Professional Documents
Culture Documents
The content covers NMT (neuromuscular techniques), MET (muscle techniques and provide an invaluable source of reference to all students
energy techniques). PR (positional release) and many other bodywork and practitioners in the field of manual therapy.
techniques for neuromusculoskeletal disorders. The text is arranged This updated volume is accompanied by Volume 2 - The Lower Body,
by regions in a muscle-by-muscle approach with templated headings which addresses the problems of the lower body (lumbar spine, sacrum,
making important information easy to locate. The theory and practice pelvis, hip, leg, and foot).
Comprehensive 'one-stop' text on care of somatic pain and dysfunction Leon Chaitow NO DO is an internationally known and respected osteopathic
Foundations, theories, and current research perspectives as to causes of and naturopathic practitioner and teacher of soft tissue manipulation methods
myofascial pain of treatment. He is author of over 60 books, including a series on Advanced Soft
All muscles covered from the perspective of assessment and treatment of
Tissue Manipulation (Muscle Energy Techniques, Positional Release Techniques,
myofascial pain
Modern Neuromuscular Techniques) and also Palpation Skills; Cranial
Describes the normal anatomy and physiology as well as the common
Manipulation: Theory and Practice; Fibromyalgio Syndrome: A Practitioner's
dysfunctions
Provides indications for treatments and guidance on making the appropriate Guide to Treatment, and many more. He is editor of the peer reviewed Journal of
treatment choice for each patient Bodywork and Movement Therapies, that offers a multidisciplinary perspective on
Practical step-by-step technique descriptions for each treatment physical methods of patient care. Leon Chaitow was for many years senior lecturer
Describes the different neuromuscular techniques (NMn in relation to the on the Therapeutic Bodywork degree courses which he helped to design at the
joint anatomy involved School of Integrated Health, University of Westminster London, where is he now
Includes muscle energy, myofascial release, and positional release techniques, an Honorary Fellow. He continues to teach and practice part-time in London, when
as well as NMT to offer a variety of treatment options not in Corfu, Greece where he focuses on his writing.
Includes location and treatment of trigger points
Covers manual and complementary techniques.
Judith Delany LMT has spent two decades developing neuromuscular
New to this edition
therapy techniques and course curricula for manual practitioners as well
Expanded text includes additions on the 'internal environment' (biochemistry),
as for massage schools and other educational venues. Her ongoing private
connective tissue, updated research, and many new illustrations
trainings with the Tampa Bay Devil Rays athletic trainers (professional
Illustrations demonstrating the bony anatomy under the treating fingers
enhance aid to the reader in visualizing what is under palpation baseball) as well as customized trainings for noteworthy US-based spas show
Fully searchable text on CD-ROM incorporation of NMT into diverse settings. She has contributed a chapter
Additional, full-colour illustrations on CD-ROM to Modern uromusular Techniques and co-authored a contribution to
Evolve website with downloadable image collection for lecturers. Principles and Practices of Manual Therapeutics. As an international instructor
of NMT American version, co-author of three NMT textbooks, and associate
Reader reviews from the first edition editor for Journal af Bodywark and Movement Therapies, her professional
-As the massoge profession embraces the knowledge base that is the foundation focus aims to advance education in all healthcare professions to include
for the work that we do, there is a need for texts and reference bootes that provide myofascial therapies for acute and chronic pain syndromes. She resides in
concrete, researched, and integrated information free from the influence of St. Petersburg, Florida where she is the director of and primary curriculum
personal sty/e. This text has accomplished the task by expertly weaving the sciences developer for NMT Center.
with the skills, and blending methods for physiologic outcomes
Sandy Fritz BS NCTMB
"This book is destined to become a classic and a 'must have' in every seriaus
manual therapist's library for years to come ... I, for one, will be recommending it
to everyone I con becouse it is without a doubt the most well thought out ond well
orgonized presentation of soft tissue manual therapy thot I have seen to date
Whitney W Lowe LMT
ISBN 978-0-443-07448-6
CHURCHILL
LIVINGSTONE
ELSEVIER
9780443074486
www.elsevierhealth.com
Clinical Application of Neuromuscular .Techniques
For Elsevier:
leon Chaitow ND DO
Consultant Naturopath and Osteopath. Honorary Fellow, University of Westminster, London, UK
Foreword by
CHURCHILL
LIVINGSTONE
ELSEVIER
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2008
CHURCHILL
LIVINGSTONE
ELSEVlER
The right of Leon Chaitow and Judith DeLany to be identified as authors of this work has been
asserted by them in accordance with the Copy right, Designs and Patents Act 1988.
No part of this publication may be reproduced, stored in a retrievaL system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the
prior permission of the Publishers. Permissions may be sought directly from Elsevier's Health
Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-
2899, USA: phone: (+ 1) 215 239 3804; fax: (+ 1) 215 239 3805; or, e-mail: healthpennissions@elseviL>r.com.
You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com).
by selecting 'Support and contact' and then 'Copyright and Permission'.
ISBN 978-0-443-07448-6
Notice
Neither the Publisher nor the authors assume any responsibility for any loss or injury and/or
damage to persons or property arising out of or related to any use of the material contained in
this book. It is the responsibility of the treating practitioner, relying on independent expertise and
knowledge of the patient, to determine the best treatment and method of application for the
patient.
The Publisher
The
Working together to grow Publishers
l:l.SI:-VltR ''I:,IJ I
Printed in China
vii
Contents
Glutamate: a contrary view of the cause of Psychosocial factors in pain management: the
tendon pain 127 cognitive dimension 170
Acute (lag) phase of the inflammatory response 128 Guidelines for pain management 171
Regeneration (repair) phase 128 Group pain management 171
Remodeling phase 128 The litigation factor 171
Difference between degenerative and Other barriers to progress in pain management 171
inflammatory processes 129 Stages of change in behavior modification 171
Antiinflammatory nutrients and herbs 129 Wellness education 172
What about antiinflammatory medication7 130 Goal setting and pacing 172
Controlled scarring - friction and prolotherapy 130 Low back pain rehabilitation 172
When inflammation becomes global 131 The biopsychosocial model of rehabilitation 172
Hormonal influences 131 Concordance 173
Muscles, joints and pain 140 Patient advice and concordance (compliance) issues 173
Reflex effects of muscular pain 141
Source of pain 142 9 Modern neuromuscular techniques 177
Is it reflex or local? 142
Neuromuscular therapy - American version 177
Radicular pain 142
Biomechanical factors 178
Are the reflexes normal? What is the source of
Biochemica I factors 179
the pain? 142
Psychosocial factors 180
Differentiating between soft tissue and joint pain 143
Biomechanical, biochemical and psychosocial
Neuropathic pain 143
interaction 180
Neurotoxic elements and neuropathic pain 144
NMT techniques contraindicated in initial
Effects of pH changes through breathing 149
stages of acute injury 181
Alkalosis and the Bohr effect 149
NMT for chronic pain 182
Deconditioning and unbalanced breathing 149
Palpation and treatment 182
Caffeine in its various forms 150
Treatment and assessment tools 189
When should pain and dysfunction be left alone? 151
Pain rating tools 190
Somatization 152
Treatment tools 190
How is one to know? 152
European (Lief's) neuromuscular technique (NMT) 191
Pain management 154
NMT thumb technique 192
Gunn's view 154
Lief's NMT finger technique 193
Questions 154
Use of lubricant 194
Pain control 154
Variations 194
8 Assessment, treatment and rehabilitation 161 Variable ischemic compression 194
A framework for assessment 195
Numerous influences 162
Some limited NMT research 196
A biomechanical example 162
Integrated neuromuscular inhibition technique 197
'Looseness and tightness' as part of the
biomechanical model 163
10 Associated therapeutic modalities and techniques 205
Lewit (1996) and 'loose-tight' thinking 164
Soft tissue treatment and barriers 164 Hydrotherapy and cryotherapy 206
Pain and the tight-loose concept - and the How water works on the body 206
trigger point controversy 164 Warming compress 206
Three-dimensional patterns 165 Alternate heat and cold: constitutional
Methods for restoration of 'three-dimensionally hydrotherapy (home application) 208
patterned functional symmetry' 165 Neutral bath 209
Neuromuscular management of soft tissue dysfunction 166 Alternate bathing 209
Manipulating tissues 166 Alternating sitz baths 210
Nutrition and pain: a biochemical perspective 167 Ice pack 210
Nutritional treatment strategies 167 Integrated neuromuscular inhibition technique (lNIT) 210
Specific nutrients and myofascial pain 167 INIT method 1 210
Allergy and intolerance: additional biochemical INIT rationale 211
influences on pain 168 Ruddy's reciprocal antagonist facilitation (RRAF) 212
What causes this increase in permeability? 169 Lymphatic drainage techniques 212
Treatment for 'allergic myalgia' 169 McKenzie Method 213
Antiinflammatory nutritional (biochemical) strategies 169 Massage 215
x CONTENTS
List of boxes
11.14 Balancing of the head on the cervical column 302 13.8 Acromioclavicular and sternoclavicular MET
11.15 Sidelying position repose 316 approaches 426
13.9 Spencer's assessment sequence including MET and
12.1 Cranial terminology and associated motion patterns
PRT treatment 427
based on traditional osteopathic methodology 326
13.10 MFR 466
12.2 The meaning of 'release' 327
13.11 Shoulder and arm pain due to neural impingement 475
12.3 Cranial bone groupings 328
13.12 Modified PNF spiral stretch techniques 478
12.4 Temporomandibular joint structure, function and
13.13 Sternalis and chest pain 479
dysfunction 359
1 3.1 4 Definition of enthesitis 492
12.5 Temporal arteritis 366
13.15 Focal hand dystonia (FHd) - 'repetitive strain injury' 503
1 2.6 Notes on the ear 370
13.16 Nerve entrapment possibilities 507
12.7 How do we maintain equilibrium? 370
13.17 Mulligan's mobilization techniques 520
12.8 Muscles producing movements of mandible 371
13.18 Arthritis 529
12.9 Latex allergy alert 371
12.10 Tinnitus: the TMD and trigger point connection 374 14.1 Identification of spinal level from spinous process 546
12.11 Deglutition 386 14.2 Liefs NMT of the upper thoracic area 549
12.12 Muscles of the eye 392 14.3 Respiratory muscles 550
14.4 Respiratory mechanics 551
13.1 Ligaments of the shoulder girdle 405
14.5 Some effects of hyperventilation 553
13.2 Caution: Scope of practice 409
14.6 Upper ribs and shoulder pain 556
13.3 Reflex tests (always compare both sides) 411
14.7 Pressure bars 566
13.4 What is normal range of arms? 411
14.8 Liefs NMT of the intercostal muscles 569
13.5 Neutralizers 413
14.9 McConnell and the diaphragm 572
1 3.6 Spencer's assessment sequence 423
13.7 Clavicular assessment 425
xvii
Foreword
Headache, TMJ, neck/shoulder pain and tennis elbow are evidence-based and I think it is worthwhile defining exactly
all common complai nts of patients seeking help from vari what evidence-based practice is. According to Sackett et al
ous hea lth practitioners. The source of the impairment (2000),
and/or the pain is often found in the neuromyofascial sys
Evidence-based practice is the integration of best research
tem. As a novice, a cli nician will approach the problem
evidence, clinical expertise and patient values. External
based on the paradigm taught in their formal training such
clinical evidence can inform, but can never replace individ
as physiotherapy, osteopathy, massage therapy, Rolfing,
ual clinical expertise, and it is this expertise that decides
acupuncture or chiropractic. Thus we see the advocacy of
whether the external evidence applies to the patient at all,
many different traditional treatments for myofascial pain
and if so, how it should be integrated into a clinical decision.
such as:
W hat is expertise? Expertise has been defined as the abil-
Physiotherapy - thermal agents followed by stretching
ity to do the right thing at the right time (Ericsson & Smith
exercises
1991). Indeed, I believe that this monumental text is evi
Osteopathy - strain/counterstrain, positional release,
dence-based since it includes the best a vailable research evi
functional and muscle energy techniques
dence and integrates it with the multi-disciplinary clinical
Massage therapy - deep pressure on tender points,
expertise that has accumulated over the last 100 years.
stroking, lymphatic massage techniques
As mentioned earlier, this text is a bout more than neuro
Rolfi ng - deep fascial release/stretching tec hniques
muscular techniques. It begins with an o verview of the
Acupunc ture - dry needling of 'An Shi' pOints
anatomy and function of connective tissue, fascia, muscles
Chiropractic - manipulation (high velocity, low amphtude
and the nervous systems (peripheral and central). The
thrust techni ques) of the spinal segment which correlates
anatomical illustrations are clear, weU-labeled and perti
to the segmental nerve supply of the affected muscle.
