraction of
the psoas tends to increase lumbar lordosis by pulling the pelvis and lower
vertebrae forward. When the patient is stooped over, the psoas tends to
decrease lumbar lordosis by flexing the lower spine (inversion of function).
Standing erect after being stooped over can be very painful if both the
psoas and gluteus maximus are short and tight. A short and tight psoas can
make it difficult to extend the lumbar spine and a short and tight gluteus
maximus can make it difficult to achieve neutral lordosis. Shortness and
tightness in these opposing muscles may cause pain if trying to stand erect
compresses the lower vertebrae, increases anterior shear, or disrupts the
contact surface between L5 and the sacrum. If being stooped over causes a
head-forward posture, compensatory overload may cause cervical pain and
irritate the quadratus lumborum, thoracis paraspinals, or rectus abdominis.
In most cases of nonspecific LBP, the psoas will test positive for
unilateral or bilateral shortness, tightness, and pain. Although lengthening
and relaxing the psoas often produces dramatic results, you cannot improve
muscle balance or lumbopelvic rhythm until the opposing hip flexors and hip
extensors—such as the psoas, gluteus maximus, and hamstrings—are free of
pain and restored to their normal length, strength, and tightness.
If shortness and tightness in the psoas causes a stooped-over posture,
back extensors—such as the erector spinae or multifidus—often become
hypertonic from the numerous eccentric contractions that are needed to keep
the trunk from falling forward because of gravity. Although treating these
muscles may give people some relief, muscles below the waist—such as the
piriformis, gluteus medius, and gluteus minimus—may also cause LBP.
Spasm in the gluteus medius is often followed by shortening of the
hamstring muscles, which tends to increase posterior pelvic tilt and decrease
lumbar lordosis. To relieve tension on the hamstrings, low-back patients
have a tendency to flex the knees, which may cause compensatory overuse,
microtrauma, and pain in the quadriceps, gastrocnemius, and soleus.
If knee flexion reduces tension on the hamstrings, they may cramp if
contracted or adaptively shorten to reduce the slack. Trunk flexion that
stretches the hamstrings after they shorten may cause stretch weakness. To
get good results, you may need to treat the psoas, hamstrings, gluteals,
piriformis, quadriceps, gastrocnemius, and soleus during the same session.

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When muscles that affect lumbopelvic rhythm become irritated and
dysfunctional, the normal result is a stooped-over posture. For people with
nonspecific LBP, changes in lumbopelvic rhythm are more likely to cause
pain during lumbar extension than during lumbar flexion. Since the direct
causes for nonspecific LBP are unknown, soft-tissue therapy focuses on
treating muscle imbalances by using modalities, manipulation, and exercise.
Compensatory changes because of muscle imbalances may cause
problems in the sternocleidomastoids, upper trapezius, levator scapulae, and
pectoralis muscles because of long-term forward flexion, which encourages
thoracic kyphosis and cervical lordosis. This explains how the cervical and
thoracic spine become involved in low back pain and why they need to be
evaluated and possibly treated. LBP needs to be treated holistically.
Asymmetry can result from hypertrophy of muscles on one side of the
body because of compensatory movements or normal usage. In low-back
patients, the erector spinae muscles have a tendency to hypertrophy on one
side of the body more than the other if lateral pelvic shift is present.
When muscles are hypertonic, the distance between the attachments
will have a tendency to decrease. When the same muscles are hypotonic, the
distance between the attachments will have a tendency to increase. When
these muscles are bilateral, body parts will have a tendency to move away
from the long side and toward the short side. When the quadratus lumborum
is hypotonic on one side and hypertonic on the opposite side, the lumbar
spine will have a tendency to deviate toward the hypertonic side.
Strength measures a muscle’s ability to exert force against resistance,
and decreases in strength can be caused by overstretching and not enough
overlap between myofilaments (stretch weakness) or tightness and too much
overlap between myofilaments (tight weakness). As a rule, tight muscles are
stronger and more resistant to stretching than overstretched muscles.
If both psoas are in spasm and the hamstrings are stretched and weak
or tight and weak, the hamstrings may not be strong enough to overcome
excessive anterior pelvic tilt that is caused by tension from the psoas. Even
if the rectus abdominis is strong, thin people with LBP may experience times
when their abdomens become pendulous and sag or their belts become tight.
Relaxing and lengthening the psoas will often correct both situations.
Besides causing short-term changes in symmetry or posture, a muscle
imbalance may cause long-term changes if abnormal tensions or abnormal
movements affect bone growth or the integrity of ligaments, fascia, or other
connective tissue. To prevent long-term changes in symmetry or posture,
muscle imbalances should be corrected as quickly as possible.

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(R) Range-of-Motion (ROM) Loss
The basic spinal movements are flexion and extension in the sagittal
plane, sidebending to the right or left in the coronal (frontal) plane, and
rotation to the right or left in the transverse (horizontal) plane. Even though
many people have larger ROMs because of genetics, conditioning, or recent
stretching, these are the normal ROMs for the thoracic and lumbar spine.
Repeatedly Trunk ROMs while Standing The ROM

testing the lost during
same ROM Flexion 80-90 degrees LBP often
may increase Extension 20-30 degrees depends on
the ROM. the intensity
Sidebending 20-35 degrees of pain.
Rotation 30-45 degrees
Spinal motion in one direction will limit motion in other directions.

When the lumbar spine is flexed, rotation and sidebending will be restricted.
Injuries often occur when the spine is flexed and rotated at the same time.
(K) Kyphotic Increase
Kyphosis is a backward convexity, prominence, or hump on the spine

caused by flexion, and chronic LBP may increase thoracic kyphosis. Usually
functional (temporary) because of spinal flexion when walking or standing,
thoracic kyphosis might become habitual or permanent without intervention.
The lumbar spine is more likely to flatten than become kyphotic.
(L) Lordotic Decrease
Lumbar lordosis is a normal (or abnormal) forward convexity in the

curvature of the lumbar spine as viewed from the side. The shape may vary,
but for a static upright posture, L1 is usually directly above the S1.
Biomechanically, lordotic curvature absorbs compressive shock and
distributes force down the spine. Despite popular belief, there is no strong
correlation between excessive lumbar lordosis and common LBP. In most
cases, lumbar lordosis will decrease during an episode of common LBP, and
pain will persist until the curvature is restored. Restoring lumbar lordosis by
inhibiting the psoas, extending the lumbar spine, and then walking for
several minutes will often produce dramatic relief from low back pain.

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(E) External Rotation
If the gluteus maximus or piriformis are chronically shortened because

of spasm or contracture and the gluteus minimus is weak, the hip will have a
tendency to rotate externally on the afflicted side. External rotation is
normally unilateral, but it can also be bilateral. If lateral pelvic shift is
present, external rotation is usually greater on the concave side.
Level II Evaluation
Level II's eight-step evaluation protocol is performed actively by the

patient without any physical assistance from the evaluator. A movement is
normal when the patient completes the entire ROM without pause, deviation
from a normal path, or pain. Muscle recruitment, coordination, and velocity
must all fall within normal ranges. The quality of a movement may be less
than normal if the interaction between agonists, antagonists, neutralizers,
stabilizers, and synergists is not properly synchronized. The failure of just
one muscle can disrupt muscle balance and jeopardize the entire movement.
The eight-step evaluation plan measures flexion (forward bending),
extension (backward bending), sidebending (lateral flexion), and rotation.
Each movement has three components: range of motion (ROM), direction of
motion, and changes in velocity. These three components define the quality
of a movement. This evaluation also uses four basic postures—standing,
supine, prone, and sitting—and three types of muscle contractions:
isometric, concentric, and eccentric. Movements that are normal can tell you
as much about a patient’s condition as movements that are abnormal.
These movements and postures can be used to reproduce low back
pain and locate regions that are symptomatic. Knowing which regions are
painful is a good starting point but not a good ending point. Once the
regions that cause pain are identified, the next step is using overpressure that
slightly exaggerates the painful movements and digital palpation to locate
the offending tissues with greater precision. Joint pain is usually caused by
pressure (compression) more than distraction (tension), whereas muscle pain
can be caused by compression, tension, or shear.
Soft-tissue therapy will not be effective unless you know which
tissues are involved. Besides helping you identify affected tissues, physical
evaluation helps you measure progress. When treating common LBP, you
make progress by correcting dysfunctions that interfere with daily activities.

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The following movements provide a method for measuring low-back
function. As a preliminary screening device, ask each patient to stand erect,
sit in a straight-back chair, and lie in prone, supine, and lateral recumbent
positions. If patients are unable to assume any of these positions without
pain, evaluate these problems before starting the eight-step evaluation plan.
Eight-Step Evaluation Protocol
1. LATERAL PELVIC SHIFT
A. Position: Standing
B. Setup:
a. Feet slightly more than shoulder-width apart
b. Hands overhead with palms facing forward
C. Movements:
a. Rotate head 80 to 90 degrees
b. Place one hand on back of head
c. Place other hand on hip over gluteus minimus
d. Sidebend and rotate shoulders toward hand on hip
e. Use hand on hip to push pelvis toward opposite side
f. Hold for 12 seconds
g. Return to setup
h. Repeat sequence on the opposite side
i. Return to setup
D. Repetitions: 3 movements to each side
E. Stretch: Gluteus minimus, gluteus medius, latissimus dorsi,
quadratus lumborum, obliquus internus and externus abdominis
F. Contract: Latissimus dorsi, quadratus lumborum, and obliquus
internus and externus abdominis
2. MODIFIED SIT-UP
A. Position: Supine
B. Setup:
a. Thigh in neutral position and knees extended
b. Thighs and knees abducted to about shoulder width
c. Hands behind head

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C. Movements:
a. Flex trunk until scapulas clear floor by several inches
b. Return to setup
D. Repetitions: 12-24
E. Stretch: Paraspinals
F. Contract: Rectus abdominis and psoas
3. DOUBLE LEG CURL
A. Position: Supine
B. Setup: Thighs in neutral position and knees extended
C. Movements:
a. Flex knees until feet are flat on floor
b. Place hand behind each calf and pull thighs into full flexion
c. With knees flexed, hold position for 12 seconds
d. Keeping knees flexed, extend thighs and place feet flat on floor
e. Extend knees and place thighs flat on floor
f. Return to setup
D. Repetitions: 12-24
E. Stretch: Gluteus maximus, hamstrings, and paraspinals
F. Contract: Quadriceps femoris, internal and external obliques, rectus
abdominis, and psoas
4. SINGLE LEG LIFT
A. Position: Supine
C. Movements:
b. Place hands behind one calf and pull thigh into full flexion
c. While thigh is in full flexion, pull leg into partial extension
d. Hold position for 12 seconds
e. Lower thigh and place foot flat on floor with knee flexed
f. Repeat sequence with opposite leg
g. Return to setup
D. Repetitions: 12 complete movements with each limb
E. Stretch: Gluteus maximus and hamstrings
F. Contract: Quadriceps femoris

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5. TRUNK ROTATION
A. Position: Lateral recumbent

B. Setup: Lower arm, thigh, and leg flexed for support
C. Movements:
a. Fully extend thigh and knee
b. Lower knee of extended thigh to floor
c. Keep shoulders perpendicular to floor
d. Hold position for 12 seconds
e. Return to setup
f. Place lower hand on lateral surface of upper knee
g. Hold knee in place with lower hand
h. Rotate upper shoulder away from lower hand
i. Extend elbow of upper arm and place back of hand on floor
j. Hold position for 12 seconds
k. Return to setup
l. Change to opposite side
m. Return to setup
D. Repetitions: 3 movements to each side
E. Stretch: Gluteus minimus, gluteus medius, gluteus maximus,
piriformis, hamstrings, quadratus lumborum, tensor fasciae latae,
quadriceps femoris, obliquus internus and externus abdominis,
and psoas
F. Contract: Gluteus minimus, gluteus medius, gluteus maximus,
piriformis, hamstrings, quadratus lumborum, tensor fasciae latae,
quadriceps femoris, obliquus internus and externus abdominis,
and psoas
6. CHEST LIFT WITH EXTENSION PUSH-UP
A. Position: Prone
B. Setup:
a. Thighs in neutral position and knees extended
b. Thighs and legs about shoulder-width apart
c. Arms abducted overhead with palms on floor
C. Movements
a. Extend spine to lift chest and arms off floor
b. Hold position for 6 seconds
c. Return to setup

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d. Place hands under chest in push-up position
e. Extend spine and push upward with arms at same time
f. Extend neck
g. With hips on floor, hold position for 12 seconds
h. Complete four extension push-ups
i. Return to setup
D. Repetitions: 3
E. Stretch: Obliquus internus and externus abdominis and rectus
abdominis
F. Contract: Gluteus maximus, hamstrings, and paraspinals
7. REVERSE LEG LIFT
A. Position: Prone
B. Setup:
a. Thighs in neutral position and knees extended
b. Thighs and legs less than shoulder-width apart
c. Arms abducted overhead with palms on floor
C. Movements:
a. Extend hips to lift both thighs off floor
b. Hold position for 6 seconds
c. Return to setup
d. Extend hip and lift one thigh off floor
e. Return to setup
f. Extend opposite hip and lift other thigh off floor
g. Return to setup
h. Complete four single leg lifts (two each side)
D. Repetitions: 3
E. Stretch: Quadriceps femoris and psoas
8. CHAIR STRETCH
A. Position: Seated in chair

B. Setup: Sitting with back straight and feet flat on floor
C. Movements:
a. Place both hands on sides of chair
b. Extend lumbar, thoracic, and cervical spine
c. Return to setup

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d. Rotate body 90 degrees and sit on edge of chair
e. Extend outer thigh to rear with ball of foot on floor
f. Place both hands on upper knee and extend spine
g. Return to setup
h. Place both hands on sides of chair
i. Extend lumbar, thoracic, and cervical spine
j. Return to setup
k. Rotate 90 degrees to opposite side and sit on edge of chair
l. Extend outer thigh to rear with ball of foot on floor
m. Place both hands on upper knee and extend spine
n. Return to setup
D. Repetitions: 3 complete movements to each side
E. Stretch: Paraspinals, soleus, gastrocnemius, quadriceps femoris, and
psoas
The patient should be told to breathe normally while performing these

movements and rest between each movement. If the patient completes this
protocol with no problem, flexion and extension should be tested from a
standing position. Since standing patients are not supported by the table or
floor as they are in a prone or supine position, flexing or extending the spine
from a standing position will be more difficult.
If the spine is functioning normally, linear or circular motions will be
smooth and continuous and starting, stopping, or turning will be painless.
Factors that can interfere with normal motions are pain, spasm, contractures,
adhesions, weakness, and neurologic or mechanical defects. Low back pain
has a tendency to decrease the ROM, alter the normal direction of motion,
decrease the velocity of motion, and cause abnormal hesitations.
Spinal movements are often combined, such as flexion and rotation.
If two spinal movements are coupled together, the range of motion for each
movement will decrease by about 50%. When measuring ROM, isolated
movements produce the greatest range. Lifting an object when the spine is
flexed and rotated, instead of just being flexed, increases the risk of injury.
Deviation from the expected direction of movement during range-of-
motion testing can be more significant than the ROM. Flexion, extension,
sidebending, and rotation are normally measured in terms of cardinal planes
(sagittal, coronal, or transverse). If person deviates from these planes in any
significant way, this indicates: (1) something is restricting the motion or (2)
the strength needed to produce the motion is insufficient.

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Most deviations are caused by spasm and pain inhibition. If LBP is
chronic, you might find adaptive shortening or restrictive adhesions. Unless
the cause for a deviation is central, such as a spinal injury, restrictions and
weakness are more likely to be unilateral than bilateral.
To verify restrictions, examiners can move the patient's body in
directions that apply stress (provocative testing). If the patient is moving or
leaning abnormally in one direction, movement in the opposite direction will
normally stretch the offending tissue and cause pain.
As a rule, movements toward restricted tissue decrease pain and
movements in the opposite direction increase pain. The exception occurs
when movements toward a restriction compress irritated tissues and cause
pain. To avoid injuring patients, testing movements should be slow and
gradual. This gives a patient time to object if the pain is too severe.
If you repeat movements in a direction that cause pain, the patient
may report that pain decreases with each movement. This decrease in pain
may occur because stretching is relaxing hypertonic muscles or lengthening
adaptively shortened tissues. Movements used for testing a restriction are
often the same movements that are used for treating the restriction. If the
force used does not traumatize tissues, movements that cause the most pain
are potentially the most productive movements for reducing pain.
Level III Evaluation
Level III covers six types of specialized testing: (1) muscle testing,
(2) straight leg raising test, (3) gluteal-drop test, (4) sacral-integrity testing,
(5) spinal-flexion testing, and (6) malingering tests.
Muscle Testing
Manual muscle testing is a clinical method for measuring the strength

of a muscle and ROM. Another name for muscle testing is resisted range-
of-motion testing. Strength measures the patient's ability to hold steady or
move against resistance. When patients hold against resistance, muscles
contract isometrically without changing in length. When patients move
against resistance, muscles contract isotonically and shorten.
Based on composition, the main factors affecting strength and
weakness of a muscle are (1) neurologic efficiency, (2) the ability of muscle
fibers to contract, (3) the integrity of tendons and aponeuroses, and (4) the
ability of deep fascia to reach normal length.

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Though joints are not part of a muscle, the integrity of joints can also
affect strength or weakness. If a joint is irritated, locked, or unstable, a
muscle crossing the joint may test weak when the muscle itself is normal.
Any condition that changes joint space above or below physiologic limits
will adversely affect the ability of joints to produce movement.
Range-of-motion testing measures joint movement by degrees of arc
in a circle. The starting position is zero (neutral position) and degrees are
added in the direction the joint moves from the starting position. Except for
rotation, the starting position is normally the same as anatomical position.
An example of range-of-motion testing is elbow flexion. Starting
from anatomical position with the forearm vertical and the palm supinated
(forward), elbow flexion is about 150 degrees for most people. Active range
of motion is normally less than passive range of motion and both are
affected by pain tolerance, training, and motivation.
If joints and the agonist are normal, the main factor limiting range of
motion is tissue extensibility of the antagonist. If the antagonist fails to
lengthen normally during contraction by the agonist, the joint's range of
motion will be limited. This explains why active range-of-motion testing
measures strength and length. Range-of-motion stretching is used to
increase or maintain the amount of motion available to a specific joint.
The following list defines active, passive, active-assistive, and resisted
range-of-motion testing.
(1) Active range-of-motion testing: the force for the movement is

provided by the patient without assistance or resistance from
the examiner.
(2) Passive range-of-motion testing: the force for the movement is

provided by the examiner without assistance or resistance from
the patient.
(3) Active-assistive range-of-motion testing: the force for the

movement is provided by the patient with some assistance from
the examiner.
(4) Resisted range-of-motion testing: the force for the movement

is provided by the patient and works against resistance from the
examiner.

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Active ROM testing is normally done before resisted ROM testing.
Active ROM testing gives the examiner a chance to observe the patient's
range of motion with gravity as the only outside force. If the patient's active
range of motion is normal, the final step is resisted range-of-motion testing.
If the patient fails active ROM testing, the next step is using passive
ROM testing to evaluate range of motion. If the patient's range of motion is
incomplete, the probable causes are joint dysfunction, spasm, or contracture.
If the patient's passive ROM is normal, active-assistive ROM testing can be
used to identify weakness. Possible causes for weakness are neurologic
dysfunction, pain avoidance, pain inhibition, disuse atrophy, or fatigue. If
the patient fails muscle testing at any level, it is usually better to stop and
treat the problem than to continue with muscle testing.
If a patient's active ROM is normal, the final step is resisted ROM.
Even if active, passive, and active-assistive ROM testing are normal, you
may still have weakness because of trauma, pain, disuse atrophy, or disease.
In resisted muscle testing, strength is measured by having a muscle
hold or move against manual resistance. Holding against resistance is easier
to apply and less likely to involve joints than moving against resistance.
Though some systems apply percentages to each grade or use pluses and
minuses to create more levels, the most workable grading system for muscle
testing uses no more than six levels of measurement that range from 5 to 0.
MUSCLE TESTING BY GRADE

NORMAL 5 Hold against gravity and full resistance.
GOOD 4 Hold against gravity and some resistance.
FAIR 3 Complete range of motion against gravity.
POOR 2 Complete ROM with gravity eliminated.
TRACE 1 Evidence of contraction only.
ZERO 0 No evidence of contraction.
Note: Normal is a higher grade than Good.
The direction of resistance used in muscle testing is normally directly

opposite the direction of pull for the muscle being tested. Deviation from
this direction allows the patient to substitute other muscles for the muscle
being tested. The amount of force used will vary with size and condition of
the patient. Examiners will learn how much force to use by experience.
Since leverage normally favors the examiner, using too much force is more
likely to cause inaccuracy than using too little force.

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Three types of positioning are used in muscle testing: (1) positioning
to prevent substitution, (2) positioning to reinforce fixator muscles, and (3)
positioning to create active insufficiency.
(1) Positioning to Avoid Substitution
Positioning isolates the muscle being tested by using stabilization to

prevent substitution. If the muscle being tested is weak, stabilization
prevents other muscles from contributing to the same movement by not
allowing the body to change position. If the initial body position favors the
pull of a muscle being tested, other muscles cannot be effectively used
without repositioning the body to change the direction of pull. An example
of stabilization is holding the pelvis in place while testing the gluteus
minimus, gluteus medius, or gluteus maximus.
(2) Positioning to Reinforce Fixator Muscles
Positioning combined with body weight and manual force can be used
to reinforce fixator muscles that allow the insertion to move by locking the
origin of a muscle in place. When a muscle contracts, tension pulls equally
at both the origin and insertion. To produce movement, stabilizing the
origin leaves the insertion, and the bone the insertion attaches to, free to
move. If fixator muscles are weak, muscle testing will not be accurate.
Fixator muscles are often antagonistic to the muscles being tested. The
examiner can use positioning, body weight, and manual force to reinforce
fixator muscles. An example of fixation is using positioning (supine), body
weight, and manual force to fixate the opposite iliac crest when testing the
psoas and psoas for strength.
(3) Positioning to Create Active Insufficiency
Active insufficiency is the failure of any muscle to generate normal

tension because the origin and insertion are too close. In certain positions,
muscles that cross two joints cannot exert enough tension to produce full
range of motion in both joints simultaneously. By placing two-joint muscles
at a mechanical disadvantage, this principle can be used to separate two-joint
muscles from one-joint muscles.
When muscles that cross one joint and muscles that cross two joints
both contribute to the same movement, the two-joint muscles can be

86
mechanically neutralized by using positions that bring the origin and
insertion closer together. Since muscles produce movement by generating
tension, the slack created by approximating origin and insertion prevents the
two-joint muscles from generating normal tension.
For example, both the gluteus maximus and the hamstrings extend the
hip. The gluteus maximus is a one-joint muscle and the hamstrings are two-
joint muscles. If the patient flexes the knee, the slack hamstrings cannot
extend the hip. The gluteus maximus can then be tested using hip extension
without interference from the hamstrings.
The same principle applies to the soleus and gastrocnemius. Though
both muscles plantar-extend the foot, the soleus is a one-joint muscle and the
gastrocnemius is a two-joint muscle. When the knee is flexed, the slack
gastrocnemius cannot plantar-extend the foot. The soleus can then be tested
using plantar flexion without interference from the gastrocnemius.
Three points are important for the safety of the patient:
Muscle Testing Safety

1 Apply resistance slowly (easy on)
2 Do not break the patient's contraction
3 Remove resistance slowly (easy off)
Resistance should be applied slowly to give the patient enough time to

apply a counterforce. Force applied too quickly will break the patient's
contraction and may cause tissue damage. Slowly applied resistance is also
used with post-isometric relaxation. As a rule, the examiner should not
apply additional force when the patient's contraction changes from isometric
to eccentric and the muscle being tested starts to yield. On the opposite side,
force removed too quickly may cause a rebound effect that results in tissue
damage. Isometric contractions should not be painful.
Isometric resistance is usually applied when a muscle is at or slightly
beyond resting length. Because of the arrangement of myofilaments in the
sarcomeres and the viscoelastic properties of a muscle, most muscles are
strongest when the muscle is at resting length or stretched slightly beyond
the resting length and weakest when the muscle is fully stretched or fully
shortened. Resting length is usually about midway between fully contracted
and fully stretched. The biceps brachii approaches resting length when the
elbow is flexed to about 90 degrees.

87
As a caution, testing a muscle when distal and proximal insertions are
not far enough apart to keep tension on a muscle during contraction may
cause cramping. Any condition that allows actin and myosin myofilaments
to overlap seems to encourage painful spasm. This can be demonstrated by
slowly contracting the biceps brachii when the elbow joint is fully flexed.
Although higher degrees of precision are sometimes required, some
muscles can be tested by testing a movement. According to Beevor's axiom,
the body knows nothing of individual muscles but thinks only in terms of
movement. If a muscle is part of a group of muscles that perform a similar
movement, the muscle can often be tested by testing the movement.
Muscles within a group can sometimes be isolated by using palpation
to identify particular muscles. If the muscle being palpated becomes painful
during contraction, the muscle may be weaker than other muscles in the
group because of a problem with the muscle itself, tendons, or aponeuroses.
Palpation may also (1) reveal trigger points or indurated bands within
a muscle, (2) cause fasciculations (involuntary contractions or twitching), or
(3) trigger a sympathetic response, such as perspiration, changes in skin
temperature, or pilomotor activity (erection of hairs and goose flesh).
If contraction is painful, the examiner should palpate for signs of
impairment when the muscle is first relaxed and then contracted. Although
most muscles are easier to palpate when relaxed, impairments are sometimes
more conspicuous when muscles are contracted. When using palpation, start
with light pressure—which is more discriminating—and then gradually
progress to moderate pressure or even heavy pressure if needed.
Even though palpation is usually combined with observation, visible
signs are often less reliable than kinesthetic signs. Involved muscles may be
larger than normal if swollen or smaller than normal if atrophied.
Inflammation may cause flushing or redness because of a histamine release
and vasodilation. Anxiety, pain, or shock may cause blanching or paleness
because of a sympathetic response and vasoconstriction. On the other hand,
involved tissues may appear normal despite major soft-tissue impairments.
Muscles that have more than one action can sometimes be tested by
using a separate test for each action. The quadriceps, for instance, have two
basic actions: extend the leg and flex the thigh. In the quadriceps test
below, strength is measured by testing thigh flexion as opposed to leg
extension. This decision was based on the observation that testing leg
extension seems to cause more pain than testing thigh flexion. When
muscles can be tested in more than one way, the way that causes the least
pain is normally the best.

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Major Muscles or Muscle Groups: Muscle Testing
1. GLUTEUS MINIMUS
Test: Abduction of hip without flexion or extension

Position: Lateral recumbent
Stabilization: Examiner stabilizes pelvis
Resistance: Against leg in direction of adduction
2. GLUTEUS MEDIUS
Test: Abduction of hip with slight extension of hip

Resistance: Against leg in direction of adduction and slight flexion
3. GLUTEUS MAXIMUS
Test: Hip extension with knee flexed to 90 degrees or more

Position: Prone
Resistance: Against lower posterior thigh in direction of flexion
4. PIRIFORMIS
Test: Lateral rotation of thigh with leg flexed to 90 degrees

Position: Prone
Stabilization: Examiner stabilizes thigh at lateral side of knee
Resistance: Against upper part of medial leg
5. HAMSTRINGS
Test: Flexion of leg to less than 90 degrees from 45 degrees

Position: Prone
Stabilization: Examiner stabilizes thigh
Resistance: Against leg at ankle in direction of extension

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6. PARASPINALS
Test: Extension of lumbar spine until thorax clears table

Position: Prone
Resistance: Against lower thoracic spine in direction of flexion
7. LATISSIMUS DORSI
Test: Adduction of medially rotated arm with palm up

Position: Prone
Stabilization: Examiner stabilizes shoulder
Resistance: Against forearm in direction of abduction
8. SOLEUS
Test: Plantar flexion of foot with knee bent to 90 degrees

Position: Prone
Stabilization: Examiner stabilizes ankle
Resistance: Against ball of foot in direction of dorsi flexion
9. GASTROCNEMIUS
Test: Plantar flexion of foot with knee fully extended

Position: Prone with foot extended over edge of table
Stabilization: Examiner stabilizes ankle
Resistance: Against ball of foot in direction of dorsi flexion
Test: Elevation of pelvis laterally

Position: Prone with legs spread to slightly beyond shoulder width
Stabilization: None required
Resistance: Traction on the ankle to resist elevation of the hip
Test: Abduction and flexion of hip with knee extended

Position: Supine

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Stabilization: Examiner stabilizes opposite ankle
Resistance: Against ankle in direction of adduction and extension
Test: Flexion of thigh with no rotation

Position: Supine with thigh and leg flexed to 90 degrees
Stabilization: None required
Resistance: Against anterior thigh near knee in direction of extension
Test: Flexion of lumbar vertebrae

Position: Supine with knees bent and feet flat on table
Stabilization: Examiner holds feet flat on table
Resistance: Gravity
14. INTERNAL OBLIQUES (OBLIQUUS INTERNUS ABDOMINIS)
Test: Flexion and rotation of lumbar spine to same side

Position: Supine with hands behind neck
Stabilization: Examiner holds legs on table
Resistance: Gravity
15. EXTERNAL OBLIQUES (OBLIQUUS EXTERNUS ABDOMINIS)
Test: Flexion and rotation of lumbar spine to opposite side

Position: Supine with hands behind neck
Stabilization: Examiner holds legs on table
Resistance: Gravity
16. ILIOPSOAS
Test: Hip flexion with leg slightly abducted and medially rotated
Position: Supine
Stabilization: Examiner stabilizes opposite iliac crest
Resistance: Against anteromedial leg in direction of extension and
slight abduction

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Straight Leg Raising Test
The straight leg raising test is possibly the most common clinical test
used to evaluate LBP. Some experts disagree on exactly what a straight leg
raising test represents and others believe the correlation between a positive
test and herniated disc disease is very poor. A positive test contraindicates
soft-tissue therapy until a physician evaluates the patient and finds that soft-
tissue therapy is indicated. The purpose for the straight leg raising test is to
identify disc protrusions, nerve root entrapments, or nerve root irritation.
Tension caused by a straight leg raising test affects the lumbosacral
plexus, the sciatic nerve, related nerve roots, and the dura mater. Since
pressure on a nerve root often produces paralysis or paresthesia but not pain,
the pain associated with straight leg raising, dorsiflexing the foot, or flexing
the neck is more likely to come from the dura mater than a nerve root.
To do this test: (1) fully extend and elevate one leg, (2) if pain is felt,
lower the leg a few degrees until no pain is felt, and (3) dorsiflex the foot or
flex the cervical spine while the leg is elevated and pain-free. To elevate the
fully extended leg, stand perpendicular to the supine patient and slowly raise
the leg by lifting up on the calcaneal tendon. Keep the other hand on top of
the patient’s knee to ensure that the leg is fully extended. The test is positive
if elevating the leg causes nerve-root pain or paresthesia to radiate below the
knee. If you dorsiflex the foot or flex the cervical spine while the leg is
pain-free and produce nerve-root pain or paresthesia that radiates below the
knee, the straight leg raising test is confirmed. Dorsiflexing the foot or
flexing the neck stretches the dural sac that protects the nerve root.
A positive sign slightly above 30 degrees is more likely to indicate
disc herniation than a positive sign slightly below 70 degrees. The average
range of motion for the extended leg is between 75 and 80 degrees without
discomfort. Since the sciatic nerve root and dura are completely stretched at
70 degrees, pain that starts after 70 degrees is more likely to be sacroiliac
joint pain or lumbar facet irritation than L4, L5, or S1 radicular pain.
Raising a straight leg or flexing the cervical spine while a patient is
seated, pressing on the lateral side of the popliteal fossa when the patient is
supine and the thigh and knee are flexed to 90 degrees, or coughing may also
elicit nerve-root pain or paresthesia that radiates below the knee.
When testing one leg, pain may occur in the other leg. This is a
positive crossed-straight-leg test. Low back or sciatic pain on the opposite
side is strongly indicative of disc herniation or nerve root entrapment.

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A straight leg raising test is often used with an ankle-jerk test or a
muscle test for the extensor hallucis. The absence of an ankle-jerk reflex,
which is measured by tapping the calcaneal tendon while the patient is prone
and the foot is hanging over the edge of the table, incriminates S1.
Weakness in the extensor hallucis, which is measured by applying isometric
resistance against extension of the great toe, incriminates L5.
Most leg pain is not caused by a disc prolapse pressing on a nerve,
and the word sciatica is often misused. Pain can be referred to the leg by
many different structures, such as muscles, fascia, ligaments, periosteum, or
facet joints. This is usually a dull, poorly localized, aching pain, and it may
affect both legs—but it seldom goes below the knee. Pain from stimulation
of a nerve root, on the other hand, is usually a sharp, well-localized pain and
it usually radiates to the foot or toes if the L5 or S1 roots are involved.
A limited ROM when doing a straight leg raising test does not prove
nerve-root involvement. Tightness in the hamstrings and the thoracolumbar
(lumbodorsal) region are possible sources of painful limitation, but they
seldom cause nerve-root pain. When referred leg pain is present, regardless
of the source, increasing tension on the source may cause the pain to radiate
more distally and decreasing tension may ease the pain.
Gluteal-Drop Test
One way to test for complete derotation of the pelvis is the gluteal-
drop test. By standing behind a patient with your palms up and placing your
right and left forefingers on the right and left gluteal folds respectively, you
can palpate the gluteus maximus when the lumbar spine is (1) fully erect, (2)
flexing, (3) extending, and (4) fully erect again.
When the spine is functioning normally, the gluteus maximus should
be (1) relaxed when the spine is erect, (2) contracting eccentrically when the
spine is flexing, (3) contracting concentrically when the spine is extending,
and (4) relaxed when the spine is erect again. When the spine is fully erect,
the pelvis should be tilted forward and lumbar lordosis should be normal.
In patients with LBP, palpation may show that the gluteus maximus is
(1) hypertonic when the spine is erect, (2) contracting eccentrically during
flexion, (3) contracting concentrically during extension, and (4) hypertonic
when the spine is erect again. If the pelvis does not rotate forward into
anterior tilt as it usually does when the spine is erect, the gluteus maximus
may fail to relax and drop down as it normally does, the gluteal fold may be
reduced or absent, and lumbar lordosis may be less than normal.

93
This response could be caused by shortness in the gluteus maximus or
hamstrings that stops the pelvis from rotating forward. This problem can
often be corrected by using trigger point therapy and ROM stretching to
reduce spasm. Compressing the gluteal fold with the thumb and fingers is a
good way to locate or neutralize trigger points. If the problem is corrected,
the gluteal fold will assume its normal position when the spine is fully erect.
A loss of lumbar lordosis can be tested from a standing position by
having patients extend the neck, inhale, and try to look up at the ceiling. If
lumbar lordosis is restricted, looking up may be difficult or impossible. You
can also test lumbar lordosis by having patients try to do an extension push-
up. If lumbar lordosis is restricted, their hips may come off the ground
before they straighten their arms. In some cases, trying to do an extension
push-up will increase lumbar lordosis and patients may find it easier to walk
after they do or try to do an extension push-up.
When this test is used, momentary releases followed by spasm may be
felt when the patient stoops over and momentary pauses followed by slight
lateral movements may be felt when the patient stands up. The releases are
probably caused by isolated groups of muscle fibers relaxing and the pauses
are probably caused by pain inhibition or pain avoidance. Even if gluteus
maximus is hypertonic and weak, the muscle’s length may be normal.
Sacral-Integrity Testing
The sacroiliac joint (SIJ) moves only a few degrees. Since testing is
not reliable, determining SIJ stability can be difficult. Aging reduces static
mobility and increases static stability, which may explain why common LBP
decreases after age 50. If instability because of pregnancy causes posterior
pelvic pain and LBP, muscle pain often becomes chronic after pregnancy.
Because of ligaments that connect the sacrum to the ilium and the
ilium to L4 and L5, movement of one structure can affect the others. While
some sacral dysfunctions do not cause LBP, others—such as tears in the
ventral or dorsal capsule or strained ligaments—do. Most pain from sacral
dysfunction is unilateral and above the knee, although it can radiate below
the knee. To test for sacral dysfunction when the patient is supine and you
are standing beside the patient and facing the patient’s head: cross your
arms just below the elbows and push down and outward on the anterior
superior iliac spine (ASIS) of each ilium with your palms (right palm on
right ASIS and left palm on left ASIS). The presence of unilateral pain
localized in the sacral area indicates sacral dysfunction.

94
Another test involves pushing the anterior superior iliac spines closer
together (compression) instead of pushing them apart (distraction). To test
for sacral dysfunction when the patient is in a lateral recumbent position
(lying on the side, thighs flexed, and upper thigh flexed more than the lower
one) and you are standing behind the patient and facing the pelvis, place
both palms (one hand on top of the other) on the uppermost ilium and push
down. Unilateral pain localized in the sacral area indicates dysfunction.
The third test for sacral dysfunction involves isometric adduction and
abduction of the thighs. To test for sacral dysfunction in this position, the
patient is supine on a table with the thighs and knees flexed and the feet flat
on the table and you are standing parallel to the patient and facing the flexed
knees. To perform the adduction test, place the patient in a position that
allows you to adduct the knees and tell the patient to abduct the knees while
you apply an isometric counterforce. The test is positive if adduction causes
localized pain in the sacral area. To perform the abduction test, change your
hand positions so your hands are in a position to prevent abduction and tell
the patient to abduct the knees while you apply an isometric counterforce.
The test is positive if abduction causes localized pain in the sacral area.
For the last test, place the patient in a prone position and press down
on the sacrum with moderate force. The test is positive if pressure causes
localized, unilateral pain in the sacral area. If the test is positive, palpate
muscles that stabilize the sacrum such as latissimus dorsi, gluteus maximus,
erector spinae, biceps femoris, piriformis, or multifidus. An SIJ dysfunction
can make these muscles hypertonic and tender. Other muscles to check are
the internal and external obliques, psoas, and transversus abdominis. It may
be helpful to ask patients where they feel hip pain before you palpate.
If a sacral dysfunction is present, fascia may be tender. Contralateral
contractions by latissimus dorsi and gluteus medius compress and stabilize
the sacrum by increasing tension on the thoracolumbar fascia, which may be
tender if these muscles are hypertonic from overuse. If the gluteus maximus
is hypertonic from overuse, the iliotibial track (fascia latae) may be tender.
Atrophy in the multifidus, which stabilizes the lumbar spine and SIJ
may indicate sacral dysfunction. If atrophy occurs, the multifidus might not
regain its normal size or function without treatment. Manipulation corrects
neurologic defects and exercise increases neurologic efficiency and mass.
Other signs that may indicate a sacral dysfunction are (1) unable to sit
squarely on the buttocks, (2) groin pain, (3) constant and diffuse pelvic
discomfort, (4) difficulty standing or hopping on one leg, (5) numbness in
thighs, and (6) discomfort when walking down stairs or down an incline.

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Spinal-Flexion Testing
Since lumbar flexion is rarely a problem in common low back pain,

being able to bend forward and touch the toes should not be used to measure
lumbar fitness. In some cases, this test will cause low back pain.
This test can also be unreliable. While the first test may indicate a
limited ROM, a second test performed fifteen seconds after the first test may
indicate normal flexibility. If a patient is stiff during the first test, doing the
first test may increase the patient’s ROM by decreasing hypertonicity. By
the same token, a test done after a patient has been walking will often show a
greater ROM than a test done just after a patient has been sitting.
Besides measuring lumbar flexibility, a fingers-to-toes test measures
hamstring length, thoracic flexion, shoulder flexibility, and anthropometric
differences such as arm, trunk, and leg length. Low-back patients with less
than normal lumbar flexibility can sometimes touch their toes because other
parts of their body have developed compensatory hypermobility.
Extending the trunk after flexion can be more hazardous for some
patients than moving the trunk into flexion. If flexion is used for testing,
you may need to help patients extend the spine after the spine is flexed.
Although sitting with the knees extended and trying to touch the toes
is probably safer than bending over with the knees extended and trying to
touch the toes, using the Schober test is a better way to measure lumbar
flexion. While the patient is standing: (1) use chalk or a grease pencil to
mark the point where a horizontal line joining the pelvic dimples—sulci
below the posterior superior iliac spines and level with S2—intersect the
spine, (2) mark one point on the spine that is 10 cm above this point and
mark another point on the spine that is 5 cm below this point, (3) tell the
patient to flex forward as far as possible without causing discomfort, and (4)
measure the distance between the upper and lower marks. If lumbar flexion
is normal, the distance will be at least 20 cm (1 cm equals 2.54 inches).
If a patient does have a loss of lumbar flexion, the significance of this
finding is not always clear. These are general guidelines for trunk flexion:
• Discogenic disease: trunk flexion is limited and painful.