nent. Many of the current hypotheses regarding the ca uses
At this point, you may be thinking 'Wait a mi nute! I do of musculoskeletal dysfunction and the various patterns of
more than tha t (or all of that, or some of tha t) for my presentation are outlined . There is an extensive discussion
patients with myofascial pain'. This is true enough, since on the current theories and evidence pertaining to the
over time most clinicians gain expertise and are exposed to cause, effect and cli nical presentation of myofascial trigger
the paradigms of other disciplines and thus their 'tool box' points. While ultima tely the text turns to the detailed trea t
grows. l11is book is a wonderful representation of all the ment of every possible muscle you could think of i n the
paradigms of the many discipl ines that ha ve ever consid upper half of the body, prior to this the a uthors discuss
ered how to rela x/release a muscle or a trigger point in a where, when and how the neuromuscular techniques fit
muscle. Yet, this book is way more than this and even more into the entire treatment protocol. This ensures tha t the
than the title Clinical Application of Neuromuscular Techniques reader is not left with the impression that neuromuscular
alludes to. release is all that is needed for treating a patient. Once into
While this text relies heavily on the clinical expertise of trea tment, consideration is given to the role of non-manual
both the authors and the historical leaders in both their pro therapies such as thermal modal ities, spray and stretch and
fessions and others, it also refers and draws on the current exercise, and then the use of the manual techni ques is
scientific evidence where it is available. Some may say that explained in great detail. Following this, the upper half of
the techniques and suggested protocols in this text are not the body is divided and each section begins with a review of
xviii FOREWORD
the regional anatomy and biomechanics and a Hsting of the Neuromuscular Techniques, a text which is applicable to the
muscles in which trigger p oints are commonly found. Each novice and the expert of any discipline that deals with
manual tecl mique is illustrated and described in explicit patients p resenting with i mp airments of the neuromyofas
detail. This is easy for the novice to follow and often con ciaI system.
tains 'pearls of clinical wisdom' for the expert clinician.
Leon C haitow and Judith DeLany are to be congratu
lated for the second editi on of Clinical Application of White Rock, Be C anada 2007 Diane Lee
References
Ericsson KA, Smith J 1991 Towards a general theory of expertise: Sackett DL, Strauss SE, Richardson WS, et al 2000 How to practice
prospects and limits. Cambridge University Press, New York & teach evidence-based medicine. Elsevier Science, New York
xix
The clinical utilization of soft tissue manipulation has logically the main focus for the p atient. However, we believe
increased dramatically in recent years in all areas of manual it is vital that loc al problems should be commonly seen by
health-care provision. A text that integrates the safe and the p ractitioner to form p art of a larger picture of compensa
proficient application of some of the most effective soft tis tion, adaptation and/or decompensation and that the back
sue tedmiques is both timely and necessary. The decision to ground causes (of local myofascial pain, for example) be
write this book was therefore based on a growing aware sought and, where possible, removed or at least m odified.
ness of the need for a text that describes, in some detail, the We also take the position t hat it is the p ractitioner's role
clinical applications of neuromuscular techniques in p artic to take account of biochemical (nutriti onal and hormonal
ular, and soft tissue manipulation in general, on each and influences, allergy, etc.), biomec hanical (posture, b reathing
every area of the musculoskeletal system. p atterns, habits of use, etc.) and/or psychosocial (anxiety,
There are n umerous texts c ommunicating the features of depression, stress factors, etc.) influences that might be
different manual therapy systems (osteopathy, chiropractic, involved, as far as this is p ossible. If appropriate, suitable
physical therapy, manual medicine, massage the rapy, etc.) advice or treatment c an then be offe red. However, if the
and of modalities employed with i. n these health-care deliv p ractitioner is not trained and licensed to do so, profes
ery systems (high-velocity thrust techniques, muscle energy sional referral becomes the obvious choice. In this way, the
tedmiques, myofascial release and many, many more). focus of health care goes beyond treatment of local condi
There are also excellent texts that describe regional p rob tions and moves toward holism, to the benefit of the patient.
lems (say of the pelvic region, temporomandibular j oint or In this volume, the person applying the techniques i s
the spine) with protocols for assessment and treatment, referred t o as the 'practitioner' so as to include all the ra
often presented from a p articular perspective. Increasingly, pists, physicians, nurses or others who apply manual tech
edited texts incorporate a variety of perspectives when niques. To ease confusion, the practitioner is depicted as
focusing on particular regions, offering the reader a broad male and t he recipient of the treatment modalities (the
view as well as detailed informati on on the topic. And t hen patient) is depicted as female so that gender references (he,
there are wonderfully crafted volumes, such as those p ro his, she, hers) used within the text are n ot ambiguous. In
duced by Travell and Simons, covering the spectrum of Volume 2, the roles are reversed with the female p racti
'myofascial pain and dysfu nction' and incorporating a tioner treating the male p atient.
deeply researched and evolving model of care. The protocols described in this text fall largely within the
We adopted Travell and Simons' view of the human b ody, biomechanical arena, with the main emphasis being the first
which offers a valuable regional approach model on which comprehensive, detailed description of the clinical applica
to base our own perspectives. To this practical and intellec tion of NMT (neuromuscular therapy in the USA, neuro
tually satisfying model, we have added detailed anatomical muscular technique in Europe). The desc riptions of NMT are
and physiological descripti ons, coupled with clinically prac mainly of the modern American version, as described by
tical 'bodywork' solutions to t he problems located in each Judith DeLany, whose many years of involvement with
region. In this first vol ume of the text, the upper b ody is cov NMT, both clinically and academically, make her a leading
ered; in Volume 2, the region from the waist down is sur authority on the subject.
veyed in the same way. As authors, we have attempted to Additional therapeutic choices, including nutri tional and
place in context the relative importance and significance of hydrotherapeutic, as well as complementary bodywork
local conditions, pain and/or dysfu nction, which are quite methods, such as muscle energy, positional release and
xx PREFACE TO THE SECOND EDITION
variations of myofascial release teclmiques, and the especially if they have had previous training in soft tissue
European version of NMT, are largely the contribution of palpation and treatment. The text of this book is therefore
Leon Chaitow, as are, to a large extent, the opening chapters intended as a framework for the clinical application of NMT
regarding the physiology of pain and dysfunction. for those already quali fied (and, where appropriate,
In addition to the practical application sections of the licensed to practice), as well as being a learning tool for
book, a nwnber of chapters offer a wide-ranging overview those in training. It is definitely not meant to be a substitute
of current think ing and research into the background of the for hands-on training with skilled in structors.
dysfunctional sta tes for which solutions a nd suggestions To this volume is married the companion text for the
are provided in la ter chapters. The overview, 'big picture' lower body, the layout and style of which is very similar. Its
chapters cover the latest research findings a nd information foundational chapters cover posture, gait, balance, influ
relevant to understanding fascia, muscles, neurological fac ences of the close environment surrounding the body, adap
tors, pa tterns of dysflmction, pain and inflammation , tations from sport and other repetitious use, and other
myofascial trigger points, emotional and nutritional influ contextual material that influences clinical thinking.
ences a nd much more. It is our assertion tha t the combina Additionally, Clinical Application of Neuromuscular
tion of the 'big picture', together with the detailed NMT Techniques - Practical Case Study Exercises is now available to
protocols, offers a foundation on which to build the excep support the practitioner in developing a model by which to
tional palpation and treatment skills necessary for finding apply the protocols to clinical cases. The use of the study
effective, practical solutions to chronic pain conditions. guide cases is enhanced with the addition of key words
Some chapters, such as Chapters 6 and 7, have evolved printed in red that may be found in the indices of the larger
substantially since the first edition, based on integration of texts. We trust that these tools, together with practitioner's
our diverse viewpoints, with the occasional result being skills and training, will assure that NMT remains a power
paradigm shifts that altered therapeutic platforms. We ful tool in the manual therapy fields.
believe that this integration of new i rtforma tion and
research, in ta ndem with our combined clinical experience,
offers an expanded perspective. Readers can use these con London 2007 LC
cepts to assist in safe application of the methods described, Florida 2007 JD
xxi
Acknowl ed g m ents
In the first edition of this text and its companion volume for support is threaded through these pages in remarkable yet
the lower body, a substantial number of people dedica ted indiscernible ways.
many hours of time to assure clarity and accuracy of the
final text. Their contribution was not lost in the second edi
AC K N O W L E D G E M E N TS F R O M T H E
tion. Instead, it served as a solid foundation to be built upon
F I RST E D IT I O N
with the contributions of revised and added material.
The authors once again express sincere gratitude to the Books are wri tten by the efforts of numerous people,
original team who help formulate this project many years a l though most of the support team is invisible to the reader.
ago and to the various authors and illustrators whose work We humbly express our appreciation to our friends and col
was cited, quoted and borrowed. Addi tionally, contribu leagues who assisted in this project and who enrich our
tions, support and inspiration for this revised edition were lives simply by being themselves.
given by William Ellio tt, Donald Kelley, Ken Crenshaw, Ron From the long list of staff members and practitioners who
Porterfield, Nathan Shaw, Mary-Beth Wagner, Andrew and dedicated time and effort to read and comment on this text,
Kaila DeLany, and Adam Cunliffe. we are especially grateful to Jamie Alagna, Paula Bergs,
In the second edition of this book, a new team of talented Bruno Chikly, Renee Evers, Jose Fernandez, Gretchen Fiery,
staff members at Elsevier offered insightful ideas, patient Barbara Ingram-Rice, Donald Kelley, Leslie Lynch, Aaron
support to achieve deadlines, and a variety of professional Mattes, Chama Rosenholtz, Cindy Scifres, Alex Spassoff,
services in order for the work to evolve. Among those who Bonnie Thompson and Paul Witt for reviewing pages of
made this second edition possible, the a uthors especially material, often at a moment's notice. And to those whose
acknowledge and appreciate the efforts of Claire Wilson, work has inspired segments of this text, such as John
Gail Wright, Claire Bonnett and the illustration team who Hannon, Tom Myers, David Simons, Janet Travell and
gave visual life to the pages of text. others, we offer our heartfelt appreciation for their many
To Sarena Wolfaard , we express deep apprecia tion for her contributions to myofascial therapies.
steady na ture and for her ability to juggle the assorted John and Lois Ermatinger spent many hours as models for
deadlines and the many phases of the project so as to keep the photographs in the book, some of which eventually
it close to its production schedule. She has proven herself as became line art, while Mary Beth Wagner dedicated her time
capable of filling the extraordinary shoes of Mary Law, who coordinating each photo session. The enthusiastic attitudes
served as the editorial director of the first edition. As to and tremendous pa tience shown by each of them turned
Mary, her contributions will last forever and her presence is what could have been tedious tasks into pleasant events.
continually missed. Many people offered personal support so tha t quality
And, most endearingly, we offer our deepest gratitude to time to write was available, including Lois Allison, Jan
our families for their pa tience, support, and inspiration, all Carter, Linda Condon, Andrew DeLany, Valerie Fox,
of which fills an ever-present and deep well from which we Patricia Guillote, Alissa Miller, and Trish Solito. Special
can draw to sustain and nurture ourselves. Their loving appreciation is given to Mary Beth Wagner and Andrea
xxii ACKNOWLED G M ENTS
Conley for juggling many, many ongoing tasks which serve worldwide. Mary's ability to foster organization amidst
to enhance and fortify this work. chaos, to find solutions to enormous challenges and to sim
Jane Shanks, Katrina Mather, and Valerie Dearing each put ply provide a listening ear when one is needed has
forth exceptional dedication to find clarity, organization and endeared her to our hearts.
balance within this text, which was exceeded only by their And finally, to each of our families, we offer our deepest
patience. The illustration team as well as the many authors, gratitude for their inspiration, patience, and ever present
artists and publishers who l oaned artwork from other books understanding. Thei r supporting l ove made this project
have added visual impact to help the material come alive. possible.
To Mary Law, we express our deepest app reciation for
her vision and commitment to complementary medicine
Chapter 1
The truth, of course, is that no tissue exists in isolation but fascia moves in response to complex muscular activities
acts - is bound to and is interwoven - with other structures, to acting on bone, joints, ligaments, tendons and fascia
the extent that a fallen arch can directly be shown to influence fascia, according to Bonica (1990), is critically involved in
TMJ dysfunction (Janda 1986). In contrast, loss of occlusal proprioception, which is, of course, essential for postural
supporting zone can change weight distribution on the feet integrity (see Chapter 3)
and alter overall body posture (Yoshino et aI 2003a,b) When . research by Staubesand (using electron microscope stud
we work on a local area, we need to keep a constant aware ies) shows that 'numerous myelinated sensory neural
ness of the fact that we are influencing the whole body. structures exist in fascia, relating to both proprioception
Remarkable research (see Box 1.5 in particular) is adding and pain reception' (Staubesand 1996)
to our understanding of just how important connective tis after joint and muscle spindle input is taken into account,
sues are in relation to musculoskeletal function, and to pain the majority of remaining proprioception occurs in fas
management (Chen & Ingber 1999, Langevin et al 2001, cial sheaths (Earl 1965, Wilson 1966)
2004, 2005, Schleip et al 2004). As a foundation of under new research by Langevin et al (2001, 2004, 2005), described
standing of connective tissue is built within this chapter, later in this chapter, suggests that a great deal of commu
this and other research evidence is presented that alters pre nication occurs by means of fascial cellular structures
vious concepts of this extraordinary matrix. (integrins).
Fascia comprises one integrated and totally connected net Fascia is one form of connective tissue, formed from colla
work, from the attachments on the inner aspects of the skull gen, which is ubiquitous. The human framework depends
to the fascia in the soles of the feet. If any part of this net upon fascia to provide form, cohesion, separation and sup
work becomes deformed or distorted, there will be com port and to allow movement between neighboring structures
pensating adaptive stresses imposed on other parts of the without irritation. Since fascia comprises a single structure,
connective tissue web, as well as on the structures that it from the soles of the feet (plantar fascia) to the inside of the
divides, envelopes, enmeshes, supports and with which it cranium (dura and meninges), the implications for body
connects. There is ample evidence that Wolff's law (Wolff wide repercussions of distortions in that structure are clear.
1870) applies, in that fascia accommodates to chronic stress An example is found in the fascial divisions within the cra
patterns and deforms itself (Cailliet 1996), something which nium, the tentorium cerebelli and falx cerebri, which are
often precedes deformity of osseous and cartilaginous struc commonly warped during birthing difficulties (too long or
tures in chronic diseases (see Box 1.3). As fascia, ligaments too short a time in the birth canal, forceps delivery, etc.).
and tendons deform when accommodating to chronic stress They are noted in craniosacral therapy to affect total body
(Dorman 1997, Lederman 1997), this might disrupt the home mechanics via their influence on fascia (and therefore the
ostasis of the body (Keeffe 1999, Kochno 2001) and certainly musculature) throughout the body (Brookes 1984, Carreiro
interferes with normal function. 2003, Von Piekartz & Bryden 2001).
Visualize a complex, interrelated, symbiotically function Dr Leon Page (1952) discusses the cranial continuity of
ing assortment of tissues comprising skin, muscles, ligaments, fascia:
tendons and bones, as well as the neural structures, blood
The cervical fascia extends from the base of the skull to the
and lymph channels and vessels which bisect and invest
mediastinum and forms compartments enclosing the esoph
these tissues - all given shape, cohesion and functional abil
agus, trachea and carotid vessels and provides support for
ity by the fascia. Now imagine removing from this all that is
the pharynx, larynx and thyroid gland. There is direct con
not connective tissue. What remains would still demon
tinuity of fascia from the apex of the diaphragm to the base
strate the total form of the body, from the shape of the eye
of the skull. Extending through the fibrous pericardium
ball to the hollow voids for organ placement.
upward through the deep cervical fascia the continuity
extends not only to the outer surface of the sphenoid, occip
ital and temporal bones but proceeds further through the
FASCIA AND PROPRIOCEPTION foramina in the base of the skull around the vessels and
nerves to join the dura.
Research has shown that:
Connective tissue is composed of cells (including fibroblasts and abnorma l crossbridges which prevent normal movement. Fol lowing
chond rocytes) and an extrace l l ular matrix of collagen and elastic tissue i nju ry, it is important that activity be introduced as soon as
fibers surrounded by a g round substance made primarily of acid the healing process will allow in order to prevent maturation of the
glycosam inoglycans (AGAGs) and water (Gray's Anatomy 2005, sca r tissue and development of adhesive crossl inks (Lederman 1 997).
Lederman 1997). Its patterns of deposition change from location to Lederman ( 1 997) tel ls us:
location, depending upon its role and the stresses applied to it.
The pattern of collagen deposition varies in different types of
The collagen component is com posed of three polypeptide cha ins
connective tissue. It is an adaptive process related to the direction
wound around each other to form triple hel ixes. These microfi la ments
of forces imposed on the tissue. In tendon, collagen fibers ore
are arranged in parallel manner and bound together by crossl inking
organized in parallel orrangement; th is gives the tendon stiffness and
hydrogen bonds, which 'glue' the e lements together to provide
strength under unidirectional loads. In ligaments, the organization of
strength and stabil ity when mecha nical stress is applied. Movement
the fibers is looser. groups of fibers lying in different directions. This
encourages the col lagen fibers to a l ign themselves a long the l ines of
reflects the multidirectional forces that ligaments are subjected to,
structural stress as well as improving the ba lance of
for example during complex movements of a joint such as flexion
glycosami noglycans and water, therefore lubricating and hydrating
combined with rotation ond shearing . . . Elostin has an arrongement
the connective tissue (Lederman 1997).
similar to that of collagen in the extracellular matrix, and its
While these bonding crossbridges do provide structu ra l support,
deposition is also dependent on the mechanical stresses imposed on
injury, chronic stress and immobility cause excessive bonding,
the tissue.
leading to the formation of scars and adhesions wh ich limit the
movement of these u sually resil ient tissues (Juhan 1 998). The loss of Elastin provides an elastic-l ike quality that allows the connective
tissue lengthening potential would then not be due to the volume of tissue to stretch to the limit of the collagen fiber's length, while
collagen but to the random pattern in which it is laid down and the absorbing tensile force. If this elastic quality is stretched over time,
it may lose its abil ity to recoil (as seen in the stretch marks of
preg nancy). When stress is applied, the tissue can be stretched
to the limit of the collagen fiber length with flexibility being
dependent upon elastic quality (and quantity) as well as the
Procollagen F i broblast extent of crossbridging that has occurred between the col lagen
fibers. Additional ly, if heavy pressure is suddenly appl ied, the
connective tissue may respond as brittle and may tea r more easily
(Ku rz 1 986).
Surrounding the col lagen and elastic fibers is a viscous, gel-l ike
------- g round substance, composed of proteoglycans and hyaluronan
\ \
/O-TropOCOllagen
(formerly called hyaluronic acid), which l ubricates these fibers and
allows them to sl ide over one another (Barnes 1 990, Ca illiet 1 996,
Gray's Anatomy 2005, Jackson et al 2001 ).
Ground substance provides the immediate envi ron ment for every
cell in the body.
The protein component is hydrophilic (draws water into the tis
sue), producing a cushion effect as well as maintaining space
between the collagen fibers (Jackson et al 200 1 ).
Ground substance provides the med ium through which other ele
ments are exchanged, such as gases, nutrients, hormones, cel l ular
'------Collagen microfibril waste, antibodies and white blood cells (Juhan 1998).
L The condition of the g round substance ca n then affect the rate of
diffusion and therefore the health of the cel l s it su rrounds.
box continues
1 Connective tissue and the fascial system 5
Box 1 .4 (continued)
Elongation
Toe Elastic
region region
Figure 1.2 Collagen's triple helices are bound together by inter Loss of mechanical
properties
and intramolecular crosslinking bonds. After Lederman (1997).
followed by what is colloquially referred to as creep a vari - fracture when rapid force meets the resistance of bone. If
able degree of resistance (depending upon the state of the tis force is applied gradually, 'energy' is absorbed by and stored
sues). This gradual change in shape is due to the viscoelastic in the tissues. The usefulness of this in tendon function is
property of corulective tissue. obvious and its implications in therapeutic terms profound
Creep, then, is a term that accurately describes the slow, (Binkley 1989).
delayed, yet continuous deformation that occurs in Hysteresis is the term used to describe the process of energy
response to a sustained, slowly applied load, as long as this loss due to friction and to minute structural damage that
is gentle enough not to provoke the resistance of colloidal occurs when tissues are loaded and unloaded. Heat will be
'drag'. During creep, tissues lengthen or distort ('deflect') produced during such a sequence, which can be illustrated
until a point of balance is achieved. An example often used by the way intervertebral discs absorb force transmitted
of creep is that which occurs in intervertebral discs as they through them as a person jumps up and down. During
gradually compress during periods of upright stance. treatment (tensing and relaxing of tissues, for example, or
Stiffness of any tissue relates to its viscoelastic properties on-and-off pressure application), hysteresis induction reduces
and, therefore, to the thixotropic colloidal nature of colla stiffness and improves the way the tissue responds to sub
gen/ fascia. Thixotropy reIates to the quality of colloids in sequent demands. The properties of hysteresis and creep
which the more rapidly force is applied (load), the more provide much of the rationale for myofascial release tech
rigid the tissue response will be - hence the likelihood of niques, as well as aspects of neuromuscular therapy, and
6 CLINICAL A PPLICATION OF NEUROMUSCULAR TECHN IQUES: THE U P PER BODY
L
Schleip et al (2004) have shown that when an isometric con to sponge-like squeezing and refilling effects in the semi-liquid
traction takes place - as in sustained effort, or therapeuti ground substance, with its intricate scrub-like arrangement
cally with methods such as muscle energy technigue (MET), of water binding glycosaminoglycans and proteoglycans.
proprioceptive neuromuscular facilitation (PNF) or other
Schleip et al (2004) have presented evidence that derives from
similar techin gues
the same German research, showing that the thoracolumbar
simultaneously loses some of its stability, making it easier to
fascia has the ability to contract, suggesting that the 'fascia
stretch.
may play an active role in joint dynamics and regulation'.
It behaves like a sponge, and if the contraction is long
Schleip et al also suggest that this research 'offers new insights
and strong enough, and if no movement occurs after the
into understanding low back instability, compartment syn
contraction, the fascia reabsorbs water, becoming stiffer as it
drome, and my ofascial release therapies'.
does so. Research into this phenomenon is in its early stages
but at this time the researchers (Schleip et a12004) have been
able to report:
DE FORMATION CHARACTERISTICS
By carefully measuring the wet weight of our fascial strips,
at different experimental stages, plus the final dry weight Cantu & Grodin (1992) describe what they see as the 'unigue'
(after later drying the strips in an oven), we found the fol feature of connective tissue as its 'deformation characteris
lowing pattern: During the isometric stretch period, water tics'. This refers to the combined viscous (permanent, plastic)
is extruded, which is then refilled in the following rest period. deformation characteristic, as well as an elastic (temporary )
Interestingly if the stretch is strong enough, and the following deformation status discussed above. The fact that cOIUlective
rest period long enough, more water soaks into the ground tissues respond to applied mechanical force by first chang
substance than before. The water content then increases to a ing in length, followed by some of the change being lost
higher level than before the stretch. Fascia seems to adapt in while some remains, has implications in the application of
very complex and dynamic ways to mechanical stimuli, to stretching technigues to such tissues. It also helps us to
the degree that the matrix reacts in smooth-muscle-like con understand how and why soft tissues respond as they do to
traction and relaxation responses of the whole tissue. It seems postural and other repetitive insults that exert load on them,
likely that much of what we do with our hands in Structural often over long periods of time.
Integration and the tissue response we experience, may not It is worth emphasizing that although viscoplastic changes
be related to cellular or collagen arrangement changes, but are described as 'permanent', this is a relative term. Such
1 Connective tissue a nd the fascial system 7
P2
Meridians
Yin Yang @ acupunclure
H= heart pOint
p= pencarolum SJ triple heat"r meridian
L= lung SI= small intestine intersection
fibers around these openings in most of the acupoints of THE IMPORTANCE OF LANGEVIN'S RESEARCH
the painful region. When those strangulated areas were
Ongoing research at the University of Vermont has pro
surgically opened a little, most of the patients experi
duced remarkable new information regarding the function
enced significant improvements (i.e. less pain)
of fascial connective tissue (Langevin et al 2001, 2004, 2005).
many of these fascial neural structures are sensory and
In evaluating the importance of the research information
capable of being involved in pain syndromes.