• Facet joint: trunk flexion with sidebending or rotation may cause pain.
• Common low back pain: trunk flexion is normal and may decrease pain.
• Piriformis syndrome: trunk flexion is normal.
• Spondylolisthesis: trunk flexion is normal.
• Spinal stenosis: trunk flexion is normal and may decrease pain.

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Malingering Tests
Malingering is the willful and fraudulent fabrication of symptoms of

an injury or illness for illegal compensation or personal gain. The best test
for malingering is the presence or the absence of verifiable evidence such as
edema, abnormal changes in tissue temperature, contractures, or atrophy. A
simple test for atrophy is measuring the circumference of a limb, such as a
leg or thigh, with a plastic measuring tape and doing a bilateral comparison.
The presence of physical signs such as lateral pelvic shift, a loss of
lumbar lordosis, or functional scoliosis would also corroborate claims of
injury. Although trigger points and hypertonicity are valid signs of injury,
these findings are often missed because the muscles were never palpated.
To test for malingering if a patient claims one leg is weak, place the
patient in a supine position with the legs about 6 inches apart, put your palm
under the heel of the normal leg, and ask the patient to raise the weak leg. If
the patient tries to raise the weak leg—whether it moves or not—you should
feel a downward force (counterforce) from the normal leg on your palm.
Another test is have the patient stand in a relaxed position and rotate
the patient’s upper body by rotating the hips—the spine should not rotate.
Rotating the lumbar spine may cause low back pain, but rotating the hips
and upper body without rotating the spine should not cause low back pain.
Other indications of malingering include exaggerated pain behavior,
tolerating hip flexion to 90 degrees while seated but not tolerating flexion to
90 degrees when prone, or complaining that mild compression, distraction,
or rotation of the cervical spine causes low back pain.
Stating that pain is everywhere, a fear of being touched, exaggerated
reflexes, or feeling mechanical vibration on only one side of the body may
indicate psychogenic pain instead of malingering. Psychological problems
may contribute to low back pain or be the result of low back pain.
Indications of malingering should be reported to the patient's primary
physician, but not to the patient. Even if malingering is suspected, any
claims made by the patient that contraindicate soft-tissue therapy should be
accepted as valid and treatment should stop until a physician authorizes—
preferably in writing—further treatment.
Observing a patient’s behavior will sometimes reveal inconsistencies
that indicate malingering. A patient who has no difficultly exiting a vehicle
but great difficulty getting up from a chair in your office is probably being
less than honest. Another indication of malingering is a patient who is not
concerned by a total lack of progress or improvement.

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CHAPTER HIGHLIGHTS
FOUR CLASSICAL METHODS EVALUATION—LEVEL I
• Palpation
• Observation
• Auscultation
• Percussion
EIGHT WORDS THAT FORM THE ACRONYM A SPARKLE—LEVEL I
Antalgic gait or posture

Spasm
Pain or tenderness
Asymmetry or posture
Range-of-motion loss
Kyphotic increase
Lordotic decrease
External rotation
EIGHT-STEP EVALUATION PROTOCOL—LEVEL II
• Lateral pelvic shift

• Modified sit-up
• Double leg curl
• Single leg lift
• Trunk rotation
• Chest lift with extension push-up
• Reverse leg lift
• Chair stretch
SIX TYPES OF SPECIALIZED TESTING—LEVEL III
• Muscle testing • Sacral-integrity testing

• Straight leg raising test • Spinal-flexion testing
• Gluteal-drop test • Malingering tests

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ALTERNATIVES
HEMME APPROACH is a scientific method for matching health-related

problems with cost-effective solutions. Once a problem has been identified
by taking a medical history and doing a physical evaluation, the next three
steps (modalities, manipulation, and exercise) focus on finding a solution.
PROBLEM
H HISTORY
E EVALUATION
SOLUTION
M MODALITIES
M MANIPULATION
E EXERCISE
The word “ALTERNATIVES” is not written in bold letters because it

represents a choice and not a step. Even though a soft-tissue therapist can
use any sequence that seems appropriate, the normal sequence would be (1)
modalities, (2) manipulation, and (3) exercise. Modalities prepare tissues for
manipulation—manipulation prepares tissues for exercise—and exercise
helps the body maintain muscle balance and normal functioning.
The basic modalities used in soft-tissue therapy are thermotherapy,
cryotherapy, and vibration. If modalities are not needed, proceed directly to
manipulation. Because of HEMME APPROACH's flexibility, practitioners can
repeat steps as many times as needed. The only required step is history. If a
patient’s medical history shows that soft-tissue therapy is contraindicated,
the process stops until a physician approves soft-tissue therapy. If therapy is
indicated, you must take a medical history and do a physical evaluation.
The four methods of manipulation used in HEMME APPROACH are:
HEMME APPROACH MANIPULATIONS

1 Trigger point therapy (trigger points)
2 Neuromuscular therapy (nerves and muscles)
3 Connective tissue therapy (connective tissue)
4 Range-of-motion stretching (trigger points and all tissues)

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These categories are based on physiology or anatomy. Trigger points
affect physiology, but they are not anatomic structures. Neuromuscular
therapy, connective tissue therapy, and ROM stretching are based on both
anatomy and physiology. Neuromuscular therapy affects nerve and muscle
tissue, connective tissue therapy affects connective and epithelial tissue, and
ROM stretching affects nerve, muscle, connective, and epithelial tissue.
If feedback from a patient shows that therapy is not working, skip or
repeat steps until you find a protocol that does work or discontinue therapy.
Finding a contraindication is usually the main reason for stopping therapy.
If therapy is not working, you might need more information. Possible
sources for new information include other health care professionals, medical
libraries, professional publications, or medical-testing facilities. When
treating common LBP, using a team approach is sometimes the best option.
Repeating all five steps (history, evaluation, modalities, manipulation,
and exercise) each time you treat a patient is not always necessary, and there
may be times when the only three steps you use are history, evaluation, and
manipulation. After you take a medical history, you may need to repeat the
evaluation-manipulation sequence many times during the treatment. When
treating common LBP, testing, treating, and retesting is an ongoing process.
Effective reasoning combines logic and intuition with knowledge and
experience. Treating common LBP is often a complex problem, and it may
help to have a clearly defined method for dealing with a complex problem.
The acronym SOS can help you simplify a complex problem and find
acceptable solutions. These steps can be applied mentally or in writing.
SOS
S Separate the problem into parts
O Organize the parts
S Simplify the problem
To use SOS, separate a problem into manageable parts. If LBP is the

problem, separate the problem into dysfunctions or muscle imbalances. To
organize the parts, match each part with therapeutic principles. If part of the
problem is a muscle imbalance and the antagonist is abnormally short, a
matching principle might be lengthen the antagonist before you strengthen
the agonist. To simplify a problem, focus on the parts that are not solved
until the entire problem is solved. In other words: “If it’s no longer broken,
stop fixing it and move on to the next problem that needs to be fixed.”

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MODALITIES
In soft-tissue therapy, modalities can be used to prepare tissues for

manipulation. Although seldom curative when used alone, modalities
facilitate manipulation by reducing pain, controlling edema, reducing spasm
(hypertonicity), decreasing tissue viscosity, and increasing or decreasing
metabolism. To get the most benefit from heat or cold, manipulate tissues
while the modalities are being applied or shortly thereafter.
Cryotherapy
Cryotherapy is a term that refers to therapeutic use of cold. Cold can

be applied by using ice packs, immersing body parts in ice water, or using
blocks of ice to stroke or press body parts. Ice massage can be used when
treating low back pain. Cubes of ice without sharp edges can be applied to
trigger points and areas of spasm. Unlike ice packs or vapocoolant sprays,
ice massage produces both thermal and mechanical effects.
Not only is ice economical, effective, and easy to use, but it is also far
less likely to cause frostbite than cold-gel packs or ethyl chloride spray. In
addition to local effects such as decreases in local metabolism, blood flow,
and pain, the application of ice to large parts of the body produces global
effects such as decreases in body temperature, pulse, and respiration.
The easiest way to make an ice pack is to fill a plastic bag with two
pounds of crushed ice, squeeze or suck out the excess air, and tie the end in a
knot. Elastic wraps can be used to hold ice packs in place and generate
moderate pressure. To make ice for ice massage, fill a small paper cup with
water and then freeze it. To use the ice, simply peel back the top of the cup
until part of the ice is exposed and use the bottom part of the cup as a holder.
Ice cubes rounded by partial melting and handled with a rubber glove can be
used for treating trigger points with ice.
Cooling occurs at different rates. Surface tissues cool much more
rapidly than deep tissues, and total immersion in ice water cools a body part
faster than ice packs or ice massage. Once a body part has been cooled,
rewarming takes about twice as long as cooling. For example, a body part
cooled for 20 minutes takes about 40 minutes to rewarm.
During the acute phase of an injury when inflammation is present and
stabilization and rest are advisable, ice packs should be applied for 20 or 30

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minutes, removed for 2 hours, and reapplied for 20 or 30 minutes—three to
five times a day. Injuries can be stabilized by using a splint, brace, or sling.
Most injuries respond favorably to ice packs applied for 20 minutes.
If injuries involve large muscles such as the gluteus maximus or if a muscle
is covered by a thick layer of adipose tissue, apply ice for 30 minutes. Ice
applied for less than 10 minutes will not affect intramuscular temperatures at
a depth greater than about 1 inch. When treating acute injuries, apply ice
immediately and then continue with periodic icing until acute inflammation
has stopped, usually about 24 to 72 hours. The acute inflammatory phase is
seldom longer than 4 days, and swelling usually stops within 48 hours.
Frostbite is defined as local tissue damage resulting from exposure to
extreme cold or contact with extremely cold objects. In mild cases, it results
in redness of the skin (erythema) and slight pain; in severe cases, the skin
becomes pale, cold to the touch, and painless or numb. Severe frostbite can
damage soft tissue down to the bone and cause gangrene. There is no danger
of frostbite when ice packs placed directly on the skin are not left in place
longer than 30 minutes. Cooling modalities such as frozen gel-packs that
produce temperatures below zero should not be placed directly on the skin,
and they may cause frostbite even when used for less than 30 minutes.
After swelling because of edema or subcutaneous bleeding stops,
switching to heat can accelerate healing by increasing blood flow and tissue
metabolism. Subcutaneous bleeding is more likely to cause discoloration
because of bruising than swelling. Most edema (excessive fluid that forms
in extravascular spaces) is caused by chemical changes that occur during
acute inflammation. The prolonged use of cold during the subacute phase
can retard wound healing by restricting blood flow and slowing metabolism.
Cold reduces hypoxia by decreasing metabolism and cellular needs for
oxygen. Tissue death from hypoxia (1) attracts phagocytes that release
potent enzymes that attack connective tissue and (2) ruptures lysosomes that
release hydrolytic enzymes that ingest cell material. While phagocytes and
lysosomes both serve a useful purpose by helping to remove dead tissue, the
same process that removes dead tissue can also cause secondary damage by
injuring healthy tissue. Cold reduces secondary tissue damage by slowing
hypoxic cell death that attracts phagocytes and ruptures lysosomes.
Since hemorrhage (blood) normally has less effect on swelling than
edema (watery fluid), reducing blood flow has less of an effect on swelling
than decreasing tissue permeability. Of the two basic effects produced by
using cold—metabolic and circulatory effects—circulatory effects are the
most important during the acute phase of injury when bleeding is present.

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Cold is an analgesic that relieves pain by (1) decreasing production of
pain-producing chemicals, (2) slowing nerve-conduction velocities, and (3)
reducing protective spasm by inhibiting muscle spindles. When acting as a
counterirritant, cold raises the pain threshold by blocking out painful stimuli
and causing the release of endorphins.
On the positive side, cold-induced analgesia facilitates exercise by
controlling pain and reducing muscle spasm. On the negative side, cold
decreases tissue extensibility by increasing tissue viscosity. Though ice can
be used effectively to facilitate exercise when pain is the limiting factor, heat
can be more effective when the ability to exercise is limited by tissue
extensibility. Ice can also be used to control pain and edema after exercise.
Ice helps to control edema by decreasing metabolism, decreasing
production of inflammatory chemicals such as histamine, and slowing
vascular changes such as vasodilation that cause microscopic bleeding or
edema. Once swelling has occurred, compression and elevation reduce
swelling more effectively than cold by reducing capillary filtration pressure.
As a rule, the acute inflammation phase is treated by cold and the
subacute phase is treated by heat. Acute inflammation becomes subacute
when edema and bleeding have stopped, usually about 24 to 72 hours after
an injury. Acute LBP is one exception. Based on clinical experience, heat
gives most patients more relief during the acute phase than cold. The times
cold may work better than heat are (1) when you can find and treat local
inflammation during the acute phase—which is difficult because of anxiety,
pain, and hypertonicity—or (2) during the chronic inflammatory phase.
Another point to consider is the difference between injury and re-
injury. A condition may be subacute in terms of the original trauma but
acute in terms of re-injury. Despite the time that passes between the original
injury and treatment, conditions resulting from re-injury should be treated as
new acute injuries and not subacute injuries.
In chronic low back pain, if reflex activity causes spasm in the lumbar
region with no subcutaneous bleeding, the injury is subacute and moist heat
is indicated. If stretching and microtrauma cause spasm in the gluteals with
possible subcutaneous bleeding, the injury is acute and ice is indicated. If
acute and subacute injuries coexist, cold is usually the best choice.
The terms chronic and acute, as used above, refer to the severity of an
injury, not to the time passing since the first occurrence of LBP. When
using the time-since-injury classification: (1) acute is less than 6 weeks
from the onset of LBP, (2) subacute is 6 weeks to 3 months after the onset of
LBP, and (3) chronic is more than 3 months after the onset of LBP.

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Acute based on a timeline is not the same as acute based on severity of
symptoms. If a back is re-injured four months after the onset of LBP, the
condition is chronic in terms of time, but acute in terms of symptoms. The
decision on which modality or treatment to use should be based on severity
of symptoms, not on how much time has elapsed since the onset of pain.
The acronym RICE emphasizes the four basic steps for using ice:
• Rest protects and stabilizes the injury and prevents further trauma.
• Ice reduces circulation and inflammation (pain and swelling).
• Compression increases hydrostatic pressure outside the blood vessels.
• Elevation reduces hydrostatic pressure inside the blood vessels.
The first step (rest) implies rest and stabilize the injured body part,
and the fourth step (elevation) implies elevate the injured body part above
the level of the heart. RICE is recommended as immediate first aid for most
acute musculoskeletal injuries. In sports medicine, crushed ice is usually
applied for about 20 minutes (the range is 10 to 30 minutes) every 2 hours
when the patient is awake and treatments are continued for about two days.
The four basic sensations that result from ice massage are (1) cold, (2)
burning, (3) aching, and (4) numbness. While most patients can distinguish
between cold and numbness, the distinction between burning and aching is
less clear. Some patients report phases two and three as aching-burning
instead of burning-aching. A few patients report cold or painful sensations
when cold is applied, but not burning or warming sensations. Many patients
report burning sensations after ice has been removed, and some report a
cutting-burning sensation when ice is stroked across the back.
The burning sensation felt after ice has been removed is possibly the
result of vasodilation and rewarming. The burning effect felt when ice is
stroked across the back is more related to the way the body interprets painful
(nociceptive) stimulus than to cold-induced vasodilation (CIVD).
There are two basic methods for using ice to neutralize trigger points:
the ice massage method and the ice pressure method. The ice massage
method is similar to stretch and spray except that vapocoolant sprays such
as ethyl chloride or Fluori-Methane are replaced by ice massage. The ice
massage strokes are applied like a spray: parallel and unidirectional.
The steps in the ice massage method are (1) slowly stroke the edge of
the ice across trigger points until the skin is slightly desensitized, and (2) use
ROM stretching to lengthen tissues. Rather than producing analgesia or
numbness, stroking with ice reduces pain by acting as a counterirritant.

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Ice Massage Method for Treating Trigger Points
• Stroke several times across the trigger points with ice.

• Apply passive range-of-motion stretching to affected body part.
Stroking across a trigger point with ice may increase tonus because of
reflex effects. Ice applied for 20 to 30 minutes may decrease local tonus, but
ice applied for 3 to 5 seconds (quick icing) may increase local tonus.
Ice Pressure Method for Treating Trigger Points
• Apply light pressure with ice until local numbness occurs.

• Apply moderate pressure with ice until trigger points are neutralized.
• Remove pressure on trigger points slowly.
• Apply moist heat for several minutes to rewarm tissues.
• Apply passive range-of-motion stretching to the affected body part.
• Have patient complete 3 repetitions of active range-of-motion stretching.
When using ice pressure, it takes about 5 to 7 minutes for numbness to

occur and then another 1 to 3 minutes for trigger points to be neutralized.
After tissues are rewarmed, use passive ROM stretching to lengthen the
affected tissues. If the passive ROM is normal, have the patient complete 3
repetitions of active ROM stretching. Patients should inhale and exhale
slowly when stretching. Some patients say that stretching is easier if they
inhale while looking up and exhale while looking down. Even if trigger
points are not present, ice can facilitate stretching by reducing local pain.
Contraindications for cold are compromised local circulation, heart
disease, acrocyanosis, Raynaud’s disease, and cold hypersensitivity. When
people with cold hypersensitivities are exposed to cold, increased histamine
levels may cause hives (cold urticaria) or edema. A vasospastic disorder,
Raynaud's disease causes excessive vasoconstriction when extremities are
exposed to cold. In Raynaud’s disease, the fingers often become cyanotic.
Indications for Cold

1 Hypertonicity
2 Pain
3 Edema
4 Trauma

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Thermotherapy
After swelling and subcutaneous bleeding have stopped, about 24 to

72 hours after an injury, heat relieves pain by reducing protective spasm,
dispersing pain-producing chemicals—which stimulate nociceptors—and
making most patients feel relaxed and comfortable. The application of heat
promotes healing by stimulating circulation, which is needed to supply
nutrients and oxygen or remove debris and chemical toxins. Either heat or
cold can reduce pain by acting as a counterirritant.
By reducing tissue viscosity, heat discourages collagen fibers from
adhering to each other during the healing process. The intersection points
between normal collagen fibers crisscrossing over the top or bottom of each
other are not attached because distance and lubrication separate the fibers
during movement. When collagen fibers adhere to each other at intersection
points, or if they connect tissues that should not be connected, flexibility is
reduced and moderate stress may cause tearing. Though heat and cold both
relieve pain and spasm, most patients seem to prefer heat over cold. Unlike
cold, heat also reduces joint stiffness and stimulates circulation.
Common methods for applying therapeutic heat include silicon gel
packs, whirlpools, paraffin baths, and infrared light. Since moist air
conducts heat more rapidly than dry air, moist heat is generally more
penetrating than dry heat. Certain electric heating pads produce moist heat
by trapping vapor that escapes from the body during the heating process.
Heat applications are normally 10 to 20 minutes in length.
Many patients find that soaking in a hot bath (100°-104°F) produces
feelings of relaxation and well-being. These effects are more psychological
than physical or physiological. Temperatures high enough to increase tissue
extensibility are normally between 105° and 110°F. These temperatures are
very hot and difficult for most people to tolerate. Tissue damage and pain
start when internal tissue temperatures reach 113°F.
For patients who can tolerate temperatures between 105° and 110°F,
the benefits beyond general relaxation are (1) reduction of pain and spasm,
and (2) greater tissue extensibility. Therapeutic stretching while patients are
still immersed in hot water is more effective than stretching after they start
to cool off. Except for psychological changes, the benefits of stretching a
patient after tissue temperatures return to normal are minimal.
Soaking in hot water on a continuous basis can produce adverse
effects. On the positive side, by lowering tissue viscosity, heat increases
tissue extensibility and decreases resistance to stretch. This makes it easier

106
for patients to attain full range of motion with less force. When tissues are
heated, stretched, and then allowed to cool while still extended, tissue
damage is less and increases in length tend to become permanent.
On the negative side, most patients do not stretch after soaking in hot
water and tissues cooled at or below resting length have a tendency to
remain short and become more resistant to active or passive stretch. This
tendency relates to a property found in thermoplastics called set. If soaking
in hot water is used as a long-term method of pain relief, range-of-motion
stretching should be used to lengthen tissues while the body cools to reduce
the risk of increasing stiffness or pain because of thermoplastic set.
Some patients report excellent results soaking in a hot bath before and
after range-of-motion stretching. Soaking before stretching decreases tissue
viscosity, increases tissue extensibility, and reduces general stiffness.
Soaking after stretching reduces general body soreness. For patients
recovering from soft-tissue injuries involving stiffness more than pain, a
good routine is (1) soak in a hot bath for 20 minutes, (2) stretch the injured
body part, (3) ice the injured body part if needed, (4) soak in a hot bath
within 24 hours after stretching, and (5) hold the injured body part in a
stretched position until the body feels cool. Soaking in a hot bath for about
20 minutes and then doing low-back exercises that stretch and strengthen
muscles at the same time may also produce good results.
The contraindications for heat are malignancy, infection, bleeding,
inflammation, vascular insufficiency, edema, burns, fever, tuberculosis,
general weakness, compromised local circulation failure, and debilitating
conditions such as heart disease. Heat is contraindicated for patients who
are insensitive to pain or unable to communicate the feeling of pain.
Indications for Heat

1 Hypertonicity
2 Pain
3 Contractures
4 Vascular stasis
Conversion Information
Fahrenheit scale: freezing 32°F — boiling 212°F
Centigrade scale: freezing 0°C — boiling 100°C
Conversion formulas:
°C = 5/9 (°F - 32) and °F = (9/5°C) + 32

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Cold or Heat
Cold decreases bleeding by causing vasoconstriction. If pain, edema,

and subcutaneous bleeding are present, cold is safer to use than heat. Heat
causes vasodilation and stimulates circulation. While cold is normally
recommended for acute inflammatory conditions, chronic inflammatory
conditions, such as chronic low back pain, often react favorably to heat.
Even though the term inflammatory is used, chronic inflammatory
conditions are not characterized by heat, redness, and edema. Since chronic
inflammation occurs after the acute phase of injury and is characterized by
pain, loss of function, and new connective-tissue formation, treatments
appropriate for subacute or chronic injuries may also be appropriate for
chronic inflammation. The possible beneficial effects of heat on chronic
inflammation include (1) reduction of ischemic pain, (2) removal of pain
mediators, and (3) elevation of the pain threshold.
Where time is a factor and subcutaneous bleeding is not present, heat
reduces muscle spasm faster than cold. Heat works by reflex effect on the
gamma system and requires only enough time for shallow penetration. Deep
cold works by slowing nerve-conduction velocities and requires enough time
for deep penetration. As nerve temperatures—not surface temperatures—
approach 50°F, nerve-conduction velocities begin to drop.
Unlike deep cooling that requires about 20 minutes and slows nerve-
conduction velocities, superficial cooling requires 10 minutes or less and
produces reflex effects. When very briefly applied for about 30 seconds, ice
can trigger a stretch reflex that aggravates spasm and makes treatment even
more difficult. When applied for about 10 minutes, ice can generate a reflex
effect that decreases tonus in underlying muscles even though cooling is
largely superficial.
Creating the best environment for wound healing requires a delicate
balance between (1) early treatment and (2) protecting injured body parts.
During the acute phase of an injury, body parts need rest and cryotherapy
can be used to reduce inflammation by reducing tissue metabolism. Once
swelling, inflammation, and subcutaneous bleeding are no longer present,
cryotherapy and gentle stretching (passive mobilization) can be used to
promote wound healing.
For good results, cold should be applied as soon as possible to acute
injuries. Even though cold can prevent swelling or reduce the rate of
swelling by decreasing metabolism and lowering vascular permeability, once
swelling has occurred, cold will not reduce swelling. Since swelling has

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normally stopped by the time an injury reaches the subacute phase, cold
applied to subacute injuries will have little or no effect on swelling.
The two basic ways to reduce swelling are (1) elevation, and (2)
compression. If swollen body parts are elevated above the heart, gravity
causes a decrease in capillary hydrostatic pressure that reduces swelling.
Compression reduces swelling by encouraging the reabsorption of fluid.
When cold and compression are used together, the cold prevents swelling
and the compression reduces any existent swelling.
Since mobilization that begins too early can retard wound healing by
increasing inflammation or disrupting newly-formed connective tissue,
injured body parts should be rested during the initial phase of an injury.
Once inflammation is no longer present and tissue integrity is partially
restored, injured body parts should be passively mobilized to improve tissue
alignment, strength, and flexibility. Passive mobilization will also improve
arterial, venous, and lymphatic circulation.
Passive mobilization that begins too late may increase the occurrence
of adhesions or contractures that decrease ROM. Because of pain, many
patients resist having injured body parts mobilized when movement would
be beneficial. Even if signs of inflammation are not present, significant pain
that starts while a body part is being mobilized and then gets progressively
worse may indicate injured tissues are not ready for movement.
Cold is preferred when treating conditions with inflammation, such as
myositis or tendonitis, because it reduces three types of secondary damage:
(1) secondary hypoxic damage that results from swelling and ischemia, (2)
secondary damage that results from leukocyte migration, and (3) secondary
damage that results when enzymes are released from lysosomes.
Heat should not be used until the vascular system is functional and
swelling and subcutaneous bleeding have stopped. If swelling is present and
heat increases edema, the excess fluids that accumulate in the interstitial
extravascular spaces can restrict blood flow and cause secondary ischemic or
hypoxic damage. If bleeding is present, heat may increase hemorrhage.
Since cold causes vasoconstriction that decreases circulation and
blood flow to injured tissues, continuing cryotherapy beyond the acute phase
can retard wound healing. If swelling or bleeding is not present, heat will
accelerate wound healing by causing vasodilation that increases blood flow
and delivers more oxygen to the injured tissues. Heat also promotes
lymphatic circulation, which is needed to remove tissue debris from injuries.
Heat seems to relieve the dull aching pain that often accompanies subacute
sprains and chronic low back pain more effectively than cold.

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Cryostretch or Thermostretch
Even when LBP is subacute, the guidelines for when to use heat or
cold for stretching are not always clear. Both heat and cold facilitate ROM
stretching, but the reasons for using them are quite different.
If pain is the main limiting factor, cryotherapy can be used to reduce
pain and prepare tissues for stretching. If tissue extensibility is the main
limiting factor, thermotherapy can be used to increase tissue extensibility
and prepare tissues for stretching. If pain and tissue extensibility are both
limiting factors, cryostretch (alternating cold applications with stretching) is
used before thermostretch (alternating heat applications with stretching).
If spasm is the main limiting factor, cryotherapy or thermotherapy can
be used to reduce spasm and prepare muscles for stretching. Since the risk
of subcutaneous bleeding is always present during spasm, cold packs or cold
(iced) towels are preferred over heat when treating restrictive spasm. To
make a cold towel: soak a towel in water and then freeze the towel.
In the absence of swelling, bleeding, spasm, or joint dysfunction, the
main factors that restrict passive ROM are usually restrictive adhesions or
contractures. Whereas cold increases connective tissue viscosity (stiffness)
and resistance to stretching, which makes it easier to break adhesions, heat
decreases tissue viscosity and resistance to stretching, which makes it easier
to permanently lengthen connective tissue without causing tears or ruptures.
Thermotherapy is sometimes preferred when dealing with chronic
injuries where connective tissue restrictions are the main factors that limit
the patient’s range of motion. Even though not as effective as cold, heat can
be used effectively to reduce pain and spasm. Heat has a tendency to relax
patients more than cold, and most patients seem to prefer heat over cold.
When preparing patients for active-assisted ROM stretching during
the subacute phase of an injury, cold is normally preferred over heat. Cold
reduces pain more effectively than heat, and it also helps prevent edema.
Treating injured body parts with an ice pack or a cold towel after ROM
stretching can help reduce pain or edema that occurs because of stretching.
Ice packs applied for 20 to 30 minutes relieve pain by analgesia, not
anesthesia. Unlike anesthesia, which produces a partial or complete loss of
sensation, analgesia reduces the patient’s sensibility to pain because painful
(nociceptive) stimuli are perceived but are not interpreted as pain. Heat can
relax hypertonic tissues by acting as either an analgesic or sedative.
While cold-induced analgesia can be used safely to facilitate exercise,
cold-induced anesthesia is not recommended because it prevents the body

110
from sensing movements that may cause tissue damage. When cold-induced
anesthesia (cryoanesthesia) is used to prepare patients for surgery, body
parts become insensitive to pain as temperatures approach freezing.
Contrast Bath or Cryokinetics
Contrast applications produce large changes in body temperature that

range from hot at one extreme to cold on the other. The cycle for treatment is
normally 4 minutes of heat (104°F) followed by 1 minute of cold (55°F). This
cycle is repeated four times, always starting with heat and ending with cold. At
the same time that contrast applications improve circulation, reduce edema,
increase local metabolism, and hasten healing, they also act as a tonic and a
neuromuscular stimulant. This creates a problem in terms of soft-tissue
manipulation since modalities that relax muscles are more conducive to soft-
tissue manipulation than modalities that stimulate muscles.
A second problem with contrast applications relates to exposure. Four
minutes of heat is not long enough to increase tissue extensibility, and 1 minute
of cold will not produce analgesic effects. Though frequently acclaimed as one
of the most potent procedures in hydrotherapy, the ability of contrast
applications to prepare the body for manipulation is limited. At best, contrast
applications, such as a contrast bath, reduce muscle spasm and relieve pain by
improving circulation and reducing edema.
Cryotherapy followed by exercise (cryokinetics) is possibly a better way
to stimulate circulation than a contrast bath. A normal sequence for
cryokinetics is (1) chill the affected body part for 20 minutes, and (2) exercise
slowly and smoothly with moderation until the body part is rewarmed. This
should take less than 40 minutes, since rewarming without exercise normally
takes about twice as long as cooling. The exercises should not be painful.
Even though cold does not seem to affect proprioception or agility, cold
increases viscosity and decreases tissue extensibility. A short stretching warm-
up will decrease joint stiffness and increase tissue extensibility. The stretching
should be done long enough to give tissues time to lengthen. If chilling
decreases strength because of decreases in neurologic efficiency, warm-up
stretching will increase strength by increasing neurologic efficiency.
Cryostretching can be used to prepare body parts for cryokinetics.
While using a contrast bath may produce a vascular pumping action, as
sometimes suggested, the pumping action produced by exercise is more
efficient because of more pumping cycles per hour. The pumping cycle for a
contrast bath begins with 4 minutes of heating and ends with 1 minute of

111
cooling. This produces 12 pumping cycles per hour. The pumping cycle for a
muscle begins with contraction and ends with relaxation. One muscle can
produce hundreds of pumping cycles per hour, and several muscles working
together could produce thousands of cycles per hour.
Lymph is a clear, colorless, or slightly yellow fluid that flows through
lymphatic vessels called lymph nodes. Since the lymphatic circulation is more
responsive to muscular activity than to hot or cold, exercise following 20
minutes of ice is more likely to stimulate lymphatic flow than a contrast bath.
Lymph flow can be stimulated after exercise by using manual pressure to
produce stroking or pumping movements in the direction of lymph flow.
Hot-to-Cold Stretch
Rather than being stretched after heating pads or silicon gel packs are
removed, tissues can be stretched while heating devices are held in place by
loosely wrapped elastic bands. This method prevents tissues from cooling
during the stretching process. Body parts can also be stretched while still
immersed in hot water.
Once stretching is complete, apply ice and hold the stretch at
maximum length until the affected tissues cool. Using heat to decrease
viscosity during stretching and ice to increase viscosity after stretching will
encourage tissues to remain at maximum length. In thermoplastics, the
tendency for the length during cooling to become the permanent length is
called set. Thermoplastics and viscoelastic materials like muscles often
behave in similar ways. The normal protocol for a hot-to-cold stretch is:
1. Apply moist heat for about 15 to 20 minutes.

2. Stretch tissues while heating devices are still in place.
3. Hold stretch and apply cold for about 15 to 20 minutes.
4. Release tension when tissues are cold.
5. Allow patient to rest for about 5 minutes without moving.
Deep Heat (Ultrasound)
Superficial heat penetrates tissue about 3 cm (1.2 in) and affects deep
tissue by producing reflex effects, whereas deep heat penetrates about 6 cm
(2.4 in) and affects deep tissue by elevating tissue temperatures. While both
types of heat increase tissue extensibility and relieve stiffness, superficial
heat reduces low-back spasm faster and more completely than deep heat.

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Basic Protocol
Basic Protocol for Using Cold or Heat
1. When treating injuries, use cold until hemorrhage and swelling

stop (usually about 24 to 72 hours) and then use heat.
2. When using cold or heat to restore normal function:
• If pain is present, use cold to relieve pain.

• If pain is not present, use heat to increase tissue extensibility.
3. To relieve chronic aches and pain, use heat.
Heat-Induced or Cold-Induced Pain
Despite the therapeutic effects, heat or cold may cause pain.

Overheating can upset the body's electrolyte balance and cause fatigue or
cramps. Temperatures above 113°F may cause tissue damage and pain. If a
patient’s skin is extremely sensitive to painful stimuli (hyperalgesic), the
threshold for pain may be lower than 113°F. On the opposite side, some
patients report that air conditioning is cold enough to chill muscles and
cause low back pain.
Cold produces pain in two ways: (1) vasoconstriction causes a
decrease in blood flow and ischemic pain, and (2) increases in tissue tension
and viscosity cause an increase in stiffness and joint pain. For pain to occur,
the temperatures must be cold enough to induce pain, but not cold enough to
cause analgesia. Cold and damp weather seem to increase muscle aches and
joint pain, whereas warm and dry weather seems to decrease pain.
Cold-induced pain is one of the main reasons practitioners give for not
using cryotherapy. While most patients seem to agree that cold causes more
discomfort than heat, many patients are willing to endure the pain if they
clearly understand the benefits of using cold instead of heat. There appears
to be a mental or physical adaptation to cold, since many patients report that
cryotherapy is less painful after the first or second session.

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EFFECTS OF COLD OR HEAT
The following tables summarize the effects of cold and heat.
NORMAL EFFECTS OF CRYOTHERAPY
1. Vasoconstriction ------------------------------------------ cold only

2. Decrease in local metabolism --------------------------- cold only
3. Decrease in local circulation----------------------------- cold only
4. Decrease in edema ---------------------------------------- cold only
5. Decrease in inflammation -------------------------------- cold only
6. Decrease in tissue extensibility ------------------------- cold only
NORMAL EFFECTS OF THERMOTHERAPY
1. Vasodilation ----------------------------------------------- heat only

2. Increase in local metabolism ---------------------------- heat only
3. Increase in local circulation ----------------------------- heat only
4. Increase in edema ----------------------------------------- heat only
5. Increase in inflammation --------------------------------- heat only
6. Increase in tissue extensibility -------------------------- heat only
NORMAL EFFECTS OF CRYOTHERAPY OR THERMOTHERAPY
1. Reduce hypertonicity ---------------------------------- cold or heat

2. Reduce pain --------------------------------------------- cold or heat

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Vibration
Vibration relaxes muscles, relieves pain, increases lymphatic and

venous circulation, and decreases sympathetic activity. The most effective
way to administer vibration is by using mechanical devices that produce an
oscillatory (back-and-forth) movement. Vibrators that produce a percussion
effect by moving up and down may cause tissue damage. Mechanical
vibration is more effective and less tiring than manual vibration.
When patients cannot tolerate compression or stretching because of
pain, vibration can be used to desensitize the offending tissues. Vibration
reduces pain in three ways (1) large-fiber inputs block out the deep pain that
is transmitted by small-fiber inputs, (2) prolonged vibration at frequencies
below 75 Hz (hertz) inhibits the muscle spindles and causes relaxation, and
(3) activation of pacinian corpuscles may cause a decrease in muscle tonus
and pain, especially at frequencies near 60 Hz.
At frequencies above 100 Hz, vibration of a normal muscle facilitates
muscle spindles and causes contraction. If high-frequency vibration (100 to
150 Hz) is used to facilitate an agonist, the antagonist may relax because of
reciprocal inhibition. When hypertonic muscles are treated with vibration,
the belly of the muscle should be slightly stretched before vibratory stimulus
is applied, and the frequency should be about 60 Hz.
By improving venous and lymphatic circulation, vibration reduces
edema and hastens resolution of inflammation. To relax muscles and relieve
pain, vibratory treatments should be at least 3 minutes long. Treatments less
than 3 minutes may stimulate more than sedate.
Practitioners using mechanical hand-held vibrators for long periods of
time may experience musculoskeletal problems themselves. There are no
standards for acceptable levels of exposure, but people using hand-held
vibrators should take frequent breaks and avoid positions that cause fatigue
or discomfort. For general safety, vibrators should not exceed 150 Hz.
Vibration can be very effective when used on the paraspinal muscles,
gluteals, quadriceps, hamstrings, gastrocnemius, soleus, or pectoralis major.
Besides reducing pain and increasing flexibility or circulation, mechanical
vibration can help some patients relax, which makes ROM stretching easier.
Contraindications for vibration include: inflammation, heart disease,
open lesions, blood clots, hemorrhage, infection, malignancy, cerebellar
dysfunction, infants, and overly sensitive or inelastic skin. Applying
mechanical vibration with too much downward pressure can increase the risk
of tissue damage and decrease the frequency of vibration.

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CHAPTER HIGHLIGHTS
THE ACRONYM RICE EMPHASIZES FOUR STEPS
Rest protects the injury and prevents further trauma.

Ice reduces circulation and inflammation (pain and swelling).
Compression increases hydrostatic pressure outside the blood vessels.
Elevation reduces hydrostatic pressure inside the blood vessels.
ICE MASSAGE METHOD FOR TREATING TRIGGER POINTS
• Stroke several times across the trigger points with ice.

ICE PRESSURE METHOD FOR TREATING TRIGGER POINTS
• Apply light pressure with ice until numbness occurs.

• Apply moderate pressure with ice until trigger points are neutralized.
• Remove pressure on the trigger point slowly.
• Apply moist heat for several minutes to rewarm tissues.
• Have patient complete 3 repetitions of active range-of-motion stretching.
FOUR INDICATIONS FOR COLD
• Hypertonicity
• Pain
• Edema
• Trauma
FOUR INDICATIONS FOR HEAT
• Hypertonicity
• Pain
• Contractures
• Vascular stasis

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FIVE STEPS FOR A HOT-TO-COLD STRETCH
• Apply moist heat for about 15 to 20 minutes.