(below) it is important to recall that approximately 80% of
Staubesand states: common trigger point sites have been claimed to lie pre
cisely where traditional acupuncture points are situated on
The receptors we found in the lower leg fascia in humans meridian maps (Wall & Melzack 1 990). Indeed, many
could be responsible for several types of myofascial pain experts believe that trigger points and acupuncture points
sensations . . . Another and more specific aspect is the inner are the same phenomenon (Kawakita et al 2002, Melzack
vation and direct connection of fascia with the autonomic et al 1 977, Plummer 1 980).
nervous system. It now appears that the fascial tonus might Others, however, take a different view. For example,
be influenced and regulated by the state of the autonomic Birch (2003) and Hong (2000) have revisited the original
nervous system . . . intervention in the fascial system might work of Wall & Melzack (1 990) and have both found this
have an effect on the autonomic nervous system, in general, to be flawed, particularly when the acupuncture points
and upon the organs which are directly effected from it. referred to as correlating with trigger points are seen to be
(Schleip 1998) 'fixed' anatomically, as on myofascial meridian maps. Both
10 CLINICAL APPLICATION O F NEUROMUSCULAR TECHNIQUES: THE UPPER BODY
Birch and Hong agree, however, that so-called 'Ah shi' tissue matrix (e.g. fibroblasts, sensory afferents, immune
acupW1cture points may well represent the same phenome and vascular cells)'.
non as trigger points. Ah shi points do not appear on the The key elements of Langevin's research can best be sum
classical acupW1cture meridian maps, but refer to 'sponta marized as follows:
neously tender ' points which, when pressed, create a Acupuncture points, and many of the effects of acupW1c
response in the patient of, 'Oh yes' ('Ah shi'). In Chinese ture, seem to relate to the fact that most of these localized
medicine Ah shi points are treated as 'honorary acupuncture 'points' lie directly over areas where there is fascial cleav
points' and are needled or receive acupressure in the same age; where sheets of fascia diverge to separate, surround
way as regular acupW1cture points, if/when they are ten and support different muscle blmdles (Langevin et al
der/painful. This would seem to make them, in all but in 2001).
name, identical to trigger points. COlU1ective tissue is a commW1ication system of as yet
It is clearly important therefore, in attempting to under unknown potential. The tiny projections emerging from
stand trigger points more fully, to pay attention to current each cell are called 'integrins'. Ingber demonstrated
research into acupuncture points and cOlU1ective tissue in (Ingber 1993b, Ingber & Folkman 1 989; see Box 1.6) inte
general, as noted in the following research. grins to be a cellular signaling system that modify their
Langevin & Yandow (2002) have presented evidence that fW1ction depending on the relative normality of the shape
links the network of acupW1cture points and meridians to a of cells. The structural integrity (shape) of cells depends
network formed by interstitial cOlU1ective tissue. Using a on the overall state of normality (deformed, stretched, etc.)
unique dissection and charting method for location of of the fascia as a whole. As Langevin et al (2004) report:
cOlU1ective tissue (fascial) planes, acupW1cture points and
acupuncture meridians of the arm, they note that: 'Overall, 'Loose' connective tissue forms a network extending
more than 80% of acupuncture points and 50% of meridian throughout the body inc/uding subcutaneous and intersti
intersections of the arm appeared to coincide with inter tial connective tissues. The existence of a cellular network
muscular or intramuscular cOlU1ective tissue planes.' of fibroblasts within loose connective tissue may have
Langevin & Yandow's research further shows microscopic considerable significance as it may support yet unknown
evidence that when an acupuncture needle is inserted and body-wide cellular signaling systems . . . Our findings
rotated (as is classically performed in acupW1cture treatment), indicate that soft tissue fibroblasts form an extensively
a 'whorl' of cOlU1ective tissue forms around the needle, interconnected cellular network, suggesting they may
thereby creating a tight mechanical coupling between the have important, and so far unsuspected integrative func
tissue and the needle. The tension placed on the cOlU1ective tions at the level of the whole body.
tissue as a result of further movements of the needle delivers Perhaps the most fascinating research in this remarkable
a mechanical stimulus at the cellular level. They note that series of discoveries is that cells change their shape and
changes in the extracellular matrix ' . . . may, in turn, influ behavior following stretching (and crowding/deforma
ence the various cell populations sharing this connective tion) . The observation of these researchers is that: 'The
Figure 1 .8 Formation of a connective tissue 'whorl' when an acupuncture needle was inserted through the tissue and progressively rotated.
Reproduced from Langevin H M, Yandow J A Relationship of acupuncture points and meridians to connective tissue planes. Anatomical Record
269(6): 257-265, 2002. Copyright 2002, Wiley-Liss, Inc. Reprinted with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.
1 Connective tissue and the fascial system 11
dynamic, cytoskeleton-dependent responses of fibrob when gravity is removed or reduced. The behavior of cells
lasts to changes in tissue length demonstrated in this changes to the extent that, irrespective of how good the
study have important implications for our understand overall nutritional state is, or how much exercise (static
ing of normal movement and posture, as well as thera cycling in space) is taking place, individual cells cannot
pies using mechanical stimulation of connective tissue, process nutrients normally, and problems such as decalcifi
including physical therapy, massage and acupuncture' cation emerge.
(Langevin et aI2005). The importance we give to this information should be
As will become clear, changes in the shape of cells also alter tied to the awareness that, as we age, adaptive forces cause
their ability to function normally, even in regard to how changes in the structures of the body, with the occurrence of
they handle nutrients. Ingber conducted research (Ingber shortening, crowding and distortion. With this, we are see
1993a,b, 2003, Ingber & Folkman 1989), much of it for ing in real terms, in our own bodies and those of our
NASA, into the reasons that astronauts lose bone density patients, the environment in which cells change shape. As
after a few months in space. He showed that cells deform they do so they change their potential for normal genetic
Tom Myers, a distinguished teacher of structural i ntegration, has subcutaneous ligament, linking the ischial tuberosities to sacrum
described a number of clinically useful sets of myofascial chai ns. The l u mbosacra l fascia, erector spinae and nuchal ligament, linking
connections between different structures ('long functional the sacrum to the occiput
continuities') that these insights a l low will be drawn on and referred sca lp fascia, linking the occiput to the brow ridge.
to when treatment protocols are discussed in this text. They a re of
particu lar importance in helping draw attention to (for example) The superficial front line (Fig. 1 .1 0) i nvolves a chain that starts
dysfu nctional patterns in the lower limb which impact d i rectly (via with:
these chains) on structures in the upper body.
the anterior compartment and the periostium of the tibia, linking
the dorsal surface of the toes to the tibial tuberosity
The five major fascial ch a i ns
rectus femoris, linking the tibial tuberosity to the anterior i nferior
The superficial back line (Fig. 1 .9) involves a chain that starts with:
iliac spine and pubic tubercle
the plantar fascia, linking the plantar su rface of the toes to the rectus abdominis as well as pectora lis and sternalis fascia, linking
calcaneus the pubic tubercle and the anterior i nferior iliac spine with the
gastrocnem ius, linking calcaneus to the femoral condyles manubrium
hamstrings, l inking the femoral condyles to the ischial sternocleidomastoid, linking the manubri um with the mastoid
tuberosities process of the tempora l bone.
box continues
1 Con nective tissue a n d the fascial system 13
expression, as well as their abilities to communicate and to changes that follow the application of manual techniques
handle nutrients efficiently. that offer pain relief and improve function is sorely needed.
Reversing or slowing these undesirable processes is
the potential of appropriate bodywork and movement
approaches. It is yet to be precisely established to what
SUMMARY OF FASCIAL AND CONNECTIVE
degree cellular function can be modified by soft tissue tech
TISSUE FUNCTION
niques, such as those used in neuromuscular therapy.
However, the normalizing of structural and functional fea
Fascia is involved in numerous complex biochemical
tures of connective tissue by means of addressing myofas
activities.
cial trigger points, chronic muscle shortening and fibrosis,
as well as perpetuating factors such as habits of use, has Connective tissue contains a subtle, bodywide signaling
clear implications. Well-designed research to assess cellular system with as yet unknown potentials.
14 CLI N I CA L A PPLICATI O N O F N EU R O M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY
L
The fascial cleavage planes appear to be sites of unique Many of the neural structures in fascia are sensory in
sensit ivity and of great importance in manual (and nature.
acupuncture) therapeutic focus. Fascia supplies restraining mechanisms by the differenti
Connective tissue provides a supporting matrix for more ation of retention bands, fibrous pulley s and check liga
highly organized s tructures and attaches extensively to ments as well as assist ing in the harmonious production
and invests into muscles. and control of movement.
Individual muscle fibers are enveloped by endomysium, Where connective tissue is loose in texture it allows move
which is connec ted to the stronger perimy sium that sur ment between adjacent structures and, by the formation of
rounds the fasciculi. bursal sacs, i t reduces the effects of pressure and friction .
The perimysium's fibers attach to the even stronger Deep fascia ensheaths and preserves the characteristic
epimy sium that surrounds the muscle as a whole and contours of the limbs and promotes the circulation in the
attaches to fascial tissues nearby. veins and lymphatic vessels.
Because it contains mesenchymal cells of an embry onic The superficial fascia, which forms the panniculus adipo
type, connective tissue provides a generalized tissue sis, allows for the storage of fat and also provides a sur
capable of giving rise, under certain circumstances, to face covering that aids in the conservation of body heat.
more specialized elements. By virtue of its fibroblastic activity, connective tissue aids
It provides (by its fascial planes) pathway s for nerves, in the repair of injuries by the deposition of collagenous
blood and lymphatic vessels and structures. fibers (scar tissue).
Box 1 . 6 Tensegrity
Oschman (2000) suggests that bones fit in both the strut and tensile the point of impact and to be absorbed throughout the structure.
categories, argu ing that: 'Bones contai n both compressive and 'The more flexible and balanced the network (the better the
tensile fibres, and are therefore tensegrity systems unto themselves: tensiona l integ rity), the more readily it absorbs shocks and converts
Tensegrity a l lows mecha nica l energy to be transmitted away from them to information rather than damage:
Regarding Ingber's work, Oschman (2000) points out that the Osch man ( 1 997) concurs, adding another element:
living tensegrity network is not only a mechanical system, but a lso a Robbie (1977) reaches the remarkable conclusion that the soft tissues
vibratory continuum. When a part of a tensegrity structure is araund the spine, when under apprapriate tension, can actually lift
plucked, the vibration produced travels throughout the entire each vertebra off the one below it. He views the spine as a tensegrity
structure: mast. The various ligaments form 'slings ' that are capable of support
Restrictions in one part have both structural and energetic ing the weight of the body without applying compressive forces to the
consequences for the en tire organism. Structural integrity, vibratory vertebrae and intervertebral discs. In other words, the vertebral col
integrity, and energetic or information integrity go hand in hand. umn is not, as it is usually portrayed, a simple stack of blocks, each
One cannot influence the structural system without influencing cushioned b y an intervertebral disc.
the energetic/informational system, and vice versa. Ingber's work
These views are also suggested by Myers (200 1 ) in his enlightening
shows how these systems also interdigitate with biochemical
book, Anatomy Trains: Myofascial Meridians for Manual and
poth ways.
Movemen t Therapists (see a lso Box 1 .4).
Of tensegrity, Juhan (1 998) tells us: Later Oschman continues:
Besides this hydrostatic pressure (which is exerted by every fascial Cells and nuclei are tensegrity systems (Coffey 1 985, Ingber Et
compartment, not just the outer wrapping), the connective tissue Folkman 1989, Ingber Et Jamieson 1985). Elegant research has docu
framework - in conjunction with active muscles - provides another mented how the gravity system connects, via a family of molecules
kind of tensional force that is crucial to the upright structure of the known as in tegrins, to the cytoskeletons of cells throughout the body.
skeleton. We are not made up of stacks of building blocks resting Integrins 'glue' every cell in the body to neighbouring cells and to the
securely upon one another, but rather of poles and guy-wires, whose surrounding connective tissue matrix. An important study by Wang
stability relies not upon flat stacked surfaces, but upon praper angles et al (1 993) documents that integrin molecules carry tension from the
of the poles and balanced tensions on the wires. . . . There is not a extracellular ma trix, across the cell surface, to the cytoskeleton,
single horizontal surface anywhere in the skeleton that pravides a which behaves as a tensegrity matrix. Ingber (1 993a,b) has shown
stable base for anything to be stacked upon it. Our design was not how cell shape and function are regulated by an interacting tension
conceived by a stone-mason. Weight applied to any bone would and compression system within the cytoskeleton.
cause it to slide right off itsjoints if it were not for the tensional
Levin (1 997) informs us that once spherica l shapes involving
balances that hold it in place and contral its pivoting. Like
tensegrity structures occur (as in the cells of the body), a many-sided
the beams in a simple tensegrity structure, our bones act more
framework evolves which has 20 triangular faces. This is the
as spacers than as compressional members; more weigh t is
hierarchica lly constructed tensegrity icosahedron ( icosa is 20 in
actually borne by the connective system of cables than by the bony
Greek) which a re stacked together to form an infinite n u mber of
beams.
tissues.
Levin ( 1 997) further explains a rchitectural aspects of tensegrity
as it relates to the human body. He discusses the work of Wh ite Et
Panjabi ( 1 978) who have shown that any part of the body wh ich is
free to move in any direction has 1 2 degrees of freedom: the abil ity
to rotate around three axes, in each direction (six degrees of
freedom) as well as the ability to translate on three planes in either
direction (a further six degrees of freedom). He then asks, how is this
stabil ized?
To fix in space a body thot has 12 degrees of freedom it seems logical
that there need to be 12 restraints. Fuller (1975) proves this ... This
A B
principle is demonstrated in a wire-spoked bicycle wheel. A minimum distributes evenly around the rim and the bicycle frame and its load
of 12 tension spokes rigidly fixes the hub in space (anything more hangs from the hubs l i ke a ham mock between trees'.
than 12 is a fail safe mechanism). Other examples of tensegrity in common use include a tent and a
crane. In the body this architectural principle is seen in many tissues,
Levin points out that the tension-loaded spokes transmit
most specifica lly in the way the sacrum is suspended between
compressive loads from the fra me to the ground while the hub
the il ia.
remains suspended in its tensegrity network of spokes: 'the load
The ensheathing lay er of deep fascia, as well as inter ubiquitous, tenacious, living tissue that is deeply
muscular septa and interosseous membranes, provides involved in almost all of the fundamental processes of
vast surface areas used for muscular attachment. the body 's structure, function and metabolism.
The meshes of loose connective tissue contain the 'tissue In therapeutic terms, there can be little logic in try ing to
fluid' and provide an essential medium through which consider muscle as a separate structure from fascia since
the cellular elements of other tissues are brought into they are so intimately related.
functional relation with blood and ly mph. Remove connective tissue from the scene and any muscle
This occurs partly by diffusion and partly by means of left would be a jelly -like structure without form or func
hy drokinetic transportation encouraged by alterations in tional ability.
pressure gradients - for example, between the thorax and
the abdominal cavity during inhalation and exhalation.
Connective tissue has a nutritive function and houses
FASCIAL DYS FUNCTION
nearly a quarter of all body fluids.
Fascia is a major arena of inflammatory processes (Cathie
Mark Barnes (1997) states:
1 974) (see Chapter 7).
Fluids and infectious processes often travel along fascial
Fascial restrictions can create abnormal strain patterns that
planes (Cathie 1 974).
can crowd, or pull the osseous structures out of proper
Chemical (nutritional) factors influence fascial behavior
alignment, resulting in compression of joints, producing
directly. Pauling (1976) showed that 'Many of the results
pain and/or dysfunction. Neural and vascular structures
of deprivation of ascorbic acid [vitamin C] involve a defi
can also become entrapped in these restrictions, causing
ciency in connective tissue which is largely responsible
neurological or ischemic conditions. Shortening of the
for the strength of bones, teeth, and skin of the body and
myofascial fascicle can limit its functional length - reducing
which consists of the fibrous protein collagen'.
its strength, contractile potential and deceleration capacity.
The histiocytes of connective tissue comprise part of an
Facilitating positive change in this system [by therapeutic
important defense mechanism against bacterial invasion
intervention] would be a clinically relevant event.
by their phagocytic activity.
They also play a part as scavengers in removing cell
Cantu & Grodin (1992) have stated that 'The response of
debris and foreign material.
normal connective tissue [fascia] to immobilization pro
Connective tissue represents an important 'neutralizer'
vides a basis for understanding traumatized conditions'.
or detoxicator to both endogenous toxins (those produced
A sequence of dy sfunction has been demonstrated as
under phy siological conditions) and exogenous toxins.
follows (Akeson & Amiel 1977, Amiel & Akeson 1983,
The mechanical barrier presented by fascia has important
Evans 1960).
defensive functions in cases of infection and toxemia.
Fascia, then, is not just a background structure with little The longer the immobilization, the greater the amount of
function apart from its obvious supporting role, but is an infiltrate there will be.
1 Connective tissue and the fascial system 17
link Et Lawson have described patterns of postural patterning link Et Lawson observed that the 20% of people whose compen
determ ined by fascial compensation and decompensation. satory pattern d id not a lternate had poor health h istories.
Treatment of either CCP or uncompensated fascial patterns has
Fascial compensation is seen as a usefu l, beneficia l and, above all,
the objective of trying, as far as is possible, to create a sym metri
functional adaptation (i.e. no obvious symptoms) on the part of
cal degree of rotatory motion at the key crossover sites.
the musculoskeleta l system, for exa mple, in response to anom
The treatment methods used to ach ieve this ra nge from direct
a l ies such as a short leg, or to overuse.
muscle energy approaches to indirect positional release techniques.
Decompensation describes the same phenomenon but only in
relation to a situation in which adaptive changes are seen to be Assessment of tissue preference
dysfunctional, to produce symptoms, evidencing a failure of
homeostatic adaptation. Occipitoatl antal area (Fig. 1 . 1 6)
Patient is supine.
By testing the tissue 'preferences' in different areas it is possible to Practitioner sits at head, and cradles upper cervical region.
classify patterns i n clin ically useful ways: The neck is fu l ly flexed.
ideal (minimal ada ptive load transferred to other regions) The occiput is rotated on the atlas to eva luate tissue preference
compensa ted patterns which alternate in direction from area to as the head is slowly rotated left and then right.
area (e.g. atla ntoocci pital, cervicothoracic, thoracolumbar, lum Cervi cothoracic area (Fig. 1 . 1 7)
bosacral) and which a re commonly adaptive in nature Patient is seated in relaxed posture with practitioner behind, with
uncompensated patterns which do not a lternate and which are
hands placed to cover medial aspects of upper trapezius so that
commonly the result of trauma. fingers rest over the clavicles.
Functi o n a l eva l u ation of fasci a l postural patterns
link Et Lawson ( 1 979) have described methods for testing tissue
preference.
There a re fou r crossover sites where fascial tensions can be
noted : occipitoatiantal (OA), cervicothoracic (CT), thoracolu mbar
(TL) and lumbosacral (LS). A
These sites a re tested for their rotation and side-bending
preferences.
link Et Lawson's research showed that most people display alter
nating patterns of rotatory preference with about 800/0 of people
showing a common pattern of left-right-Ieft-right (termed the
common compensatory pattern or CCP) 'reading' from the occipi
toatlantal region downwards.
Fig u re 1 . 1 6 Alternative hand positions for assessment of u pper F i gu re 1 . 1 7 AEtB: Hand positions for assessment of u pper
cervical region tissue d i rection prefe rence. cervicothoracic reg ion tissue di rection preference.
box continues
1 Connective tissue and the fascial system 19
The hands assess the area being palpated for its 'tightness/loose NOTE: By holding tissues in their 'loose' or ease positions, by holding
ness' preferences as a slight degree of rotation left and then right tissues in their 'tight' or bind positions and introd ucing an isometric
is introduced at the level of the cervicothoracic junction. contraction or just by holding tissues at their barrier, waiting
for a release, changes ca n be encouraged. The latter a pproach would
Thoraco l u m b a r area be i nducing the myofascial release in response to lig ht, sustained
Patient is supine, practitioner stands at waist level facing cepha load.
lad and places hands over lower thoracic structures, fingers a long
lower rib shafts lateral ly. Questions following assessment exercise:
Treating the structure being pal pated as a cyl inder, the hands test
the preference the lower thorax has to rotate a round its central 1 . Was there an 'a lternating' pattern to the tissue preferences?
axis, one way and then the other. 2. Or was there a tendency for the tissue preference to be the same
i n all or most of the four a reas assessed?
Lumbosacral a rea 3 . If the latter was the case, was this in an i ndividual whose health
Patient is supine, practitioner stands below waist level facing is more compromised than average - in line with Zink & Lawson's
cepha lad and places ha nds on anterior pelvic structu res, using the suggestion?
contact as a 'steering wheel' to eval uate tissue preference as the 4. By means of any of the methods suggested in the 'Note' above,
pelvis is rotated around its central axis while seeking information are you able to produce a more balanced degree of tissue
as to its 'tightness/looseness' preferences. preference?
and consciousness directly. A computer, with its software superficial tissues (involving autonomic responses) as well as
programs and memory and information storage capacities deeper tissues (influencing the mechanical components of
pales to insignificance in comparison with the evolutionar the musculoskeletal system) and that also address the factor
ily ancient solid-state system that is expressed within every of mobility (movement) meet with the requirements of the
cell and sinew of the body. body when dysfunctional problems are being treated. NMT,
Since the primary channels of this informational system as presented in this text, adopts this comprehensive approach
are the acupuncture meridians, it is not surprising that and achieves at least some of its beneficial effects because of
there are energy psychology methods that involve tapping its influence on fascia.
on key paints on the meridian system. Such tapping will In the upcoming chapters we will see how influences
introduce electrical fields into the meridian system because from the nervous system, inflarrunatory processes and pat
of the piezoelectric or pressure-electricity effect (e.g. terns of use affect (and are affected by) the fascial network.
Lapinski 1977, MacGinitie 1995). Such currents, then, will In the second volume of this text, the principles of tenseg
be transduced into signals that will be propagated through rity, thixotropy and postural balance will be seen to form an
the meridian/living matrix system for a certain distance, intricate part of the foundations of whole-body structural
since the meridians are low resistance pathways to the flow integri ty. As will become clear in the next chapter, Ingber
of electricity (e.g. Reichmanis et aI 1975). (2003) now tends to use the term 'structural continuum' as
an advance on the tensegrity model, wherein the entire
body and all its myriad structures are seen to be interde
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Cantu & Grodin (1992) conclude that therapeutic approaches the structures of the body is a foundation for the use of ther
which sequence their treahuent protocols to involve the apeutic bodywork methods.
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I
23
I
Chapter 2 I
Muscles
-- Upper trapezius
-- Spine of scapula
----Infraspinatus
Site of vertebral
malrotation---L-- '----- Teres minor
----- Piriformis
Iliopsoas-----t---'
TFUITB------1
t------ Biceps femoris
Gastrocnemius and
soleus-------t
Striated (skeletal) muscles are com posed of fasciculi, the nu mber of filaments). it partially hydrolyzes them to produce an energized (pre
which is dependent upon the size of the muscle. Each fascicle is made cocked) myosin head. This preloaded thick filament has a high
up of bundles of (approximately) 1 00 fibers with each fiber containing affinity for the thinner actin component. When a muscle is at rest,
up to around 2000 myofibrils (Macintosh et al 2006, Simons et a l binding of the two filaments m ust be blocked or else continual
1 999). Each myofibri l is composed of a series of sarcomeres laid end to contraction will resu lt, such as seen in rigor mortis. The tropomyosin
end; these conta in two primary types of protein filament, actin a nd filament overlies the myosin binding sites on the actin molecule,
myosin, as well as a stabi lizing filament (titin) a nd other proteins, such thereby preventing coupling of the two fi la ments.
as troponin, tropomyosin and nebulin. In most a natomy books the As an action potential spreads across the muscle fiber, signaling
reader can easily find illustrations and d iscussions regarding the contraction, it travels down the transverse tubu les, which lie close to
distinct bands and shadings, such as the Z-line, H-zone and M-region, the term inal cisternae (lateral sacs), the storage site for Ca2+. As the
which are created by the myofibri l components. action potential progresses, it causes a depolarization of the
The sliding fi lament theory, first proposed by biophysicist Jea n membrane, an opening of the calcium cha n nels and the release of
Hanson and physiologist H ugh Esmor H uxley in 1 954, offers a n Ca2+ from the sarcoplasmic reticu lum.
explanation of how m uscles shorten during contraction. Although The release of Ca2+ cata lyzes tropon in to cha nge its sha pe,
scientists have fa iled to fu l ly explain the biomechanics of movement, thereby moving tropomyosin aside. This process exposes the binding
the sl iding fila ment theory remains today as the foundational sites on the actin molecule and allows myosin to attach itself to the
platform. The fol lowing i l l u strates the basis of this theory. actin fi la ments. This occurs to many filaments sim u l taneously, not
Figure 2.4 i l l u strates the relationsh ip of acti n, myosin and other just the one described here. The myosin heads (and possibly shafts)
components of the m u scle cell during contraction. As ATP binds to flex, causing nu merous myosin and actin fi la ments to slide past each
the myosin heads (which form the crossbridges between the two other, resulting in muscle contraction.