• Stretch tissues while heating devices are still in place.
• Hold stretch and apply cold for about 15 to 20 minutes.
• Release tension when tissues are cold.
• Allow patient to rest for about 5 minutes without moving.
BASIC PROTOCOL FOR USING COLD OR HEAT
• Use cold until hemorrhage and swelling stop (usually about 24 to 72

hours) and then use heat.
• If pain is present, use cold to relieve pain.
• If pain is not present, use heat to increase tissue extensibility.
• To relieve chronic aches and pain, use heat.
SIX NORMAL EFFECTS OF COLD
• Vasoconstriction
• Decrease local metabolism
• Decrease local circulation
• Decrease edema
• Decrease inflammation
• Decrease tissue extensibility
SIX NORMAL EFFECTS OF HEAT
• Vasodilation
• Increase local metabolism
• Increase local circulation
• Increase edema
• Increase inflammation
• Increase tissue extensibility
EFFECTS OF COLD OR HEAT
• Reduce hypertonicity and reduce pain

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MANIPULATION
Manipulation is the therapeutic use of manual force, which is usually

applied by using the hands or elbows. Most of the manipulations used in
soft-tissue therapy are low-velocity pushing or pulling movements directed
at tissues such as muscles, tendons, ligaments, fascia, or joint capsules.
Soft-tissue therapy is broadly defined as manipulation of soft tissue
for therapeutic purposes, with or without modalities or exercise, and it can
be curative or palliative. Even though soft tissue refers to any tissue that is
not bony (osseous), soft-tissue therapy can affect posture, joint space, and
skeletal alignment, and it may cause joints or joint capsules to pop or crack.
Soft-tissue therapy is used for treating soft-tissue impairments, which
are soft-tissue defects or dysfunctions that are usually characterized by pain,
limited ROM, and weakness. Some soft-tissue impairments (hypermobility)
are not always painful and may have a greater than normal ROM.
When properly used, soft-tissue therapy creates conditions that allow
the body to heal itself. Basic guidelines are using the least amount of force
needed to accomplish your goals and do the patient no harm.
The four basic types of manipulation used in soft-tissue therapy are
trigger point therapy, neuromuscular therapy, connective tissue therapy and
range-of-motion stretching. These four types of manipulation, which are all
noninvasive, address the four types of tissue found in the human body:
epithelial tissue, muscle tissue, nerve tissue, and connective tissue.
A muscle imbalance can be defined as a disparity between the length
and strength of opposing muscles. This implies that at least one of the
opposing muscles is abnormally short, abnormally weak, or has an abnormal
resistance to passive stretch. Factors that may cause greater than normal
resistance to passive stretch (stiffness) include proliferation of connective
tissue (fibrosis) or spasm (hypertonicity). Factors that may cause less than
normal resistance to passive stretch include neurologic or metabolic defects.
Soft-tissue therapy can be defined as the process of restoring normal
function by correcting soft-tissue impairments and allowing the body to heal
itself. When viewed as a problem-solving process, the first part of soft-
tissue therapy involves identifying the problem (medical history and
physical evaluation), and the second part involves solving or treating the
problem (modalities, manipulation, and exercise). The effects produced by
soft-tissue therapy can be local, such as relaxing a hypertonic muscle in the
arm, or global, such as increasing lymphatic circulation or activating the
autonomic (sympathetic or parasympathetic) nervous system.

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Manipulation of superficial tissue can also produce psychological
effects such as general relaxation and a sense of well-being. Psychological
effects are possibly related to a decrease in muscle tension or the release of
endogenous opioids such as endorphins or enkephalins. Most patients report
that human touch is psychologically more satisfying than mechanical touch
and that slow rhythmic movements, such as slow rhythmic traction, are more
relaxing than rapid movements that lack consistency or regularity.
One way soft-tissue manipulation creates an environment that allows
the body to heal itself is by helping people resume their normal activities as
soon as possible. When dealing with common low back pain, it is well
established that people who resume their normal daily activities as soon as
possible have less disability and a better chance at full recovery.
Inactivity that continues after the acute phase of any injury can lead to
deconditioning, atrophy, contractures, adhesions, and venostasis. Since the
lymphatic system is passive and depends on active or passive movement to
stimulate circulation, inactivity can reduce lymphatic circulation faster than
it decreases venous circulation, which may cause edema and fibrosis.
After the soft-tissue impairments that prevent normal movement have
been resolved, such as a muscle imbalance, the sequence for encouraging
movement and restoring normal functions has three progressive stages: (1)
passive movement, (2) active-assisted movement, and (3) active movement.
Practitioners are responsible for sequencing manipulations to produce
the best possible outcomes. The typical sequence in soft-tissue therapy is (1)
trigger point therapy to reduce pain, (2) neuromuscular therapy to inhibit
hypertonic muscles or facilitate weak muscles, (3) connective tissue therapy
to lengthen adaptively shortened tissues or break restrictive adhesions, and
(4) range-of-motion stretching to improve muscle tonus, lengthen restricted
tissues, and produce a normal range of motion. A competent practitioner
should be skilled in all four methods of manipulation and flexible enough to
modify the sequence based on positive or negative feedback from patients,
observation of clinical signs or symptoms, and practical experience.
Improvements in mobility after manipulation are caused by several
different factors: (1) reduction of pain can decrease pain inhibition and pain
avoidance, (2) neuromuscular inhibition can decrease resistance to passive
stretch, (3) neuromuscular facilitation can strengthen weak muscles, and (4)
stretching contractures or breaking adhesions can increase range of motion.
Manipulation can also have psychological benefits, such as improving
people’s outlook on life by showing them that a full recovery is possible and
giving them the confidence they need to resume normal daily activities.

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Soft-tissue therapy is based on scientific principles called axioms or
laws, and these principles explain and simplify the logic behind soft-tissue
therapy. The following principles are widely accepted by medical science.
Some laws that were once accepted, such as Pflüger’s law of radiation and
the Arndt-Schultz law, are no longer considered valid.
The Principles of Soft-Tissue Therapy
The HEMME Approach is based on three fundamental principles:
HEMME’s 1st law: Most conditions treatable by soft-tissue therapy are

characterized by pain, limited range of motion, or weakness.
Most soft-tissue impairments cause a decrease in ROM, but a few cause

an increase in ROM, such as weakness in muscles, ligaments, or fascia that
stabilize a joint or compensatory hypermobility because of hypomobility.
HEMME’s 2nd law: Most conditions treatable by soft-tissue therapy can

be identified and treated by using five basic steps: History, Evaluation,
Modalities, Manipulation, and Exercise.
HEMME’s 3rd law: Always be ready, willing, and able to disregard any
law, principle, axiom, or belief that proves to be incorrect.
Ten other principles that apply to soft-tissue therapy include:
1. Beevor's axiom: The brain knows nothing of individual muscles,

but thinks only in terms of movement.
2. Creep: Deformation of viscoelastic materials when exposed to a

slow, constant, low-level force for long periods of time.
3. Facilitation-Inhibition:
A. When a nerve impulse passes once through a set of neurons to

the exclusion of other neurons, it usually takes the same path in
the future and resistance to the impulse becomes less.
B. As opposites, facilitation encourages a process and inhibition
restrains a process.

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4. Head's law: If painful stimulus is applied to areas of low sensibility
in close central connection with areas of high sensibility, pain may be
felt where sensibility is high.
5. Hilton's law: The nerve trunk that supplies a joint also supplies the
muscles that move the joint and the skin that covers the insertions of
the muscles that move the joint.
6. Hysteresis: Energy loss and a change of shape in viscoelastic

materials subjected to stress or to cycles of loading and unloading.
7. Sherrington's laws:
A. Every posterior spinal root nerve supplies one particular region

on the skin, although fibers from segments above and below
can invade this region.
B. Reciprocal Inhibition: when the agonist receives an impulse to
contract, the antagonist relaxes.
C. Irradiation: nerve impulses spread from a common center
and disperse beyond the normal path of conduction.
Dispersion tends to increase as the intensity of stimulus
becomes greater.
8. Sherrington's reflex: A muscle contracts in response to passive

longitudinal stretch. (also called stretch reflex or myotatic reflex)
9. Thixotropy: Certain gels liquefy when agitated by factors such as

high-repetition stretching exercises and revert to gel upon standing.
10. Wolff's law: Bone and collagen fibers develop a structure most
suited to resist the forces acting upon them.
One law that is now considered obsolete is the Arndt-Schultz law:

weak stimulus causes activity, moderate stimulus increases activity, strong
stimulus retards activity, and very strong stimulus stops activity. While this
law seems to describe the sequence that occurs when digital pressure is
applied to an active trigger point—increasing pressure will increase pain
until numbness occurs—if pressure is applied to a point where inflammation
or infection is present, the pain will probably not change to numbness.

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Soft-Tissue Therapy
Regardless of which muscle imbalances are causing or perpetuating a

lumbopelvic disorder, the soft-tissue impairments are usually the same—
trigger points, hypertonicity, hypotonicity, hypermobility, hypomobility,
restrictive adhesions, contractures, and nerve or vascular compression—and
the treatments are the same: (1) trigger point therapy, (2) neuromuscular
therapy, (3) connective tissue therapy, and (4) ROM stretching.
The problems caused by soft-tissue impairments include pain, pain
inhibition, pain avoidance, stiffness, instability, weakness, or mental stress.
Soft-tissue impairment may cause or be caused by inflammation—which is
characterized by pain, redness, edema, and loss of function—or start a pain
cycle that perpetuates or starts other pain cycles.
In most books on manual therapy, spasm is defined as the involuntary
contraction of a muscle beyond physiologic needs. This differs from classic
definitions, which usually define spasm as a sudden involuntary contraction.
Most muscles in spasm are tender when stretched or compressed and they
may have trigger points that cause a sudden or gradual increase in tonus.
Hypertonicity can increase a muscle’s resistance to active or passive
stretch without changing the muscle’s length. If this occurs, inhibition and
slow local stretching can be used to decrease tonus and reset proprioceptors.
This method is less likely to cause a permanent increase in the muscle’s
length than range-of-motion stretching. Permanently lengthening a muscle
beyond normal may cause hypermobility, weakness, or instability.
Most contractures increase a muscle’s resistance to active or passive
stretch and shorten the muscle. Since contractures are often caused by the
pathologic shortening of a muscle due to fibrosis, ROM stretching—which
can increase the muscle’s length and decrease tightness at the same time—is
usually a good option. If spasm is present, inhibition techniques followed by
ROM stretching will reduce hypertonicity and lengthen the muscle.
Some contractures are caused by the adaptive shortening of (1) dense
regular connective tissue such as ligaments and tendons, (2) dense irregular
connective tissue such as joint capsules and dermis, or (3) loose irregular
connective tissue such as superficial fascia, deep fascia, and muscle sheaths.
Adaptive shortening occurs when connective tissues are immobilized, and
decreases in water content or ground substance let adjacent collagen fibers
approximate and form microscopic cross-links. These cross-links, which
increase resistance to passive stretch, can be broken by local stretching or
by ROM stretching. Gradual stretching is safer than rapid stretching.

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Immobilization can affect both muscle tissue and connective tissue. If
muscles are immobilized in a shortened position for five days, connective
tissues in the muscle’s belly will increase and sarcomeres will decrease. If
fibrosis and a loss of sarcomeres continues, resistance to active or passive
stretching will increase and the muscle will atrophy, shorten, and weaken.
If an immobilized muscle loses normal function because of a decrease
in flexibility or strength, ROM stretching, neuromuscular facilitation, and
exercise are the best ways to restore normal function. In most cases, active
movements increase protein synthesis, muscle mass, the oxidative capacity
within fibers, muscular strength and endurance, and joint mobility.
When ROM stretching is used, care must be taken not to overstretch
tissues and cause severe microtrauma, tearing or rupture. This could trigger
a pain cycle that increases adaptive shortening because of muscle guarding
(pain inhibition or pain avoidance) or muscle splinting (reactive spasm).
Overstretching can be caused by active or passive stretching, and any
trauma that results can change the patient’s condition from chronic to acute.
Chronic lumbopelvic disorders are classified as acute when inflammation is
present, regardless of when the pain started, and subacute or chronic after
the inflammation has been resolved. Chronic implies the granulation phase,
fibroblastic phase, and maturation phase of wound healing are complete.
Other than cryotherapy and possibly light touch, there is very little
you can do during the inflammatory phase. If swelling is not present during
the granulation phase, heat can be used to increase circulation, which may
accelerate wound healing. Using gentle stretching (mobilization) may help
to improve the quality of scar tissue being formed during the fibroblastic or
maturation phase, and further stretching after the maturation phase can be
used to correct any soft-tissue impairments that developed during the
wound-healing process. Failure to recognize that lumbopelvic disorders can
change quickly from chronic to acute often leads to inappropriate treatment.
Another problem that can lead to inappropriate treatment is failure to
realize that even though inflammation may be present, there will probably be
parts of the body that are not affected by inflammation. While treating
inflamed tissues with rest, ice, compression, or elevation (RICE) can be
useful at times, treating a body part not affected by inflammation can be
counterproductive. As a guideline, inflammation starts shortly after trauma
occurs and continues for about 24 to 72 hours unless further trauma occurs.
Proliferation of connective tissue starts after the inflammatory phase
and then continues until tissues reach the maturation phase and heal. Since
most new collagen fibers are not as strong or as well arranged as mature

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fibers, passive mobilization can be used to align, lengthen, and strengthen
new fibers. Using rest instead of mobilization increases the risk of having
restrictive adhesions, contractures, or weak and poorly formed scar tissue.
Mobilization combined with kneading massage and heat can reduce spasm
and accelerate healing by improving circulation. Most myofascial injuries
heal in about 6 weeks and most ligamental injuries heal in about 12 weeks,
but the time between injury and healing is subject to wide variations.
Treating lumbopelvic disorders is mostly a matter of being able to
identify and correct muscle imbalances. The basic steps are (1) reduce pain,
(2) lengthen abnormally short muscles, and (3) strengthen abnormally weak
muscles. The types of therapy that are used to achieve these goals are
trigger point therapy, neuromuscular therapy, connective tissue therapy, and
ROM stretching. Therapy must never disrupt the healing process or cause a
permanent loss of function. The primary uses for each type of therapy are:
• Trigger point therapy: neutralize trigger points and reduce pain.

• Neuromuscular therapy: reduce hypertonicity and strengthen muscles.
• Connective tissue therapy: release adhesions or lengthen contractures.
• Range-of-motion stretching: lengthen abnormally short tissues.
These methods of therapy also have secondary functions: trigger

point therapy can reduce hypertonicity, neuromuscular therapy can reduce
pain and lengthen or shorten muscles, connective tissue therapy can reduce
pain and lengthen muscles or fascia, and ROM stretching can reduce pain,
increase joint space, reset proprioceptors, and stretch or break adhesions.
Patients need to understand that therapy can be painful. Trigger point
therapy is almost always painful, and ROM stretching can be painful. The
best ways to minimize pain are (1) use the least amount of force necessary to
achieve your goals, (2) apply force as slowly as possible, (3) remove force as
slowly as possible, (4) use ice to reduce the pain before you apply force, (5)
use heat to increase tissue extensibility before you apply force, and (6) stop
therapy if patients report high levels of pain or stress.
Tell patients that even if they feel no pain during therapy, they may
feel pain or discomfort 24 hours later. This type of delayed-onset pain may
last for several days. If pain becomes intense, patients should be advised to
seek immediate medical attention. Severe pain 24 hours after therapy may
indicate that too much force or too much stretching was used during the
patient’s last session. During the early stages of therapy, keeping patients
active is often more important than trying to restore normal function.

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Compensatory Stress
Most lumbopelvic disorders involve compensatory changes. If two

opposing muscles are working together as a pair and the agonist goes into
spasm and shortens, the antagonist may try to compensate by lengthening.
For example, if the quadriceps (thigh flexors) shorten because of spasm, the
hamstrings (thigh extensors) may compensate by lengthening. This creates a
muscle imbalance: one muscle is too long and the other is too short.
Both muscles may also become weak. Abnormally short muscles can
develop tight weakness because the actin and myosin myofilaments have too
much overlap and they stop producing normal tension within their range of
motion. Abnormally long muscles often develop stretch weakness because
the filaments do not have enough overlap and they stop producing normal
tension within their range of motion. Other factors such as pain inhibition,
pain avoidance, or trigger points may also cause weakness.
In addition to stretch weakness, muscles that are held in a stretched
position for a long time often become irritated because of microtrauma or
tearing within the muscle or at the musculotendinous juncture. When these
muscles are put in a slack position, they may go into spasm and shorten to
less than their normal resting length. This puts opposing muscles in a state
of contraction that is similar to cocontraction, which is where two opposing
muscles contract at the same time to make a body part or posture rigid.
A different type of compensation occurs when one spinal segment or
part of a joint becomes hypomobile and other spinal segments or parts of the
joint become hypermobile. If part of a sacroiliac joint becomes hypomobile
(limited mobility), other parts often become hypermobile (joint laxity and
excessive mobility). If this occurs, releasing restrictions may restore normal
mobility since decreasing hypomobility may also decrease hypermobility. If
left untreated, hypermobility can cause inflammation or instability.
If hypermobility causes pain or instability, the sequence for treatment
is (1) release restrictions, (2) avoid activities that cause hypermobility, and
(3) strengthen muscles that will increase stability. If a spinal segment or
joint is unstable, muscles that cross the segment or joint are probably the
ones that can increase stability. Compensatory hypertrophy, an increase in
the size of a muscle because of abnormal stress, may also increase stability.
After you treat the muscles affecting a hypermobile segment or joint,
you then treat any muscle imbalance that occurs because of hypomobility.
Some of the muscles may be too long because of the abnormal tension or too
short because of adaptive shortening. All muscles may test weak.

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Adaptive Shortening
Adaptive shortening is a tightness that occurs when a muscle remains

abnormally short for a long time. If someone with LBP develops a stooped-
over posture, the rectus abdominis often becomes slack. Since a slack
muscle tends to shorten, the rectus abdominis may adaptively shorten. If a
muscle is abnormally short, stretching exercises that lengthen a muscle will
be more effective than strengthening exercises that tend to shorten a muscle.
Adaptive shorting of connective tissue is one of the causes for contractures.
If the rectus abdominis has adaptively shortened, range-of-motion
stretching should be used until the muscle allows full extension of the spine.
Until this is done, passive resistance to spinal extension will be greater than
normal and muscles like the multifidus or erector spinae will need to work
harder than normal when they extend the spine.
Even though evidence-based research shows that doing exercises to
strengthen the rectus abdominis will not prevent LBP, many practitioners
still recommend standard sit-ups and other trunk-flexion exercises before
they evaluate the rectus abdominis for length and strength. People with
common LBP usually walk stooped over because trunk-flexor muscles like
the rectus abdominis are too short or too tight, not because they are weak.
If the rectus abdominis has normal length but is weak, strengthening
the muscle may decrease excessive anterior pelvic tilt and reduce excessive
lumbar lordosis. How much this will help patients with LBP is hard to say,
since the hip extensors also reduce anterior pelvic tilt and the correlation
between common LBP and excessive lumbar lordosis is very weak. On the
contrary, decreases in lumbar lordosis seems to correlate with common LBP
more than increases in lumbar lordosis. This could explain why trunk-
extension exercises often produce better results than trunk-flexion exercises.
Lengthening the rectus abdominis may strengthen the muscle by
reducing hypertonicity and increasing neurologic efficiency. If trunk-flexor
muscles are actively stretched by contracting trunk-extensor muscles, being
stretched and lengthened may strengthen the trunk flexors. Using the trunk
extensors to stretch the rectus abdominis will not be possible if the pelvis
will not tilt forward far enough to allow lumbar lordosis.
When the trunk flexes forward, eccentric (lengthening) contractions
by hip or spinal extensor muscles are used to reduce the velocity of forward
movement. This places a stress on the extensor muscles that often leads to
microtrauma, muscle soreness, or spasm. Perhaps the best reason for doing
flexion exercises is that trunk flexion stretches hip and spinal extensors.

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General Background
The exact causes for common (nonspecific) LBP cannot be identified.

In most cases, lab results and x-rays are not definitive and more than one
factor is causing or exacerbating the patient’s condition. When dealing with
a patient who is suffering from common LBP, bed rest is rarely needed and
early treatment that increases physical activity is usually the best option.
Since common low back pain is not a disease and it seldom results
from a known injury, it is not realistic to postpone treatment until the exact
causes for the pain can be identified. If preliminary screening evaluations
indicate there are no serious pathological findings, it is better to treat the
symptoms and try to give patients palliative relief than to do nothing. Early
treatment shows patients what they are physically capable of doing, helps
them resume their normal daily activities, and reduces long-term disability.
Common LBP can be effectively treated without knowing the exact
causes for the pain. Treatment protocols that use feedback from patients,
muscle testing, and palpation to identify and treat symptoms, such as pain, or
dysfunctions, such as a muscle imbalance, can give people dramatic relief
and help create an environment for the body to heal itself. With proper
therapy, most disc and facet problems resolve themselves without surgery.
Even though most cases of common LBP resolve themselves within 6
to 8 weeks with or without treatment, most cases that are not treated leave
unresolved problems, such as latent trigger points, tight muscles, or a weak
multifidus that may precipitate new episodes of LBP. Improper treatment,
such as not correcting soft-tissue impairments that interfere with movement
before you start an exercise program, will usually produce poor results.
When applied to LBP, acute and subacute can mean different things.
To say acute means brief, not chronic, or not severe and subacute occurs
somewhere between acute and chronic is not very helpful. Defining acute as
a time when inflammation is present and the signs of inflammation—pain,
swelling, redness, and loss of function—are visible is more practical. The
boundaries between acute and chronic are also imprecise. Chronic LBP and
visible inflammation from microtrauma often occur at the same time.
During the subacute phase, inflammation is less apparent than during
the acute phase and gentle manipulation can promote healing by improving
the quality of the wound repair. Manipulation that slowly lengthens tissues
during the wound-healing process can improve circulation, reduce pressure
on nerves that are being impinged, promote better alignment of connective
tissue, and prevent contractures or restrictive adhesions from forming.

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To say manipulation should always be started within three days is not
realistic. In some cases, using medication to relax muscles or reduce pain
and one or two days of inactivity is appropriate. Manipulation that involves
anything more than very light pressure and low levels of stress may cause
the patient extreme discomfort and disrupt the wound-healing process. Too
much tension or compression applied to areas of inflammation during the
acute phase of common low back pain may increase inflammation and retard
healing. Modalities such as cryotherapy or thermotherapy are usually safer
during the inflammatory phase of common LBP than manipulation.
The need for soft-tissue manipulation becomes especially great during
the subacute phase. If irritated joints and surrounding tissues are causing
pain or spasm, the joints and periarticular tissues will have a difficult time
healing correctly until the muscles that move the joints function normally.
Pain inhibits joint movement by causing pain inhibition, which stops
muscles from contracting normally, or pain avoidance, which stops people
from contracting a muscle or moving a joint because of pain. Muscle spasm
(hypertonicity) can shorten agonistic muscles, stretch antagonistic muscles,
increase resistance to passive stretch, cause muscle imbalance, reduce joint
space, increase joint compression, cause abnormal joint compression, and
reduce a joint's ability to absorb shock. Until pain and spasm are reduced
and muscle balance is restored, a joint will not function normally.
Even if a joint dysfunction was not the initial cause of low back pain,
muscle dysfunctions can irritate joints and lead people to believe that their
back pain was caused by a joint. If joint dysfunctions cause the initial onset
of LBP, muscle dysfunctions can perpetuate the pain, increase inflammation
of the joint, prevent healing, and escalate common low back pain to a point
where conservative treatments are no longer a viable option. If used early
and correctly, soft-tissue therapy may obviate the need for surgery.
Balancing Muscles
Most cases of common LBP are caused or perpetuated by some type

of lumbopelvic dysfunction that occurs because of irritated muscles, joints,
or discs. When these structures are irritated, typical signs and symptoms are
pain, limited ROM, and weakness, although weakness in muscles, fascia, or
ligaments may increase the ROM. Since common LBP is not caused by a
discopathy or any pathologic condition that requires immediate intervention,
the main priority for a manual therapist is to treat lumbopelvic dysfunctions,
such as muscle imbalances, which impede the body’s ability to heal itself.

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Muscle imbalances invariably occur in almost every case of common
low back pain, and a practical first step after inflammation subsides is trying
to restore muscle balance. The lumbar spine moves in six basic directions—
flexion, extension, sidebending right, sidebending left, rotation clockwise,
and rotation counterclockwise—and a muscle imbalance involving the trunk
can restrict all six directions at the same time.
The two most common muscle imbalances affecting the lumbar spine
are a flexion-extension imbalance and a sidebending imbalance. Although
lateral pelvic shift is classified as a sidebending imbalance, it also affects
rotation and it may affect flexion or extension.
The normal sequence for treating common low back pain is (1) treat
lateral pelvic shift if present and (2) treat flexion-extension imbalances. In
common low back pain, extension is usually more of a problem than flexion,
and extension problems are usually most apparent when attempting to stand
upright from a sitting or stooped-over position.
The methods for reducing lateral pelvic shift are (1) use manual force
to reposition the pelvis while the patient is standing, (2) put a bolster under
the pelvis while the patient is lying on the right or left side and let gravity
reposition the pelvis, (3) use the thighs as levers to reposition the pelvis
while the patient is supine, and (4) have the patient stand erect and sidebend
to reposition the pelvis. After the hips have been moved back into place,
hold the position until the muscles that caused the lateral pelvic shift relax.
If the hips do not shift back into place or the pain becomes too severe,
changing the angle of lumbar flexion or extension may free the hips and
relieve the pain. If the patient presents signs or symptoms that indicate a
pathologic agent might be involved, discontinue therapy until the possibility
of anything contraindicating soft-tissue manipulation has been eliminated.
Bilateral pain might be from the spine and pain that radiates below the knee
might be from spinal nerves that are irritated and then compressed by a disc.
After the lateral pelvic shift has been corrected, test sidebending in
both directions. If sidebending is normal, test rotation in both directions. If
rotation is restricted, have the patient sit on a chair, stand in front of the
patient and hold the patient’s knees between your knees, place your hands on
the patients shoulders, and gently rotate the patient to increase the ROM.
Rotation may cause audible popping. If you view intervertebral joints
as a triad—one disc and two facet joints—popping is caused by distracting
the facet joints, which causes cavitation. After a joint pops, it usually takes
about 20 minutes before it will pop again. Increasing the force you apply
just to get an audible pop that has no effect on ROM is very dangerous.

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If the muscles that cross a facet joint are relaxed, less force is needed
to separate the joints and cause a popping sound. While the popping sound
itself has no therapeutic value—other than placebo effects—separating joint
surfaces and stretching the joint capsule may produce reflex effects because
of mechanoreceptors that reduce tonicity. Stretching the paravertebrals in a
direction perpendicular to the thoracic spine may also cause joint popping.
After lateral pelvic shift, if present, has been corrected, the next step is
treating flexion-extension muscle imbalances. Trunk extension is usually
more restricted than trunk flexion, and trying to restore lumbar lordosis after
the spine is flexed can be painful. If trunk extension is restricted, people
with LBP often rise very slowly from a seated or stooped-over position.
Three muscles that can limit trunk extension are the psoas, gluteus
maximus, and hamstrings. In most cases, the psoas—a trunk flexor—is tight
and the gluteus maximus and hamstrings—trunk extensors—are weak. If
psoas tightness causes excessive anterior pelvic tilt, tension on the
hamstrings may cause stretch weakness or reactive spasm. The gluteus
maximus is often weak because of pain inhibition or trigger points, but even
when the muscle is hypertonic, the ROM can be normal. Excessive anterior
pelvic tilt may weaken the rectus abdominis because of stretch weakness.
If abnormal stress is caused by a tight psoas, the gluteus maximus and
hamstrings often become irritated and may shorten if placed in a slack
position. They may also develop tightness (greater resistance to passive or
active stretch than normal), and have trigger points or tender points.
When treating these muscles, take care not to increase their length
beyond what is needed for a normal ROM. This applies especially to the
hamstrings. You restore muscle balance by helping opposing muscles
achieve their normal ROM, not by stretching them until one or more of them
has a greater than normal ROM. Some ROM stretching or local stretching
may be needed to reset proprioceptors, but too much stretching may cause
hypermobility or instability and make it harder to balance opposing muscles.
Another flexion-extension muscle imbalance involves the piriformis,
gluteus medius, and hamstrings instead of the psoas, gluteus maximus, and
hamstrings. This syndrome seems to affect people 50 years of age or older
more than younger people, and the main cause appears to be heavy or
repetitive lifting and myofascial strain. In some cases, neutralizing trigger
points on the piriformis or gluteus medius provides immediate relief.
If this type of muscle imbalance causes a long-term increase in trunk
flexion, the psoas will have more slack than normal and it may shorten. Most
muscles left in a slack position for a long time will adaptively shorten.

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The methods for treating most muscle imbalances are usually similar:
reduce pain or tightness, lengthen abnormally short muscles, and strengthen
abnormally weak muscles. Pain can be reduced by using modalities, such as
cryotherapy or thermotherapy, neutralizing trigger points (or tender points)
with digital ischemic pressure, or reducing hypertonicity or spasms by using
inhibition techniques. Neutralizing trigger points not only reduces the pain
from trigger points, but it also helps reduce the pain from hypertonicity or
spasm and helps prevent the recurrence of pain from hypertonicity or spasm.
Lengthening abnormally short muscles can be accomplished by using
heat to increase tissue extensibility and then using local or ROM stretching
to increase length. Local stretching, which stretches part of a muscle, can be
done by pushing or pulling in a direction perpendicular or parallel to a
muscle. ROM stretching, which stretches the entire muscle, is usually done
by separating the origin and insertion (parallel stretching). In some cases
you can stretch the entire muscle by pushing or pulling the muscle’s belly in
a perpendicular direction. Local stretching can relax the entire muscle.
Local, perpendicular stretching can be applied by pushing or pulling a
muscle in opposite directions at the same time, which may create a force
couple if the forces are equal, opposite, parallel, and separated by distance.
Slow stretching usually produces a greater permanent change in the
length and less trauma than rapid stretching. If a muscle is hypertonic or in
spasm, inhibition techniques, such as post-isometric relaxation or reciprocal
inhibition, can make stretching easier and safer by reducing tonicity.
The first step in strengthening a muscle is using inhibition techniques
to reduce hypertonicity or using facilitation techniques to increase tonus in
flaccid muscles. The next step is neutralizing trigger points followed by
ROM stretching to reset proprioceptors, and the last step is using resistance
exercises to increase a muscle’s strength by increasing mass or improving
recruitment patterns. Exercise can be used to restore normal strength if a
muscle has been deconditioned by inactivity or increase strength above
normal if extra strength is needed for work or sports-related activities.
Neutralizing latent trigger points is a part of soft-tissue therapy that is
often overlooked. After a patient is capable of resuming normal activities,
use palpation and observation to search for trigger points that the patient
may not be aware of. These trigger points are capable of restarting a muscle
imbalance that leads to another episode of low back pain. Even if patients
are pain-free and appear to be fully recovered, conduct an exit evaluation to
check for soft-tissue impairments that may have been missed. In particular,
check the multifidus for trigger points, hypertonicity, and weakness.

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TRIGGER POINT THERAPY
Trigger points are hyperirritable spots or zones that trigger pain when
properly stimulated by pressure. The cause for trigger points appears to be
mechanical stress that causes macrotrauma or microtrauma. Trigger points
can present as nodules or palpable bands of tense, indurated tissue. Though
trigger points can occur in cutaneous, ligamentous, or periosteal tissue, most
trigger points occur in muscle or fascia (myofascial trigger points). Trigger
points, which are frequently associated with LBP, are often characterized by
the accumulation of metabolic by-products and oxygen deprivation.
Trigger points can produce local pain or tenderness, refer pain to other
areas, and reduce mobility by causing excessive muscle tension, pain
inhibition, or pain avoidance. The mechanisms that cause trigger points
include disruption of muscle tissue or connective tissue, local inflammation,
abnormal metabolic activity, or abnormal changes in tonicity. Contributing
factors are psychological stress, nutritional inadequacies, sleep disturbances,
postural asymmetries, abnormal temperatures, or muscle imbalances.
Trigger point therapy progresses from one trigger point to the next
until all trigger points are neutralized. Even though muscles usually become
less sensitive with each treatment, trigger point therapy should be continued
until all trigger points are neutralized. Failure to neutralize all trigger points
may cause the recurrence of common LBP. When myofascial trigger points
are present, most of the following signs or symptoms will be present:
• points or zones that are tender when pressure is properly applied

• distinct patterns of referred pain or radiated pain
• the presence of taut, indurated, or ropy bands within a muscle
• tremors or fasciculations when pressure is properly applied
• jump signs or local twitch responses when pressure is properly applied
• abnormal weakness, shortness, tightness, or spasm within a muscle
Trigger points can be palpated, but not biopsied. From all indications
they are physiological or molecular, but not cellular. In many respects they
appear to be a highly localized collection of fluids and pain-producing
chemicals such as histamine, prostaglandins, and bradykinin.
The hardness of trigger points is probably caused by spasm, edema, or
changes in tissue viscosity. This would explain the rapid change from hard
to soft when trigger points are treated with digital pressure. Digital pressure
inhibits spasm by dispersing pain-producing chemicals and reduces edema

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by compressing tissues with excessive fluid. The fact that trigger points
become soft and pliable directly after treatment makes it unlikely that
contracture, fibrous connective tissue, or fatty infiltration are the main
causes for palpable hardness.
Spasm and edema partially explain why trigger points are painful.
Spasm produces pain by causing ischemic damage and allowing noxious
metabolites such as lactic acid or adenosine diphosphate to accumulate,
while edema causes pain by causing secondary tissue damage because of
swelling and lowering the threshold to pain. By reducing spasm and edema,
trigger point therapy helps to reduce pain.
Though commonly referred to as points, trigger points are more likely
to affect zones or bands within a muscle than small discrete points within a
muscle. Sometimes large portions of a single muscle behave like a single
trigger point. Treating several trigger points within a hypersensitive muscle
will often neutralize other trigger points and relax the entire muscle.
Most trigger points produce deep aching pain rather than superficial
pain. When pressure stimulates a trigger point, the patient may recoil or
experience autonomic responses such as vasoconstriction, perspiration, or
dizziness. Autonomic responses can affect heart rate, skin temperature, and
respiration rate. Activation of trigger points may cause spasm, weakness in
surrounding muscles, involuntary tremors, or difficult breathing (dyspnea).
Trigger points can produce changes in skin temperature, as evidenced
by palpation or shown by thermograms. Temperatures higher than normal
may indicate active inflammation or rapid metabolism. Temperatures lower
than normal may indicate circulatory insufficiency or sluggish metabolism.
Spasm and edema are two of the main causes for circulatory failure in
soft tissue. High rates of metabolism and low rates of circulation produce
ischemic damage that corresponds with pain and weakness. When trigger
points are properly treated, temperatures normalize, circulation improves,
pain diminishes, and muscles become stronger. Although trigger points are
sometimes inactive for a long time, they are not self-limiting, and complete
neutralization without treatment is rare.
Locating trigger points depends on finding characteristic signs such as
(1) pain when pressure is correctly applied, (2) referred pain, (3) a jump
response, (4) a local twitch response, and (5) hardness or ropiness within a
muscle. Light pressure is usually more discriminating than heavy pressure
when locating trigger points, and light pressure can be applied by using the
fingers or thumb to compress or pinch suspect tissues. If heavy pressure is
used, the trigger point might be located and neutralized at the same time.

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Trigger points are sometimes easier to locate if muscles are stretched.
If stretching a body part produces a dull pain, palpate the stretched muscle
for trigger points. If trigger points are not found, the origin of pain might be
the joint or joint capsule. Trigger points usually produce intermittent pain,
whereas joint and capsular pain is usually present day and night.
If a patient recoils while pressure is being applied, the jump sign is
positive. If the trigger point is in a muscle, slight pressure will sometimes
cause spontaneous contraction of the entire muscle. This contraction may or
may not be strong enough to move the affected body part. A positive jump
sign combined with simultaneous radiation of pain to other parts of the body
is strong evidence of trigger point involvement.
Cutaneous tissue responses and a positive twitch response can be used
for additional verification. If skin that is pinched and pulled away from the
body feels coarse, granular, and inelastic, the cutaneous tissue response is
positive. If taut bands of indurated tissue within the muscle respond
elastically by snapping back into place after plucking the tissues like a guitar
string, the twitch response is positive. The twitch response is caused by
muscle fibers contracting in response to transverse stretching.
The amount of pressure used during palpation is critical because too
much pressure can obscure physical signs. Responses produced by light
pressure are sometimes canceled by heavy pressure that restricts tissue
movement and deadens pain. Light pressure is also more sensitive to
differences in tissue consistency than heavy pressure. In some cases, heavy
pressure will change tissue consistency before differences in tissue
compliance can be felt. In trigger point therapy, it is not uncommon for
evaluation and treatment to occur simultaneously. Even light palpation will
at times neutralize trigger points.
Muscular weakness and resistance to passive stretch are consistent
with trigger point activity, but they are not definitive because spasms,
contractures, or neurologic conditions can produce similar conditions. If
taut bands of muscular tissue caused by trigger point involvement compress
a nerve, the physical signs are similar to those caused by fibrous or
osseofibrous entrapment. In both cases, nerve conductivity may be reduced
and the patient may experience weakness, aching pain, or paresthesia. If
trigger points are indirectly causing the entrapment, trigger point therapy and
stretching should eliminate the signs and symptoms of entrapment.
Piriformis syndrome is caused by a nerve entrapment that mimics
sciatica. If spasm in the piriformis compresses the sciatic nerve, the parts of
the nerve that pass through the piriformis often become irritated and radiate

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unilateral, sciatic-like pain. Trigger points in the piriformis can refer pain to
the gluteal area but not the sacral area. Neurovascular entrapments related to
spinal stenosis produce a similar pain, but the symptoms are usually
bilateral. There seems to be a correlation between piriformis syndrome and
hypermobility of the lumbar spine.
If compressing or stretching the piriformis does not cause nerve-root
pain, have the patient sit on a chair with the knees flexed to 90 degrees and
the feet flat on the floor. If this does not cause pain, have the patient flex the
neck, fully extend the knee, and dorsiflex the foot. If this causes nerve-root
pain to radiate below the knee, the patient may have sciatica rather than
piriformis syndrome. Some people claim that sitting in a chair and using the
above neck, knee, and foot movements as an exercise reduces sciatic pain.
Satellite trigger points are trigger points activated by another trigger
point in the same reference zone. When left untreated, satellite trigger points
can become primary trigger points and develop their own satellite patterns of
distribution. Untreated satellite trigger points can also reactivate primary
trigger points that became clinically quiescent after treatment.
Secondary trigger points develop in synergistic or antagonistic
muscles because of overload. When active trigger points weaken the agonist
and make it more resistant to passive stretch, synergistic muscles
compensate for weakness in the agonist by substitution, while antagonistic
muscles work harder than normal to stretch the agonist because of passive
resistance. This creates compensatory overload that encourages secondary
trigger points to form in synergistic or antagonistic muscles. Primary,
secondary, and satellite trigger points should always be treated together.
The hamstrings, gluteus maximus, and lower paraspinals participate in
forced extension. If one muscle is treated for trigger points, the other
extensors should be checked. The psoas and rectus femoris are hip flexors,
while the gluteus maximus and hamstrings are hip extensors. If trigger
points are found in either the flexors or extensors, the opposing groups
should also be checked for trigger points.
Besides synergistic or antagonistic relationships, some muscles such
as the erector spinae and multifidus, which are on both sides of the spine,
work together as a unit. If muscles on one side are treated for trigger points,
muscles on the other side should be checked also and treated if necessary.
If decreases in lumbar lordosis and increases in thoracic kyphosis
occur at the same time, anterior trigger points that parallel the edges of the
sternum need to be treated when posterior trigger points that parallel the
spine are treated. Most patients are not aware of anterior trigger points.

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If anterior points exhibit tenderness and edema, they might be called
Chapman’s points or neurolymphatic reflex points and 15 seconds or more
of light rotary massage over these points is often more effective than the
type of light-to-moderate vertical pressure that is used to treat trigger points.
After treating points along the sternum, neutralize any trigger points that are
found in pectoralis major, which attaches to the sternum, clavicle, and ribs.
When trigger points in erector spinae or multifidus are neutralized on
one side, mirror-image pain may appear on the other side. This may happen
when two sides or two muscles function together as a unit and one side is
more affected by pain than the other side. When pain on the most sensitive
side is neutralized, pain on the opposite side becomes more perceptible.
Three factors that explain why trigger point therapy reduces pain:
(1) Digital pressure disperses pain-producing chemicals.
(2) Digital pressure stimulates production of endogenous opioids.
(3) Trigger points stimulated by pressure act as a counterirritant.
(1) When digital pressure disperses blood, lymph, and inflammatory

mediators, such as prostaglandin and bradykinin, away from trigger points,
the soft tissues affected by the ischemic pressure turn white (blanch). A
decrease in electrical conductivity while tissues are ischemic indicates that
pain-producing electrolytes, such as hydrogen or potassium ions, have been
dispersed. When digital pressure is released, blood reacts to a lower
hydrostatic pressure by reentering ischemic areas (hyperemia) and tissues
turn red (flush). Because of ischemic pressure and reactive hyperemia, the
concentration of pain-producing chemicals decreases, which reduces pain,
increases local circulation, raises oxygen levels, and promotes healing.
(2) Trigger point therapy reduces pain by stimulating the body to
produce endogenous opioids such as endorphins that affect the limbic
system and brain stem, enkephalins that affect the central nervous system,
and dynorphins that are active in the brain and pituitary gland. Endogenous
opioids produce analgesia by binding to the opiate receptor sites involved in
pain perception. Opioids produce a type of analgesia that is similar to that
produced by opiates, and the effects of both substances can be canceled by a
drug called naloxone that prevents or reverses the effects of morphine and
other opioid drugs. If patients take naloxone, the pain-relieving effects of
trigger point therapy and acupuncture will be greatly reduced.