-r=I!=I=I" i;!i
However, the head group cannot
bind because of the blocking of the
Thick (myosin) filament I actin binding sites by tropomyosin.
, Note: Reactions shown occurring in
only one crossbridge, but same
process takes place at all or most
A new molecule of ATP binds to crossbridges.
the myosin head, causing it to I
release from the actin molecule.
Partial hydrolysis of this ATP
(ATP- Pi) will 'recock' the
myosin head and produce a
high-affinity binding site for actin.
: If Ca2+levels are still elevated,
a8;i;lgat r Ca2+ released from sarcoplasmic
, reticulum in response to action
,, reform,
the crossbridge will quickly , potential binds to troponin, causing
causing further sliding of I tropomyosin to move and expose
I the actin and myosin filaments I
I
the myosin binding site on the actin
past each other. If Ca2+ is no molecule, The crossbridge is
ATP
f -
I
ADP-Pi ADP and Pi are released, the myosin I
head nexes, and the myosin and ,
I actin filaments slide past each other. I
I _ _ _ I
Figure 2.4 The contraction of the myofilaments resu lts from the interaction of actin and myosin. Redrawn after Hansen Et Koeppen (2002).
box continues
2 M uscles 27
Once this occurs, the myosin loses its energy a nd remains bonded
to the actin until it is re-energized with AlP. In other words, the AlP
unlocks the myosin head and preloads it for the next cycle. However,
the absence of adequate AlP and the presence of Ca2+ ca n cause the
fi laments to remain in a shortened position for a n indefinite period
of time.
After the contraction is completed, if adequate AlP is avai lable,
the myosin can be detached, the Ca2+ can be actively transported
back into the term inal cisternae of the sarcoplasmic reticulum,
thereby allowing the tropomyosin to slide back into place and cover
the actin-reactive sites. Muscle fiber relaxation occurs.
For best results (maximal force output and fu nctional shorten i ng)
the fi la ments should beg in at normal resting length, neither
overapproximated nor overstretched. This will a l low the maximal
number of myosin heads to be used. Adequate AlP is needed for
myosin energy and Ca2+ must be avai lable as a catalyst to tropon in.
A functional calcium pump will a llow for removal of the molecule.
AlP is also needed for this step since the calcium requires active
transportation, which requires energy.
When ischemia reduces the availability of elements used by the
local mitochondria to produce AlP, a local energy crisis develops.
When this is taken into account with the above description, one can
readily understand how persistent muscle fiber shortening
(contractu res) might form. Due to the unavai labil ity of AlP to d rive
the ca lcium pump, the conti nual presence of Ca2+ in the immed iate
vicinity of the filaments wou ld add to the conti nuity of muscle
shortening. It is also easily apparent that these would be chemically
induced by local factors rather than neurona lly d riven.
In Chapter 6 we will explore what occurs when some of these
steps are altered from their n ormal process (by trauma, overuse,
strain, etc.) and how these filaments produce some of the most
vicious, un relenting, pain-producing elements - myofascial trigger
points.
Thin filaments
Figure 2.5 From whole muscle to the sarcomere's actin and myosin
elements. Reproduced with pe rm i ss ion from Gray's Anatomy (2005).
pennate, which have fascicles running at an angle to the energy from chemically bound energy (in the form of
muscle's central tendon (its longitudinal axis). These fasci adenosine triphosphate ATP).-
cles favor strong movement and are divided into unipennate This process of energy production depends on an ade
(flexor pollicis longus), bipennate, which has a feather-like quate supply of oxygen, something that will be normal in
appearance (rectus femoris, peroneus longus) and multi aerobically fit tissues, but not in the tissues of the decon
pennate (deltoid) forms, depending on the configuration of ditioned individual (see below).
their fibers in relation to their tendinous attadunents Some of the energy so produced is stored in contractile
circular, as in the sphincters tissues for subsequent use when activity occurs. The force
triangular or convergent, where a broad origin ends with a that skeletal muscles generate is used to produce or pre
narrow attachment, as in pectoralis major vent movement, to induce motion or to ensure stability.
spiral or twisted, as in latissimus dorsi or levator scapulae. Muscular contractions can be described in rela tion to
what has been termed a strength continuum, varying from
a small degree of force, capable of lengthy maintenance,
ENERGY PRO DUCTION IN NORMAL TISSUES to a full-strength contraction, which can be sustained for
very short periods.
Muscles are the body's force generators. In order to When a contraction involves more than 70% of available
achieve this function, they require a source of power, strength, blood flow is reduced and oxygen availability
which they derive from their ability to produce mechanical diminishes.
28 CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY
Quadrilateral
Figure 2.6 Types of muscle fiber arrangement. Reproduced with permission from Gray's Anatomy (2005).
penetrate to the endomysium where all the blood passes site) will diffuse elsewhere until pressure is released, at
through to the capillary bed before collection into venules which time a 'flushing' of the previously ischemic tissues
and veins to leave again through the hilus. Alternatively, will occur. A blanching/ flushing combination repeated sev
some of the blood passes into the arterioles of the epi- and eral times can act as a local 'irrigation pump' to significantly
perimysium in which few capillaries are present. Arteriove increase blood flow to localized ischemia.
nous anastomosis [a coupling of blood vessels] are abundant As explained below, when a situation of increased alka
here, and most of the blood returns to the veins without linity (respiratory a lkalosis) leads to the smooth muscles
passing through the capillaries; this circuit therefore consti around blood vessels constricting, blood supply w ill be
tutes a non-nutritive [collateral} pathway through which diminished. In addition, oxygen release to the tissues will
blood may pass when the flow in the endomysia I capillary also be reduced in such a setting due to the Bohr effect
bed is impeded, e.g. during contraction. (Pryor & Prasad 2002).
Some a reas of the body have relatively inefficient anasto
In this way blood would keep moving but would not be moses and are termed hypovascular. These are particularly
nourishing the tissues it was destined for, if access to the prone to injury and dysfunction. Examples include the
capillary bed was blocked for any reason. This includes supraspinatus tendon, which corresponds with 'the most
when ischemia is present in the tissues due to overuse, pro common site of rotator cuff tendinitis, calcification and
longed shortening due to postural positioning, and tight spontaneous rupture' (Cailliet 1991, Tulos & Bennett 1984).
clothing, such as an elastic waistband in pants applying Other hypovascular sites include the insertion of the infra
pressure to the lower back tissues. spinatus tendon and the intrascapular aspect of the biceps
This is also particularly relevant to deep pressure tech tendon (Brewer 1979).
niques, designed to create 'ischemic compression' - for The lymphatic drainage of muscles occurs via lymphatic
example, when treating myofascial trigger points. When capillaries that lie in the epi- and perimysial sheaths. They
ischemic compression is applied, the blood destined for the converge into larger lymphatic vessels that travel close to
tissues being obstructed by this pressure ( the trigger point the veins as they leave the muscle.
Coming in contact with lymph is to connect with the liquid 1813-1878) in which the cells are immersed, receive their nutritive
dimension of the organ ism. (Ch ikly 1 996) substances and reject damaging by-products. Lymph is a fluid which
The lymphatic system serves as a collecting and filtering system originates in the connective tissue spaces of the body. Once it has
for the body's interstitial fluids, while removing the body's cellular entered the first lymph capillaries ... this fluid is called lymph.
debris. It is able to process the waste materials from cel l u lar
Col lection beg ins in the interstitial spaces as a portion of the
metabolism and provide a strong line of defense agai nst foreign
circu lating blood is picked up by the lymphatic system. This fl uid is
invaders while reca pturing the protein elements and water content
comprised primarily of large waste particles, debris and other material
for recycling by the body. Through 'immunolog ica l memory',
from which protein might need to be recovered or that may need to
lymphocyte cells, which reside in the lymph and blood a n d are part
be disposed. Foreign particulate matter and pathogenic bacteria are
of the general immune system , recognize invaders (antigens) a nd
screened out by the lymph nodes, which a re interposed a long the
rapidly act to neutra l ize these. This system of defending during
course of the vessels. Nodes a lso produce lymphocytes, which makes
invasion and then clea ning up the battleground makes the lymphatic
their location at various points a long the transportation pathway
system essential to the health of the organism.
convenient should infectious material be encountered.
Organization of the lymph system Lym ph nodes (Chikly 200 1 ):
The lymphatic system comprises an extensive network of lymphatic
filter and purify
capilla ries, a series of collecting vessels and lymph nodes. It is
capture and destroy toxins
associated with the lymphoid system (lymph nodes, spleen, thymus,
reabsorb a bout 40 0/0 of the lymphatic liq uids, so concentrating
tonsi ls, appendix, mucosal-associated lym phoid tissue such as
the lymph while recycling the removed water
Peyer's patches and bone ma rrow), which is pri marily responsible for
produce mature lymphocytes - white blood cells that destroy
the immune response (Braem 1 994, Chikly 1 996, 2001 ). The
bacteria, virus-infected cel ls, foreign matter and waste
lym phatic system is:
materia ls.
an essential defensive component of the immune system
a carrier of (especially heavy and large) debris on behalf of the Production of lymphocytes increases (in nodes) when lym phatic flow
circulatory system is increased (e.g. with lymphatic d ra i nage techniques).
a transporter of fat-soluble nutrients (and fat itself) from the A lymphatic ca pillary network made of vessels slightly larger than
digestive tract to the bloodstream . blood ca pil laries d rains tissue fl uid from nearly a l l tissues and organs
that have a blood vascularization. The blood circu latory system is a
Chikly (2001) notes: closed system, whereas the lymphatic system is an open-end system,
The lymphatic system is therefore a second pathway back to the beginning blind in the interstitial spaces. The moment the fluid
heart, parollel to the blood system. The interstitial fluid is a very enters a lymph capillary, a fla p valve prevents it from returning into
important fluid. It is the real 'interior milieu' (Claude Bernard, the interstitia l spaces. The fluids, now cal led 'lymph', continue
box continues
30 CL I N I CA L A P PL I CATI O N OF N E U RO M U S C U LAR T EC H NIQU ES: T H E U P P E R B ODY
coursing th rough these 'precollector' vessels which empty into lymph the head and neck and right side of the thorax and empties in a
col lectors. similar manner to that of the l eft side.
The collectors have valves every 6-20 mm that occur directly Stimulation of Iymphangions (and therefore lymph movement)
between two to th ree layers of spira l muscles, the unit being occurs as a result of automotoricity of the Iymphangions (electrical
ca lled a Iymphangian (Fig. 2.7). The alternation of valves and potentials from the autonomic nervous system) (Kurz 1 986). As the
muscles gives a characteristic 'monil iform' shape to these vessels, spiral muscles of the vessels contract, they force the lymph through
like pearls on a string. The Iymphangions contract in a peristaltic the flap valve, which prevents its return. Additionally, stretching of the
man ner that assists in pressing the fluids through the va lved system. muscle fibers of the next Iymphangion (by increased fluid volume of
When stimulated, the muscles can substantially increase (up to the segment) leads to reflex muscle contraction (internally stimulated),
20-30 ti mes) the capacity of the whole lymphatic system (Chikly thereby producing peristaltic waves along the lymphatic vessel. There
2001). are a lso external stretch receptors that may be activated by manual
The la rgest of the lymphatic vessels is the thoracic duct, wh ich methods of lymph drainage which create a similar peristalsis.
begins at the cisterna chyli, a large sac-like structure withi n the Lymph movement is also augmented by respiration as the altering
abdominal cavity located at approximately the level of the 2nd intrathoracic pressure produces a suction on the thoracic duct and
lumbar vertebra. The thoracic duct, containing lymph fluids from cisterna chyli and thereby increases lymph movement in the duct
both of the lower extremities and a l l abdominal viscera except part and presses it toward the venous arch (Kurz 1 986, 1 987). Skeletal
of the liver, runs posterior to the stomach a n d intestines. Lymph muscle contractions, movement of l imbs, peristalsis of smooth
fluids from the left upper extremity, left thorax and the left side of muscles, the speed of blood movement in the veins into which the
cranium and neck may join it just before it empties into the left ducts empty and the pulsing of nearby arteries a l l contribute to
subclavian vein or may empty nearby into the internal jugular vein, lymph movement (Wittl inger & Wittl inger 1 982). Exposure to cold,
brachiocepha l ic junction or directly into the subclavian vein. The tight cloth ing, lack of exercise and excess protein consumption can
right lymphatic duct d rains the right upper extrem ity, right side of hinder lymphatic flow (Kurz 1 986, Wittlinger & Wittlinger 1 982).