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(3) Trigger point therapy relieves pain by acting as a counterirritant.
According to Melzack and Wall's gate-control theory of pain, the large
diameter A-beta nerve fibers that transmit superficial pain can inhibit the
small diameter A-delta and C nerve fibers that transmit deep pain. Since
most people find the superficial pain more tolerable than deep aching pain,
counterirritants such as trigger point therapy and chemical irritants are very
useful. The most common chemical irritants are those that feel hot or cold
when applied to the skin. Some people call superficial pain a "good hurt."
Though digital pressure is normally effective in treating trigger points,
the amount of pressure needed varies from case to case. Moderate to heavy
pressure is normally more effective than light pressure. Trigger points in
large deep muscles or muscles that overlay soft tissue often require more
pressure than trigger points in small superficial muscles or muscles that
overlay bone. Lighter than normal pressure can be used if the same trigger
point is treated repeatedly on successive days.
Compared with moderate to heavy pressure, light pressure is more
likely to cause facilitation than inhibition. When trigger points in muscles
are stimulated by light pressure, hypertonia and spasm increase as the
muscle attempts to guard itself against the insult. With light pressure, pain
tends to increase and then remain constant. This differs from moderate to
heavy pressure that normally causes the pain to intensify and then diminish
as the pressure continues and the muscles relax.
When moderate to heavy pressure is used, pressure should be applied
slowly and released slowly. Slowly applied pressure causes less trauma
because tissues have more time to absorb force and accommodate the
changes caused by pressure. Slowly released pressure lessens the recoil
effect that normally occurs after pressure is removed. Both measures will
increase the patient's comfort and improve the probabilities that treatments
will have a longer-lasting effect. The principle of "easy on, easy off" applies
to both muscle testing and trigger point therapy.
When treating trigger points, medical sources commonly recommend
20 to 60 seconds of continuous ischemic pressure. This duration might be
longer in large muscles such as the gluteus maximus or quadriceps, but it is
seldom shorter. With the exception of the paraspinals, pressure applied for
less than 12 seconds is more likely to irritate than sedate.
The gluteal muscles, in particular, will sometimes react with reflex
contractions and local twitch responses when stimulated by ischemic
pressure for short periods of time. These responses may give the impression
that muscles are fighting the pressure. As the pressure continues, sensitivity

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to pressure decreases and the muscle begins to relax. In the gluteal muscles,
reflex spasm can be very strong and may continue for more than a minute.
The best method for gauging time is continuing pressure until the
tissue changes in consistency and softens or melts down. Feedback from the
tissue and the patient is a better way to estimate treatment time than arbitrary
numbers such as 20 or 60 seconds. In a large, indurated muscle such as the
gluteus maximus, changes in tissue consistency may take several minutes.
Regardless of duration, digital pressure should not be used in the presence of
inflammation as indicated by pain, swelling, redness, and heat.
The normal sequence is a sharp increase in pain followed by a gradual
decrease in pain. If the patient reports no reduction in pain after one minute
of pressure, stop the pressure and look for signs or symptoms that indicate
the trigger point being treated is not causing the pain. If the pain is being
referred from another trigger point, then find and treat the origin of the pain.
If the pain is being caused by inflammation, acute trauma, or nerve
entrapment, trigger point therapy will not be effective.
If pain continues to decrease as pressure is being applied, continue the
pressure until the affected tissues become less resistant to pressure. Changes
in tissue consistency normally coincide with pain relief. If trigger point
therapy is successful, the patient will experience less pain and greater
mobility within minutes after treatment.
If patients cannot tolerate digital pressure, it may be possible to pinch
the skin directly over the trigger point and partially desensitize the area by
reflex effect. Once the skin is desensitized, trigger points are less sensitive
to pressure. Skin pinching may neutralize trigger points in a muscle without
any further treatment. Although trigger points can be treated with tissues
stretched or slack, the slack position is often less painful.
The final phase of trigger point therapy is stretching. If tissues are not
stretched to normal length, trigger points are likely to recur. Low-velocity
stretching helps to restore normal length without causing a stretch reflex or
tearing tissues. Though stretching will in some cases eliminate trigger
points without digital pressure, it can also irritate trigger points and cause
spasm. Stretching is normally safer and much less painful if trigger points
are neutralized first. Heat can be applied before stretching to increase tissue
extensibility and reduce any existing spasm.
It is not uncommon to treat identifiable trigger points during one
session and have the patient return for the next session with entirely different
trigger points. It is possible that elimination of primary points during the
first session makes secondary trigger points more discernible during the

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second session. In any event, treatment should be continued until all trigger
points are eliminated as completely as possible. It is common to find great
improvement after one treatment.
When trigger points and spasm are widespread, the origin of pain is
difficult to localize and most skeletal muscles can develop trigger points.
The origins of pain can be obscured by trigger point zones that represent
areas of referred pain. Autonomic, sensory, or motor responses caused by
trigger point activity can be observed anywhere within the zone.
As spasm recedes, the origins of pain usually become more apparent.
The first tissues that caused the pain are often the last tissues that respond to
therapy. Most soft-tissue impairments cannot be completely resolved until
all trigger points are neutralized and all affected tissues are stretched.
This is a summary of basic trigger point classifications:
• active trigger point: symptomatic with characteristic behavior

• associated trigger point: developed in response to another trigger point
• latent trigger point: symptomatic only when palpated or compressed
• primary trigger point: caused directly by dysfunction in a muscle
• satellite trigger point: caused by trigger points in a different structure
• secondary trigger point: caused by compensatory overload
• attachment trigger point: caused by tension at muscle attachments
Other points that may respond to trigger point therapy besides trigger
points are tender points, acupuncture points, acupressure points, reflex
points, motor points, stimulation points, and neurovascular points. Of all
these points, trigger points and tender points seem to be the closest. Trigger
points are to myofascial pain syndrome (MPS) what tender points are to
fibromyalgia syndrome (FMS). Trigger points and tender points produce
similar pain (a dull constant aching pain or a sharp stabbing shooting pain),
and they seldom produce a burning sensation.
Palpation, the most reliable way to identify trigger points, can be used
when myofascial tissues are stationary, stretched, or moving. To save time,
have patients point to where it hurts and use muscle testing. Any muscle
that tests short or weak is a good candidate for trigger points. Most muscles
become painful if trigger points are rapidly stretched or compressed by
external forces or contraction. Muscle attachments are under the most stress
at the end of the ROM. Trigger points can also be activated by changes in
temperature (hot to cold), chemical irritants, and psychological stress.

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Deep Sliding Pressure (DSP)
In trigger point therapy, deep sliding pressure (DSP) can be used as a

provocative test for locating trigger points or as a treatment when trigger
points present themselves as ropy or indurated bands within a muscle. To
use DSP, apply digital pressure as you would when treating a trigger point
and then maintain the pressure as you slide your fingers over the top of the
ropy or indurated bands. The areas being treated will turn white because of
ischemic pressure and turn red because of reactive hyperemia.
The rate of movement depends on how quickly the tissues release.
Rather than using large amounts of force to push through resistant tissues,
ischemic pressure should not be advanced until the tissues melt down and
feel soft. This reduces the effort needed to move the gliding stroke forward.
Since deep sliding pressure is used for treating ropy, indurated fibers
within a muscle, the movements can be linear, curved, circular, or spiral,
depending on where the fibers are and how the fibers are arranged (bands or
zones). After the initial pressure causes the tissues to soften, pressure is not
usually released until all of the fibers within the band or zone have softened.
Although there may be an increase in pain when a gliding stroke advances,
moving the stroke slowly, waiting for tissues to soften before you move
forward, and using lubrication to reduce friction will help to reduce pain.
When used properly without too much force or velocity, deep sliding
pressure is more effective and less painful than treating zones or bands point
by point. If the first sweep through a band or zone fails to release tension,
several more sweeps can be made. Deep sliding pressure is very effective
when treating any skeletal muscle with hard or indurated bands.
Deep sliding pressure is very effective when treating the hamstrings,
quadriceps, gastrocnemius, soleus, and paravertebral muscles. Using deep
sliding pressure that converges toward the belly of the muscle will have a
tendency to relax hypertonic muscles because of proprioceptive inhibition.
When treating a muscle such as the gastrocnemius or soleus, you can
apply ischemic pressure by pinching the ropy or indurated fibers with your
fingers and thumb. After the tissues between your fingers and thumb have
softened, advance the stroke as you would when using DSP until all of the
tissues are soft. If most of the fibers in a muscle are ropy or indurated, start
at one end and maintain digital pressure until you reach the other end.
If one deep stroke is insufficient to neutralize all trigger points, use
additional strokes. It usually takes more force and more time to complete
the first stroke than it does to complete subsequent strokes.

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After you treat a muscle, use palpation to check for trigger points and
hypertonicity. If therapy is successful, the muscle will be soft and pain free.
Just as most patients are surprised to find that they have trigger points in a
muscle when you palpate the muscle, they are also surprised to find that
neutralizing the trigger points will give almost immediate relief.
When deep sliding pressure is applied between the medial borders of
the paravertebrals and the lateral borders of the lower spine, the pressure
often produces a state of sedation that resembles a drug-like state. Some
patients go to sleep and others report extreme relaxation or feelings of well-
being. Pulse and respiration are usually slow. When aroused, some patients
will be slightly incoherent and their eyes will be slightly unfocused. From
all indications, DSP along the spine relaxes muscles and may cause the
release of endogenous opioids such as endorphins or enkephalins.
This technique can be applied with the patient sitting and upper spine
flexed forward over a padded table or prone on a table with the arms along
the sides. The direction for DSP is normally toward the head (cephalad),
although pressure in the opposite direction also seems to work. Lubricant is
especially important when working along the spine because it reduces
friction and allows both sides of the spine to be treated at the same time.
DSP applied between the lateral borders of the paravertebrals and the medial
(vertebral) borders of the scapulas may neutralize trigger points and relax
muscles, but it seldom produces a drug-like state.
When applied to a tendon, deep sliding pressure produces inhibitory
pressure that encourages a muscle to relax. Start at the musculotendinous
juncture and move toward the bony attachment (away from the belly of the
muscle). Vibration applied to a tendon may produce a similar effect. Deep
pressure or vibration may inhibit tonus by activating pacinian corpuscles or
triggering a Golgi tendon organ response (inverse stretch reflex).
Strokes that start at one end of a muscle and move to the opposite end
may cause reflex inhibition as the stroke approaches the belly of the muscle
and reflex facilitation as the stroke moves away from the belly. Stroking
that compresses the belly of a muscle encourages inhibition, and stroking
that stretches the belly of a muscle encourages facilitation. Velocity is also a
factor. Slow stretching or stroking of a muscle encourages inhibition, and
rapid stretching or stroking of a muscle encourages facilitation.
To inhibit a muscle, start with one hand on each attachment and
slowly stroke toward the belly. To facilitate a muscle, start with one hand on
each side of the belly and rapidly stroke away from the belly. This type of
rapid stroking may trigger a stretch reflex and cause contraction.

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Multifidus Triangle
The multifidus triangle is a prime area for trigger point activity. This
triangle is formed by three points: (1) the iliac crest, (2) the spinous process
of L4, and (3) a point midway between the inferior sacral foramina. This
triangle contains facets, fascia, the transversus, iliolumbar, and interspinous
ligaments, and the insertions of the quadratus lumborum, erector spinae, and
multifidus, a muscle that often contributes to stiffness and low back pain.
Besides opposing flexion when the oblique abdominal muscles rotate
the thorax, the multifidus can increase lumbar lordosis. If the multifidus is
trying to increase lumbar lordosis at the same time the psoas is trying to
decrease lumbar lordosis, this may explain why the multifidus triangle often
becomes irritated and has trigger points during episodes of low back pain.
Ligamentous Trigger Points
Like trigger points in muscles or fascia, the trigger points that occur in
ligaments can be treated by using ischemic pressure. Because ligaments are
composed of dense fibrous connective tissue, ligamentous trigger points
often require more pressure than myofascial trigger points. If more pressure
is needed, the thumb, fingers, or hypothenar eminence of one hand can be
placed over the thumb or fingers of the other hand to increase pressure.
Trigger points that might cause LBP can often be found in the heavy
ligaments that stabilize either L5 (iliolumbar ligament) or the sacroiliac joint
(sacroiliac, sacrospinous, or sacrotuberous ligaments). Like the piriformis,
both the sacrospinous and sacrotuberous ligaments can refer pain—but not
numbness or weakness—to the buttocks and down the leg (false sciatica).
Trigger points in the fibular collateral ligament may refer pain to the knee.
Gluteus medius tenderness is often more apparent than interspinous
tenderness and may be caused by sacroiliac ligamentous insufficiency. Pain
in the outer buttocks that radiates down the side or back of the thigh is often
caused by strain at the sacral attachment of the sacrotuberous ligament.
These are the main lumbar and sacral ligaments:
(1) Iliolumbar ligament: connects L4 and L5 with iliac crest

(2) Sacroiliac ligament: connects sacrum to ilium
(3) Sacrospinous ligament: connects sacrum and coccyx to ischial spine
(4) Sacrotuberous ligament: connects sacrum, coccyx, and iliac spines
to ischial tuberosity

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Self-Treatment
The key to managing nonspecific LBP is self-treatment. People need

to become actively involved in their own treatments, and they need to avoid
longterm dependence on any type of passive therapy that provides nothing
more than short-term symptomatic relief. Self-treatment that helps you stay
active during an episode of LBP will put you back in control of your life.
With proper instruction, most people can perform basic trigger point
therapy on themselves. The gluteus maximus can be treated if a person takes
a supine position and places a small rubber ball or the knuckles of one hand
directly under a trigger point in the muscle. By shifting body weight, the
person can apply pressure on the trigger point. This position should be held
steady until the trigger point is neutralized and stops causing pain.
People should be told that smaller muscles normally require less time
and pressure than larger muscles. Since the weight of the gluteus maximus
is twice the weight of the gluteus medius and four times the weight of the
gluteus minimus, more time and pressure may be needed for treating the
gluteus maximus than for treating the gluteus medius or gluteus minimus.
Although most people can be taught how to palpate for trigger points
without knowing the names or location of each muscle, they should be told
or shown which parts of the body are most likely to have trigger points that
cause LBP. The gluteus medius, which often has tears or inflammation just
below the iliac crest, is a major source for trigger points. Besides the gluteal
muscles, people should learn to check the psoas, quadriceps, hamstrings,
piriformis, gastrocnemius, soleus, quadratus lumborum, and paraspinals.
People should also be told and shown how to stretch body parts after
they treat a trigger point. Stretching can usually be done by using opposing
muscles, other body parts—such as the opposite hand or leg—or gravity.
Even if trigger point therapy is done correctly, conditions that may
perpetuate trigger points are smoking, poor nutrition, and a lack of exercise.
A good exercise for people with trigger points and LBP is walking briskly
30 to 45 minutes per session 3 to 4 times a week. Even though increasing
muscular strength tends to increase muscular endurance, high-repetition,
low-intensity exercises that increase muscular endurance are safer than low-
repetition, high-intensity exercises that increase strength. For trigger point
therapy or exercise to be effective, people need to give their bodies time to
heal and they need to get sufficient recuperative sleep. Factors that may also
perpetuate trigger points are postural or symmetry problems, muscle
imbalances, and folic acid or vitamins B1, B6, B12, or C insufficiencies.

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Major Muscles or Muscle Groups: Trigger Point Zones
1. GLUTEUS MINIMUS
A. Medial buttocks
B. Lower lateral buttocks
C. Back of thigh and calf
D. Lateral aspects of thigh, knee, and leg
2. GLUTEUS MEDIUS
A. Upward to lowest lumbar region

B. Above and below crest of ilium
C. Region of sacroiliac joint and sacrum
D. Posterior and lateral aspects of buttocks
3. GLUTEUS MAXIMUS
A. Entire buttocks region

B. Entire lower sacrum
C. Region of coccyx
4. PIRIFORMIS
A. Sacroiliac region
B. Buttocks and hips near muscle attachments
C. Proximal two-thirds of posterior thigh
5. HAMSTRINGS
A. Lower buttocks and region of gluteal fold

B. Posterior and medial thigh
C. Popliteal region
A. Upward to back of shoulder

B. Laterally across posterior thorax
C. Anteriorly to abdomen

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D. Lower thoracic and upper lumbar regions
E. Sacroiliac region
F. Entire buttocks region
Paraspinal muscles include the superficial paraspinals (erector spinae)

and the deep paraspinals (transverse spinae).
7. LATISSIMUS DORSI
A. Back of shoulder
B. Inferior angle of scapula
C. Down medial and lateral aspects of arm and forearm
D. Mid-back region
8. SOLEUS
A. Upward to sacroiliac joint

B. Posterior aspect of calf
C. Region of heel
9. GASTROCNEMIUS
A. Lower posterior thigh

B. Popliteal region
C. Posterior aspect of calf
D. Instep of foot
A. Crest of ilium
B. Lower quadrant of abdomen
C. Lower buttocks
D. Region of greater trochanter
A. Region of greater trochanter

B. Down lateral thigh along iliotibial band toward knee

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A. Region of greater trochanter

B. Lateral aspect of thigh down iliotibial band toward knee
A. Abdominal region
B. Horizontally across mid-back region
C. Horizontally across sacroiliac and low-back region
D. Groin
14. OBLIQUUS INTERNUS ABDOMINIS
A. Chest
B. Abdominal region
C. Groin
15. OBLIQUUS EXTERNUS ABDOMINIS
A. Chest
B. Abdominal region
C. Groin
16. ILIOPSOAS
A. Ipsilaterally along lower thoracic and lumbar spine

B. Sacrum to upper buttocks
C. Region of iliacus
D. Anterior thigh
E. Groin
Trigger points are far more common than most people realize. When
treating LBP, check for trigger points in muscles, muscle attachments, and
ligaments. Rather than rely on charts to show you where trigger points are
located, use feedback from patients and systematic palpation. Since trigger
points refer pain, the place where pain is felt may not be the origin of the
pain. If trigger points present as ropy or indurated bands within a muscle
rather than discrete points or nodules, locate and treat the entire band.

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NEUROMUSCULAR THERAPY
After trigger point therapy has been used to neutralize trigger points,
neuromuscular therapy can be used to inhibit muscles with too much tonus
(hypertonicity) or facilitate muscles with too little tonus (hypotonicity). The
word spasm is often used as a substitute for the word hypertonicity, but
spasticity implies exaggerated tendon reflexes and increased muscle tone.
Neuromuscular therapy is characterized by manual techniques that
inhibit or facilitate muscle fibers. The primary tissues acted upon are nerve
or muscle tissue. Inhibition tends to lengthen hypertonic muscles and
facilitation tends to shorten hypotonic muscles. Extensibility is the ability of
muscles to lengthen and contractility is the ability of muscles to shorten.
Muscles can lengthen to 50 percent more than resting length and shorten to
50 percent less than resting length. Inhibition encourages muscles to relax
and facilitation encourages muscles to contract.
Neuromuscular techniques strengthen a muscle by eliminating factors
that cause weakness. This allows the patient to attain the greatest amount of
strength possible without using exercise to increase potential strength. By
using inhibition and facilitation to balance opposing muscles in terms of
length and strength, neuromuscular therapy restores function and prepares
the patient for the next stage of therapy, which is normally exercise.
As the opposite of inhibition, facilitation stimulates reflex activity that
causes contraction. The least amount of stimulus that causes a muscle to
contract is called the absolute threshold. When stimulation exceeds the
absolute threshold, muscles contract and produce force. If the force of
contraction is greater than resistance, muscles contract concentrically and
produce motion. If the force of contraction is not greater than resistance,
muscles contract isometrically and body parts remain stationary.
Inhibition encourages relaxation by decreasing reflex activity. Two
basic principles are (1) deactivating any mechanism that facilitates tends to
inhibit facilitated muscles and (2) deactivating any mechanism that inhibits
tends to facilitate inhibited muscles. After inhibitory mechanisms have been
deactivated, facilitated muscle fibers will contract maximally if the level of
stimulation is greater than the absolute threshold for activation. If
stimulation is not above this threshold, the muscle fibers will not contract.
The immediate goal of neuromuscular therapy is to balance muscles.
This means balancing and normalizing opposing muscles or muscle groups
in terms of length and strength. Possible effects from a muscle imbalance
are microtrauma, pain, limited ROM, weakness, and a loss of function. Pain

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may result if muscles, joints, or ligaments are stretched or compressed, and
range of motion may decrease if agonistic muscles are too weak to initiate
movement or antagonistic muscles are too short to allow movement.
Pathologic joints can produce pain and limit ROM, but dislocations,
loose bodies, and menisci tears are less common than muscle imbalances. If
a joint is implicated, a muscle imbalance may have caused the dysfunction,
and the joint may not begin to heal until the muscle imbalance is corrected.
Because of a muscle imbalance, asymmetrical forces may cause one
side of a joint to wear more rapidly than the other side and become irritated,
or both opposing muscles may be too short and cause excessive tension that
reduces joint space and limits ROM. If restoring muscle balance normalizes
the joint, muscles are more likely than joints to be the cause of dysfunction.
Meltzer's Law of contrary innervation states that all living functions
are controlled by opposing forces. This law relates to the Chinese concept
of yin-yang, which states that opposing and complementary forces control
all of nature. In neuromuscular therapy, the opposing forces are inhibition
and facilitation. Inhibition restricts and facilitation promotes.
Muscles produce motion by contracting the agonist and relaxing the
antagonist, and they restrict motion by contracting the agonist and partially
relaxing the antagonist. To stabilize (brace) a body part, the agonist and the
antagonist cocontract, which means they exert equal force but produce no
motion. The transversus abdominis and multifidus cocontract to stabilize the
trunk just before the extremities move. If anything delays or prevents
cocontraction, trunk instability can adversely affect arm or leg movements.
Neuromuscular techniques help muscles function normally by using
inhibition or facilitation to keep muscles responsive and properly balanced.
Inhibition—reduce facilitation, decrease tonus, normalize reflex activity
• Lengthen hypertonic muscles

• Strengthen weak muscles
Facilitation—reduce inhibition, increase tonus, normalize reflex activity
• Shorten stretched muscles

• Strengthen weak muscles
The standard protocol for using neuromuscular therapy to optimize

and balance muscles or muscle groups has six basic steps:

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1. Evaluate length by range-of-motion testing.
2. Use inhibition to lengthen restricted tissues.
3. Evaluate strength by muscle testing.
4. Use facilitation to strengthen weak muscles.
5. Reevaluate length and then strength.
6. If needed, treat again with inhibition or facilitation.
A basic principle that applies to soft-tissue therapy is first lengthen

and then strengthen. It is rarely advisable to strengthen a muscle with
limited ROM. Making the muscle stronger will increase the risk of
traumatizing the muscle during ballistic movements. When treating LPDs,
lengthen a tight psoas before you strengthen a weak gluteus maximus.
If one muscle is too short, the opposing muscle is too long, and both
muscles are weak, lengthen the short muscle first. This will decrease tension
on the longer muscle and help it assume its normal length.
If two opposing muscles are long and weak, strengthen both muscles
and then monitor length to ensure that both muscles shorten at the same rate.
If a muscle is abnormally short and weak but correcting the shortness
may require extensive treatment, lengthening and strengthening can be
combined to avoid deconditioning the muscle and possible atrophy. The
first half of the treatment should focus on lengthening restricted tissue, and
the second half of the treatment should focus on strengthening the muscle.
KEY POINT: FIRST LENGTHEN AND THEN STRENGTHEN
Neuromuscular therapy affects motor functions (nerves and muscles)

more than trigger point therapy or connective tissue therapy. Neurologic
conditions that may cause a loss of motor function are (1) hypertonicity
(excessive tonus), (2) hypotonicity (insufficient tonus), and (3) changes in
activation or recruitment patterns. These conditions relate to proprioceptive
input from muscle spindles or Golgi tendon organs, and they may cause a
muscle imbalance because of abnormal shortness or weakness.
Tonus is caused by slight, continuous, partial contractions of a muscle
while a person is conscious. Tonic contractions increase a skeletal muscle’s
resistance to passive elongation (stretching) and help postural muscles stay
at a fairly constant length. Without tonus, muscles become flaccid and the
body cannot maintain posture. With too much tonus, the body may appear
spastic because of stiff, awkward, or jerky movements. Muscle spindles and
Golgi tendon organs regulate muscle tone at the reflex level.

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The contractile strength of a muscle is determined by the number of
muscle fibers contracting within the muscle, and this number depends on the
intensity and frequency of stimulation. Factors that prevent stimulation or
reduce existing stimulation decrease contractile force. Muscle spindles
facilitate contraction, whereas Golgi tendon organs inhibit contraction.
When body parts move, muscles usually follow a specific sequence of
activation or recruitment. Synergists and stabilizers are usually activated
before agonists. If a synergist or stabilizer becomes dysfunctional because
of proprioceptive inhibition or pain, the activation sequence may change
enough to cause defective movement. The activation sequence can also be
changed if tightness in the antagonist interferes with the agonist.
Changes in activation or recruitment patterns may occur with or
without pain. Although pain is a common cause for limited mobility in the
lumbopelvic region, pain does not always precede proprioceptive inhibition.
Stretch weakness, caused by excessive activation of the Golgi tendon organs
or insufficient myofilament overlap, may cause weakness without pain.
Finding a weak muscle is often more difficult than finding a tender
muscle. Palpation can be used to locate muscles that are tender, but active
muscle testing against resistance is needed to locate muscles that are weak.
Inhibition caused by changes in joint space may not be painful. If
muscle tension decreases joint space enough to slightly irritate the joint,
mechanoreceptors may cause weakness without causing significant pain. It
is not uncommon to find joints that are weak and swollen, but not painful.
Proprioceptors respond to stimulus such as pressure, equilibrium, or
stretch and give information concerning the movements or postures. In
neuromuscular therapy, the most important proprioceptor is probably the
muscle spindle, which (1) measures how rapidly and to what extent muscles
are changing in length and (2) can trigger a stretch reflex.
Inhibition
Three ways to inhibit a muscle are (1) proprioceptive inhibition, (2)

post-isometric relaxation, and (3) reciprocal inhibition. Proprioceptive
inhibition includes direct manipulation of muscle spindles or Golgi tendon
organs. Since hypomobility and a less-than-normal ROM are more common
than hypermobility and greater-than-normal ROM, proprioceptive inhibition
is normally used before proprioceptive facilitation. Techniques that inhibit a
muscle and techniques that facilitate a muscle often produce the same result:
strengthen a muscle that is weak because of neurologic inefficiency.

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Proprioceptive Inhibition
Soft-tissue therapy uses two types of proprioceptive inhibition: (1)

compression of muscle spindles or (2) activation of Golgi tendon organs.
While compressing muscle spindles is often easier and more effective than
stretching Golgi tendon organs, both techniques are useful.
Compressing the belly of a muscle toward the center relaxes the
intrafusal fibers in the muscle spindles and causes reflex inhibition. This can
be done by grasping the muscle near the musculotendinous junctures and
using convergent force to compress the belly of the muscle until both hands
meet near the center.
The direction of push is parallel to the muscle and the rate of push is
slow enough for tissues to thin out, melt down, or dissolve as the fingers
move toward the center of the belly. The need for anything more than
moderate force indicates that movements are too fast. Hypertonic muscle
will normally relax and test weak after muscle-spindle-cell inhibition.
The second way proprioceptors can be used to inhibit a muscle is by
using passive ROM stretching to activate the Golgi tendon organs and cause
stretch weakness. The Golgi tendon organs seem to protect muscles against
being actively or passively overstretched. This technique works better for
extremity muscles than for torso muscles. Since Golgi tendon organs are
normally activated by using range-of-motion stretching to separate the distal
and proximal attachments of a muscle (origin and insertion), muscles in the
arms and legs are easier to stretch than muscles that control the trunk.
In addition to stretching, direct pressure seems to activate Golgi
tendon organs and cause reflex inhibition. If a muscle is hypertonic, heavy
digital pressure applied to the tendon where it attaches to the muscle will
sometimes decrease tonus. The concentration of Golgi tendon organs is
greater near the musculotendinous junction than near the point where the
tendon attaches to the periosteum and bone. Periosteum is very sensitive.
Inhibition caused by stretching the Golgi tendon organs is called
stretch weakness, and inhibition caused by direct pressure is called pressure
inhibition. Another type of Golgi-tendon-organ inhibition is autogenic
inhibition, which means the inhibition is self-induced. Autogenic inhibition
is a spinal reflex that stops a muscle from contracting if further contraction
might cause tissue damage. Unlike stretch weakness, which occurs because
myofilaments do not have enough overlap to generate normal force, tight
weakness occurs because the myofilaments have too much overlap. Stretch
weakness, like hypermobility, does not always cause pain.

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Post-Isometric Relaxation (Inhibition)
If hypertonic muscles contract isometrically, the refractory period that

follows contraction may decrease neurologic efficiency and reduce tonicity
(rebound phenomena). During this period, muscles that become hypotonic
will be easier to lengthen. Isometric contractions may also cause autogenic
inhibition because of tension on the Golgi tendon organs. The technique of
lengthening a muscle after an isometric contraction is called post-isometric
relaxation. The normal sequence is contract-relax-passive stretch.
Start with light contractions. If contractions are too strong, accessory
muscles may be activated and irritate the muscles that are being treated.
Contractions can be as small as 10% maximal effort, and the hold period can
be as short as 5 seconds or as long as 30 seconds. If light contractions are
used, the contract-relax cycle can be repeated up to 5 times.
Keep patients comfortable, take the slack out of muscles before they
contract, and use isometric resistance as a counterforce against the patient’s
contraction. When the muscle stops contracting, try to lengthen the muscle
by slowly increasing the distance between the muscle attachments.
Breathing cycles should correspond correctly with periods of exertion
and relaxation. The best method is having the patient (1) exhale during
exertion, (2) inhale during the first stage of relaxation, and (3) exhale during
the second stage of relaxation as muscles are being passively stretched.
1. Patient exhales and contracts (practitioner applies counterforce).

2. Patient inhales and relaxes (practitioner stops counterforce).
3. Patient exhales and deepens relaxation (practitioner stretches muscle).
After the basic three-part sequence of contract-relax-passive stretch,

the patient should be encouraged to actively stretch the target muscle. The
sequence then becomes contract-relax-passive stretch-active stretch.
Reciprocal Inhibition
When muscles oppose each other, facilitation of one causes reciprocal

inhibition of the other. When the agonist contracts, the antagonist relaxes to
allow stretching by the agonist. Relaxation of the agonist is apparently
caused by a reflex activity that allows proprioceptors in the agonist to
interact with proprioceptors in the antagonist. If the agonist contracts and
the antagonist fails to relax, the agonist may be normal but test weak.

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If a muscle appears to be weak, test opposing muscles for tightness. If
opposing muscles have a higher than normal resistance to passive stretch,
the muscle may be normal. Coordinated movement is possible because one
muscle relaxes when the opposing muscle contracts. Anything less than
total relaxation of the antagonist restricts shortening of the agonist.
If a flexor muscle is hypertonic, contracting the opposing extensor
muscle should cause the flexor muscle to relax. If a flexor muscle such as
the biceps brachii is in spasm, contracting the triceps brachii should cause
the biceps brachii to relax. If contracting the triceps brachii stretches the
biceps brachii, the stretching may help to relax spasm in the biceps brachii.
Stretching to Reset Proprioceptors
After relaxing a muscle that is abnormally short because of spasm or

hypertonicity, the final step is stretching the muscle to reset proprioceptors
and prolong the effects of therapy. Once reset, a proprioceptor’s old
memory is replaced by a new memory. If the old memory represents
hypertonicity and limited length, range-of-motion stretching can be used to
establish a new memory that represents normal tonicity and length.
The mechanism that muscles use to store memory is poorly
understood. Unlike viscoelastic materials such as connective tissue that
have an elastic memory based on physical properties, the memory process in
proprioceptors seems to represent a complex interaction between
proprioceptors, muscle tissue, spinal nerves, and the brain. Whereas elastic
memories respond to physical force, proprioceptive memories respond to
both physical force and psychological stress.
In soft-tissue therapy, the normal sequence for using inhibition and
range-of-motion stretching is (1) relax the muscle by using inhibition, and
(2) reset proprioceptors by using range-of-motion stretching. Range-of-
motion stretching will also lengthen connective tissue that is abnormally
short because of adhesions or contractures. Heat can be used with range-of-
motion stretching to increase tissue extensibility and reduce spasm.
Even though range-of-motion stretching is not commonly considered
a method of inhibition, when applied slowly and progressively, it can be
used to relieve spasm with or without modalities. Using range-of-motion
stretching to relieve spasm is more likely to cause tissue damage than using
proprioceptive inhibition, post-isometric relaxation, or reciprocal inhibition
to relieve spasm. Range-of-motion stretching is most effective when used to
reset proprioceptors after a muscle has been neurologically inhibited.

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Positional Release
Another possible way to stop inappropriate proprioceptive activity is

to put a body part into its position of greatest ease and hold this position for
about 60 seconds to three minutes. This position reduces afferent discharge
from facilitated muscle spindles by placing the muscle in a slack position.
Before positioning the patient, practitioners should use palpation to
identify tender points that indicate areas of tension within muscles. Tender
points can be used to sense the position of greatest ease while positioning the
body part or to tell practitioners at what point the tissues relax or soften.
When using positional release inhibition, the pressure on tender points
should be continuous, but not strong enough to cause ischemia.
After tissues being palpated relax and soften, the body part is returned
slowly to its neutral position. This prevents reactivation of inappropriate
muscle-spindle activity. Positional release inhibition is extremely gentle and
works well with patients who cannot tolerate other techniques.
When using positional release, there is a risk that putting a hypertonic
muscle in a slack position will cause a spasm or a cramp. If this happens,
slow and gentle ROM stretching will normally relax the muscle.
Gliding Strokes in Neuromuscular Therapy
In neuromuscular therapy, gliding strokes can be used along the spine

and the medial border of the erector spinae to inhibit contraction. This
method is similar to the deep sliding pressure used in trigger point therapy
except there are no trigger points and less pressure can be used.
One possible explanation for the inhibition is fatigue. Stimulation
produced by gliding along the lower spine may be great enough to fatigue or
desensitize the spindle cells. A second explanation is that pressure may be
great enough to cause either pressure inhibition or the release of endorphins
or enkephalins. A third possibility is neuromuscular activity between the
skin and underlying muscles that contributes to reflex inhibition. Whatever
the explanation, it can be shown clinically that gliding the thumbs along the
medial border of the paraspinals will cause inhibition and relaxation.
To complicate the issue, continuous pressure applied for 8 to 12
seconds at intervals of one inch or less along the thoracic and lumbar spine
seems to produce the same effect: local inhibition and general relaxation.
The 8 to 12 seconds of continuous pressure is considerably less than the 20
to 60 seconds of continuous pressure used in trigger point therapy.

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Facilitation
Forces that decrease tension on muscle spindles inhibit contraction,

and forces that increase tension on muscle spindles facilitate contraction. If
a muscle is abnormally short, use inhibition and stretching to lengthen the
muscle before using facilitation to strengthen the muscle. Facilitation can be
used without inhibition and stretching if the muscle has a normal ROM.
Activation of the Stretch Reflex
Muscle spindles may react to sudden stretching by triggering a stretch

reflex, and tendon reflexes are actually stretch reflexes. If sharply striking
the patellar tendon rapidly stretches the quadriceps and there is no knee jerk,
the L3 nerve root may be involved. If sharply striking the Achilles tendon
stretches the calf muscles and there is no ankle jerk, the S1 nerve root may
be involved. The stretch reflex protects muscles from overstretching.
A stretch reflex can be triggered when one opposing muscle contracts
and the other opposing muscle undergoes a short, quick stretch as it reaches
the end of its ROM. Elongation from ballistic stretching can also trigger a
stretch reflex. Another way to elicit a stretch reflex is to put a muscle under
tension by having it actively contract against manual resistance and then
give it a short, quick stretch. If there is tension from contraction, you can
activate a stretch reflex when the muscle is not fully elongated.
The muscle’s belly has the highest concentration of muscle spindles.
A passive way to facilitate a muscle is to place both hands near the center of
the belly and then use three to four short, quick, longitudinal pulls to stretch
the muscle away from the belly. Weak muscles often test stronger after
facilitation. If stretching or contraction create tension, muscle spindles can
be activated by plucking, tapping, or rapidly shaking the belly.
Repeated Contractions
If a muscle’s length is normal, facilitate and strengthen the muscle by

using repeated contractions against progressive resistance. If a muscle is
abnormally short, lengthen the muscle first and then facilitate. Inhibition
strengthens a muscle by reducing neurologic input that prevents contraction;
facilitation strengthens a muscle by increasing input that causes contraction.
Besides warming a muscle, decreasing viscosity, increasing blood flow, and
stimulating metabolism, repeated contractions may trigger a stretch reflex.

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If muscles are bilateral, such as the gluteals or hamstrings, contracting
the strong muscles on one side facilitates the weak complementary muscles
on the other side. Contracting strong muscles first not only facilitates the
weak muscles, but it may also increase irradiation, which is the spread of
nerve impulses following a strong contraction that recruits the synergists. If
you are treating a weak extremity, facilitate the strong extremity first.
The breathing sequence to use during contraction and relaxation is (1)
exhale during contraction, (2) inhale while muscles are still contracted, and
(3) exhale during relaxation. Patients should be instructed to breathe deeply
during contraction and relaxation and not to hold their breath.
Even though individual muscles are sometimes facilitated to improve
neurologic efficiency, the brain thinks in terms of movement, not individual
muscles (Beevor’s Axion). If one muscle contracts to produce a movement,
other muscles are normally acting synergistically to enhance the movement.
Patients who try to move by consciously contracting individual muscles
often develop a condition that resembles ataxia, the inability to coordinate
muscles during a voluntary movement. In sports training this condition is
sometimes called paralysis by analysis. To avoid incoordination, encourage
patients to think in terms of movement, not in terms of individual muscles.
Muscle Palpation
Palpation is used to monitor the presence or strength of contractions.

Touching a muscle and using verbal instructions or a mirror can help people
focus on particular muscles. Touching a muscle is very useful when people
cannot follow verbal instruction or see the muscle. If touching is done with
a series of solid taps, the tapping itself may help to facilitate the muscle.
Palpation can also be used to monitor how much a muscle relaxes. If
a muscle is bilateral, palpate both muscles simultaneously and then compare
one muscle with the other. Bilateral comparison is used in muscle testing.
Touching the muscle during contraction and giving verbal or visual
feedback can be used to enhance contraction or relaxation of the muscle.
Light pressure may encourage facilitation and deep pressure may encourage
relaxation. A workable sequence is (1) apply light pressure as a muscle
contracts and (2) apply moderate to heavy pressure as a muscle relaxes.
If one bilateral muscle is weaker than the other, measure both muscles
and compare size. If someone is right-handed and the right arm is smaller
and weaker than the left arm, atrophy may be present. Most right-handed
people have larger and stronger muscles on the right side than on the left.