White pulp
Spleen
Afferent
lymphatic
vessels
via Lymphatic
efferent drainage
lymphatic
vessels
marrow
tissue:
including:
connective tissue,
epithelia, non-encapsulated
lymphoid tissue of gut, elc.
box continues
2 M uscles 31
Contraction of neighboring muscles compresses lymph vessels, mov significantly increases lymph movement by crosswise and lengthwise
ing lymph in the directions determined by their valves; extremely little stretching of the anchoring filaments that open the lymph
lymph flows in an immobilized limb, whereas flow is increased by capillaries, thus allowing the i n terstitial fluid to enter the lymphatic
either active or passive movements. This fact has been used clinically system. However, shearing forces (like those created by deep
to diminish dissemination of toxins from infected tissues by immobi pressure gliding techniques) can lead to temporary i n hibition of
lization of the relevant regions. Conversely, massage aids the flow of lymph flow by inducing spasms of lymphatic muscles (Kurz 1 986).
lymph from oedematous regions. (Gray's Anatomy 1995) Unless the vessels are d amaged, lymphatic movement can then be
reactivated by use of manual tech niques that sti mulate the
By recovering up to 20% of the interstitial fluids, the lymphatic
Iymphangions.
system rel ieves the venous system (and therefore the heart) of the
While each case has to be considered individual ly, numerous
responsibility of transporting the large molecules of protein and
conditions, ranging from postoperative edema to premenstrual fluid
debris back to the general circulation. Additional ly, the lymphocytes
retention, may benefit from lymphatic d rainage. There are, however,
remove particulate matter by means of phagocytosis, that is, the
conditions for which lymphatic d rainage would be contrai ndicated or
process of ingestion and digestion by cel ls of solid substances (other
precautions exercised. Some of the more serious of these conditions
cells, bacteria, bits of necrosed tissue, foreign particles). By the time
include:
the fluid has been returned to the veins, it is ultrafiltered, condensed
and hig hly concentrated. acute infections and acute inflammation (generalized and local)
thrombosis
In effect, if the lymphatic system did not regain the 2-20% of the
circulatory problems
protein-rich liquid that escaped in the interstitium (a large part of
cardiac conditions
which the venous system cannot recover), the body would probably
hemorrhage
develop major edemas and autointoxication and die within 24-48
malignant cancers
hours. (Chikly 2001, Guyton 1986)
thyroid problems
Conversely, when applying lymph d rainage techniques, care must be acute phlebitis.
taken to avoid excessive increases in the volume of lymph flow in
Conditions that might benefit from lymphatic d rainage but for which
people who have heart conditions as the venous system must
precautions are indicated include:
accom modate the load once the fluid has been delivered to the
subclavian veins. Significantly increasing the load could place certain edemas, depending upon their cause, such as cardiac
excessive strain on the heart. insufficiency
Lymphatic circulation is separated i n to two layers. The superficial carotid stenosis
circulation, which constitutes approxi mately 70% of all lymph flow bronchial asthma
(Chikly 2001 1. is located just under the dermoepidermic junction. The burns, scars, bruises, moles
deep muscular and visceral circulation, below the fascia, is activated abdom i nal surgery, radiation or undetermined bleeding or pain
by muscular contraction; however, the superficial circulation is not removed spleen
directly sti mulated by exercise. Additional ly, lymph capi l l aries major kidney problems or insufficiency
(Iacteals) in the jejunum and i l eum of the digestive tract absorb fat menstruation (drain prior to menses)
and fat-soluble nutrients that ultimately reach the liver through the gynecological infections, fibromas or cysts
blood ci rculation (Braem 1 994). some pregnancies (especially in the first 3 months)
Manual or mechanical lymphatic d rainage tech niques are chronic infections or inflammation
effective ways to increase lymph removal from stag nant or edemic low blood pressure.
tissue. The manual techn iques use extremely light pressure, which
MOTOR CONTROL AND RESPIRATORY below), which interferes with the first tvvo of those three ele
ALKALOSIS ments - the CNS as well as muscle function.
People who 'overbreathe', or who have marked upper
Motor control is a key component in injury prevention. Loss chest breathing patterns ('brea thing pattern disorders' or
of motor control involves failure to con trol joints, com BPD), automatically exhale more carbon dioxide (C02) than
monly because of incoordination of agonist-antagonist is appropriate for their current metabolic needs. Exhaled
muscle coactivation. According to Panjabi (1992), three sub CO2 derives from carbonic acid in the bloodstream, and an
systems work together to maintain joint and spinal stability: excessive reduction of this leads to a situation known as res
piratory alkalosis, where the pH of the blood becomes more
1. The central nervous subsystem (control)
alkaline than its normal of ::'::7 .4 (Lum 1987, Pryor & Prasad
2. The muscle subsystem (active)
2002).
3. The osteoligamentous subsystem (passive).
There are a number of major consequences of increased
Anything that interferes with any aspect of these features of alkalinity, one of which is a contrac tion of smooth muscle
normal motor control may contribute to dysfunction and cells (SMC) . This reduces the diameter of all struc tures sur
pain. This includes a condition in which the bloodstream rounded by smooth muscles, such as the blood vessels and
increases in alkalinity because of overbreathing (for exam intestinal structures. Reduced diameter of blood vessels
ple hyperventilation, the extreme of overbreathing, see limits blood supply to the tissues and the brain, thereby
32 C L I N I CA L A P P L I CATI O N OF N E U RO M USCULAR TEC H N I Q U ES: TH E U P P E R B ODY
resulting in a variety of symptoms (see below), one of which motor discharges, muscular tension and spasm, speeding of
is increased fatigability. It is postulated that SMC contrac spinal reflexes, heightened perception (pain, photophobia,
tion may also influence fascial tone (Schleip et aI 2004). (See hyperacusis) and other sensory disturbances. ' Muscles
Chapter 1 for information regarding smooth muscle cells affected in this way inevitably become prone to fatigue,
and their location and behavior in connective tissues.) altered function, cramp and trigger point evolution (George
et al 1964, Levitzky 1995, Macefield & Burke 199 1).
TWO KEY DEFINITIONS
Hypocapnia: Deficiency of CO2 in the blood, possibly CORE STABILITY, TRANSVERSUS ABDOMINIS,
resul ting from hyperventilation, leading to respiratory THE DIAPHRAGM AND BPD
alkalosis. It is well established that the tone of both the diaphragm
Hypoxia: Reduction of O2 supply to tissue, below physio and transversus abdominis hold the key to maintenance of
logical levels despite adequate perfusion of the tissue by core stability (Panjabi 1992) .
blood. McGill et al (1995) have observed a reduction in spinal
Lum (1987) reports that research indica tes that not less than support if there is both a load challenge to the low back,
10% of patients attending general internal medicine practice combined with a demand for increased breathing (imagine
in the US have such breathing pattern disorders as their pri shoveling snow!). 'Modulation of muscle activity needed to
mary diagnosis. Newton (2001) agrees with this assessment. facilitate breathing may compromise the margin of safety of
The authors of this text suggest that there exists a large tissues that depend on constant muscle activity for support.'
patient population with BPDs who do not meet the criteria Hodges & Gandevia (2000) reported that after approxi
for hyperventilation, but whose breathing patterns may mately 60 seconds of overbreathing, the postural (tonic) and
contribute markedly to their symptom picture, and whose phasic functions of both the diaphragm and transversus
mo tor control is likely to be negatively affected as a result abdominis are reduced or absent.
(Chaitow 2004).
TERMINOLOGY Basement
z ----- - - - /
Myofilaments
MUSCLE TONE AND CONTRACTION 11\.I/1\L'!V111 _
Muscles display excitability - the ability to respond to stimuli Figure 2.8 Organization of skeletal muscle. Redrawn after Hansen
& Koeppen (2002).
and, by means of a stimulus, to be able to actively contract,
extend (lengthen) or to elastically recoil from a distended posi
tion, as well as to be able to passively relax when stimulus
A motor nerve fiber will always activate more than one
ceases.
muscle fiber and the collection of fibers it innervates i s
Lederman (1997) suggests that muscle tone in a resting
called a motor unit. The greater the degree o f fine control a
muscle relates to biomechanical elements - a mix of fascial
muscle is required to produce, the fewer muscle fibers a
and connective tissue tension together with intramuscular
nerve fiber will innervate in that muscle. This can range
fluid pressure, with no neurological input (therefore, not
from 10 muscle fibers being innervated by a single motor
measurable by EMG). If a muscle has altered morphologi
neuron in the extrinsic eye muscles to one motor neuron
cally, due to chronic shortening, for example, or to compart
innervating several hundred fibers in major limb muscles
ment syndrome, then muscle tone, even at rest, will be
(Gray's Anatomy 2005, p. 121).
altered and palpable.
Because there is a diffuse spread of influence from a sin
He differentiates this from motor tone, which is measura
gle motor neuron throughout a muscle (i.e. neural influence
ble by means of EMG and which is present in a resting mus
does not necessarily correspond to fascicular divisions)
cle only under abnormal circumstances - for example,
only a few need to be active to influence the entire muscle.
when psychological stress or protective activity is involved .
The functional contractile unit of a muscle fiber is its sar
Motor tone is either phasic or tonic, depending upon the
comere, which contains filaments of actin and myosin. These
nature of the activity being demanded of the muscle - to
myofilaments (actin and myosin) interact in order to
move something (phasic) or to stabilize it (tonic). In normal
shorten the muscle fiber. Gray's Anatomy (2005) describes
muscles, both activities vanish when gravitational and
the process as follows:
activity demands are absent.
Contraction occurs in response to a motor nerve impulse At higher power, sarcomeres are seen to consist of two types
acting on muscle fibers. of filament, thick and thin, organized into regular arrays.
34 CLI N I CAL A P PL I CAT I O N OF N E U RO M U S C U LA R TEC H N I Q U E S : T H E U P P E R B O DY
The thick filaments, which are c. 15 nm in diameter, are There are also several phasiC (type II) fiber forms, notably:
composed mainly of myosin. The thin filaments, which are
type IIa (fast-twitch fibers) which contract more speedily
8 nm in diameter, are composed mainly of actin. The arrays
than type I and are moderately resistant to fatigue with
of thick and thin filaments form a partially overlapping
relatively high concentrations of mitochondria and myo
structure . . . The A-band consists of the thick filaments,
globulin
together with links of thin filaments that interdigitate with,
type IIb (fast-twitch glycolytic fibers) which are less
and thus overlap, the thick filaments at either end . . . The
fatigue resistant and depend more on glycolytic sources of
I-band consists of the adjacent portions of two neighbouring
energy, with low levels of mitochondria and myoglobulin
sarcomeres in which the thin filaments are not overlapped
type lIm (superfast fibers) which depend upon a unique
by thickfilaments. It is bisected by the Z-disc, into which the
myosin structure that, along with a high glycogen con
thin filaments of the adjacent sarcomeres are anchored. In
tent, differentia tes them from the other type II fibers
addition to the thick and thin filaments, there is a third type
(Rowlerson 1981). These are found mainly in the jaw
of filament composed of the elastic protein, titin . . . The
muscles.
banded appearance of the individual myofibrils is thus
attributable to the regular alteration of the thick and thin fil As mentioned above, long-term stress involving type I mus
aments arrays. cle fibers leads to them shortening, whereas type II fibers,
undergOing similar stress, will weaken without shortening
over their whole length (they may, however, develop local
ized areas of sarcomere contracture, for example where trig
VULNERABLE AREAS
ger points evolve without shortening the muscle overall).
Shortness/ tightness of a postural muscle does not neces
In order to transfer force to its attachment site, contractile
sarily imply strength. Such muscles may test as strong or
units merge with the collagen fibers of the tendon which
weak. However, a weak phasic muscle will not shorten
attaches the muscle to bone.
overall and will always test as weak.