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CONNECTIVE TISSUE THERAPY
Connective tissues support and connect other tissues. Compared with

most other tissues, connective tissues have very few cells. Most connective
tissues are composed of an intercellular substance or matrix that gives each
type of connective tissue unique properties. With the exception of cartilage,
most connective tissues are extremely vascular. Aponeuroses, dermis, deep
fascia, ligaments, and tendons are dense fibrous connective tissues, bone is a
hard connective tissue, and blood or lymph are liquid connective tissues.
Other types of connective tissue are areolar (loose) and adipose (fat).
Connective tissues have three main components: cells, fibers, and
matrix or ground substance. The most common mechanical properties of all
connective tissues except bone are elasticity and plasticity. Elastic materials
yield to stress and then resume normal shape. Plastic materials yield to
stress and remain permanently deformed.
Immobilization after an injury increases the density of collagen and
the frequency of cross-bridging between fibers. The cross-bridging makes
collagen fibers more resistant to passive stretch and less mobile. Stretching
and exercise increase flexibility by reducing the number of cross-links. The
protein titin may also increase intercellular resistance to passive stretch.
The ability of ground substance to hold water allows for diffusion of
metabolites between capillaries and cells. The presence of hyaluronic acid
in ground substance reduces friction by increasing water retention.
Hyaluronic acid molecules form large random chains that are filled with
water. Proteoglycans, such as hyaluronic acid, give connective tissues
elasticity and resistance to compression.
Excessive water retention produces higher tissue tension and greater
resistance to pressure. Tissue tension is a palpable sign that often occurs
after trauma or during inflammation. Edema reduces range of motion and
mobility by increasing tissue tension and causing spasm.
Reduced water retention increases friction between fibers and causes
cross-bridging—the occurrence of abnormal links between connective tissue
fibers. Friction and cross-bridging irritate tissues and reduce connective
tissue mobility. Without water retention, tissues lose elasticity.
Three principles help explain connective tissue therapy:
1 Thixotropy
2 Hysteresis
3 Creep

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Thixotropy
Thixotropy is a two-part property of certain gels: (1) the gels become

liquid when agitated by any force that puts energy into the system, and (2)
the liquids revert to gels when the energy dissipates. The energy input from
manipulation—compression, tension, or shear—is friction or heat.
The gel-sol (gelatum to solution) theory proposes that aqueous
(watery) solutions within connective tissue become highly viscous during
long periods of inactivity and produce a sticky gelatinous substance (gel)
that limits tissue mobility. A gel is the solid or semisolid phase of a
colloidal solution, and a sol is the liquid phase. Colloidal solutions are
formed by dispersing submicroscopic particles, such as proteins, in a liquid.
Because of thixotropy, connective tissue manipulation is thought to
increase tissue mobility by liquefying viscous gels, decreasing tissue
viscosity, and reducing tissue tension. Viscosity is a stickiness that causes
tissues to bind with each other and tissue tension stimulates reflex activity
that facilitates muscle contractions. Reducing viscosity allows tissues to
slide freely over each other and decreasing tissue tension reduces reflex
facilitation that causes hypertonia. Because of thixotropy, tissue may give
the appearance of thinning out or melting down after manipulation.
Hysteresis
According to the concept of hysteresis, cyclic loading causes

viscoelastic materials to soften and change shape because energy is lost in
the form of friction and heat. Cyclic loading refers to cycles of loading and
unloading such as pull–and–release or push–and–release. Connective tissue
(collagen) is considered a viscoelastic material because of two properties:
viscosity and elasticity. Even with low magnitudes of force, connective
tissue will lengthen progressively without tearing or rupture if cyclic loading
reduces the energy that binds the tissues together.
Hysteresis can be used to lengthen abnormally short connective tissue
by following a sequence of (1) slow stretch, (2) 5-second hold, and (3) slow
release. This sequence should be repeated about 10 times. Repeated bouts
of stretch, hold, and release should cause a permanent increase in tissue
length without significant tissue damage. Because of hysteresis, cyclic
loading can also be used to relieve tissue congestion or local edema by
improving vascular flow and lymphatic drainage. Stretching too quickly
may trigger a stretch reflex and cause hypertonicity.

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Creep
Creep is defined as deformation of viscoelastic materials when

exposed to a slow, constant, low-level force for long periods of time. When
individuals stand on their feet all day long, they become shorter by the end
of the day because of creep. Even though body weight does not change, the
steady load from body weight causes deformation of intervertebral disks and
subsequent loss of height. The principle of creep applies directly to
myofascial release as found in osteopathy. The application of heat tends to
accelerate lengthening because of creep in muscles and tendons.
After the patient is properly positioned for access and comfort, tissues
are stretched carefully until solid resistance is felt. Small degrees of
constant tension are then applied steadily until the tissues start to relax and
lengthen. The point at which tissues start to lengthen is sometimes referred
to as a meltdown or release. Constant tension is continued until the tissues
are fully elongated or no further stretching is needed. The keys to using
creep effectively are (1) minimize force and (2) maximize time.
Once a tissue is fully elongated, the body part should be held in this
position long enough for the tissue to fully relax. This can be done without
using additional force. According to biomechanics, when deformation is
held constant, internal stresses within a structure will decrease with time.
Holding tissues in position long enough for total relaxation to occur will
increase the probability that changes in tissue length will be permanent.
Adhesions
Both ROM stretching and local stretching can break the adhesions that
form when a wound heals. Restrictive adhesions are abnormal fibrous bands
that limit motion by connecting tissues that are normally separate. ROM
stretching increases the distance between insertions, whereas local stretching
usually pushes or pulls a muscle perpendicular to the fibers.
Adhesions that form between the dermis and superficial fascia in
response to inflammation or trauma are fairly common. Depending on how
they form, adhesions can be symptomatic or asymptomatic. Adhesions that
entrap nerves, irritate nerves, or restrict mobility are usually symptomatic.
Restrictive adhesions often occur over the scapulas. If adhesions
prevent the dermis from sliding freely over the top of underlying structures,
limited mobility and local pain may occur. When adhesions break, relief
from pain is almost immediate and the skin starts to move freely again.

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Skin Rolling
Skin rolling is a particular sequence of forces—tension, compression,

and bending—applied to skin or subcutaneous fascia. When properly used,
it can break restrictive adhesions, increase tissue mobility, or improve fluid
dynamics. Adhesions that are asymptomatic may not require treatment.
Using both hands together, the sequence for skin rolling is (1) use the
balls of the thumbs and forefingers to pull skin away from the patient’s body
and create a skin fold, and (2) use the forefingers to bend the skin over the
thumbs and pull the skin fold back (toward practitioner). Once created, the
skin fold is moved forward by (1) using the balls of each thumb to push the
skin fold forward while (2) the finger tips of each hand pull new skin back
over the thumbs. If adhesions are detected in areas where skin is loose, skin
rolling will normally generate enough tension to break the adhesions.
If restrictive adhesions are not released by skin rolling, the thumbs
and forefingers can be used to pull the skin fold away from the patient’s
body. When adhesions break, the rupture can often be heard as a popping or
snapping sound or felt as a sudden release of tension.
Skin rolling is used to release fibrous adhesions that connect skin and
superficial fascia to deep fascia. If the skin is too sensitive for skin rolling,
gently pinching the skin until the thickness of the skin fold decreases will
often reduce tenderness enough to allow skin rolling. The areas that benefit
most from skin rolling are tissues above or adjacent to (1) the lumbar spine,
(2) the sacrum, or (3) the iliotibial band.
Transverse stretching that pulls the superficial paraspinals away from
the lumbar spine will make skin rolling easier because it relaxes the muscles
and makes skin more pliable. To use this technique: place the fleshy mass
on the medial side of your palm (hypothenar eminence) close to the spine,
place the other hand on the opposite side of the spine to stabilize the back,
and use the hypothenar eminence to pull the muscles away from the spine.
If the patient is prone, placing one ankle over the opposite knee will make
the superficial paraspinals on the flexed-knee side more prominent.
Once tissue mobility is restored, local and range-of-motion stretching
will help preserve mobility. Low-back exercises that flex the trunk, such as
abdominal exercises, will also stretch the lower back. Stretching should be
followed by long stroking movements to disperse fluids and sedate muscles.
Adhesions and restrictions are less likely to re-form if lumbar tissues
are mobilized on a regular basis. Without continuous passive mobilization,
adhesions and restrictions have a tendency to recur in the same place.

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Tender points characterized by an increased thickness in skin or
subcutaneous tissue will also respond to skin rolling. Once these tender
areas are located, the skin should be held in place and pinched until the
tissues palpably soften and pain dissipates. This technique may be painful,
and superficial edema and subcutaneous fat often make it difficult to even
grasp and roll a skin fold. Tender points of this nature may be aggravated by
heat and are often found adjacent to the lumbar spine and sacrum.
Skin Pulling
Even though the low back seems to be more sensitive to skin rolling
than the shoulder, some patients will find skin rolling painful and difficult to
tolerate regardless of what tissues are being treated. For these people,
pulling loose skin away from the body can be used as a substitute for skin
rolling. Body parts can be repositioned to reduce cutaneous tissue tension in
the areas being treated, which will make it easier to pull the skin. Skin
pulling is done by grasping skin between the thumb and forefinger and then
pulling the skin away from the body at about an 80- to 100-degree angle.
Skin pulling begins by using minimum force to pull loose tissue away
from the body and holding the position long enough for tissues to lengthen
(creep). The pressure generated by holding the tissues in place may cause
some degree of tissue thinning (thixotropy). The process is repeated several
times to maximize tissue mobility (hysteresis). For breaking adhesions,
skin-pulling techniques are not as effective as skin rolling.
The same principle that applies to skin rolling also applies to skin
pulling: once tissue mobility is restored, stretching will help preserve tissue
mobility. Adhesions or restrictions are less likely to reform if skin pulling is
used every few weeks. Self-treatment is easier with skin pulling than with
skin rolling: stand upright, increase lumbar lordosis, and use your thumbs
and fingers to pull skin away from the lumbar spine or sacrum.
Trigger points can sometimes be found in what appears to be normal
skin, and skin rolling or skin pulling can be used to neutralize trigger points.
Systematically pinching small areas of skin (dermis and epidermis) with the
finger and thumb is probably the best way to locate these trigger points.
Since a skin disorder, such as scarring, may decrease a joint’s ROM,
skin rolling or skin pulling may increase the joint’s ROM. Skin rolling or
skin pulling may also reduce joint pain. Based on Hilton’s law, reducing
pain in the skin above the insertions of a muscle that moves a joint may also
reduce pain in the muscle that moves the joint and reduce pain in the joint.

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Cross-Fiber Friction
Cross-fiber friction combines downward pressure with perpendicular

force to produce local friction as fingers or thumbs move back-and-forth
across a tissue such as a tendon or ligament. Normal treatments are 10 to 20
minutes, twice a week. Because of the need for deep friction, lubricants are
not used. Another name for cross-fiber friction is transverse friction.
Cross-fiber friction can be applied by making a body part stationary
and moving a digit side-to-side over the surface of the body part or making
the digit stationary and moving the body part side-to-side under the digit.
Even though both methods produce lateral cross-fiber friction, moving a
digit is usually easier than moving a large body part.
The reasons for cross-fiber friction are (1) break restrictive adhesions,
(2) reduce the number of cross-links between connective-tissue fibers, and
(3) align scar tissue parallel to the lines of stress (Wolff’s law). Cross-fiber
friction promotes healing by increasing local circulation, and it reduces pain
by acting as a counterirritant, by dispersing pain-producing chemicals, or by
encouraging the body to produce endorphins.
With the exception of breaking adhesions or helping to align scar
tissue, the effects produced by trigger point therapy and cross-fiber friction
are very similar. Since trigger point therapy is faster and less painful than
cross-fiber friction, the primary justification for using cross-fiber friction
relates to fibrosis, adhesions, and scar tissues.
Unlike trigger point therapy, cross-fiber friction shears the cross-links
between collagen fibers that form during the early phases of wound healing.
Where trigger point therapy tends to focus on muscles and fascia, cross-fiber
friction focuses on connective tissue structures such as tendons or ligaments.
Since trigger point therapy combined with ROM stretching is usually
more effective in preventing adhesions and helping to align scar tissue than
cross-fiber friction, the best time for using cross-fiber friction is during the
early phases of an injury when mobilization is not recommended because of
pain, spasm, or tissue disruption. During this phase, friction should be light
and superficial to avoid disrupting properly placed scar tissue. Even though
passive mobilization should begin as early as possible, applying cross-fiber
friction directly over a lesion may improve wound healing.
When treating LBP, areas that may be affected by repetitive stress are
musculotendinous junctures and tendo-periosteal-bone junctures (enthesis).
These areas often become painful when stretching reaches the end of the
ROM. Cross-fiber friction may help restore function in these areas.

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Trigger point therapy can also be used in combination with cross-fiber
friction. When used together, trigger point therapy desensitizes hyperesthetic
(sensitive) tissues and cross-fiber friction stretches tissues. Ice can be used to
induce analgesia before cross-fiber friction or trigger-point therapy are used.
Though cross-fiber friction can produce some degree of anesthesia, the
process is normally more painful than trigger point therapy. To induce
anesthesia, the treatment should begin with light pressure and limited
movement and progress to heavier pressure and deeper movement. Instead of
anesthesia, many patients report that pain intensifies during the initial minutes
of treatment and continues without abatement until friction is stopped.
The recommended frequency for cross-fiber friction, like most forms of
soft-tissue manipulation, is twice a week. This allows tissue enough time to
recover between treatments. Cross-fiber friction should not be used for more
than about two weeks. After two weeks, other forms of manipulation such as
trigger point therapy and neuromuscular therapy are normally more effective.
Cross-fiber friction tends to be ineffective when used alone. Before a
tendon is treated, the muscle attached to the tendon should be treated with
trigger point therapy or neuromuscular therapy to reduce pain and spasm.
Cross-fiber friction is not recommended for the belly of a muscle. After cross-
fiber friction, partial or complete range-of-motion stretching will help to relieve
muscle tension on the tendon if tissues are stable enough to permit stretching.
Icing contact points for about 20 minutes after manipulation reduces the
possibility of therapy-induced (iatrogenic) pain or swelling.
To avoid digital fatigue when using cross-fiber friction, practitioners can
use fingers from the same or opposite hand to reinforce the fingers that are
doing the actual stroking. (Finger is defined as any one of five digits on the
hand, including the thumb.)
To avoid excessive joint compression, digits should not be elevated
more than about 30 degrees above the surface of the patient’s skin. Below 45
degrees, more force is directed horizontally than vertically. At 45 degrees,
vertical and horizontal forces are equal. At angles greater than 45 degrees but
less than 90 degrees, vertical force is greater than horizontal force. At 90
degrees, all force is directed downward with no horizontal component. The
higher the angle, the greater the downward pressure on the patient and the
greater the pressure on the practitioner’s digital joints.
Whether finger-shaped objects made of wood, metal, plastic, or rubber
with various types of handles are used in place of fingers or thumbs when
administering cross-fiber friction or trigger point therapy is a matter of personal
choice. The advantage of using devices such as a T-bar is being able to

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generate high degrees of pressure without causing the practitioner digital stress.
The disadvantage is losing the sensitivity of human touch.
Since the need for high degrees of force in soft-tissue therapy is minimal
if pressure is applied slowly and correctly, the disadvantages of using special
devices to administer cross-fiber friction or trigger point therapy may outweigh
the advantages. Despite the popular trend in therapy that favors replacing
manual medicine with machines, there is still no substitute for the sensitivity of
human touch.
Layers
A general practice in connective tissue therapy is to view the body as a

series of layers. When muscles are placed in a stretched position, working
superficial layers first will make it easier to reach the deeper layers. After the
tissue consistency of a superficial layer changes from hard to soft, the next
layer below should be easier to palpate, and the amount of force needed to
work the deeper layer should be about the same as the amount of force needed
to work the layer above. While the primary purpose of this technique is to
reach and work deep connective tissue such as fascia, possible secondary
benefits are neutralization of trigger points and the release of endorphins.
Special Stretching Techniques
Crossover stretching is very good for stretching superficial tissue. To

apply the stretch, cross the forearms just above your hands, place the palms
about shoulder-distance apart, and then push down and outward with your
palms. You can increase the tension by leaning down and lowering your
body weight. As you lean down, your palms will move several inches apart
and both palms may rotate in a medial (inward) direction.
Force-couple stretching uses a force couple. When a pair of equal,
opposite, and parallel forces acting on a body are separated by distance, they
form a force couple. To apply the stretch, stand parallel to the patient, place
one hand flat on the proximal side of the thoracic or lumbar spine (little
finger parallel to and touching the spine), place the other hand flat on the
distal and opposite side of the spine (proximal edge of palm parallel to and
touching the spine), and then press down and rotate the hands about 10
degrees. This movement will pull the paravertebral muscles away from the
spine and it may cause a popping sound when the muscles pull on the
vertebrae. Force-couple stretching can be used after crossover stretching.

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RANGE-OF-MOTION STRETCHING
Range-of-motion stretching (ROM stretching) is the fourth and final

method of manipulation. The soft tissues affected by range-of-motion
stretching include muscles, fascia, tendons, ligaments, and joint capsules.
Range-of-motion stretching lengthens muscles and fascia by increasing the
distance between distal and proximal insertions. Besides improving active
and passive range of motion, ROM stretching improves muscle response by
stimulating the stretch-sensitive proprioceptors in muscles and the pressure-
sensitive mechanoreceptors in joints.
A muscle is an organ composed of three types of tissue: muscle
tissue, nerve tissue, and connective tissue. If a muscle is normal and the
joints the muscle crosses are normal, connective tissue such as fascia is far
more likely to restrict active or passive stretching than muscle tissue. If a
muscle is hypertonic and the joints the muscle crosses are normal, muscle
tissue is more likely to restrict stretching than connective tissue.
Since connective tissue is both viscous and elastic, connective tissue
follows the same laws of physics that apply to other viscoelastic materials.
These laws include hysteresis and creep. Because of proprioceptors such as
muscle spindles and Golgi tendon organs, muscle tissue is controlled more
by neuromuscular properties than by viscoelastic properties. The
neuromuscular principles that apply to muscle tissue include facilitation-
inhibition, reciprocal inhibition, and Sherrington’s reflex.
Since ROM stretching affects connective tissue and muscle tissue, it
also affects a muscle’s physical and neuromuscular properties. Compared
with neuromuscular therapy, ROM stretching is more effective in terms of
lengthening connective tissue, but less effective in terms of relaxing muscle
tissue, although it can reduce cramping. If neuromuscular therapy is used to
lengthen a muscle by relaxing muscle tissue, ROM stretching needs to be
used afterward to reset the gamma motor neurons that innervate muscle
spindles and help the proprioceptors adjust to the muscle’s new length.
ROM stretching is better for resetting proprioceptors than local stretching.
Range-of-motion stretching lengthens a muscle more effectively than
lateral or longitudinal stretching produced by local pressure with the hands
or elbows. While lateral or longitudinal stretching can be used effectively to
lengthen superficial fascia that lies just below the skin, the same techniques
have less effect on deep fascia that covers or separates muscles. When deep
pressure is used, lateral or longitudinal stretching are normally more painful
than range-of-motion stretching.

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The reason for therapeutic ROM stretching is to help joints achieve or
maintain a normal ROM by lengthening abnormally short tissues. Joints are
not biomechanically efficient if they are too stable (insufficient mobility) or
too mobile (insufficient stability). Even so, a joint can be hypermobile and
not be unstable. Increasing a joint's ROM beyond normal—which martial
art and dance instructors often encourage—increases the risk of injury. If a
joint is already hypermobile, be careful not to increase hypermobility.
Because human touch has the ability to measure the direction and
magnitude of resistance, manual stretching is safer and more effective than
mechanical stretching. Patients can verbally and physically resist stretching
that is done by hand, but not stretching that is done by a machine.
Although range-of-motion stretching is usually safe because patients
have the ability to stop the tension at any time, caution must be used not to
overstress healing tissues. Stress applied early during the wound-healing
process (1) promotes remodeling and proper alignment of scar tissue, (2)
increases lubrication that allows glide between fibers, and (3) improves
flexibility by reducing cross-links and breaking adhesions. Excessive stress,
on the other hand, can disrupt tissues and slow the healing process.
As a rule, stretching is not beneficial until the acute phase of an injury
is over (about 24 to 72 hours), as indicated by the absence of swelling or
subcutaneous bleeding. Since proliferation of scar tissue is greatest during
the first three weeks of wound healing, stretching to improve mobility
should be started as soon as possible. Abnormal patterns of movement
because of adhesions can start to develop within 24 hours after immobility.
Low-force, long-duration stretching is normally more effective during
the wound-healing process than high-force, short-duration stretching. Since
high-force, long-lever techniques are seldom needed, hand placement is
normally close to the tissue being stretched. Care should be taken to avoid
increasing hypertonicity or causing inflammation because of overtreating.
Indirect (Functional) Techniques
Barriers are any obstacles or impediments that reduce motion within a

single plane. A joint’s ROM can be limited by bone or soft-tissue structures
such as joint capsules, muscles, fascia, tendons, or skin. Of the soft-tissue
structures, joint capsules and muscles are the most likely to limit ROM and
skin is the least likely. Soft-tissue impairments that can limit a joint’s ROM
are pain inhibition, spasms, contractures, adhesions, and swelling (edema).
Each joint has three standard ranges of motion:

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• Active range of motion: up to the physiological barrier.
• Passive range of motion: up to the anatomical barrier.
• Anatomic range of motion: beyond the anatomical barrier.
The active range of motion describes the entire range of motion

patients are able to achieve by using their own muscles. The active range of
motion stops at the physiologic barrier and may be called the physiologic
range of motion. The active range of motion is the range most affected by
pain inhibition. Range-of-motion stretching has a tendency to increase the
active range of motion, whereas aging has a tendency to decrease the active
range of motion. The frequent goal of soft-tissue therapy is to increase or
maintain the active range of motion.
The passive range of motion describes the entire range of motion
possible when external forces are used to move a body part. In soft-tissue
therapy, the most common type of external force is manual pressure. The
passive range of motion stops at the anatomical barrier.
Within the passive range of motion, there are two regions: the elastic
region where tissues resume their previous shape when external forces are
removed and the plastic region where tissues remain permanently deformed
when external forces are removed. The dividing line between elastic and
plastic deformation is the elastic barrier. To produce a permanent increase
in range of motion, tissues must be stretched beyond the elastic barrier.
The anatomic range of motion describes the entire range of motion
possible without causing tissue damage. Exceeding the anatomical barrier
will cause fractures, dislocations, ruptures, or soft-tissue tears.
The restrictive barrier at the end of the passive range of motion is
normally characterized by an increase in tension or pain. The feel when
approaching the end of this range of motion (end-feel) can be hard, as in the
bone–to–bone contact felt during complete elbow extension, or soft, as in the
muscle–to–muscle contact felt during complete elbow flexion.
The restrictive barrier that prevents a range of motion from becoming
larger is called the outer barrier, and the barrier that prevents a range of
motion from becoming smaller is called the inner barrier. The theoretical
point within a range of motion where the agonistic muscles are in a resting
position—neither stretching nor contracting—is called a neutral point.
When a body part’s range of motion increases beyond the neutral
point, tension increases until the outer barrier stops any further movement.
Techniques that increase tension (bind) by moving in the direction of the
outer barrier are called direct techniques. Range-of-motion stretching is a

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direct technique. Techniques that decrease tension (ease) by moving in the
direction of the inner barrier are called indirect techniques. Slacking a
muscle, the opposite of stretching a muscle, is an indirect technique.
Indirect techniques are analogous to pushing a stuck drawer closed
before trying to open it again. Like a drawer, pushing a body part into a
position of less stress before pulling it into a position of greater stress may
help to align contact surfaces or move particles such as joint mice out of the
way that are interfering with normal movement. Joint mice are defined as
small fibrous, cartilaginous, or bony loose bodies in the synovial cavity of a
joint that may interfere with normal joint movement.
While direct techniques that apply force directly against abnormal or
pathologic barriers are more common than indirect techniques that move a
body part in the direction of greatest comfort, slacking a muscle before
stretching it will sometimes produce a greater increase in range of motion
than stretching alone. A similar effect can be achieved by separating joint
surfaces with longitudinal traction before using direct techniques, such as
range-of-motion stretching, to increase range of motion.
One theory to explain why indirect techniques work contends that
moving in the direction of the inner barrier stimulates mechanoreceptors in
the joint that inhibit muscle contraction. Mechanoreceptors are a special
type of receptor found in joints that respond to mechanical deformation or
pressure. If a muscle’s range of motion is being restricted by spasm, this
may explain how indirect techniques decrease resistance to passive stretch.
Another possibility is that indirect techniques improve joint function
in four ways: (1) increase joint space, (2) reduce internal resistance, (3)
improve metabolism, and (4) reduce afferent impulses. Afferent (sensory)
nerves conduct the impulses from pain receptors in a joint to the brain.
Since muscular pain is often caused by hypertonicity, any technique
that has a potential for relaxing muscles needs to be considered. Because
they move in directions that decrease tissue tension, indirect techniques can
sometimes be used when direct techniques cause too much pain. Two other
options are (1) recheck and neutralize any trigger points that may have been
missed or (2) use neuromuscular inhibition techniques to reduce tonus. If
you stretch hypertonic muscles, you may increase tonicity or cause trauma.
The risk factors associated with ROM stretching are too much force,
too much speed, and a greater than normal ROM, which may happen if the
length of a muscle with trigger points is normal and local stretching will not
reset the proprioceptors after the trigger points have been neutralized. Most
overstretched muscles can be shortened by using facilitation and exercise.

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Mechanics of Stretching
There are many varieties of stretching, and each method has its own
merits. A well-rounded practitioner will be familiar with the different types
of stretching and know when to use them and how to use them.
Soft-tissue manipulation can prepare tissues for stretching:
(1) Trigger point therapy can be used to relieve pain that limits range of
motion by physically or psychologically inhibiting movement. If
trigger points are located that appear to be causing limited range of
motion, ice or ischemic pressure can be used to neutralize the trigger
points in preparation for stretching.
(2) Muscle-spindle-cell inhibition is most effective when spasm in a limb

or the neck restricts movement. By using convergent force toward the
belly of a muscle, muscle spindles inhibit contraction and make the
muscle less resistant to stretch.
(3) Post-isometric relaxation, as discussed under neuromuscular therapy,

is a second way to inhibit contraction. Although post-isometric
relaxation is sometimes presented as a stretching technique, it is
technically a neuromuscular technique that prepares the muscle for
stretching by inhibiting contraction.
If pain or spasm are severe, heating or cooling modalities can be used

in conjunction with soft-tissue manipulation to relieve pain or relax spasm.
In addition to standard neuromuscular techniques, other types of inhibition
include: (1) rocking motions applied slowly and rhythmically to the body,
(2) stroking, pinching, or tapping techniques applied gently to the skin that
overlies hypertonic muscles, and (3) mechanical or manual vibration applied
to body parts affected by hypertonic muscles. Other techniques that often
produce general relaxation are scratching or vibration applied to the scalp,
gentle traction applied to the head, gentle mobilization to a limb, rocking
applied to the body, and deep pressure or stroking applied to the soles of the
feet, palms of the hands, or the lateral sides (peroneal regions) of the leg.
Muscle relaxants and nonsteroidal anti-inflammatory drugs may also help.
Six principles that relate to most range-of-motion stretching:

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1. The patient needs to be physically and mentally relaxed. Relaxation
techniques include light massage, supportive conversation, peaceful
music, slow rocking, soft lighting, and deep breathing. The working
environment and patient’s posture should be conducive to relaxation.
2. Static stretching with slow, progressive tension is more likely to

produce a permanent increase in tissue length without tearing than
ballistic (dynamic) stretching with rapid, pulsating tension.
3. Low-force, long-duration stretching is more likely to produce a

permanent increase in tissue length without trauma than high-force,
short-duration stretching
4. Low-velocity stretching is more likely to produce a permanent

increase in tissue length without trauma than high-velocity stretching.
5. Heat increases tissue extensibility and promotes stretching; cold

decreases tissue extensibility and retards stretching.
6. Standard advice for permanently increasing a muscle’s length, such as

stretch twice a day every day or hold the stretch for 30 to 60 seconds,
may not work if muscles have trigger points, spasms, or contractures.
The two methods of stretching used in ROM stretching are based on

different principles: (1) multiple-repetition stretching is based on hysteresis,
and (2) single-repetition stretching is based on creep. While both methods
use slow, progressive force to generate tension, the holding period between
stretch and release is longer in single-repetition stretching than in multiple-
repetition stretching. Ballistic stretching has practically no holding period
between stretch and release. Stretching 3 to 5 times per week can produce
gains, and stretching once a week may be enough to maintain gains.
Multiple-Repetition Stretching: This method is based on hysteresis

and uses multiple repetitions of low-force stretching with a short holding
period to produce a permanent change in a tissue’s length. Viscoelastic
materials such as connective tissue lose energy and become more pliable
when subjected to multiple cycles of stress and relaxation. The tissues are
stretched slowly at the beginning of each movement and released slowly at
the end of each movement.

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The average number of repetitions is usually 3 to 12, and the holding
period for each repetition is no more than 15 seconds. In multiple-repetition
stretching, the holding period should be long enough to produce a decrease
in tissue tension and lengthen the tissues.
Because the first stretch in multiple-repetition stretching is more

likely to break adhesions or lengthen restricted tissues than subsequent
stretches, the force needed for the first stretch may be greater than the
force needed for subsequent stretches. If tissues are heated before the first
stretch, the force needed during the first stretch may be less.
Single-Repetition Stretching: This method is based on creep and

uses low and continuous force with a long holding period to permanently
lengthen restricted tissue. Tissues are held under constant tension until the
internal stresses dissipate and the tissues relax and lengthen. The minimum
holding period for single-repetition stretching is about 15 seconds, and the
normal range is 30 seconds to several minutes. Since the body part is
stationary for a longer time, heat is more effective with single-repetition
stretching than with multiple-repetition stretching.
Single-repetition stretching can be used to stretch two body parts at
the same time. With patients supine and their knees extended, practitioners
can lift one ankle with each hand and then step back until the arms are fully
extended. Traction is then applied to both legs at the same time by stepping
away from the patient. This stretch can also be done with the patient on the
floor. Practitioners need to be very careful not to hyperextend their own
backs when stepping away from the patient to apply traction.
This technique helps to realign soft tissues and bring the iliac crest on
the high side into alignment with the iliac crest on the low side. It also
stretches soft-tissue structures surrounding the head of the femur, which at
times becomes tight enough to reduce joint space and irritate the hip joint.
While minor differences in leg length are normally asymptomatic, this
stretch will sometimes correct apparent differences in leg length. Since most
differences in leg length are functional as opposed to anatomical, corrections
are usually temporary and soon disappear with normal usage.
As with all stretches, caution should be taken not to injure any joints
that are located within the line of pull. Though traction, in general, seems to
improve mobility of joints, any complaints of ankle, knee, or hip joint
weakness would contraindicate leg traction.

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Fascial Stretching
If a muscle is unable to achieve normal length and muscle tissues are

functioning normally, the restriction is probably caused by the inability of
fascia to lengthen normally. Fascia is a sheet of fibrous connective tissue
that (1) envelops the body beneath the skin, (2) encloses muscles and groups
of muscles, and (3) separates muscle layers or muscle groups. Fascia also
forms sheaths for the nerves and vessels, envelops various organs and
glands, and becomes specialized around joints, where it forms or strengthens
ligaments. Superficial fascia lies directly below the skin, while deep fascia
is any fascia below superficial fascia.
Even though fascial stretching can be accomplished by using deep
pressure with the hand or elbow, range-of-motion stretching is generally less
painful and more effective. The key to fascial stretching is slow, steady
tension with moderate force. In terms of principles, creep applies more
directly to fascial stretching than does hysteresis. As the duration of
stretching increases, the amount of tension needed to lengthen fascia
decreases. Even if the same amount of lengthening occurs, a 3-minute
stretch with moderate force is less likely to cause tissue damage than a 1-
minute stretch with a larger amount of force.
When a muscle is stretched, the different bundles of deep fascia
surrounding or separating the muscle do not always lengthen at a uniform
rate, for two reasons. First, the bundles of fascia themselves are not
uniform, and therefore do not always lengthen at a uniform rate.
Second, based on Hooke’s law, tension is proportional to changes in
length until the elastic limit of a material is exceeded. When stretched below
the elastic limit, fascia returns to its original length when tension is removed.
Changes in fascial length are not permanent until the tissue is stretched
beyond the elastic limit and starts to deform plastically. Once fascia is
stretched beyond the elastic limit, less force is needed to continue
lengthening the same tissue at the same rate. Stretching fascia beyond the
plastic limit will cause rupture.
When fascial stretching is done with slow manual traction, the body
part being stretched may give the impression of lengthening or unwinding by
stages. A similar effect can be produced by flexing the trunk forward and
letting the arms hang freely from the shoulders. As gravity pulls the upper
body closer to the floor, the rate of descent will usually vary by stages as
muscles first tighten and then release. Some people will feel a twisting or
unwinding of the trunk as the fingers approach the floor.

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Increases in fascial length are permanent only to the extent that other
factors, such as immobility or letting fascia remain slack for more than a
short time, do not cause a decrease in length. If fascia does not undergo
frequent stretching, it will probably shorten. Local longitudinal stretching
applied while fascia is already under tension from ROM stretching often
produces greater increases in fascial length than ROM stretching used alone.
When fascial stretching is used to improve muscle balance, the normal
sequence is (1) lengthen short muscles by stretching fascia and (2) shorten
stretched muscles by using facilitation. Since there is no safe and easy way
to shorten fascia, tissues that are not abnormally short should not be
stretched. Overstretching fascia causes instability (excessive ROM with no
protection from myofascial or ligamentous constraints).
Crossover Stretch
When stretching multidirectional paravertebral muscles, a crossover

stretch, which produces local stretching, can be used to supplement ROM
stretching. To apply the crossover stretch with the patient prone on a table
and the practitioner standing parallel to the patient, cross the forearms just
slightly above the hands, place one palm on L5, the other palm on L1, and
then push down and outward. You can increase the tension by leaning down
and lowering your body weight. As you lean down, your palms will move
farther apart and both palms may rotate in a medial (inward) direction.
Crossover stretching can be used to stretch the paravertebral muscles
along the thoracic spine. To apply the stretch with the patient prone on a
table and the practitioner standing parallel to the patient, cross the forearms
just slightly above the hands, place one palm on T1, the other palm on L1,
and then push down and outward. You can increase the tension by leaning
down and lowering your body weight. As you lean down, your palms will
move farther apart and both palms may rotate in a medial (inward) direction.
When the forearms are crossed, the contact point is a pivot point or
fulcrum between your forearms. As the palms slowly move apart, the pivot
point may slide upward toward the elbows. The palms separate more during
a paravertebral stretch than during a local stretch.
Treat the paravertebral muscles on both sides of the spine and use a
very slow stretch. If the spine is stiff or restricted, stretching and relaxing
the muscles along the spine will usually improve mobility. Pay particular
attention to the multifidus, which often becomes hypertonic or weak. You
can repeat the same stretch several times on each side if necessary.

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Ballistic Stretching
In ballistic stretching, muscles are stretched by bouncing movements

with no hold at the end of the movement. Because of a stretch reflex that
causes muscles to contract when suddenly stretched, ballistic stretching may
increase resistance to active stretch and cause muscle soreness. Causing
muscles to contract and lengthen at almost the same time may cause tissue
damage or pain. Because static stretching is easier to control, less likely to
trigger a stretch reflex, and safer than ballistic stretching, static stretching is
preferred over ballistic stretching.
While not the safest way to permanently lengthen a muscle, ballistic
stretching is practical for people like athletes or professional dancers who
participate in activities that require high-velocity ballistic movements.
Plyometrics is a type of exercise drill that uses jumping to improve
speed and power. Plyometric training combines ballistic movements with
eccentric and concentric contractions. Despite the potential dangers,
plyometrics have been successively used to improve the performance of
athletes and dancers who require explosive jumping power.
Special Stretching Methods
Though most forms of ROM stretching use manual force, different

ways to supplement manual force include (1) mechanical stretching devices,
(2) passive or active assistance by the patient, and (3) gravity. Mechanical
stretching devices, which are sometimes used by athletes to increase ROM,
are not recommended for therapy. Most machines, unlike humans, cannot
feel changes in tissue tension or listen to feedback from patients.
One variant of mechanical stretching that can be useful is having the
patient actively stretch a muscle as far as possible and then use a wall, table,
chair, or some other device to hold the body part in place until the muscle
being stretched relaxes. The patient must have the ability to safely
discontinue the stretch at any time if pain becomes too severe. This
approach works well when stretching exercises are done at home.
Passive-assisted stretching can be used if spasm, contracture, or pain
inhibition are restricting movement. In passive-assisted stretching, outside
manual force stretches the muscle to the greatest length possible within
normal limits and then the patient uses active contraction by opposing
muscles to hold the stretch for about 12 seconds. This helps to strengthen
antagonistic muscles that are weak because of stretch weakness.

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Passive-assisted stretching is very effective when the active stretch
follows a passive post-isometric relaxation stretch. The sequence would be
(1) the patient contracts and then relaxes the target muscle, (2) the
practitioner stretches the target muscle, and (3) the patient uses antagonistic
muscles to stretch the target muscle.
When active-assisted stretching is used, the patient actively contracts
antagonistic muscles during the entire stretch. This not only strengthens
antagonistic muscles, but also helps to improve neurologic efficiency and
coordination. Active-assisted stretching seems to encourage patients to
work harder than they would if they were using active stretching alone.
Gravity is an excellent way to supplement manual force when a body
part can be positioned so that gravity works to stretch the target muscle.
Light manual force combined with gravity or gravity alone can be used to
produce a slow, progressive stretch. Adding weights to increase the weight
of a body part may not be advisable. Joints that tolerate the normal weight
may not tolerate the additional weight. When using a gravity stretch, be
careful not to lengthen or tear ligaments, which may cause joint instability.
Stretching a muscle against active resistance by the patient can be
used to lengthen muscles that are severely shortened by contractures. To do
isolytic stretching, the patient contracts the muscle being stretched while the
practitioner uses enough force to overcome the patient’s resistance and
lengthen the muscle. On the positive side, isolytic stretching increases
muscle length by stretching or breaking down fibrotic tissues or reducing
hypertonicity. On the negative side, the risk of tearing a muscle, rupturing a
tendon, or pulling a tendon away from its bony insertion makes isolytic
stretching potentially more dangerous than most other forms of stretching.
When used properly, breathing facilitates stretching. Deep abdominal
breathing produces general relaxation, and the normal sequence for
breathing and stretching is (1) apply tension (stretch) while the patient
exhales, and (2) hold or release tension while the patient inhales. In most
cases, breathing should be slow, smooth, rhythmic, and regular, and patients
should be discouraged from holding their breath. Several practice stretches
that incorporate stretching with proper breathing are usually more effective
than verbal instructions alone.
Manual traction is a special form of stretching that affects ligaments
and joint capsules more than muscles or tendons. Just as synovial joints
have normal ranges of motion, they also have normal amounts of joint space
between the articulating surfaces. Decreasing joint space can decrease range
of motion, and increasing joint space can increase range of motion.

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Using manual traction (distraction) along the longitudinal axis of a
load-bearing joint, which increases joint space, encourages mobility, and
using approximation along the longitudinal axis of a load-bearing joint,
which decreases joint space, encourages cocontraction and stability. When
opposing muscles that move a joint contract simultaneously (cocontract),
stability should increase. For example, if a patient is prone and one leg is
flexed to 90 degrees, simultaneously contracting the ipsilateral hamstrings
(flexors) and quadriceps (extensors) will make it difficult to flex or extend
the leg, which decreases mobility and increases stability.
Contraindications to Stretching
• severe pain or discomfort

• acute tissue damage or hemorrhage
• inflammation, infection, or swelling around joints
• instability or hypermobility
• recent fractures or dislocations
• degenerative bone or joint disease
• mental instability
Neutral Positioning
Neutral positioning is used to increase ROM when continuous tension

on a hypertonic muscle is not practical because of pain. Neutral positioning
begins by moving slowly in a direction that increases tension on the muscle
until the patient reports mild pain and then moving slowly in the opposite
direction just far enough to reduce tension and stop the pain. This neutral
position should be held for about 90 seconds. During this time, the patient
should be told to breathe normally or slightly deeper than normal.
After 90 seconds, slowly move the same body part in the same
direction until the muscle is completely slack and hold this position for
about 90 seconds. Slack is created by approximating the distance between
the distal and proximal insertions of a muscle. This entire movement should
be relatively pain-free and the final position should be a position of comfort.
After the 90 seconds is over, slowly move in the opposite direction—
which will increase tension. When the patient reports mild pain, stop and
then move in the opposite direction just far enough to reduce tension and
stop the pain, which is done by approximating the muscle insertions.

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The point between pain and no pain is called a neutral point. If
neutral positioning is effective, the second neutral point will establish a
greater range of pain-free motion than possible with the first neutral point.
Continue the sequence as long as the neutral point continues to move in a
direction that increases range of motion.
A second way to establish a neutral point is to move slowly in a
direction that increases tension on the muscle until the patient reports slight
pain and then hold the position for about 30 seconds. If the pain stops, this
position can be used as a neutral point. If the pain continues, move slowly
in the opposite direction until the pain stops, and use this position as a
neutral point. Moving in a direction that increases tension on a muscle is
sometimes called moving in the direction of restriction.
Despite occasional good results, the scientific justification for using
neutral positioning remains unclear. One possibility is that moving a patient
from a position of pain to a position of no pain decreases sensitivity to pain
by decreasing afferent input to the central nervous system. It is also possible
that decreasing painful stimulus gives nociceptors, proprioceptors, or
mechanoreceptors a chance to reset and return to normal sensitivity.
Neutral positioning does not always work—and it may exacerbate the
problem. If a muscle is hypertonic, moving it in a direction that decreases
tension may slacken the muscle and cause contraction more than relaxation.
Hypertonic muscles that become slack may go into spasm or cramp. This
explains why people with common LBP are often told (1) keep moving and
(2) do not remain in any one position for more than a short time.
If neutral positioning is used, patients should be carefully instructed
not to contract muscles that are in a pain-free position. If the pain-free
position creates slack, contracting the muscle may cause severe spasm or
cramping. This can be demonstrated by strongly contracting the hamstrings
when the knee is completely flexed. If this situation occurs, slow stretching
with heat or cold can be used to relieve spasm and lengthen the muscle.
Aquatic Stretching
Some patients report that stretching in water produces good results.

Buoyancy is the upward force water exerts on a partially or fully immersed
body. Because buoyancy can be used to counteract the effects of gravity, the
body is able to move, stretch, or stand up from a stooped-over position with
less muscular effort. As ROM and strength improve, patients can move their
bodies farther out of the water to increase the effects of gravity.

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Active or self-assisted stretching—using one or more body parts to
stretch another body part—is easier to use in water than passive or active-
assisted stretching. Swimming is also considered an excellent exercise for
improving or maintaining a patient’s ROM. For the patient’s safety, aquatic
stretching must always be properly supervised by qualified personnel.
Pain Related to Stretching
Patients should be told that stretching, as well as other forms of

manipulation, may cause a temporary increase in pain. This pain is normally
delayed for about 24 hours and may continue for several days. The pain
normally starts to diminish after the second day and there may be signs of
improvement such as increases in mobility. Once the pain subsides, patients
will normally show marked improvement.
While pain during stretching and delayed pain after stretching are
fairly common, there should be no pain directly after stretching. Pain that
continues directly after stretching may indicate the stretch was too severe. If
muscles are not held in place until they relax, there could be reflex spasm
that causes pain when the tension is released.
Therapeutic Stretching
Therapeutic stretching focuses on the basic actions of each muscle or

muscle group. These stretches can be modified or other stretches used to
address muscles that have more than one action. Therapeutic stretching is a
combination of art and science. Without being able to sense tissue changes,
such as small releases that indicate a tissue is lengthening, stretching can be
dangerous. For therapeutic stretching to be safe, you must: (1) understand
the mechanics of stretching, (2) listen carefully to feedback from patients
and (3) monitor subtle changes in tissue tension or consistency.
Even if you focus on one basic action, there are usually several ways
to stretch the same muscle. The sixteen stretches listed below are done on a
table, but some could be done from a chair. Sitting in a chair with the knees
flexed and bending the trunk forward stretches the gluteus maximus, while
sitting in a chair with the knees extended and bending the trunk forward
stretches the hamstrings. Sitting in a chair with the feet on the floor and
rotating the spine stretches the muscles that rotate the spine. If you sit on a
chair, cross one leg over the top of the other leg’s knee, and then pull the
thigh of the top leg toward the opposite hip, you can stretch the piriformis.

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The ROMs used in any book are approximations, and the way ROMs
are described may vary. ROMs are approximations because they are not the
same for every normal person, and the way ROMs are described may vary
because the reference point for the same ROM can be a limb or a joint. For
example, the ROM for the thigh or hip will be the same, about 120 degrees,
but some books use 110 degrees for the ROM and others use 125 degrees.
Therapeutic stretching should not be used to permanently increase a
muscle’s length if the length is already normal. To measure a muscle’s
length, measure the ROM that is opposite the ROM produced by the muscle.
Since the hamstrings extend the hips, measuring the ROM that is opposite
extension (flexion) will indicate if the length of the hamstrings is normal.
The hamstrings have two normal ROMs: knee flexion (135 degrees)
and hip extension (30 degrees). If the knee is capable of full extension (the
opposite of flexion), the main issue becomes hip extension (the opposite of
flexion). Since the normal ROM for hip flexion is 120 degrees, if the hip is
capable of flexing 120 degrees, the length of the hamstrings is normal. On
the other hand, if the hip is capable of extending 30 degrees, the length of
the quadriceps, a hip flexor, is normal. If the length of the hamstrings is
normal, the length of gluteus maximus, a hip extensor, is also normal.
ROMs are based on averages, and published figures may vary by
more than 10 degrees. Even if a ROM is normal based on published figures,
it is not normal if pain or tenderness is present, since a normal ROM is pain-
free. Abnormal tightness also indicates the ROM is not completely normal.
Some muscles can be tested for length by using a simple test. Sit with
your knees flexed to 90 degrees (feet flat on the floor) and try to touch your
shoulders to your knees. If you can, the length of the gluteus maximus is
probably normal. To test the hamstrings, sit with your knees fully extended
(heels on the floor) and see if you can touch your shoulders to your knees. If
you can, the length of the hamstrings is probably normal.
To test the psoas for length, place the patient on a table with one thigh
and leg fully flexed and the other thigh flat on the table with the leg hanging
over the end of the table. To measure tightness on the side opposite the
flexed thigh and knee, press down on the flexed knee (hyperflexion) and
watch the opposite thigh. If the back stays flat and the opposite thigh comes
off the table, the psoas on the same (ipsilateral) side is probably short.
Because the seventeenth muscle, transversus abdominis, is a trunk
stabilizer, it is easier to use internal force than external force to stretch the
muscle. The muscle’s action is expiration, the stretch is strong inspiration.
Shortness in any muscle is a good reason to check for trigger points.

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Major Muscles or Muscle Groups: Range-of-Motion Stretching
1. GLUTEUS MINIMUS The ROMs and actions

produced by a muscle
RANGE OF MOTION are subject to variation
because no two people
are exactly the same
Normal action: abduct hip (50 degrees) and the experts who
Opposing action: adduct hip (30 degrees) do the research do not
always agree.
STRETCH
Position: Lateral recumbent (lying on side)

Contact: Lower arm, leg, thigh, and body make contact with table
Setup: Upper thigh extended and hanging freely beyond edge of table
Practitioner: Posterior and facing upper thigh
Fixation: Against upper scapula to prevent lateral rotation of shoulders
Force: Against distal thigh in direction of adduction
2. GLUTEUS MEDIUS
RANGE OF MOTION
Normal action: abduct hip (50 degrees)

Opposing action: adduct hip (30 degrees)
STRETCH

Setup: Upper thigh extended and hanging freely beyond edge of table
Practitioner: Posterior and facing upper thigh
Fixation: Against upper scapula to prevent lateral rotation of shoulders
3. GLUTEUS MAXIMUS
RANGE OF MOTION

180
Normal action: extend hip (30 degrees)
Opposing action: flex hip (120 degrees)
STRETCH
Position: Supine
Contact: Arms, leg, thigh, and body make contact with table
Setup: Knee and hip fully flexed
Practitioner: To same side and facing head
Force: Against distal thigh in direction of flexion
4. PIRIFORMIS
RANGE OF MOTION

STRETCH

Setup: Upper thigh flexed and hanging freely beyond edge of table
Practitioner: Anterior and facing upper thigh
Fixation: Against upper iliac crest to prevent medial rotation of hips
5. HAMSTRINGS
RANGE OF MOTION
Normal action: extend hip (30 degrees)

Opposing action: flex hip (120 degrees)
STRETCH
Position: Supine
Contact: Arms, leg, and body make contact with table
Setup: Foot dorsiflexed, knee extended, and hip fully flexed

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Practitioner: To same side and facing head
Force: Against calcaneal tendon in direction of flexion
RANGE OF MOTION
Normal action: extend trunk (20-30 degrees)

Opposing action: flex trunk (80-90 degrees)
STRETCH
Position: Supine
Contact: Arms and body in contact with table
Setup: Both hips fully flexed
Practitioner: To the side and facing head
Force: Against both distal thighs in direction of flexion
7. LATISSIMUS DORSI
RANGE OF MOTION
Normal action: adduct arms (50 degrees)

Opposing action: abduct arms (180 degrees)
STRETCH
Position: Supine
Contact: Thighs, legs, and body in contact with table
Setup: Abduct arms to approximately 170 degrees
Practitioner: At head facing feet
Force: Using wrist hold, apply traction in direction parallel to body.
Note: After the arms are abducted, the hands should touch the table. This
stretch can be done with both the patient and the practitioner on the floor.
8. SOLEUS
RANGE OF MOTION

182
Normal action: plantar-flex ankle (50 degrees)
Opposing action: dorsiflex ankle (20 degrees)
STRETCH
Position: Prone
Contact: Arms, leg, thighs, and body in contact with table
Setup: Knee and ankle flexed to 90 degrees
Practitioner: To same side and facing flexed ankle
Force: Against ball of foot in direction of dorsiflexion
9. GASTROCNEMIUS
RANGE OF MOTION
Normal action: plantar-flex ankle (50 degrees)

Opposing action: dorsiflex ankle (20 degrees)
STRETCH
Position: Supine
Contact: Arms, thighs, legs, and body in contact with table
Setup: Knees fully extended and ankle flexed to 90 degrees
Practitioner: At feet and facing head
Force: Against ball of foot in direction of dorsiflexion
RANGE OF MOTION
Normal action: sidebend or abduct trunk (20-35 degrees)

Opposing action: sidebend or abduct trunk (20-35 degrees)
STRETCH

Contact: Lower arm, thigh, leg, and body in contact with table
Setup: Upper thigh extended and knee hanging freely over edge of table

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Practitioner: Posterior and facing extended thigh
Fixation: Against upper scapula to prevent lateral rotation of shoulder
Force: Against distal upper thigh in direction of adduction and extension
RANGE OF MOTION

STRETCH

Contact: Lower arm, thigh, leg, and body in contact with table
Setup: Upper thigh extended and knee hanging freely over edge of table
Practitioner: Posterior and facing extended thigh
Fixation: Against upper iliac crest to prevent lateral rotation of hip
Force: Gravity or against upper thigh in direction of adduction
RANGE OF MOTION
Normal action: flex hip (120 degrees)

Opposing action: extend hip (30 degrees)
STRETCH
Position: Prone
Contact: Arms, thighs, legs, and body in contact with table
Setup: Knee fully flexed
Practitioner: To the same side and facing flexed knee
Fixation: Against distal ankle to prevent extension of knee
Force: Against distal thigh in direction of extension
RANGE OF MOTION

184
Normal action: flex trunk (80-90 degrees)
Opposing action: extend trunk (20-30 degrees)
STRETCH (OPTION ONE)

Position: Prone
Contact: Legs, thighs, and body in contact with table
Setup: Place bolster under chest
Practitioner: To side and facing lumbar spine
Fixation: Bolster provides upward counterforce
Force: Gravity provides downward force
STRETCH (OPTION TWO)
Position: Prone
Contact: Legs, thighs, and body in contact with table
Setup: Place hands in push-up position
Practitioner: To side and facing lumbar spine
Fixation: Hips stay in contact with table
Force: Push up with arms and shoulders (extension push-up)
14. INTERNAL OBLIQUES
RANGE OF MOTION
Normal action: rotate trunk to same side (30-45 degrees)

Opposing action: rotate trunk to opposite side (30-45 degrees)
STRETCH

Contact: Lower arm, thigh, leg and body in contact with table
Setup: Upper thigh flexed and hanging freely over edge of table
Practitioner: To side and facing chest and upper shoulder
Fixation: Against distal thigh to prevent lateral rotation of hips
Force: Against upper shoulder in direction of lateral rotation
Note: Even though the internal oblique and external oblique stretches are
similar, the oblique muscles being stretched by lateral rotation of the spine are
located on opposite sides of the body. Lateral rotation stretches the internal
oblique adjacent to the table and the external oblique opposite the table. As
stated before, the movements produced by contraction and the movements used
for stretching are normally in opposite directions.

185
15. EXTERNAL OBLIQUES
RANGE OF MOTION
Normal action: rotate trunk to opposite side (30-45 degrees)

Opposing action: rotate trunk to same side (30-45 degrees)
STRETCH

Contact: Lower arm, thigh, leg and body in contact with table
Setup: Upper thigh flexed and hanging freely over edge of table
Practitioner: To side and facing chest and upper shoulder
Fixation: Against distal thigh to prevent lateral rotation of hips
Force: Against upper shoulder in direction of lateral rotation
16. ILIOPSOAS
RANGE OF MOTION
Normal action: flex trunk and hip (80-90 degrees)

Opposing action: extend trunk and hip (20-30 degrees)
STRETCH
Position: Supine
Contact: Entire body except overhanging extremity in contact with table
Setup: (1) Thigh and leg hanging over end of table
(2) Opposite thigh and knee fully flexed with knee near chest
Practitioner: To same side as overhanging limb and facing pelvis
Fixation: Against flexed leg to prevent extension of thigh
Force: Against distal overhanging thigh in direction of extension
Note: Trigger point therapy followed by ROM stretching will usually relax the
psoas. Keep the knees fully extended and the thighs flat on the table during
trigger point therapy. Retest the psoas for length after therapy to confirm the
results (page 178). If the thigh comes off the table, the psoas is probably too
short. If the leg hanging over the end of the table starts to extend, a two-joint hip
flexor such as the rectus femoris or tensor fasciae latae (TFL) may be too short.
A short TFL may cause medial rotation of the hip when the leg starts to extend.

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CHAPTER HIGHLIGHTS
THE THREE HEMME LAWS
• HEMME’s 1st law: Most conditions treatable by soft-tissue therapy are

• HEMME’s 2nd law: Most conditions treatable by soft-tissue therapy can
be identified and treated by using five basic steps: History, Evaluation,
• HEMME’s 3rd law: Always be ready, willing, and able to disregard any
law, principle, axiom, or belief that proves to be incorrect.
TEN LAWS OR PRINCIPLES OF SOFT-TISSUE THERAPY
• Beevor's axiom
• Creep
• Facilitation-Inhibition
• Head's law
• Hilton's law
• Hysteresis
• Sherrington's laws
• Sherrington's reflex
• Thixotropy
• Wolff's law
SIX SIGNS CHARACTERISTIC OF TRIGGER POINTS
• Points or zones that are tender when pressure is properly applied

• Distinct patterns of referred pain or radiated pain
• The presence of taut, indurated, or ropy bands within a muscle
• Tremors or fasciculations when pressure is properly applied
• Jump signs or local twitch responses when pressure is properly applied
• Abnormal weakness, shortness, tightness, or spasm within a muscle

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THREE WAYS TRIGGER POINT THERAPY REDUCES PAIN
• Digital pressure disperses pain-producing chemicals

• Digital pressure stimulates production of endogenous opioids
• Trigger points activated by pressure act as a counterirritant
SEVEN TRIGGER POINT CLASSIFICATIONS
• Active trigger point: symptomatic with characteristic behavior

• Associated trigger point: developed in response to another trigger point
• Latent trigger point: symptomatic only when palpated or compressed
• Primary trigger point: caused directly by dysfunction in a muscle
• Satellite trigger point: caused by trigger points in a different structure
• Secondary trigger point: caused by compensatory overload
• Attachment trigger point: caused by tension at muscle attachments
FOUR BASIC GOALS OF NEUROMUSCULAR THERAPY
• Inhibition: lengthen hypertonic muscles

• Inhibition: strengthen weak muscles
• Facilitation: shorten stretched muscles
• Facilitation: strengthen weak muscles
THREE WAYS TO INHIBIT A MUSCLE
• Proprioceptive inhibition
• Post-isometric relaxation
• Reciprocal inhibition
THREE PRINCIPLES OF CONNECTIVE TISSUE THERAPY
• Thixotropy
• Hysteresis
• Creep

188
EXERCISE
No treatment for common LBP will be effective unless you have self-
control and you do what you can to help yourself. If someone with LBP is
receiving medical treatment, the doctor may write an exercise prescription
and specify who should administer the exercise program. If someone with
common LBP is not receiving medical treatment, there are various groups of
professionals, such as physical therapists, athletic trainers, or certified
personal trainers, who can recommend or supervise an exercise program.
Even though common LBP is not classified as a disease, the pain and
loss of mobility can prevent people from performing normal daily activities,
which may cause psychological stress. How people take responsibility for
their own lives and deal with the pain and loss of mobility will determine
whether LBP becomes manageable or results in a permanent disability. If
you ignore the value of self-help and self-treatment, you will be letting LBP
reduce the quality of your life far more than necessary.
The soft-tissue therapy exercise plan for managing common low back
pain is (1) regular and correct exercise, (2) early detection and treatment of
soft-tissue impairments, and (3) prevention—which is the awareness and
avoidance of any activities that cause low back pain. Three conditions that
contribute to a healthy back are (1) physical and psychological relaxation,
(2) adequate nutrition, and (3) correct and properly applied treatment.
The main purpose for a low-back exercise program is to keep muscles
balanced and functioning normally. The back is healthiest when opposing
muscles are well balanced in terms of length, strength, and tightness.
A properly designed low-back exercise program will lengthen short
muscles, strengthen weak muscles, and restore normal tightness. The final
test of a low-back exercise program is how it affects people’s ability to flex,
extend, sidebend, and rotate the spine. These movements should be painless
throughout the entire ROM—which should be normal—and they should be
executed with normal speed, normal strength, and good coordination. If any
of these movements are less than normal, the risk of LBP will be higher.
Exercise, in general, helps to restore function in at least five ways: (1)
improving the alignment of connective tissues during wound healing, (2)
increasing mineralization of bone, (3) improving neurologic efficiency, (4)
helping to modulate pain, and (5) reducing congestion and fluid venostasis
by improving fluid dynamics. Other factors that most well-rounded exercise
programs will try to improve are muscle strength, muscle endurance, aerobic
endurance, proprioception, balance, and coordination.

189
Low-back exercise programs are considered successful when they (1)
lessen the severity of existing low back pain, (2) shorten recovery time, (3)
reduce the recurrence of low back pain, (4) prevent permanent disability, and
(5) restore normal function. To claim that a low-back exercise program is
successful just because pain diminishes in six weeks of treatment is not
realistic. About 70% of all low-back-pain patients recover within six weeks
with or without treatment. About 50% of all cases are resolved within 2
weeks and 90% or more cases recover within 3 months. The normal wound-
healing time for the ligaments in a sprained ankle is about 3 months.
Regular and Correct Exercise
A good exercise program needs to be both safe and effective. Any

exercise that moves a body part beyond normal limits, such as hyperflexion
or hyperextension of the lumbar spine, is potentially dangerous. People need
to understand that even though some stretching may be good, more
stretching is not always better. This is a very hard message for some people
to understand. People also need to understand that even though exercise is
normally good, too much exercise may cause low back pain.
Exercise can relieve pain and help the body restore muscle balance by
lengthening abnormally short muscles, strengthening weak muscles,
loosening tight muscles, improving joint functions, or breaking adhesions.
Besides increasing strength (the ability to exert force), exercise can also
increase endurance (the ability to resist fatigue).
Exercise should not cause excessive pain either during the exercise or
after the exercise. The intensity or frequency of an exercise program should
not be increased if the added exertion contributes to overuse injuries, a loss
of sleep, or chronic fatigue. Levels of exercises that interfere with normal
breathing patterns or encourage participants to hold their breath should be
avoided. Unlike the music used in aerobic exercise programs to stimulate
activity, the music recommended for low back exercises should motivate
participants to relax and work progressively toward greater mobility.
Encourage people to recommend changes in their exercise program.
If changing the movements used in an exercise (direction, velocity, or range
of motion) accelerates healing without causing harm, there is no reason not
to allow the change. In some cases, adding new exercises that are similar to
old exercises or adding completely new exercises will be helpful. Since
people with common low back pain often have a very good understanding of
what their bodies need, not listening to what they say is a serious mistake.

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Exercise Principles
Exercise can influence whether someone has a full recovery, a partial

recovery, or no recovery. Even though exercise programs without soft-tissue
manipulation are seldom effective, the value of exercise cannot be overstated.
Deconditioning because of prolonged bed rest or inactivity can cause muscle
atrophy, fibrosis, circulatory insufficiency, loss of bone mass, chronic fatigue,
and a low tolerance for pain. People who will not exercise on a regular basis
often become dependent on medication or manipulation and their symptoms
increase. Even if soft-tissue manipulation is very successful, regular exercise is
needed because it reduces the risk that a muscle imbalance will cause future
episodes of low back pain. If low back pain recurs, good physical fitness can
reduce the severity of symptoms and decrease rehabilitation time.
Stretching to increase limited flexibility is normally the first part of any
exercise program. After a full, pain-free ROM is possible, the second part is
trying to increase muscular strength or muscular endurance. Doing low-back
exercises shortly after you wake up and get out of bed is not recommended. If
you do exercise shortly after you wake up, walk around, stretch, and let your
tissues warm up and loosen up before you start your exercises.
Explain to people that the early stages of a low-back exercise program
should not be extremely painful or cause fatigue. Perspiration, shortness of
breath, difficulty talking, and rapid pulse indicate that the exercises they are
doing are too intense. If an exercise program is too difficult, most people will
not continue the program and the program may be harmful.
Once pain is reduced and people feel stronger, they sometimes forget
that trauma takes time to heal. These people need to change their activities or
limit the intensity of their activities until the injured tissues are completely
healed. The activities that caused an injury may also cause a recurrence.
If you work with people who suffer from LBP, you need to monitor the
effects exercise has on the person’s condition and watch for any signs that
indicate the exercise program needs to be modified. If a person is doing the
exercises correctly and pain or disability increase, the exercises may need to be
stopped or the person may still have soft-tissue impairments.
Even though the belief that stretching and doing a warm-up reduces
injuries has not been proven, it can be shown that many athletes do stretching
and warm-up exercises to help loosen tissues that are tight because of injuries.
If people need to stretch and do warm-up exercises before they do their back
exercises, this could be a red flag that indicates a need for further evaluation,
such as checking for inflammation or untreated soft-tissue impairments.

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Even after a full recovery, people should be instructed to eliminate any
activities that may have caused low back pain. Though some injuries, such as
traffic accidents, may be difficult to prevent, most people need to avoid
participating in recreational activities that they already know will cause LBP.
If the activity is vital to the patient's self-interest, such as work-related
duties, the alternatives are (1) condition the body to accept the added stress by
using exercise to improve flexibility, strength, endurance, coordination, or
balance and (2) avoid conditions that increase the risk of injury, such as
working when tired or fatigued or using poor body mechanics when you lift.
Flexibility is usually the first objective of an exercise program. The
same rule that applies to soft-tissue manipulation also applies to an exercise:
lengthen first, strengthen second. After muscles are capable of achieving a
normal pain-free ROM, the next objective is strengthen weak muscles. Until
you have enough flexibility to achieve a normal pain-free ROM and enough
strength to perform one repetition of the movement, muscular endurance and
cardiorespiratory endurance are secondary concerns.
Just as high levels of motivation and good genes can help someone
become a good athlete, low levels of motivation and a genetic predisposition
for lumbopelvic disorders can make it difficult for someone to overcome LBP.
When dealing with someone who lacks motivation or someone who has
physical characteristics that make exercise difficult, encouraging compliance
can be more of a problem than designing a good exercise program.
Many people seem to forget that physical fitness and physical skills are
perishable, which means that fitness and skills will decrease over time if they
are not maintained by exercise and practice (use it or lose it). If a low-back
exercise program is discontinued because the pain has stopped, the benefits
gained from the program may be lost and lumbopelvic pain may recur.
Exercise programs are based on five principles:
PHYSICAL FITNESS PRINCIPLES

1 The Overload Principle
2 The Intensity Principle
3 The Frequency and Duration Principle
4 The Specificity Principle
5 The Training Principle

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Overload Principle
The overload principle refers to exercising at levels of stress that are

higher than normal. When working at normal levels of stress, fitness remains
about the same. The body responds to higher than normal levels of stress by
making physiologic changes called adaptations that improve the body's ability
to deal with future stress. These changes affect strength, muscular endurance,
flexibility, and cardiorespiratory fitness. Once new levels of stress become
normal, higher levels of stress are needed for improvement.
Overload can be produced by using various forms of resistance such as
gravity, weights, weight machines, opposing muscles, or resistance from a
therapist. Progressive-resistance exercises are based on the principle that
resistance should be increased incrementally after a body adapts to each new
level of stress. Adaptations continue until a body reaches its own limits.
One session of an exercise produces temporary changes that are called
responses. These changes become more permanent after repeated bouts of the
same exercise. It is not the exercise itself, but the changes that occur because
of exercise that improve biologic efficiency.
The overload principle applies to isometric, concentric, and eccentric
exercises. Isometric contractions do not produce movement because internal
forces are not strong enough to overcome external resistance. Muscles that
contract isometrically develop tension without changing length.
Concentric contractions produce movement because the internal forces
are strong enough to overcome external resistance. Muscles that contract
concentrically develop tension and shorten. Eccentric contractions allow the
muscle to increase in length because internal forces are not strong enough to
overcome external resistance and the muscle contracts and lengthens at the
same time. If the trunk flexes forward, spinal extensors contract eccentrically
to control the rate of descent or contract isometrically to stop the descent.
Isometric contractions improve static strength, which is used to grip or
hold an object, and concentric contractions improve dynamic strength, which is
used to push or pull an object. It usually requires less effort to grip or hold an
object than it does to push or pull an object.
Because there is no movement, isometric contractions generate less
friction and are less likely to aggravate joints or damage periarticular tissues
than concentric or eccentric contractions. Isometric exercises can sometimes
be used when concentric or eccentric exercises would be unsafe.
Flexibility refers to mobility or ROM, and the overload principle can be
applied to flexibility exercises. Structures that may limit flexibility are

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muscles, tendons, ligaments, fascia, body fat, skin, joint capsules, or joints.
Flexibility is joint-specific: having greater than normal flexibility in one joint
does not mean that all joints have greater than normal flexibility.
Pain can be used to measure overload when stretching normal tissues:
(1) start the stretch, (2) stop the stretch if you feel pain, (3) hold the stretch
until the pain stops, (4) repeat the sequence, and (5) stop stretching if holding
the stretch does not stop the pain or no more stretching is needed. If tissues are
abnormal because of spasms or contractures, stretching after you start to feel
mild pain may be the only way to relax or permanently lengthen tissues.
Another way to measure overload when stretching is to use resistance:
(1) start the stretch, (2) stop when you feel resistance, (3) hold the stretch for
less than 2 seconds or more than 15 seconds, (4) release the tension, (5) repeat
the sequence until the tension causes pain or no more stretching is needed.
Some people believe that stretching less than 2 seconds will not trigger a
stretch reflex, but others disagree. Many people also believe that a stretch
should be held longer than 15 seconds and they recommend 30 or 60 seconds.
To achieve maximum gain, stretching twice a day every day is probably better
than stretching once a day 3 to 5 times a week. On the other hand, people need
to remember that too much flexibility may cause instability and pain.
Intensity Principle
Overload is measured by the amount of energy expended to overcome

resistance and by the rate of expenditure (intensity). Muscle tissues have a
threshold for improvement, and strength gains will not occur if the intensity is
below this level. Strength training and muscular endurance training require
higher levels of intensity than flexibility or cardiovascular fitness training.
In sports training, intensity is often measured by fatigue, which means
muscles have lost their ability to contract and they momentarily fail. Fatigue is
caused by depletion of glycogen in the muscle, accumulation of metabolic
waste, depletion of oxygen, or failure of the body to regulate temperature.
In therapy, a muscle may fatigue after one attempt to move a body part
against gravity. Although fatigue is a good indicator that muscles are being
used to the fullest extent possible, this level of intensity is normally too high
for most patients. Muscle fatigue is inversely related to contractile force. High-
intensity exercises that use near-maximum strength fatigue muscles rapidly,
and low-intensity exercises that use 30 percent or less of maximum strength
fatigue muscles slowly. In terms of rehabilitation, low-intensity exercises are
usually safer and more effective than high-intensity exercises.

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In general: low-repetition exercises use higher intensities than high-
repetition exercises, 1 to 7 repetitions are used for strength, 8 to 12 repetitions
are used for strength and endurance, and 12 or more repetitions are used for
endurance. Some endurance exercises use thousands of repetitions.
Even though it is not completely clear what causes muscle soreness,
intensity of exercise appears to be a factor. Microtrauma, spasm, and edema
are several of the main factors that may cause muscle soreness. According to
one theory, muscle soreness occurs when the by-products of metabolism, such
as lactic acid, accumulate in the tissues and cause edema. As the fluids shift
back into blood plasma from the tissues, hydrostatic pressure decreases and
pain subsides. Even though the accumulation of metabolites is probably a
major factor in causing muscle soreness, the role of lactic acid is less certain:
(1) lactic-acid levels are not elevated in the muscles long enough to explain
muscle soreness, (2) eccentric exercises produce more muscle soreness but less
lactic acid than concentric exercises, and (3) some people who experience
muscle soreness are unable to produce lactic acid because of hereditary defects
or disease, such as McArdle's disease.
Microtrauma is probably the main cause for muscle soreness. During
intense exercise, microtrauma triggers the release of inflammatory mediators
such as hydrogen ions, potassium ions, substance P, histamines, bradykinin,
serotonin, and prostaglandins. These chemicals are then followed by pain,
spasm, edema, and secondary tissue damage because of ischemia. Since pain,
spasm, and edema restrict blood vessels and reduce circulation when metabolic
demands are high, metabolites accumulate and cause more pain.
In many respects, a sequence of muscle soreness resembles a pain cycle.
The differences appear to be onset and resolution. In muscle soreness the
onsets are sudden because of exercise; in pain cycles the onsets are insidious
because the immediate causes are difficult to identify. Muscle soreness is
normally self-limiting and resolves without treatment. Pain cycles are
normally self-perpetuating and seldom resolve without treatment.
It appears that exercise intensity has a direct effect on microtraumas. As
the intensity of exercise increases, microtraumas increase. Though high-
intensity exercises favor rapid gain, they increase the risk of muscle soreness,
torn muscles, ruptured tendons, fractured bones, and dislocated joints. Low-
intensity exercises favor long-term improvements but slower progress. Since
for many patients even small amounts of exertion may cause some degree of
improvement, it is usually safer to sacrifice rapid gains in exchange for long-
term progress. An effort of about 60 percent of maximum strength is usually
sufficient to increase the cross-sectional area of a muscle fiber (hypertrophy).

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When muscles increase in size because of hypertrophy, part of this
increase results from an increase in the diameter of muscle fibers and part
results from an increase in the volume of connective tissue. Most skeletal
muscles are about 85 percent muscle fiber and 15 percent connective tissue. If
all other factors are equal, which is seldom the case, a muscle's maximum force
potential is proportional to the muscle’s cross-sectional area. If factors such as
neurologic efficiency, biomechanics, motivation, or nutrition are not equal, a
muscle’s cross-sectional area and strength will not be proportional.
Frequency and Duration Principle
In addition to intensity, frequency and duration also affect progressive

overload. Frequency is the number of times per week an exercise is repeated
and duration is the amount of time an exercise session continues per day.
Therapy sessions should be spaced far enough apart to allow sufficient
time for rest. As tissues break down (catabolism) from exercise, rest periods
are needed for growth or repair (anabolism). High-intensity exercises require
longer rest periods than low-intensity exercises. Although flexibility training
can usually be done more times per week than strength training, the desired
frequency requires a case-by-case assessment. Exercising 3 times per week
usually produces greater strength gains than exercising 2 times per week, but
working out 2 times per week gives the body more recovery time. Since most
exercise training is done outside the clinic, the patient's motivation or time
schedule may determine how many sessions per week are appropriate.
The duration of exercise can also vary. Thirty minutes per session is
about the average, with 15 minutes the lower limit and 50 minutes the upper
limit. High-intensity exercises require less time than low-intensity exercises
and strength training requires much less time than aerobic training. Poorly
conditioned patients often need shorter sessions than physically fit patients.
Specificity Principle
Specific exercises produce specific adaptations. Each exercise has its

own characteristics in terms of muscle groups, rates of energy expenditure, and
patterns of movement. These patterns include velocities, accelerations,
distances, amounts of force, and directions of movements.
The value of training depends on what type of transfer occurs between
training and the activity that training is preparing you for. Transfer is positive
if the training is beneficial and negative if the training is detrimental. Positive

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transfer is greatest when the training and the activity you are training for are
nearly identical. To increase positive transfer, a sprinter should spend more
time running than swimming or cycling. It is often easier to train people with
no experience than to train people with a negative transfer from prior training.
Even though practice does not always make perfect, good training encourages
perfection and bad training can create bad habits that are hard to break.
If you are being tested, the best way to ensure a positive transfer is to
practice the same activity that is being used for testing. If testing involves
riding a stationary bicycle or running on a treadmill, you can train by riding a
stationary bicycle or running on a treadmill. Using similar activities, such as
training by running on a track instead of on a treadmill, may also work.
Although training activities should normally be the same or similar to
the activities you are training for, if you are deficient in certain areas, you may
need to correct your deficiencies before you start regular training. If a test
requires that you do 50 push-ups and you are not strong enough to do one
push-up, you can train by doing bench presses until you are strong enough to
do one push-up and then you can train for the test by doing push-ups. If a test
involves complex skills, you may need to correct several deficiencies.
Training Principle
The training principle states that patients normally make the greatest
gains during the early stages of an exercise program. Patients in poor condition
seem to improve faster than patients in good condition. The most common
reasons for early improvement are better use of body mechanics and reduction
of counterproductive movements. Neural changes that improve neurologic
efficiency often precede morphologic changes that alter the mass or chemical
composition of a muscle. As patients develop more self-confidence and relax,
general performance seems to improve.
Progress is often slower after the first four weeks of a training program
and some patients become frustrated, lose interest in the program, and stop
exercising. Explaining the training principle can make it easier for people to
understand the nature of progress and give them encouragement to continue.
Despite the benefits of exercise and the consequences of inactivity, there
will always be some people who refuse to exercise. The best approach is try to
design an exercise program that is both enjoyable and beneficial. In most
cases, a person's willingness to exercise at home without supervision will have
a greater long-term effect on recovery than supervised exercise. It is very
difficult to help people who will not help themselves.

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Exercise and Manipulation
Even though soft-tissue manipulation prepares the body for exercise,

new soft-tissue impairments may occur after you start exercising. Palpation
and muscle testing are the best ways to identify soft-tissue impairments. The
affected tissues are usually tense, swollen, or painful when palpated and
muscle testing can show if tissues are weak, abnormally short, or tight.
If you find a soft-tissue impairment, try to correct the problem. After
ROM stretching has been used to lengthen abnormally short muscles and
facilitation has been used to strengthen weak muscles, exercise can be used
to help people maintain a normal ROM and strengthen muscles that are still
weak. After manipulation has removed enough soft-tissue impairments to
make exercise feasible, soft-tissue manipulation and exercise should both be
used. If new soft-tissue impairments occur because of the exercise program,
soft-tissue therapy can be used to treat the new impairments.
If you test opposing muscles when people are suffering from LBP, it
is normal to find that the agonist is stretched and weak and the antagonist is
tight and weak. After manipulation is used to lengthen the short muscle and
facilitate the weak muscle, exercise can be used to strengthen both muscles.
Contrary to what some people believe, exercise is not a substitute for
soft-tissue manipulation. Patients will not get the best care possible if either
type of treatment is withheld. It is very unfortunate for patients that many
practitioners who specialize in manual therapy do not understand the value
of exercise and many practitioners who specialize in exercise therapy refuse
to believe that soft-tissue manipulation is beneficial or necessary.
Intervention Exercises
Stretching and strengthening exercises restore function by improving

flexibility and strength. When properly applied, exercises counteract the
effects of deconditioning, which include stiff joints, atrophy, tightening of
connective tissue, neuromuscular inhibition, alteration of neural input from
the brain to muscles, and a loss of muscular and cardiovascular endurance.
Relaxing, low-impact exercises are the most appropriate exercises for
most people with common low back pain. Simple exercises such as flexing,
extending, rotating, and sidebending the lumbar spine from an office chair
can help offset the adverse effects of sitting too long. If most of your day is
spent sitting in an office chair, try to stand up, walk around, and do a corner,
sidebending, or extension stretch at least once every 15 to 30 minutes.

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(1) Corner stretch (standing push-up position)
a. Stand and face the corner of a wall.

b. Position your body arm's length from where the two walls meet.
c. Put hands with palms out and fingers up in front of your shoulders.
d. At shoulder level, place palms on adjacent walls with fingers up.
e. Stretch chest muscles by gently leaning into the corner.
f. Return to starting position.
(2) Sidebending stretch
a. Stand with your back against the wall.

b. With arms hanging down, place palms on wall.
c. Move closer and press scapulas to the wall.
d. Keep hands and scapulas on wall and sidebend in both directions.
e. Return to upright position.
(3) Extension stretch (standing push-up position)
a. Stand and face a wall at arm’s length.

b. Place palms on wall with fingers up.
c. Lean in and touch chest to wall with feet and palms held in place.
d. Hold position till the body relaxes and lumbar spine extends.
e. Return to starting position.
For people with common LBP, leaning against a wall with the chest or
raising the hands directly overhead can be painful. Most of this pain is
probably caused by increasing lumbar lordosis, though part of the pain from
raising the hands overhead may be caused by stretching the latissimus dorsi,
which is connected to the gluteus maximus via the thoracolumbar fascia.
If hypertonic muscles shorten, getting out of a chair or walking can be
very painful. Slow movements are often less painful than rapid movements
because muscles that lengthen slowly have more time to deform internally
than muscles that lengthen rapidly. Giving a muscle more time to lengthen
tends to reduce tension placed on distal and proximal attachments. Trigger
points and inflammation often occur at or near muscle attachments.
If you have LBP, avoiding stationary positions will help you avoid
pain. Constantly moving around reduces the time muscles are slack, which
makes it less likely that hypertonic muscles will tighten or go into spasm.

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Home Exercises
The Level II evaluation movements shown in Appendix 1 can be used

as part of a home-exercise program. Although exercise is very important for
people with common LBP, no one should enter any exercise program until
they are screened by an exercise professional who can determine if they need
to have a medical examination. These low-impact movements can help
prevent LBP or reduce the severity of future episodes, but they may be
contraindicated if someone’s medical condition precludes exercise.
These movements focus on restoring flexibility, strength, endurance,
balance, and coordination that have been lost because of LBP. They may
also improve the quality of proprioceptive input from muscle spindles or
Golgi tendon organs and promote healing by increasing local circulation.
Exercise can reduce pain and stiffness by inhibiting nociceptors that
receive or transmit pain, inhibiting proprioceptors or mechanoreceptors that
increase hypertonicity, lengthening restricted tissues, and keeping joint or
tendons lubricated. Other benefits of exercise are higher levels of physical
fitness, psychological relaxation, and a general feeling of well-being.
These movements use isometric, concentric, or eccentric contractions.
Isometric contractions increase blood pressure more than other contractions
if near-maximal contractions are held more than 6 seconds, but concentric
and eccentric contractions are more likely to cause muscle soreness. To
decrease the risk of increasing blood pressure, do not use near-maximal
isometric contractions and rest at least 20 seconds between contractions. To
decrease the risk of muscle soreness, reduce intensity or frequency and try to
avoid eccentric contractions, one of the main causes for muscle soreness.
When doing low-back exercises, consistency is very important. Even
if you have no pain for months, not exercising increases the risk of having
LBP recur or having an episode that is longer-lasting and more severe.
Being self-reliant is the best way to manage common LBP unless you
would rather become dependent on therapy or medication. If self-help for
pain and self-directed exercise are both used, you can (1) palpate tissues for
pain, (2) use digital pressure to decrease the pain, (3) stretch the affected
tissue with ROM stretching, and (4) strengthen weak muscles with exercise.
If you stay active, you will decrease the risk of dependency and disability.
The phrase "Train, don't strain" is not always appropriate when you
have common LBP. To accelerate recovery, prevent deconditioning, and
reduce the risk of disability, people must learn to "work through the pain" if
working through the pain decreases symptoms and restores normal function.

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When used with moderation and judgment, "No pain, no gain" may be the
only approach that works when you have common low back pain.
Stretching adaptively shortened scar tissues or contractures enough to
cause a permanent increase in length may cause moderate pain. If shortened
tissues are not stretched, pain avoidance, pain inhibition, spasm, and further
proliferation of connective tissue (fibrosis) may decrease your ROM.
Pain is difficult to avoid when stretching scar tissue or contractures,
but stretching should not produce sciatic pain below the knees. Exercises
that radiate pain, paresthesia, or numbness distally away from the spine need
to be discontinued until a physician determines if the exercises are safe.
Pain caused by stretching should lessen significantly shortly after the
stretch is completed. Pain that continues long after a stretch is completed
may indicate the stretch was too severe or a pathologic condition is present.
Too much stretching may traumatize tissues and cause acute inflammation,
whereas constant pain that does not change regardless of activity or position
indicates a pathologic condition. The ideal stretch is one that causes little or
no pain and relieves all symptoms, such as pain or stiffness, shortly after the
stretch is completed. These stretches are rare when you have common LBP.
Eight-Step Exercise Plan (See pages 77-81 and Appendix 1)
1. LATERAL PELVIC SHIFT (See page 77)
Special note: If lateral pelvic shift is present, correct it before attempting

flexion or extension exercises. You can use a mirror to determine how much
lateral pelvic shift has occurred. Attempts to shift the hips back in place can
be painful and there may be a loss of balance.
People who are unfamiliar with counting repetitions may need help. One
way is to count the first sidebend as one, your return to the starting position
as two, the second sidebend to the other side as three, and the second time
you return to the starting position as one. Each time you complete all four
movements, increase the number you use the second time you return to the
starting position by one. The numbers for the first two repetitions therefore
would be one, two, three, and one and one, two, three, and two.
If this exercise is too difficult for a starting exercise, do not push with the
hand that is on the hip. Either let the hand hang loosely down along the side
or place the hand on the axilla (armpit) below the raised arm and let the
fingers wrap around the latissimus dorsi. You should be able to feel the
latissimus dorsi stretching when you sidebend to the opposite side.

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2. MODIFIED SIT-UP (See pages 77-78)
Full sit-ups with anterior pelvic rotation are unnecessary and may irritate
the back. Modified sit-ups are done with the knees fully extended and the
pelvis and legs flat on the floor. A modified sit-up can also be done with the
knees flexed and the feet flat on the floor. Both exercises are good for
strengthening the psoas, but keeping the legs flat increases stability.
A good position for resting after this exercise is a prone position with the
arms abducted to about 170 degrees, the backs of the hands resting on the
floor, and the knees extended. This position will stretch latissimus dorsi.
3. DOUBLE LEG CURL (See page 78)
Double leg curls stretch the low back with less danger than bending
forward from a standing or sitting position and trying to touch the toes. The
hand position behind the calf instead of over the knee protects the knee joint
from hyperflexion. It also increases lumbar flexion more than a hand
position over the knee or behind the thigh. There might be joint popping
along the spine during the first or second repetition of this exercise.
4. SINGLE LEG LIFT (See page 78)
Most participants will like this exercise and wish to increase the number
of repetitions. There is no need to lock the knee and dorsiflex the foot
during elevation, although this would increase tension on the hamstrings.
Hold stretch for 2 seconds and then slowly release.
5. TRUNK ROTATION (See page 79)
Trunk rotation may stretch the erector spinae and cause joint popping
along the spine. Hearing joints pop is psychologically satisfying for many
people, and the movements that cause the popping sound may activate reflex
arcs that relax hypertonic muscles. Patients need to understand that the
absence of a popping sound does not mean the exercise was incorrectly
done. Other than placebo effects, a popping sound has no therapeutic value.
Participants should also be reminded that the hip-extension portion of this
exercise is just as important as the hip-flexion and trunk-rotation portions of
the exercise. If ranges of motion are normal, the knee of the extended thigh
should be able to touch the floor.

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6. CHEST LIFT WITH EXTENSION PUSH-UP (See pages 79-80)
Flexion exercises decrease lumbar lordosis, strengthen trunk flexors, and

stretch muscles that extend the spine; whereas extension exercises increase
lumbar lordosis, strengthen muscles that extend the spine, and stretch trunk
flexors. If the pelvis cannot tilt forward into a neutral position because of
abnormal tension from the hip extensors, extension exercises can help the
pelvis overcome this tension and move into a neutral position.
If you normally complete this exercise without a problem, and then for no
apparent reason you find yourself unable to lift your chest off the ground or
do an extension push-up, you may be entering an early stage of LBP pain
because hypertonic muscles—such as the psoas or gluteus maximus—are
causing a muscle imbalance that interferes with lumbopelvic rhythm.
Even with early intervention, it may not be possible to stop a full-blown
episode of LBP from occurring. If a small myofascial strain causes a minor
muscle imbalance, soft-tissue therapy might be sufficient to stop an episode
of LBP from progressing. If a large myofascial strain causes major tissue
damage to a site where muscles or ligaments attach to a bone (enthesis), soft-
tissue therapy is unlikely to stop an episode from progressing.
7. REVERSE LEG LIFT (See page 80)
If you normally complete this exercise without problems, the inability to

lift one or both thighs off the ground may indicate existing or impending low
back pain. Double-leg lifts may help facilitate single-leg lifts because of
reciprocal inhibition, but single-leg lifts improve ROM and coordination
more than double-leg lifts. This exercise is very good for activating the
multifidus during the early stages of common LBP. During the later stages
of LBP, the supplemental movements for the multifidus on page 205 can be
used. The multifidus cocontracts with the transversus abdominis to help
stabilize the trunk, and both muscles usually require specific interventions.
8. CHAIR STRETCH (See pages 80-81)
When you do this exercise, the scapulas should be mildly adducted

during the movement that extends the cervical, thoracic, and lumbar spine.
Participants should be reminded to consciously stretch the soleus and
gastrocnemius when they extend the outer thigh and place the ball of the foot
on the floor. This exercise is also good for stretching the quadriceps.

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Evaluation-Exercise Movements
Using the same movements for both evaluation and exercise has
several advantages. First, the patient learns the exercises during the
evaluation process. After the evaluation-treatment-and-retesting sequence
has been repeated several times, most patients know the movements.
Second, if the movements used to evaluate a patient are valid
measures of low back function, then using the same movements for exercise
should logically improve low back function. This parallels the principle of
specificity found in exercise physiology: specific exercises produce specific
adaptations. To a lesser extent, testing will also produce specific adaptions.
Though it may be necessary to use fewer repetitions during evaluation
than during exercise, it is wise to use at least two or three repetitions of each
movement during evaluation. Using only one movement may deprive you of
valuable information that will not appear until muscles are used enough to
irritate trigger points, cause muscle fatigue, or irritate inflamed tissues.
Third, patients are more willing to participate in exercise programs
when they can measure the results. If the evaluation and exercise
movements are the same, evaluations by supervising personnel will measure
the progress that results from doing the exercises. If the results are positive
and the patient shows improvement, this will inspire the patient to continue
with the program. Patients who continue the same program without direct
supervision will already know how to measure their own progress based on
previous evaluations by professional staff.
Patients will also learn how to forecast impending episodes of low
back pain by changes in their ability to perform these movements. This will
give patients a chance to seek professional help before the problem escalates
into major disability. The need for professional intervention may decrease
as patients become more physically fit, self-reliant, and knowledgeable.
The first sign of impending low back pain is normally tightness and a
limited ROM. The chest-lift exercise is usually the first exercise that shows
signs of impending low back pain. Continuation of exercise will sometimes
prevent LBP. If tightness continues or exercise becomes difficult or very
painful, patients should stop their workouts and seek professional help.
Since decreases in lumbar lordosis may increase thoracic kyphosis,
limited thoracic mobility may also be predictive of low back pain. When
treating lumbar pain, it is worthwhile to evaluate the thoracic and cervical
spine and treat any soft-tissue impairments that you find.

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For prevention, exercises should be done three times a week. If the
patient feels an episode of low back pain approaching, exercises should be
done at least twice a day, once in the morning and once in the evening. If
the patient has definite signs of low back pain, the ideal frequency is one
complete set of exercises every four hours. If the pain is too severe, patients
should discontinue the exercise program and seek professional help.
Exercise is extremely important after the pain from an episode of low
back pain starts to subside. As pain diminishes, the first stage of recovery is
moderate pain with greater function. The second stage is minor pain with
stiffness, especially in the morning when getting out of bed. This indicates
there is still enough hypertonicity to cause muscle stiffness, but not enough
to cause serious pain. Lumbopelvic pain will not disappear completely until
after joint and muscle stiffness has been resolved.
ROM stretching, muscle testing, and palpation can be used to identify
which muscles are still hypertonic. If not properly treated, these muscles
may shorten because of contractures or weaken because of tight weakness
and the opposing muscles may weaken because of stretch weakness.
Length-strength abnormalities between opposing muscles can start a muscle
imbalance that causes chronic LBP, long-term disability, or psychoneurosis.
If tissues are torn during an episode of low back pain, collagen fibers
begin producing scar tissue. Without movement during the healing process,
collagen fibers are laid down in random patterns and these tissues become
inelastic. With movement during the healing process, collagen fibers are
laid down in response to lines of stress and scar tissues are less rigid.
The influence of stress also enhances the quality and strength of
newly formed collagen fibers. Even though stress improves the quality of
scar tissue, the properties of scar tissue are different from the tissues being
replaced. While this may not change the function of tendons or ligaments to
any great extent, the quality of muscle tissue, cartilage, and nerve tissue can
be adversely affected by excessive amounts of scar tissue. Range-of-motion
stretching is the best way to lengthen scar tissue that is too short.
Perception of Pain
Most people believe the only thing that causes severe pain is a serious
injury or disease. While this may be true in some cases, it is not true when
dealing with common (nonspecific) LBP, where severe pain is often caused
by normal movements, such as standing up. The problem with LBP is that
not moving because of pain may cause serious complications or disability.

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Supplemental Evaluation-Exercise Movements (See Appendix 2)
1. STANDING SPINE-EXTENSION (Multifidus)

If your finger position is correct, you can feel the
A. Position: Standing multifidus contract when you rotate the spine.
B. Setup:
a. Feet slightly wider than shoulders and spine slightly extended
b. Fingertips pressing down on medial edge of lumbar multifidus
C. Movements:
a. Feel multifidus contract when you inhale slowly and deeply
b. Feel multifidus contract when you exhale slowly and deeply
D. Repetitions: 3 to 6 (Relax 15 seconds or more between repetitions.)
E. Stretch: Trunk flexors
F. Contract: Trunk extensors After the multifidus
has regained normal
strength, exercising it
2. KNEELING LEG-EXTENSION (Multifidus) less than once or
twice a week may
A. Position: Kneeling on hands and knees cause a strength loss.
B. Setup:
a. Feet slightly wider than shoulder-width apart
b. Hands in push-up position and fingers pointing forward
C. Movements:
a. Slowly and smoothly extend hip with leg fully extended until the
hip is slightly higher than the spine and hold about 1 to 6 seconds
b. Return to kneeling position and repeat exercise with opposite leg
D. Repetitions: 6 to 12
E. Stretch: Trunk and thigh flexors To increase endurance, use a 1-
second hold and 24 repetitions.
F. Contract: Back and thigh extensors
Variations you can do while kneeling on your hands and knees: (1)
extend a leg and contralateral arm simultaneously instead of extending just
the leg. Extending the arm and leg at the same time will increase tension on
the latissimus dorsi and the thoracolumbar fascia. Keep your hip and spine
level and do not extend your arm or hip more than a few degrees above your
spine and (2) starting with your spine relaxed and neutral—flex your back to
decrease lumbar lordosis while you flex your neck, inhale, and look down
and then extend your back to increase lumbar lordosis while you extend your
neck, exhale, and look up. Repeat this sequence 3 to 6 times. These
movements should be smooth, relaxing, and not painful or stressful.

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3. ISOMETRIC HAND-TO-KNEE (Transversus Abdominis)
A. Position: Supine
C. Movements:
b. Place left knee and left thigh into full flexion
c. Isometrically press right palm against left knee for 6 seconds
d. Return to setup
e. Flex knees until feet are flat on floor
f. Place right knee and right thigh into full flexion
g. Isometrically press left palm against right knee for 6 seconds
h. Return to setup
i. This movement can also be done from a seated position
E. Stretch: Gluteus maximus, hamstrings, and paraspinals
F. Contract: Quadriceps femoris, psoas, obliquus internus and externus
abdominis, rectus abdominis, and transversus abdominis
4. FORCED EXPIRATION (Transversus Abdominis)
A. Position: Supine
C. Movements:
a. With palms facing inward, place thumbs medial to anterior
superior iliac spine (ASIS) and apply slight downward pressure
b. Inspire deeply and let the abdominal muscles push the thumbs
gently upward
c. Expire deeply, let the fingers drop slowly and gently downward
with the abdominal muscles, and pause for a few seconds
d. Expire hard enough to pull the navel toward the spine, but not hard
enough to tense the abdominals and push the fingers upward
E. Stretch: Transversus abdominis and other abdominal muscles
F. Contract: Transversus abdominis and other abdominal muscles
Many people find this exercise very relaxing. Since stress contributes
to low back pain by increasing hypertonicity and causing sleep deprivation,
anything that increases relaxation is probably beneficial.

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Compliance
Exercises will not do you any good unless you do them. Most people
do low-back exercises for three reasons: reduce the intensity of pain, reduce
the duration of pain, or prevent future episodes of LBP. Things that
discourage people from doing low-back exercises are (1) a lack of time, (2)
failure to understand the exercises, and (3) pain. After an episode of LBP is
over, many people do not exercise because the pain is gone and there is no
compelling reason for them to exercise (out of sight—out of mind).
Even though anecdotal evidence indicates that exercise can reduce the
frequency, duration, or severity of LBP, random controlled trials are largely
inconclusive regarding the value of exercise in general or the value of any
specific exercise. One reason for inconclusive evidence is a lack of funding
for projects that do not involve surgery or pharmaceutical products.
Since the qualifications needed to offer an exercise program are not
usually regulated by law, the competence of the people who teach exercise
classes can vary. Common (nonspecific) LBP is not a disease, and there are
many different types of people who teach low-back exercises, such as yoga,
dance, or gymnastic instructors; certified personal trainers; athletic trainers;
occupational therapists; physical therapists; chiropractors; osteopaths;
podiatrists; and doctors of medicine, such as a physiatrist or orthopedist.
Prevention
The goals of therapy are (1) reduce pain, (2) restore normal tonus, (3)
lengthen restricted tissues, (4) strengthen weak muscles, and (5) restore
normal functions by improving balance and coordination. Standing on one
leg with the hands on the hips is a good exercise for improving balance and
walking is a good exercise for improving coordination. After people regain
normal functions, you can help them preserve these gains by encouraging
them to participate in low-back programs or physical-fitness training.
Besides knowing how to avoid low back pain, people need to know
what they can do if an episode of low back pain occurs. Having one episode
of low back pain is a strong indication that others will occur in the future.
If an episode of low back pain cannot be prevented, people need to
know that resuming normal activities is usually better than long-term bed
rest—although one or two days of rest may be reasonable—and working
through the pain as long as the pain is not excessive is usually better than
trying to avoid physical activity until the pain is almost completely gone.

208
The educational side of prevention involves not putting enough stress
on tissues to cause an injury. Factors that affect the risk of injury are the (1)
intensity of force, (2) frequency of force, (3) duration of force, (4) rate of
loading, and (5) direction of force. Regardless of which tissues are affected,
increasing the intensity, frequency, or duration of force will increase the risk
of injury. Although increasing the rate of loading will usually increase the
risk of injury—the faster you apply force to a tissue the harder it is for the
tissue to accommodate the force—forces applied quickly to soft and pliable
tissue, such as muscle tissue, are less likely to cause a serious injury than
forces applied quickly to hard or rigid tissue, such as osseous (bony) tissue.
The direction of force can also be a factor if a body part is forced to
move beyond its normal ROM, such as hyperextension of the elbow. Body
mechanics determine how much flexibility a joint has. Moving the spine in
two directions at the same time will normally limit the spine’s flexibility in
both directions. If the spine is flexed and rotated, the maximum ROM for
both movements (flexion and rotation) will be reduced. Low-back injuries
often occur when the spine is flexed and rotated at the same time.
Velocity is another factor that may affect tissue damage. While the
claim that fast ballistic stretching is potentially more dangerous than slow
static stretching may be true, there are many activities in sports and dancing
that require fast ballistic movements. If any activity you participate in
requires fast ballistic movements and you practice for this activity, you are
probably better advised to use fast ballistic movements during practice than
to use slow movements during practice and fast movements when you
compete or perform. If practice is going to help you perfect your skills and
make correct execution of those skills almost automatic, there needs to be a
strong similarity between what you practice and what you are practicing for.
Physical fitness can affect how well tissues are able to accommodate
stress, but the relationship between fitness and injuries is not always clear.
While it may be tempting to say that high levels of physical fitness reduce
the risk of having low back pain, physical fitness means different things to
different people. Marathon runners are often considered physically fit
despite a lack of spinal flexibility or arm strength, and professional dancers
are often considered physically fit despite having hypermobile joints.
Rather than say high levels of physical fitness will help you avoid low
back pain, it is more accurate to say that people with the following traits are
less likely to have a serious problem with common low back pain: muscular
strength, muscular endurance, aerobic endurance, normal flexibility, and a
good balance between opposing muscles or muscle groups.

209
Safe Lifting
Low-velocity lifting that gives the body time to recruit the appropriate
muscles and summate forces is usually safer than high-velocity lifting that
gives the body less time to prepare and requires more power (work divided
by time). Although lifting slowly decreases the risk of tears or ruptures by
giving tissues more time for elastic or plastic deformation, lifting slowly
may increase the risk of injury if the longer duration causes muscle fatigue.
Reducing risk requires moderation and judgment. If the only way you
can lift an object is by jerking it into motion or your arms start to shake
during the lift, you may be pushing your body beyond safe limits.
Objects are easier to control when lifted upward along a vertical plane
than upward and sideward along a diagonal plane. If a heavy object needs to
be lifted up and then moved sideways, rather than rotate your spine, lift the
object straight up and then move it sideways by moving your feet.
There are three biomechanical principles that relate to lifting: spinal
mechanics, leverage, and the summation of forces. In terms of mechanics,
the spine is biomechanically most efficient when performing one motion at a
time. If you try to lift an object while performing two spinal motions at the
same time, such as rotating while flexing or extending the spine, neither
motion will have a full ROM, which increases the risk of injury because you
may exceed the usable ROMs by hyperflexing or hyperextending the spine.
In terms of leverage, lifting is safest when the objects being lifted are
held as close to the body as possible. Decreasing the distance between the
body and the objects being lifted decreases the length of the lever arm and
increases mechanical advantage. The same principle applies if you carry an
object: hold it close to your body. If an object is dirty or abrasive, wearing
a safety apron can make it easier to hold the object close to your body.
The last biomechanical principle, summation of forces, refers to using
as many muscles as possible to produce the same movement. When lifting
an object from the ground, squatting down and lifting with the legs, thighs,
and back decreases the risk of injury because more muscles are contributing
to the same movement. Bending over at the waist to lift an object from the
ground puts most of the strain on the back extensors. Compared to bending
over at the waist, squatting down makes it easier to hold objects close to the
body and it reduces the risk of hyperflexing the spine when starting the lift.
If you have squatted down to pick something up with your right hand,
you can increase summation by pressing down on the left knee with the left
elbow. This will stabilize your position and it may help you stand up.

210
If you bend over at the waist to lift a light object from the ground, you
can lower your body by flexing your knees as you bend forward. But if you
do not flex your knees, avoid arching your back into extension when you
straighten up, which puts a heavy strain on your back extensors. Also avoid
flexing your spine after your pelvis has stopped rotating, which may cause a
hyperflexion injury. When lifting objects from the ground, squatting down
with the knees flexed and the head higher than the hips is safer than bending
over at the waist with the knees straight and the head below the hips.
The squatting movement also tightens the iliotibial band, which makes
the gluteus maximus biomechanically more efficient during the hip-
extension stage of lifting. When flexing the knees during heavy lifting, the
quadriceps tense the iliotibial band of the tensor fasciae latae, which is one
of several insertion points for the gluteus maximus. This combination is
thought to strengthen pelvic rotation, which extends the back. Keeping the
back flat or slightly lordotic can also help optimize your strength.
Attitude and judgment are often more important than your level of
physical fitness or how you lift. Even if you are physically fit and you are
lifting correctly, exceeding your own limits by trying to lift weights that are
far beyond your ability to lift may cause an injury. When estimating your
capacity to lift a heavy object, you need to consider several factors: (1)
fatigue, exhaustion, lack of sleep, or poor nutrition can lower your strength,
(2) physical skills are perishable because they decrease over time without
practice, (3) distractions, depression, or mental pressure can lower your skill
level, and (4) previous injuries can lower your strength and decrease motor
control. If you constantly push yourself to the limit, it will probably be only
a matter of time before you exceed your limits and get injured.
Most people are capable of lifting more weight if they warm up by
doing a few light contractions before they lift. The reasons for a warm-up
include: less resistance to passive stretch because tissue viscosity will be
lower, more strength because light contractions facilitate muscles, and better
metabolic efficiency because tissue temperatures will be higher.
The following principles will help you reduce the risk of a low-back
injury when lifting objects or moving them sideways. Though they apply to
heavy objects more than light objects, these principles can also be applied to
light objects. If you always flex your knees and squat down when you pick
things up, you are less likely to get injured when something you reached
down to pick up turns out to be heavier than you thought it was. The same
principle that applies to lifting heavy objects also applies to holding heavy
objects: avoid holding heavy objects when your spine is fully flexed.

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• If the weight exceeds your capacity to lift, get help.
• Avoid lifting heavy objects if other alternatives exist.
• Avoid lifting heavy objects when your spine is fully flexed.
• Squat down and bend your knees when lifting heavy objects.
• Pushing a heavy object is usually safer than pulling or lifting it.
• Even if the object you are lifting is light, try to bend your knees.
• Stand erect and do a brief warm-up before you lift heavy objects.
• Stand on a stable surface when lifting or moving objects sideways.
• Keep heavy objects being lifted or moved sideways close to the body.
• Do not lift or move heavy objects sideways while the trunk is rotated.
• Do not hold your breath when you are lifting or moving heavy objects.
• To move a heavy object sideways, move your body by moving your feet.
Think before you lift and use good judgment. If a lift in progress
cannot be completed, dropping the object is usually safer than lowering it to
the ground. Be careful when lifting objects that are awkward to hold, and
take periodic breaks to avoid fatigue when doing heavy or repetitive lifting.
Coping Mechanisms
Standing with the spine almost fully flexed and the knees straight
often causes severe spasms. The spine cannot remain in this position unless
the spinal extensors contract isometrically to keep the spine from dropping
into full flexion, and long-term isometric contractions impose major stress
on the spinal extensors, especially if someone is not in good shape. If stress
causes severe spasms, then pain, weakness, and fatigue will usually follow.
Sitting positions that increase lumbar flexion increase stress on the
multifidus. If the multifidus is hypertonic and stretching irritates it, it may
go into spasm when you sit up straight or stand up, which decreases tension
on the muscle and increases slack. If the multifidus goes into spasm, you
may see people putting their hands over the muscle. You can reduce stress
when you lean forward by resting your elbows on a table or on your knees.
If you work in a seated position, standing up and moving around one
or more times per hour or changing your sitting position will help you avoid
spasms. Slouching is not bad for your back, especially if you use one or
both elbows for support. If you work in a standing position, standing with
one foot on a small wooden block and changing from one foot to the other
when you start to feel pain or stiffness may help to reduce muscle strain.

212
Regardless of how they look to other people, bad postures are the ones
that cause pain and good postures are the ones that increase comfort. Two
rules that apply to posture: (1) if remaining in a posture causes pain or
discomfort, change your posture and (2) a good posture conserves energy by
using skeletal and ligamentous support more than muscular support.
If you are sitting for a long time, using a lumbar support, such as a
rolled towel, behind your lower back to increase lumbar lordosis may help to
reduce pain. Another option is to place two firm objects, such as tennis
balls, on the seat directly behind the gluteals. With one object positioned on
each side of the sacrum, sit back on the objects until you feel slight pressure.
If the objects are properly positioned, the pressure may give you some relief.
When rising from a chair, low-back patients should slide to the front
of the seat, use their arms to help their legs raise their body off the seat, and
rise slowly. Some patients may need to walk forward several steps before
they can stand completely upright. Once they are standing upright, some
patients get additional relief by extending their neck and looking upward.
Sleeping
Most people find a firm mattress, such as those found in hotels, more
comfortable than a soft mattress. While some people prefer water beds over
conventional beds, others prefer to sleep on chairs. Sleeping supine, with or
without a pillow under the knees, is usually less painful than sleeping prone.
Some people like to sleep in a fetal position with a pillow between the legs.
Most people with LBP will find it easier to get on or off a bed when the top
of the mattress is near waist level rather than closer to the floor.
Though finding a sleeping position that gives you the best rest will
help you avoid sleep deprivation, many of the positions—such as sleeping in
a fetal position with the hips flexed—encourage trunk flexors, such as the
psoas, to shorten. One way to stretch the trunk flexors before you get out of
bed is lie supine on the bed and put a pillow under your gluteals. If this
causes too much pain, you can carefully get out of bed and stretch the trunk
flexors by standing up very slowly—which may also cause pain.
After you get out of bed, rapid walking is one of the best exercises for
conditioning the low back. Unlike jogging, walking produces physical and
psychological relaxation with minimal stress. Running and jogging often
result in knee, hip, and ankle joint injuries from impact and overuse. Unlike
swimming or cycling, walking provides enough impact to strengthen bones.
Even so, degenerative joint disease may contraindicate walking.

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Too little exercise is usually more of a problem than too much, but
there are times when exercising is counterproductive. If you must exercise
in the morning because of a work schedule that limits your time, give your
body time to warm up and loosen up before you start. If you have a fever
and your joints are painful, postpone exercise until your health improves.
You must also give your body time to recover after an exercise session.
Smoking and Vibration
Smoking is a risk factor for LBP and sciatica because it reduces blood
flow to the discs, decreases the mineral content of bone, and increases the
risk of spinal degeneration. It also appears that smokers have higher levels
of emotional stress, tend to be less active, and cough more than nonsmokers.
Whole-body vibration is also a risk factor. This risk factor usually
applies to work-related activities such as driving trucks or heavy equipment.
Personal Trainers
Personal trainers are becoming very popular in the United States and
their popularity is expected to continue. By definition, personal trainers are
fitness professionals who evaluate clients, prescribe appropriate exercises,
supervise exercises, and monitor progress. Some personal trainers are
certified by national organizations and others are not. Although it appears
that personal trainers are not required to have a state license or certification,
anyone planning to become a personal trainer should check state and local
laws or consult an attorney before opening a business.
According to a widely-used textbook (Earle, 2004), personal trainers
can assess, motivate, educate, train, and prescribe exercise, but not diagnose
or treat diseases or prescribe medication. While it might be acceptable for a
personal trainer to work with people who suffer from common (nonspecific)
LBP—which is not a disease—it is doubtful that a personal trainer should
work with someone who is under a physician’s care because of bone cancer
without the physician’s approval. Like other professionals, personal trainers
can be held legally accountable by the courts for acts of negligence.
Whether personal trainers will ever be required to have a state license
is difficult to say. What does seem very likely is that some organization will
offer a national test for certified personal trainers. Because of the rising cost
of health care, it also seems likely that more people with common low back
pain will be using a personal trainer to help them stay physically fit.

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CHAPTER HIGHLIGHTS
EFFECTIVE LOW BACK PAIN EXERCISE PROGRAMS WILL
• lessen the severity of existing low back pain

• shorten recovery time
• reduce the recurrence of low back pain
• prevent permanent disability
• restore normal function
FIVE PHYSICAL FITNESS PRINCIPLES
• The Overload Principle

• The Intensity Principle
• The Frequency and Duration Principle
• The Specificity Principle
• The Training Principle
TWELVE WAYS TO LOWER THE RISK OF LIFTING
• If the weight exceeds your capacity to lift, get help.

• Avoid lifting heavy objects if other alternatives exist.
• Avoid lifting heavy objects when your spine is fully flexed.
• Squat down and bend your knees when lifting heavy objects.
• Pushing a heavy object is usually safer than pulling or lifting it.
• Even if the object you are lifting is light, try to bend your knees.
• Stand erect and do a brief warm-up before you lift heavy objects.
• Stand on a stable surface when lifting or moving objects sideways.
• Keep heavy objects being lifted or moved sideways close to the body.
• Do not lift or move heavy objects sideways while the trunk is rotated.
• Do not hold your breath when you are lifting or moving heavy objects.
• To move a heavy object sideways, move the body by moving your feet.

215
OBJECTIVES
OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED are the final two

steps in the HEMME APPROACH. Objectives are satisfied when someone (1)
regains normal functions and resumes normal daily activities or (2) achieves
a lesser goal if a full recovery is not possible. Objectives are not satisfied if
someone shows no improvement or insufficient improvement.
Some problems are not solved because people refuse to change their
lifestyle or eliminate factors that contribute to the problem. If people
continue pursuing activities that cause overuse injuries, therapy will not be
effective. People with low intakes of vitamin C and B complex are more
prone to soft-tissue impairments and overuse injuries than people with
healthy diets. Refusal to exercise, change eating habits, drink fluids, or stop
smoking can adversely affect therapeutic outcomes.
In other cases, the practitioner is at fault. Inappropriate treatments or
overtreatment are sometimes more damaging than no treatment. It is well
documented that patients who receive treatment, especially spinal surgery,
often have worse outcomes than patients who were not treated.
When treating common (nonspecific) low back pain, finding the best
therapeutic options can be difficult. When treating a dysfunction, such as a
muscle imbalance, the exact causes for the dysfunction are unknown and
therapy is sometimes based on a blend of intuition, speculation, observation,
and logic. Treating common LBP is often a combination of art and science.
The primary goals when treating common LBP are (1) reduce pain,
(2) normalize ROM, (3) improve the quality of movement, and (4) restore
normal function. Secondary goals are (1) stop the present episode of LBP as
quickly as possible, (2) prevent future episodes of LBP or reduce the
severity of future episodes, and (3) prevent permanent disability.
Even though episodes of common LBP frequently recur, some things
can be done to reduce the risk: treat conditions that may cause LBP in the
future, encourage activities that make people more resistant to LBP,
discourage activities that may cause LBP, and help people identify early
warning signs that indicate a need for immediate treatment. People need to
understand the importance of taking responsibility for their own health.
If a patient’s condition gets worse or shows no improvement, refer the
patient to someone else. The patient might require more than conservative
care or the patient might be more interested in getting secondary gain from
attention, sympathy, litigation, or insurance than in making a full or partial
recovery. Making referrals when appropriate is a sign of professionalism.

216
CONCLUSION
Considering the psychological, social, and economic consequences of

common LBP, there is a pressing need for new approaches that are both
conservative and cost-effective. With a success rate of less than 50%,
surgery is correctly regarded as a salvage procedure recommended for only
the most intractable cases. Some doctors claim that besides being a medical
epidemic, LBP is an epidemic of unnecessary surgery. Some studies in the
United States have shown that increasing the number of spine surgeons that
live in a community also increases the number of back operations per capita.
LBP is the third most common reason for surgery in the United States.
Although less dangerous than surgery, classical treatments based on
medication, bed rest, and pain-avoidance often leave people deconditioned,
demoralized, and sometimes permanently disabled. LBP is the second most
common reason patients seek treatment from primary care physicians and is
also the leading cause of disability in people under 45 years of age.
Something needs to change, but old ways often die hard, especially if
people fear change or they have a vested interest in maintaining the status
quo. Despite large volumes of evidence-based research that clearly shows
those who follow the disc paradigm and related dogma have failed to reduce
the severity or frequency of common low back pain, conservative methods
of treatment such as soft-tissue therapy are not widely understood or used.
For people with common LBP, soft-tissue therapy is very effective.
For people with pathologic conditions such as spinal cancer, congenital
conditions such as scoliosis, or neurologic conditions such as sciatica, other
types of intervention, such as surgery, may be necessary. Besides correcting
mechanical dysfunctions, such as muscle imbalances that cause LBP, soft-
tissue therapy helps people cope with pain, resume normal daily activities,
avoid long-term disabilities, and take responsibility for their own health.
Soft-tissue therapy is not a panacea, and treating common LBP often
requires educated trial and error. The learning process when working with
nonspecific LBP is never-ending, and failures are going to occur. You often
learn more from your failures than from your successes. Many people still
find it difficult to understand that working through the pain and staying as
active as possible produces better outcomes than bed rest or inactivity.
Above all else, always bear in mind a statement made by Hippocrates,
the Greek Father of Medicine (circa 460 to 400 BC): "Whenever a doctor
cannot do good, he must be kept from doing harm." In other words, your
first and highest duty must always be, “Do the patient no harm.”

217
APPENDIX 1
Evaluation-Exercise Movement (1)

Lateral Pelvic Shift
After you shift the

pelvis in one direction,
shift the pelvis in the
opposite direction.

218
Modified Sit-Up
Top view
LBP is often characterized by tightness in the hip flexors and weakness in

the abdominal muscles. Even though both regular sit-ups and modified
sit-ups will strengthen the abdominal muscles, modified sit-ups are less
likely to increase tightness in the hip flexors than regular sit-ups.

219
Double Leg Curl
Side view Angled view
Most lumbar flexion comes from the lower lumbar spine: about
75% occurs at the lumbosacral joint and about 15% to 20%
occurs between L4 and L5. Trunk flexion is about 80-90
degrees, but lumbar flexion alone is about 40 to 60 degrees.
This movement flexes the lumbar spine and changes the normal
lordotic curvature to a straight or very slightly flexed curve.

220
Single Leg Lift

221
Trunk Rotation
Doing this movement on the floor with a mat is safer than doing
it on a table. You can do a quadriceps stretch from this position
if you move the upper thigh into extension by pulling back on the
ankle with the upper hand (palm down). After you rotate the
trunk in one direction, rotate the trunk in the opposite direction.
Top view
Inferior knee remains on mat while the superior

knee drops downward towards mat.
Top view
Inferior knee remains on mat while left hand

holds the other knee on mat and the back of
the right hand touches the mat.

222
Chest Lift with Extension Push-up
A provocative test or movement that increases pain during the early stages of
therapy may help reduce or prevent pain during the later stages of therapy.
If people with nonspecific LBP have normal lumbar flexion and limited lumbar
extension, the probable cause is abnormal tension from the psoas, which
tends to increase lumbar lordosis when standing erect and decrease lumbar
lordosis when stooped over (inversion of function). Abnormal tension from
the psoas may also cause increased lumbar lordosis (hyperlordosis) when
rising from a stooped-over position or walking while stooped over.
Besides stretching the psoas, extension exercises can help restore normal
lordosis if abnormal tension from the hip extensors—hamstrings or gluteus
maximus—prevents the pelvis from tilting forward into a neutral position. The
force generated by extension exercises can help the pelvis overcome this
tension and tilt the pelvis forward into a neutral position, which restores
neutral lumbar lordosis. If the pelvis is locked in a posterior position because
of abnormal tension from the gluteus maximus, extension exercises can be
very painful and they may cause slight stretching of the gluteus maximus.

223
Reverse Leg Lift
If holding both thighs off the floor for 6 seconds causes slight pain, holding
them off the floor for 12 seconds may increase the pain and help you locate
the origin of pain. Applying isometric resistance against one or both thighs
during extension may also help you locate the origin of pain. If four leg lifts
cause slight pain, eight leg lifts may increase the pain and help you locate the
origin of pain. If forcing a muscle to work harder increases pain, possible
causes for the pain include a lack of strength or endurance, increased tension
on a torn muscle or ligament, or inflammation of a joint or muscle insertion.

224
Chair Stretch
This movement
should elevate your
chest.
This movement
should increase
lumbar lordosis.
Never assume a muscle is tight or weak before you test the muscle.
Contrary to what is called the lower crossed syndrome—where the hip
flexors and erector spinae are tight and the abdominals and gluteus
maximus are weak—testing may show that the hip flexors are tight and
weak, the erector spinae is weak, the abdominals are strong, and the
gluteus maximus is tight and weak.

225
APPENDIX 2
Supplemental Evaluation-Exercise Movement (1)

Standing Spine-Extension (Multifidus)
Extending the lumbar spine when you inhale, returning it to a

neutral position when you relax, and then extending it again
when you exhale may increase multifidus activity.

226
Kneeling Leg-Extension (Multifidus)

227
Isometric Hand-to-Knee (Transversus Abdominis)

228
Forced Expiration (Transversus Abdominis)
This movement is
Top view done with the body
supine, and the two
arrows below show
where light thumb
pressure is used to
monitor contraction
of the transversus
abdominis. If this
movement is done
correctly, expiration
should not push the
thumbs upward.

229
BIBLIOGRAPHY
Adler, Susan S., Dominiek Beckers, and Math Buck. 2003. PNF in practice.
2d ed. Berlin: Springer-Verlag.
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GLOSSARY
Achilles tendon reflex An ankle jerk caused by the involuntary contraction

of the calf muscles when the Achilles tendon is sharply struck.
acrocyanosis A circulatory disorder in which the fingers and hands, and

less commonly the toes and feet, are persistently cold and blue (cyanotic).
action Anatomical movement produced by the normal contraction of a

muscle.
active exercise The force needed to move a body part is provided entirely by
the voluntary contraction of muscles that normally control the body part.
active movement Movement of a body part caused entirely by a person’s

own effort without assistance or resistance from external forces.
active trigger points Hyperirritable spots or zones that actively produce

pain and may cause autonomic responses.
active-assisted exercise The force needed to move a body part is provided

primarily by the voluntary contraction of muscles that normally control the
body part and secondarily by another means such as a therapist, a mechanical
device, or one of the patient's other body parts.
acute Short duration, not chronic, rapid onset, severe.
acute inflammation Inflammation with rapid onset and clear termination

characterized by pain, swelling, redness, heat, and loss of function.
adaptive shortening A tightness that occurs when a muscle remains

abnormally short for a long time.
adhesion A tissue structure holding parts together that are normally separated.
afferent nerve A sensory nerve conveying impulses from the periphery to

the central nervous system.

244
agonist Muscle or muscle group primarily responsible for performing some
movement (prime mover).
all-or-none law The weakest stimulus capable of producing a response

causes skeletal muscle fibers to contract maximally.
anabolism The constructive phase of metabolism.
analgesia A decrease or absence of sensitivity to pain.
anesthesia Partial or complete loss of feeling, with or without loss of

consciousness.
ankylosis Fixation of a joint.
anoxia Without oxygen.
antagonist Muscle or muscle group that opposes the movement of the

agonist and produces the opposite movement.
antalgic A posture or gait that avoids pain.
aponeurosis A flat fibrous sheet of connective tissue that attaches muscles

to bone.
approximate To bring close together.
asymptomatic No visible symptoms.
ataxia Loss of motor coordination.
atonia Lack of tension or tone, flaccid.
atrophy Decrease in size of an organ or tissue.
attachment trigger point A trigger point caused by tension at distal or

proximal muscle attachments. The two most common sites are the
musculotendinous juncture and the tendo-periosteal-bone juncture.

245
auscultation Evaluating a patient by listening to sounds within the body.
ballistics A study of motion and trajectory.
baroreceptor A sensory nerve ending that is sensitive to pressure changes,

such as those caused by stretching the wall of a blood vessel.
barrier An obstruction that tends to restrict free movement.
bath immersion of the body or any of its parts in water—liquid or vapor—

for therapeutic purposes.
Beevor's axiom The brain knows nothing of individual muscles, but thinks
only in terms of movement.
blanch To become pale, white, or lose color.
capsulitis Inflammation of a capsule.
CAT SCAN Computerized (axial) tomography scan.
catabolism Destructive phase of metabolism.
caudad In direction toward the feet, tail, or distal end, opposite cephalad.
cavitation Formation of a cavity or microscopic bubbles.
cephalad In direction toward the head, opposite caudad.
chronic inflammation A persistent inflammation appearing quickly or

slowly with a vague termination and characterized more by pain, loss of
function, and formation of new connective tissue than by swelling, redness,
or heat.
chronic low back pain Low back pain persisting 3 months or longer.
clinical trial A research protocol designed to evaluate the efficacy or safety

of a drug or a therapeutic agent and to produce scientifically valid results.

246
clonus Uncontrolled spasmodic muscle jerking.
cocontraction Mutual contraction of opposing (antagonistic) muscles for the

purpose of stabilizing a body part.
cold compress A cloth dipped in cold or ice water, wrung out, and applied
to the body as a form of cryotherapy.
collagen A white fibrous protein found in connective tissue.
common low back pain Nonspecific low back pain.
compensatory Making up or compensating for a defect, deficiency, or loss.
concentric contraction A muscle shortens during contraction.
consensual A reflex action in which stimulation on one side of the body

causes a circulatory, muscular, or glandular response on the opposite side of
the body. A consensual reaction to light occurs when light directed at one
eye causes the opposite pupil to contract (consensual light reflex).
contractility Having the ability to contract or shorten in response to

stimulus.
contraction Increased tension caused by physiologic shortening of a

muscle.
contracture A pathologic shortening of a muscle due to spasm or fibrosis that

increases resistance to active or passive stretch.
contraindication A special symptom or circumstance that makes the use of

a particular therapy inappropriate, normally because of risk.
contralateral Affecting opposite side or on opposite sides of the body.
counterirritation Superficial irritation that relieves another irritation or

deep pain.
cramp Strong and painful spasm.

247
creep Deformation of viscoelastic materials when exposed to a slow,
constant, low-level force for long periods of time.
crepitus The sound or sensation of bone rubbing against bone.
cryotherapy Therapeutic application of cold.
cyanosis Bluish or gray discoloration of skin due to deficient oxygenation of

the blood and abnormal amounts of reduced hemoglobin in blood.
cyst A closed sac or pouch containing fluid, semisolid, or solid material.
decompression Remove pressure.
demineralization A loss or decrease of mineral salts, especially from bone.
denudation Removal of protective covering.
derivation The drawing of blood or body fluids away from congested parts
of the body to other parts of the body.
diaphoresis Profuse sweating or perspiration.
diathermy Use of high-frequency currents to heat deep tissue.
digit A finger (including the thumb) or toe.
discography X-ray taken after injecting an absorbable contrast medium into

an intervertebral disk.
discopathy Disease of an intervertebral disc (disk).
disease A morbid or pathologic condition that deviates from normal

function where the etiologic agent, signs, and symptoms are identifiable.
disinhibition Removal or abolition of an inhibition.
distal Situated away from the center of the body.

248
distraction Pulling on a limb in a distal direction (extension of the limb) or
using traction to separate joint surfaces without injury or dislocation.
divergence The moving of two or more forces away from a common center.
dystrophy Progressive abnormal changes that result from defective

nutrition of a tissue or organ.
eccentric contraction A muscle lengthens during contraction.
efferent nerve A motor nerve conveying impulses from the central nervous
system to the periphery.
elastic Having the property of returning to the original shape after being
stretched, compressed, or otherwise distorted.
elastin A yellow elastic fibrous mucoprotein found in connective tissue.
EMG Abbreviation for electromyogram, the graphic record of muscle

contraction that results from electrical stimulation.
endogenous Produced or developed from within the organism.
enthesitis Traumatic disease occurring at the insertion of muscles where

repeated stress causes inflammation and possibly fibrosis or calcification.
entrapment syndrome Entrapment of a nerve by hard or soft tissue.
enzyme Complex proteins produced by living cells that are capable of

inducing chemical changes in other substances without being changed
themselves.
epidemic A disease that attacks many people at the same time in the same
geographic region.
epidemiology A science that defines and explains the interrelationships

between factors relating to the frequency and distribution of disease.

249
ergonomics Study of human factors relating to the design and operation of
machines and the physical environment.
erythema Inflammatory redness of skin that results from dilatation and

congestion of superficial capillaries.
etiology Scientific study involving the causes of disease.
exacerbation Aggravating symptoms or increasing the severity of a disease.
exostosis Bony growth arising from the surface of bone.
extensibility The ability to lengthen.
exteroceptor A sense organ receiving stimuli from outside the body.
extracellular Outside the cell.
extravasation Fluids escaping from vessels into surrounding tissue.
fascia A fibrous connective tissue membrane covering, supporting, and

separating a muscle.
fasciculation Spontaneous contraction or twitch of a group of muscle

fibers.
fasciitis Inflammation of any fascia.
fibrinolytic Dissolution or splitting up of fibrin.
fibroblast A cell that produces connective tissue.
fibroma A fibrous, connective-tissue tumor.
fibromyalgia Chronic pain and stiffness in muscles or joints.
fibroplasia Development of fibrous tissue during wound healing.

250
fibroplastic Producing fibrous tissue.
flaccid Soft, relaxed, flabby, or without muscle tone.
flail joint Excessive mobility of a joint, usually because of paralysis.
flush Sudden or transient redness of skin.
FMS Abbreviation for fibromyalgia syndrome.
force That which changes or tends to change a body's motion or shape.
force couple A force couple is created by two equal, opposite, and parallel
forces that are separated by distance and produce a rotary force (torque).
gamma motor neuron An efferent nerve cell that innervates the ends of
intrafusal muscle fibers.
ganglion Benign cystic tumors developing on a tendon or aponeurosis.
gangrene Necrosis (tissue death) due to a loss or decrease of blood supply

or bacterial invasion.
goniometry The measurement of joint angles and range of motion.
guarding Involuntary muscle contractions that limit range of motion to

avoid pain.
handedness Preferential use of right hand or left hand when performing

voluntary motor acts.
Head's law If painful stimulus is applied to areas of low sensibility in close

central connection with areas of high sensibility, pain may be felt where
sensibility is high.
hematoma A localized collection of blood in a tissue or organ.
HEMME Acronym for History, Evaluation, Modalities, Manipulation, and

Exercise.

251
HEMME’s 1st law Most conditions treatable by soft-tissue therapy are
HEMME’s 2nd law Most conditions treatable by soft-tissue therapy can be

identified and treated by using five basic steps: History, Evaluation,
HEMME’s 3rd law Always be ready, willing, and able to disregard any law,
principle, axiom, or belief that proves to be incorrect.
herniated disk Protrusion of the nucleus pulposus through the outer ring
(annulus fibrosis) of an intervertebral disk. Also called a ruptured disk or
slipped disk.
hertz (Hz) A unit for measuring frequency equal to 1 cycle per second. One
million hertz (Hz) equals one megahertz (MHz).
Hilton's law The nerve trunk that supplies a joint also supplies the muscles
that move the joint and the skin that covers the insertions of the muscles that
move the joint.
homeostasis A state of equilibrium in the body controlled by positive and

negative feedback.
Hooke’s law The stress applied to stretch or compress a body is

proportional to the strain or changes in length thus produced, provided that
the elastic limit of the body has not been exceeded.
hydrolytic Causes hydrolysis: chemical decomposition of a substance into

simpler compounds by splitting bonds and adding the elements of water.
hydrostatic pressure The pressure exerted by fluids.
hydrotherapy The use of water in any of its three forms—liquid, solid, or

vapor—for therapeutic purposes.
hyper- Prefix meaning more than, excessive, above.
hyperemia Increased amount of blood in a body part.

252
hyperhidrosis Excessive or profuse sweating.
hyperirritable Increased response to stimulus.
hypermobility Excessive mobility of any joint.
hypersensitivity Abnormal sensitivity to stimulation by a foreign agent

with exaggerated responses.
hyperthermia Abnormally high fever induced therapeutically.
hypertonia Excessive tone of skeletal muscles that increases resistance to

passive stretch.
hypertonic A state of greater than normal tension in muscles.
hypertrophic scar An elevated scar resembling a keloid scar but not

spreading in surrounding tissues.
hypertrophy Increase in size of an organ or tissue.
hypo- A prefix meaning less than, deficient, beneath.
hypomobility Decreased mobility of a joint or range of motion.
hypothermia A body temperature significantly below 98.6°F because of

prolonged exposure to cold.
hypotonia Diminished tone in skeletal muscles and decreased resistance to

passive stretch.
hypotonic A state of less-than-normal tension in muscles.
hypoxia Inadequate or decreased concentration of oxygen.
hysteresis Energy loss in viscoelastic materials subjected to stress or cycles of

loading and unloading.

253
iatrogenic An adverse state or condition induced by treatment.
idiopathic A disease of spontaneous origin with unknown cause.
impulse 1. Sudden pushing or rapid loading. 2. Suddenly applied force or

rapid loading because of changes in momentum that occur over a short time
interval. 3. A change in momentum calculated by multiplying magnitude of
force by time of application.
induration Hardening of soft tissue caused by extravasation of fluids.
infection Multiplication of pathogenic organisms in the body.
inflammation A localized protective response to tissue damage or irritation

that is characterized by pain, swelling, redness, heat, and loss of function.
insidious A disease that appears slowly and progresses with few or no

symptoms indicating the illness.
inspection Examination by the eye.
instability Excessive ROM with no protection from myofascial or

ligamentous constraints.
ipsilateral Affecting same side or on same side of the body.
irradiation The spreading of a nerve impulse or response to stimulation

(increased facilitation or inhibition) from a common center and beyond the
normal path of conduction.
ischemia Insufficient or decreased blood supply to a tissue or organ due to

constriction, obstruction, or pressure (ischemic pressure).
isolytic contraction A muscle lengthens involuntarily during contraction.
isometric contraction Contraction of a muscle with no change in length.
isotonic contraction Contraction of a muscle with a decrease in length.

254
itis- A suffix that is often used to indicate inflammation.
joint mice Bits of bone or cartilage that are present in joint space.
jump sign A general, involuntary response caused by withdrawal from pain

when pressure is applied to a trigger point.
keloid scar A raised, red, smooth scar that is often painful.
kinetics A study of forces acting on a system.
kyphosis Backward convexity, prominence, or hump on the spine caused by

flexion.
latent State of being concealed, hidden, or inactive.
latent trigger points Trigger points that lie dormant except when palpated.
law of reciprocity The intensity and duration of radiant energy are

inversely proportional.
LBP Acronym for low back pain.
lesion Pathologically altered tissue, injury, or wound.
leukocyte Any white blood cell.
ligament A band of fibrous connective tissue connecting the articular ends

of bones.
lipoma A fatty tumor that is not metastatic.
loading To increase the mass or weight supported by an object or organism.
lordosis A normal or abnormal forward convexity in the curvature of the

lumbar (L1-L5) spine or cervical spine (C1-C7) as viewed from the side.

255
LPD Abbreviation for lumbopelvic disorder.
lumbopelvic rhythm A combination of lumbar and pelvic movements

that occur during flexion or extension of the trunk.
lymphoma A general term for any neoplastic disorder of lymphoid tissue.
lyse Break up or disintegrate.
lysosome A membranous organelle found in many cells that contains a

hydrolytic enzyme capable of digesting foreign material such as bacteria.
malignancy A cancer that causes serious illness or death.
malingering Pretending to be ill.
manipulation Therapeutic use of manual force with or without impulse.
matrix The intercellular substance of a tissue.
mechanism of injury The forces that caused the injury.
mechanoreceptor A receptor that responds to mechanical pressure or

distortion.
Meltzer's law (Contrary Innervation): All living functions are continually

controlled by two opposing forces.
metabolite Any product of metabolism.
metastasis Spread of malignant cells.
microtrauma Very small or microscopic injury or lesion.
mobilization Making a joint movable.
modality A therapeutic or physical agent such as thermotherapy (heat),

cryotherapy (cold), hydrotherapy (water), or vibration.

256
mottled A blotchy discoloration of skin often caused by heat.
MPS Acronym for myofascial pain syndrome.
MRI Acronym for magnetic resonance imaging.
muscle atrophy A decrease in the size of a muscle.
muscle hypertrophy An increase in the size or mass of a muscle fiber.
muscle imbalance A length-strength disparity between opposing muscles

that results in a loss of function.
myalgia Muscular pain.
myelography X-ray of spinal column after injection of contrast medium

into the spinal subarachnoid space.
myofascial Involving muscles and fascia.
myofascial release An osteopathic technique for slowly stretching muscles

and fascia that follows the principle of creep.
myofibroblasts A cell seemingly responsible for contracture of wounds.
myofibrosis Replacement of muscle tissue by fibrous connective tissue.
myositis Inflammation of a voluntary muscle.
myotenositis Inflammation of a muscle and its tendon.
necrosis Death of a tissue.
necrotic inflammation Acute inflammation with fairly rapid necrosis.
neoplasm A new and abnormal formation of tissue with uncontrolled and

progressive cell growth, which may be malignant or benign.

257
neoplastic Pertaining to abnormal tissue growth.
nerve conduction velocity The speed at which a peripheral nerve impulse

travels the length of a nerve.
neuralgia Pain along the course of a nerve.
neurapraxia 1. A traumatized nerve that no longer conducts even though

anatomic structure appears to be intact. 2. Loss of conduction in a nerve
because of local pressure or ischemia.
neuritis Inflammation of a nerve.
neutral lordosis Normal lordosis when a person is standing erect and the
spine is neither flexed nor extended.
nociceptor A nerve for receiving and transmitting injurious or painful

stimuli.
nonspecific Not due to any known cause.
nonspecific low back pain Common low back pain.
NSAID Acronym for nonsteroidal anti-inflammatory drug.
opioid A non-opium-derived narcotic that occurs naturally in the body and

decreases the sensation of pain.
osteoarthritis Chronic disease involving degeneration of joints.
osteoblast A cell that produces bone.
osteophytes A bony outgrowth that often occurs near joints.
pacinian corpuscle Encapsulated sensory nerve endings that are sensitive

to deep or heavy pressure and vibration.
palliative Relieving severity, intensity, or symptoms, but not a cure.

258
pallor Lack of color or paleness of skin.
palpation Examining the body by application of hands or fingers to the

surface of the body.
paralysis Loss or impairment of voluntary muscle function.
paresis Incomplete loss of voluntary muscle function.
paresthesia Abnormal sensation of burning, tickling, or tingling sometimes

referred to as a feeling of pins and needles.
passive exercise The force needed to move a body part is provided entirely by
a therapist, a mechanical device, or one of the patient's other body parts.
passive movement Movement of a body part that is caused entirely by

external forces such as those provided by a therapist or machine.
patellar reflex A leg jerk caused by the involuntary contraction of the

quadriceps muscle when the patellar tendon is sharply struck.
pathogenesis The pathologic mechanism that results in development of a

disease, illness, or morbid process.
percussion Tapping sharply on the body to determine position, size, and

consistency of underlying structures.
periosteum A fibrous connective tissue membrane that covers bone.
phagocyte A cell that can ingest and destroy foreign particulate matter such
as microorganisms or antigens coated with antibodies. Microphages ingest
mainly bacteria while macrophages ingest dead tissue and present antigens
to T-helper lymphocytes.
phagocytosis The process of ingestion and digestion of solid substances by

phagocytic cells.
physiatrist A doctor specializing in physical medicine.

259
piezoelectricity Electric currents generated by pressure upon certain
crystals such as quartz or calcite (bone).
pilomotor Pertaining to the arrector muscles that cause hairs to move or

stand erect (goose flesh).
PIP Acronym for proximal interphalangeal joint.
placebo Any substance or procedure that produces an effect because the

patient expects or believes that the effect will occur.
plastic Having the property of not returning to the original shape after being
stretched, compressed, or otherwise distorted.
plyometrics Exercises that use a stretch-contract sequence of movement to

increase explosive power.
PNF Acronym for proprioceptive neuromuscular facilitation.
prone Lying horizontal with face down, opposite of supine.
proprioceptor A receptor within the body that responds to pressure,

position, or stretch.
proteoglycans The extracellular matrix of connective tissue composed of

glycosaminoglycans (GAG) bound to protein chains.
proximal Situated nearest the trunk or point of origin.
psychogenic Created by the mind.
radiation 1. Pain or nerve impulses that spread out in all directions from a
common center. 2. The transfer of heat from objects by electromagnetic rays
that can travel through a vacuum.
radiculitis Inflammation of a spinal nerve root, especially the portion of the

root that lies between the spinal cord and spinal canal, accompanied by pain,
numbness, or increased sensitivity to touch.

260
range of motion The maximal span of a joint as measured by angular
displacement between two adjacent segments.
Raynaud's disease A vasospastic peripheral vascular disorder that causes

excessive vasoconstriction when extremities are exposed to cold.
reaction Response to brief hot or cold stimulus (heat sedates and cold
stimulates).
rebound tenderness Pain or discomfort when pressure is released.
recruitment Activating additional motor units to produce greater activity as

the intensity of stimulus remains constant and the duration of stimulus
increases.
reflex An involuntary response to stimulus.
reflexogenic Producing, increasing, or causing a reflex action.
remodeling The reshaping of an injured part or area during wound healing.
resistive exercise The force needed to move a body part is provided entirely
by the voluntary contraction of muscles that normally control the body part and
resistance to the movement is supplied by some external force.
rheumatoid arthritis A form of arthritis involving inflammation of joints,

stiffness, and swelling.
RICE Acronym for rest, ice, compression, and elevation.
ROM Acronym for range of motion.
SAID Acronym for specific adaptations to imposed demands.
salicylate Any salt of salicylic acid used in drugs such as aspirin to reduce
pain and temperature.
satellite trigger points A trigger point activated by another trigger point in

the same reference zone.

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sciatica Severe pain along the sciatic nerve.
sclerosis Hardening of an organ or tissue that may result from inflammation

and the excessive growth of fibrous tissue.
scoliosis A lateral curvature of the spine normally consisting of a primary

curve and a secondary compensatory curve.
secondary trigger points Trigger points that develop in a synergist or

antagonist because of overload.
self-limiting A condition that runs a definite course and then stops without
treatment.
servomechanism A control mechanism that operates by positive or negative

feedback.
shivering Involuntary trembling from cold or fear.
sidebending Lateral flexion.
sign Objective evidence of an illness.
soft-tissue impairment A soft-tissue lesion, defect, or dysfunction that

usually causes pain, limited range of motion, or weakness.
soft-tissue therapy Manipulation of superficial or soft tissue for therapeutic

purposes, with or without modalities, exercise, or mechanical devices.
somatic dysfunction An impaired or altered function of the body that

involves skeletal, arthrodial, or myofascial structures and related vascular,
lymphatic, or neural structures.
SOS Acronym for separate the problem into parts, organize the parts, and
simplify the problem.
spasm An involuntary muscle contraction and the presence of persistent and

palpable hypertonicity or tenderness.

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spastic Characterized by spasms or spasticity.
spinal segment The functional unit of a spine consisting of two contiguous

vertebrae with an intervening disk, two facet joints, intrinsic muscles, and
interconnecting ligaments.
splinting Rigidity or fixation of a body part because of reflex spasm.
spondylolisthesis Anterior displacement of lower lumbar vertebrae over the

body of the sacrum.
spondylosis Vertebral ankylosis that may involve osteoarthritis.
spondylotherapy Spinal manipulation for treating disease.
sprain Trauma to a joint causing injury to ligaments.
stasis Stagnation of blood or other body fluids.
stenosis Constriction or narrowing of a passage.
strain Trauma to a muscle or musculotendinous unit.
strength The ability of a muscle to contract and exert muscular force.
stress (1)The results produced when a structure is acted upon by force. (2)
The force or pressure applied to the body or parts of the body.
stretch reflex A muscle contracts in response to passive longitudinal

stretch. (Also called myotatic reflex or Liddell-Sherrington reflex.)
stretch weakness A weakness caused by continuously keeping a muscle

stretched beyond its normal (neutral) physiologic resting length.
subluxation A partial or incomplete dislocation.
substitution The function of one muscle being replaced by the function of

another muscle or a muscle group that has a similar function or action.

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successive induction Contraction of the agonist to facilitate the antagonist.
supine Lying horizontal with face up, opposite of prone.
symptom Subjective evidence of an illness.
syndrome A group of signs and symptoms related to each other because of

a common disease.
synergist A muscle functioning in cooperation with another muscle.
temperature A relative measure of hotness or coldness resulting from the

average kinetic energy of any substance.
tendon A fibrous connective tissue attaching muscles to bones.
tendonitis Inflammation of a tendon.
tenosynovitis Inflammation of a tendon sheath.
TENS Acronym for transcutaneous electrical nerve stimulation.
tensile strength The maximum longitudinal (tensile) stress a material can

endure without elongation.
thermotherapy Therapeutic application of heat.
thixotropy A property of certain gels that liquefy when agitated and become
semisolid again when left standing.
tight weakness A weakness caused by continuously keeping a muscle in a

position that is shorter than its normal (neutral) physiologic resting length.
(The muscle may test normal in the shortened position but test weak in a
lengthened position.)
tightness A muscle that has greater resistance to passive or active stretch than
normal and is usually—but not always—shorter than normal.
(The word tight is often used interchangeably with the word taut.)

264
tonus A partial, steady contraction of skeletal muscle that causes firmness,
aids in the maintenance of posture, and helps blood return to the heart.
torque A turning caused by a rotary force acting about a pivot point.
traction Process of pulling apart.
trigger point A tender point or spot on the body that produces sudden pain
when stimulated by pressure or compression.
trigger zone A tender zone or area on the body that produces sudden pain
when stimulated by pressure or compression.
tumor A swelling or enlargement, one of the four cardinal signs of

inflammation.
twitch response Transient contraction of a muscle fiber group when

pressure is applied to a trigger point.
urticaria Eruption of skin characterized by severe itching.
van't Hoff's law The rate of chemical reactions increases twofold or more
for each 10°C rise in temperature.
vasoconstriction Decrease in the caliber of a blood vessel.
vasodilation Increase in the caliber of a blood vessel.
viscoelastic A viscous material that is also elastic (e.g., connective tissue).
viscosity Resistance to flow or shear caused by stickiness or cohesion.
Weigert’s law The loss or destruction of living tissue is apt to be followed

by overproduction of such tissue during the process of wound healing.
Wolff's law Bone and collagen fibers develop a structure most suited to
resist the forces acting upon them.

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INDEX
Adaptive shortening, 24, 73, 82, 121-122, 125, 243

A SPARKLE, 65-66, 68-76, 97
Bed rest, 2, 29, 32, 126, 190, 207, 216
Ballistic stretching, 154, 169, 173, 208
Chapter highlights
Introduction, 33
HEMME APPROACH, 39
History, 45
Evaluation, 97
Modalities, 115
Manipulation, 186
Exercise, 214
Contraindications, 35, 40, 45, 104, 106, 114, 175
Coping mechanisms, 211
Creep, 119, 156, 158, 160, 164, 169-171, 186-187, 247
Crossover stretch, 163, 172
Cryotherapy, 29, 39, 98, 100-104, 107-113, 247
Deep Sliding Pressure (DSP), 139-140
DID FIT, 44
Evaluation-exercise movements
Chair stretch, 80-81, 202
Chest lift with extension push-up, 79-80, 202
Double leg curl, 78, 201
Lateral pelvic shift, 77, 200
Modified sit-up, 77-78, 201
Reverse leg lift, 80, 202
Single leg lift, 78, 201
Trunk rotation, 79, 201
Fallacies, 2-12, 33
Hysteresis, 120, 156-157, 160, 164, 169, 186-187, 252
Lateral pelvic shift, 22, 25, 47, 69, 72, 74, 76, 96, 128-129, 200
Leg length, 9, 95, 170
Level I evaluation, 65-76, 97
Level II evaluation, 65, 76-82, 97, 199
Level III evaluation, 65, 82-97
Lumbopelvic rhythm, 1, 5, 15-16, 19-22, 24, 26, 28, 54, 70, 73-74, 202
Major muscles or muscle groups, 46-47

266
Description, 48-54
Illustrations, 55-64
Anterior hip, 58
Anterior limb, 62
Lateral limb, 61
Lateral midsection, 64
Posterior hip, 57
Posterior limb, 60
Posterior thorax, 63
Posterior torso, 59
Major muscles or muscle groups: muscle testing, 88-90
Major muscles or muscle groups: range-of-motion stretching, 179-185
Major muscles or muscle groups: trigger point zones, 143-145
Multiple-repetition stretching, 169-170
Muscles
external obliques, 53, 56, 60, 64, 90, 145, 185
gastrocnemius, 51, 60-62, 89, 144, 182
gluteus maximus, 48, 56, 60-61, 88, 143, 179-180
gluteus medius, 48, 56-57, 60, 88, 143, 179
gluteus minimus, 48, 56-57, 88, 143, 179
hamstrings, 49, 56, 60-61, 88, 143, 180-181
semimembranosus, 49, 60
semitendinosus, 49, 60
biceps femoris, 49, 60-61
psoas, 53, 55-56, 58, 62, 90, 145, 185
psoas major, 53, 58, 62
psoas minor, 53, 58
iliacus, 53, 58
internal obliques, 53, 64, 90, 184
latissimus dorsi, 51, 63-64, 89, 144, 181
paraspinal muscles, 49-50, 59, 89, 143-144,181
superficial paraspinals (erector spinae), 49, 143-144, 201
iliocostalis lumborum, 49, 59
longissimus thoracis, 49-50, 59
spinalis thoracis, 50, 59
deep paraspinals, 50
rotatores lumborum, 50
multifidus, 50, 54, 56, 59, 141
semispinalis thoracis, 50

267
piriformis, 48, 57, 88, 95, 143, 180
quadratus lumborum, 51, 56, 58-59, 89, 144, 182
quadriceps femoris, 52, 56, 61-62, 90, 145, 183, 221
rectus femoris, 52, 56, 61-62
vastus lateralis, 52, 61-62
vastus medialis, 52, 62
vastus intermedius, 52, 62
rectus abdominis, 52, 56, 64, 90, 145
soleus, 51, 60, 62, 89, 144
tensor fasciae latae, 51, 61, 62, 89-90, 144
transversus abdominis, 54, 64
Pain cycles, 26, 28, 121, 194
PDQ, 42
Pelvic-lockup, 21
Post-isometric relaxation, 149, 151-152, 168, 174, 187
Positional release, 153
Posture, 8, 68-69, 72-75, 212
REALISM, 41, 45
Safe lifting, 209-211
Self-treatment, 142
Single-repetition stretching, 169-170
Skin pulling, 160
Skin rolling, 159-160
SOAP, 37-38
Soft-tissue impairments, 30, 117, 119, 121-122, 165
Stretch weakness, 7, 14, 30, 70, 74, 124, 129, 149-150, 173, 262
Supplemental evaluation-exercise movements, 205-206
Testing, 65, 82-96
muscle testing, 82-90
straight leg raising test, 91-92
gluteal-drop test, 92-93
sacral-integrity testing, 93-94
spinal-flexion testing, 95
malingering tests, 96
Thermotherapy, 29, 105-113, 263
Tight weakness, 14, 21, 30, 74, 124, 150, 263
Thixotropy, 120, 156-157, 160, 263
Trigger point classifications, 138
Trigger point signs or symptoms, 131-145

268
HEMME APPROACH QUIZ
1. A theoretical framework for conducting research is called a:
a. disorder
b. paradigm
c. dysfunction
d. pathogenesis
2. The peak range for low back pain is:
a. 20 to 40 years of age
b. 20 to 55 years of age
c. 30 to 50 years of age
d. 40 to 50 years of age
3. According to the AHCPR, which criterion justifies surgery?
a. back pain persisting after four weeks of conservative care

b. sciatica persisting after at least four weeks of conservative care
c. low back pain that recurs more than once every two years
d. any back pain that extends below the knee
4. Which of the following is true?
a. Increasing trunk flexion prevents low back pain.

b. Abdominal exercises such as sit-ups prevent low back pain.
c. Bad posture is the major cause of low back pain.
d. Even if pain is present, try to stay as active as possible.
5. A length-strength disparity between opposing muscles is called a:
a. muscle imbalance
b. locked facet
c. motion-segment imbalance
d. muscle bundle

269
6. Which muscle does not stabilize the sacrum?
a. gluteus maximus
b. latissimus dorsi
c. biceps brachii
d. biceps femoris
7. The stiffening of a joint because of a fibrous or bony union is called:
a. scoliosis
b. ankylosis
c. myofibrosis
d. cyanosis
8. Based on lumbopelvic rhythm, trunk flexion stops when the:
a. spine and pelvis are fully flexed

b. spine and pelvis are fully rotated
c. spine is fully flexed and the pelvis is fully rotated
d. spine is fully rotated and the pelvis is fully flexed
9. During pelvic-lockup, the pelvis is in a:
a. anterior-tilt position
b. neutral position
c. posterior-tilt position
d. rotated position
10. Muscles that play a major role in lateral pelvic shift are the:
a. psoas and the hamstrings

b. quadratus lumborum and quadriceps
c. psoas and quadratus lumborum
d. hamstrings and quadriceps

270
11. Which combination poses a high risk of trauma?
a. normal stresses applied to normal tissues

b. abnormal stresses applied to normal tissues
c. normal stresses applied to abnormal tissues
d. abnormal stresses applied to abnormal tissues
12. Which is not a soft-tissue therapy goal when treating LBP?
a. reduce pain
b. restore function
c. encourage movement
d. make patients more dependent on therapy than on themselves
13. Which of the following is a possible cause for common LBP?
a. muscles
b. facet joints
c. spinal discs
d. all of the above
14. According to international guidelines for patients with common LBP:
a. Do not recommend more than 2 weeks of bed rest.

b. Avoid pain by trying to remain relatively inactive.
c. Prescribe specific exercises during the acute phase.
d. Explain to patients that common LBP is not a disease.
15. The five letters in the acronym HEMME stand for:
a. holism, expectations, motive, means, elimination

b. heat, elevation, methodology, mobilization, effort
c. history, evaluation, modalities, manipulation, exercise
d. helplessness, explanation, medicalization, media, execution

271
16. Which sign or symptom does not contraindicate soft-tissue therapy?
a. difficulty standing erect

b. numbness or weakness without pain
c. weakness of ankle dorsiflexion or dropped foot
d. cauda equina syndrome
17. The M in the acronym REALISM stands for:
a. modalities
b. medicalizing
c. motivation
d. malposition
18. Tightness (resistance to passive stretch) in a muscle can result from:
a. neuromuscular factors
b. connective tissue factors
c. viscoelastic factors
d. all of the above
19. The letter F in the acronym DID FIT stands for:
a. frequency
b. fulcrum
c. function
d. none of the above
20. Which muscle extends, abducts, and rotates the hip laterally?
a. gluteus minimus
b. gluteus intermedius
c. gluteus medius
d. gluteus maximus

272
21. Which muscle often remains weak after LBP is over?
a. hamstrings
b. multifidus
c. quadriceps
d. rectus abdominis
22. Which muscles stabilize the back (spine) by cocontraction?
a. psoas and longissimus thoracis

b. rectus abdominis and hamstrings
c. transversus abdominis and multifidus
d. quadriceps and erector spinae
23. Which muscles control anterior pelvic tilt?
a. psoas, rectus femoris, tensor fasciae latae, and erector spinae

b. hamstrings, gluteus maximus, rectus abdominis, and obliques
c. quadratus lumborum, gluteus medius, tensor fasciae latae
d. transversus abdominis and multifidus
24. The multifidus:
a. is deep to the thoracolumbar fascia and erector spinae

b. can be palpated during lumbar extension
c. can be palpated during forced expiration
d. all of the above
25. Which statement is correct?
a. the internal obliques are hidden below the external obliques

b. the external obliques rotate the spine to the same side
c. the internal obliques rotate the spine to the opposite side
d. the multifidus is deep to the rotatores

273
26. The first "A" in the acronym A SPARKLE stands for:
a. antalgic gait or posture

b. ankylosis
c. asymmetry
d. atonia
27. What type of pain is caused by compression, tension, or shear?
a. chemical
b. mechanical
c. thermal
d. electrical
28. Which muscle sidebends to the opposite side?
a. psoas
b. quadratus lumborum
c. internal oblique
d. external oblique
29. The normal ROM for thoracic and lumbar flexion are:
a. 30-45 degrees
b. 20-35 degrees
c. 80-90 degrees
d. 90-100 degrees
30. Which type of contraction is not used in a level II evaluation?
a. isolytic
b. isometric
c. concentric
d. eccentric

274
31. If two spinal movements are coupled together, the ROM for each:
a. increases by about 10%

b. increases by about 90%
c. decreases by about 50%
d. remains the same
32. The force for movement is provided by the patient without assistance
or resistance from the examiner:
a. active ROM
b. passive ROM
c. active-assistive ROM
d. resisted ROM
33. What is the highest muscle-testing grade possible?
a. strong
b. good
c. normal
d. pass
34. Which activity increases the risk of injury?
a. apply resistance slowly

b. break the patient’s contraction
c. remove resistance slowly
d. none of the above
35. Which muscle is being tested when the foot is plantar-flexed with the
knee fully extended?
a. biceps femoris
b. psoas
c. soleus
d. gastrocnemius

275
36. Pain from stimulation of a nerve root is usually:
a. dull pain and well-localized

b. dull pain and not well-localized
c. sharp pain and well-localized
d. sharp pain and not well-localized
37. Trunk flexion that is limited and painful indicates:
a. discogenic disease
b. common low back pain
c. piriformis syndrome
d. spondylolisthesis
38. Chronic low back pain is often defined as:
a. less than 6 weeks from the onset of LBP

b. less than 3 months from the onset of LBP
c. more than 3 months after the onset of LBP
d. more than 6 months after the onset of LBP
39. According to the acronym RICE, which two steps stabilize an injury
and reduce inflammation:
a. the ice and compression steps

b. the compression and elevation steps
c. the rest and ice steps
d. the rest and elevation steps
40. Hemorrhage and swelling usually stop within:
a. 12 to 24 hours
b. 12 to 36 hours
c. 24 to 48 hours
d. 24 to 72 hours

276
41. A tightness that occurs when a muscle remains abnormally short for a
long time is called:
a. stretch weakness
b. adaptive shortening
c. tight weakness
d. stretch tightness
42. Which sign or symptom is not usually characteristic of trigger points?
a. points or zones that are tender

b. taut, indurated, or ropy bands
c. tremors and palpitations
d. jump signs or twitch responses
43. A trigger point caused directly by dysfunction in a muscle is a(n):
a. active trigger point

b. latent trigger point
c. primary trigger point
d. satellite trigger point
44. Which is considered a key principle in soft-tissue therapy?
a. facilitation decreases tonus

b. inhibition increases tonus
c. lengthen first and strengthen second
d. inhibition always causes pain
45. Three principles that help explain connective tissue therapy:
a. thixotropy
b. hysteresis
c. creep
d. all of the above

277
46. What kind of stretching lengthens a muscle by using bouncing
movements with no hold at the end?
a. multiple-repetition stretching
b. single-repetition stretching
c. ballistic stretching
d. crossover stretching
47. Which condition contraindicates stretching?
a. spasm or hypertonicity
b. cramps or hypertonicity
c. instability or hypermobility
d. contractures or hypomobility
48. If the thigh comes off the table when you press down on the opposite
(contralateral) flexed knee, which muscle is probably short?
a. hamstrings
b. gluteus maximus
c. psoas
d. gastrocnemius
49. Which principle implies testing or training activities should closely

resemble the activities you are preparing for?
a. overload principle
b. intensity principle
c. specificity principle
d. training principle
50. Which principle will help you reduce the risk of a low-back injury?
a. Keep your spine fully flexed when lifting heavy objects.

b. Squat down and bend your knees when lifting heavy objects.
c. When doing a heavy lift, keep the object away from your body.
d. Keep your trunk rotated when lifting or moving heavy objects.

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HEMME APPROACH TO

Thank you for investing in our HEMME APPROACH TO LUMBOPELVIC

This course is not easy. Since 18 hours of continuing education credit

Above all else, please follow these three instructions:

• COMPLETE THE TOP OF THE ANSWER SHEET.

HEMME APPROACH TO LPD ANSWER SHEET

Please circle the best answer.

HEMME APPROACH PUBLICATIONS

HEMME APPROACH TO LUMBOPELVIC DISORDERS

HEMME APPROACH TO LUMBOPELVIC DISORDERS

If we have permission to use your comments, please sign below.

HEMME APPROACH TO LUMBOPELVIC DISORDERS

Copyright, David H. Leflet, 2005

Published by HEMME APPROACH PUBLICATIONS

The author grants permission to photocopy a limited

Although the author has made every effort to ensure the

It is the responsibility of the practitioner to determine the

HEMME APPROACH TO LUMBOPELVIC DISORDERS

Back pain was a 20th-century medical disaster and the legacy

Voluminous literature on the problems of the low back has been

Conservative care commends itself, when properly carried out, as the

Common (nonspecific) low back pain is not a disease because exact

HEMME APPROACH TO LUMBOPELVIC DISORDERS

HEMME APPROACH TO LUMBOPELVIC DISORDERS

HEMME APPROACH TO LUMBOPELVIC DISORDERS

Dave Leflet, MS, LMT, CFL

HEMME APPROACH TO LUMBOPELVIC DISORDERS

HEMME APPROACH ................................................................................ 34

HEMME APPROACH TO LUMBOPELVIC DISORDERS

HEMME APPROACH TO LUMBOPELVIC DISORDERS

Level II Evaluation ................................................................................ 76

MODALITIES ............................................................................................. 100

HEMME APPROACH TO LUMBOPELVIC DISORDERS

MANIPULATION ....................................................................................... 117

HEMME APPROACH TO LUMBOPELVIC DISORDERS

EXERCISE .................................................................................................. 188

HEMME APPROACH TO LUMBOPELVIC DISORDERS

OBJECTIVES .............................................................................................. 215

CONCLUSION ............................................................................................ 216

APPENDIX 1 ............................................................................................... 217

APPENDIX 2 ............................................................................................... 225

BIBLIOGRAPHY ........................................................................................ 229

GLOSSARY ................................................................................................ 243

INDEX ......................................................................................................... 265

QUIZ ............................................................................................................ 268

So why is back pain, in particular, such a problem? What is

A back pain patient in the United States is five times more

The best way to treat nonspecific (common) low back pain is

HEMME APPROACH TO LUMBOPELVIC DISORDERS

The word disorder means a disturbance of function, structure, or both

Rather than start by explaining what should be done, it might be easier

(1) Bed Rest

Fallacy: Bed rest cures common low back pain.

Truth: Activity promotes healing and decreases disability.

HEMME APPROACH TO LUMBOPELVIC DISORDERS

There is no strong correlation between the occurrence of common low

HEMME APPROACH TO LUMBOPELVIC DISORDERS

Truth: Surgery is appropriate for only a small number of cases.

It is interesting to note that the probability of having back surgery is

• sciatica persisting after at least four weeks of conservative care

In addition to having similar criteria, the North American Spine Society

HEMME APPROACH TO LUMBOPELVIC DISORDERS