At the transition area, between muscle and tendon, these
Fiber type is not totally fixed, in that evidence exists as to
structures virtually 'fold' together, increasing strength
the potential for adaptability of muscles, so that committed
while reducing the elastic quality.
muscle fibers can be transformed from slow twitch to fast
This increased ability to handle shear forces is achieved
twitch, and vice versa (Lin 1994).
at the expense of the tissue's capacity to handle tensile
An example of this potential, which has profound clinical
forces.
significance, involves the scalene muscles. Lewit (1985) con
The chance of injury increases at those locations where
firms that they can be classified as either a postural or a pha
elastic muscle tissue transitions to less elastic tendon and
sic muscle. The scalenes, which are largely phasic (type II)
finally to non-elastic bone - the attachment sites of the
and dedicated to movement, can have postural functions
body.
thrust upon them, as with forward head postures, or when
chronically contracted to maintain a virtually permanently
elevated status of the upper chest, as in asthma. If these pos
MUSCLE TYPES tural demands are prolonged, more postural (type I) fibers
may develop to meet the situation. If overuse continues (as
Muscle fibers exist in various motor unit types - basically in upper chest breathing involving the upper ribs being reg
type I slow red tonic and type II fast white phasic (see ularly elevated during inhalation), these now postural mus
below). Type I are fatigue resistant while type II are more cles will shorten, as would any type I muscle when
easily fatigued. chronically stressed (Janda 1982, Liebenson 2006).
All m uscles have a mixture of fiber types (both I and II), The following findings, relating to the scalene muscles,
although in most there is a predominance of one or the were reported in a study that evaluated the link between
other, depending on the primary tasks of the muscle (pos these and inappropriate breathing patterns, in this instance,
tural stabilizer or phasic mover). mainly asthma.
Those which contract slowly (slow-twitch fibers) are clas
sified as type I (Engel 1986, Woo 1987) . These have very low The incidence of scalene muscle pathology was assessed in
stores of energy-supplying glycogen, but carry high con 46 consecutively hospitalized patients with bronchial
centrations of myoglobulin and mitochondria. These fibers asthma and irritable cough diagnoses. Three tests described
fatigue slowly and a re mainly involved in postural and sta by Travell & Simons were used in patient evaluation,
bilizing tasks. The effect of overuse, misuse, abuse or disuse including palpation for scalene trigger points and the use of
on postural muscles (see Chapters 4 and 5) is that, over Adson's test. Breathing patterns were also evaluated in all
time, they will shorten. This tendency to shorten is a clini patients for the presence of paradoxical breathing patterns.
cally important distinction between the response to 'stress' Scalene muscle pathologtj [dysfunction] was identified in 20
of type I and type II muscle fibers (see below). of the 38 bronchial asthma patients (52%), and in 5 of the
2 M uscles 35
A.Jf----- Gastrocnemius
11:...f/----Tibialis posterior
A B
Figure 2 .. 9 Major postural muscles. A : Anter ior. B : Posterior. Reproduced with permission from Chaitow ( 1 996).
8 irritable cough syndrome patients (62%). Postisometric abdominal (or lower) aspects of pectoralis major, middle
relaxation technique [muscle energJj] was used in those with and lower aspects of trapezius, the rhomboids, serratus
scalene dysfunction. Self-administered stretching tech anterior, rectus abdominis, gluteals, the peroneal muscles,
niques for home use were also taught. One patient with par vasti and the extensors of the arms.
adoxical breathing pattern was taught an alternative Some muscle groups, such as the scalenii, are equivocal.
breathing pattern. The authors are of the opinion that Although commonly listed as phasic muscles, this is how
bronchial asthma and irritable cough syndrome patients they start life but they can end up as postural ones if suffi
should be examined and evaluated by Rehabilitation cient demands are made on them (see above) .
Medicine Department stafffor functional pathology of the
scalene muscles. They are also of the opinion that examina
tion, treatment and self-administered stretching techniques COOPERATIVE MUSCLE ACTIVITY
should be a par t of routine management of bronchial asthma
patients. (Pleidelova et al 2002) Few, if any, muscles work in isolation, with most move
ments involving the combined effort of two or more, with
Among the more important postural muscles that become one or more acting as the 'prime mover ' or agonist.
hypertonic in response to dysfunction are: Almost every skeletal muscle has an antagonist that per
forms the opposite action, with one of the most obvious
trapezius (upper), sternocleidomastoid, levator scapula
and upper aspects of pectoralis major in the upper trunk examples being the elbow flexors (biceps brachii) and
extensors (triceps brachii).
and the flexors of the arms
quadratus lumborum, erector spinae, oblique abdomi Prime movers usually have synergistic muscles that
nals and iliopsoas in the lower trunk assist them and which contract at almost the same time. An
tensor fascia latae, rectus femoris, biceps femoris, add uc example of these roles would be hip abduction, in which
tors (longus, brevis and magnus), piriformis, semimem gluteus medius is the prime mover, with tensor fascia latae
and gluteus minimus acting synergistically and the hip
branosus and semitendinosus in the pelvic and lower
adductors acting as antagonists, being reciprocally inhibited
extremity region.
(RI) by the action of the agonists if movement is to occur. RI
Phasic muscles, which weaken in response to dysfunction is the physiological phenomenon in which there is an auto
(i.e. are inhibited), include the paravertebral muscles (not matic inhibition of a muscle when its antagonist contracts,
erector spinae), scalenii and deep neck flexors, deltoid, the also known as Sherrington's law II.
36 CL I N I CA L A P PL I CATION OF N E U RO M USCULAR TECH N I Q U E S : T H E U P P E R BODY
It is general ly accepted that muscles respond to overuse, misuse or result in postural adaptations. Treatment would aim to nor
disuse by either shortening or weaken ing (and possibly lengtheni ng). ma lize the tissues and lengthen the fibers.
As Kolar has explained (in Liebenson 2006, p. 533) : 'There is clinical
and experi mental evidence that some muscles are incli ned to Many of these categories interface - for instance, overused tight
inh ibition (hypotonus, weakness, inactivity), while other muscle muscles tend to create joint pressure leading to interneuron
groups are likely to be hyperactive with a tendency to become short: responses. Psychological stress might result in muscle tightening and
It was Janda (1 969, 1 983a) who first showed that these cha nges trigger point formation. Al though the body has a number of response
fol lowed certa in rules, and who named them as phasic (those choices that it can make to cope with the load to which it is
tending to inh ibition) and postura l (those tending to shortening). A adapting (biochemical, biomechan ical and psychosocial), the
plethora of different descriptors have been used to l abel these two practitioner a lso has a wide range of choices i n the way of
muscle groups, including stabil izer, mobil iz er; global, local ; i nterventions. Chapters 9 a nd 10 carry a ful l discussion of some of
superficial, deep, etc. (Norris 1 995a,b), adding a sense o f potential those options.
disagreement and confusion to the understa nding of what is in In sum mary, whatever the causes, there are two main responses
essence relatively simple: some muscles fol low one pathway toward by muscles when chronically stressed :
dysfunction, while others fol low a different pathway - whatever
names they are ascribed. In the interest of simpl icity, the authors of 1 . They are inh ibited and show evidence of hypotonus and weakness
this text have continued to designate these different muscle types as (phasic). or
postura I a nd phasic. 2. They develop hypertonus, and possibly spasm and rigidity
Liebenson (2006, p. 4 1 1 ) d iscusses Janda's classification of tense (postural).
and tight muscles and further separates muscle dysfunction into a
va riety of different treatment-specific categories that are either
neuromuscular or connective tissue related. These cha nges appear to involve mainly the contractile elements of
These classifications are as fol lows: muscles. However, i n some i nstances, connective tissue may a lso be
involved, resulting in contracture (Ja nda 1 99 1 ) .
There is quite natura l ly n o t only a functional but a lso a structural
Neuromuscular: aspect to these differences, and these have been identified by
1. Reflex spasm: As a response to n ociception, this often acts as physiologists. As Kolar expla ins (Liebenson 2006, p. 533) :
a spl inting mechan ism. Treatment would aim toward removal
of the cause of pa in, such an infla med appendix.
Differences are found in the nervous structure in control of these [dif
2. Interneuron: This del icate part of the reflex arc can become
ferent] muscles, for it is the type of neurons that determines the type
involved when afferent information is sent from spinal or
of muscle fibre. It is therefore better to speak of tonic and phasic
peripheral joints. Treatment would a i m to normalize the
motor units. Tonic motorneurons, i.e. small alpha motor cells, inner
involved joints.
vate red muscle fibres, whereas phasic motorneurons (large alpha
3. Trigger point: This is thought to be associated with loca lized
cells) innervate white muscle fibres. In humans, both types of motor
congestion within the muscle stem m i n g from short muscle
units are present in every muscle, in different proportions.
fibers. A variety of treatments are offered in this book to nor
malize myofascial tissue.
4. Limbic: This is associated with psychological stress. It can be Examples of patterns of imbalance which emerge as som e muscles
treated with counseling, stress management and a variety of weaken and lengthen and their synergists become overworked, while
relaxation methods including yoga and meditation. their antagonists shorten, ca n be summarized as follows.
Connective tissue:
1 . Overuse muscle tightness: This stems from muscle imba la nces,
overuse, faulty movement patterns and other stresses that
Observation
Observation can often provide evidence of a n imbalan.ce involving muscle l ength tests, movement patterns and inner holding
cross patterns of weakness/lengtheni n g and shortness. A number of endurance times. Posture is valuable because it provides a quick
tests can be used to assess muscle i mbalance: postural i n spection, screen.
box continues
2 M u scles 37
Inner range endurance tests Gluteus maximus: Patient is prone. Practitioner lifts one leg into
'I nner holding isometric endura nce' tests can be performed for extension at the hip (knee flexed to 90') and the patient is asked
muscles that have a tendency to lengthen, in order to assess their to hold this position.
abil ity to maintain joint alignment in a neutral zone. Usually a Posterior fibers of gluteus medius: Patient is sidelying with lower
lengthened muscle will demonstrate a loss of endura nce, when leg straight and uppermost leg flexed at hip and knee so that the
tested in a shortened position. This ca n be tested by the practitioner m edial aspect of both the knee and foot are resting on the
passively prepositioning the muscle in a shortened position and floor/surface. Practitioner places the flexed leg into a position of
assessing the d u ration of time that the patient can hold the muscle maximal unforced externa l rotation at the hip, so that sole of
in this position. There a re various methods used, including 10 foot is in contact with the floor su rface, and the patient is asked
repetitions of the holding position for 1 0 seconds at a time. to maintain this position.
Alternatively, a single 30-second hold can be requested. If the Norris states:
patient ca nnot hold the position actively from the moment of
passive prepositioning, this is a sign of ina ppropriate antagon ist Optimal endurance is indicated when the full inner range position can
muscle shortening. be held for 10 to 20 seconds. Muscle lengthening is present if the limb
Norris (1 999) describes an exa mple of inner range holding tests. falls away from the inner range position immediately.
Movement can only take place normally if there is coor even within the same muscle, changes dependent upon the
dination of all the interacting muscular elements. With desired effect.
many habitual complex movements, such as how to rise The ways in which skeletal muscles produce or deny
from a sitting position, a great number of involuntary, movement in the body, or in part of it, can be classified as:
largely unconscious reflex activities are involved. In many
postural, where stability is induced. If this relates to
cases, patterns of dysfunction, including muscle substitu
standing still, it is worth noting that the maintenance of
tion and changes in firing sequence, develop and often add
the body's center of gravity over its base of support
undesirable consequences. Altering such patterns has to
requires constant fine tuning of a multitude of muscles,
involve a relearning or repatterning process (see Chapters 4
with continuous tiny shifts back and forth and from side
and 5).
to side
The most important action of an antagonist occurs at the
ballistic, in which the momentum of an action carries on
outset of a movement, where its function is to facilita te a
beyond the activation produced by muscular activity
smooth, controlled initiation of movement by the agonist
(the act of throwing, for example)
and its synergists, those muscles that share in and support
tension movement, where fine control requires constant
the movement. When agonist and antagonist muscles con
muscular activity (playing a musical instrument, such as
tract simultaneously they act in a stabilizing fixator role,
the violin, for example, or giving a massage).
which results in virtually no movement.
Sometimes a muscle has the ability to have one part act
ing as an antagonist to other parts of the same muscle, a
phenomenon seen in the deltoid, where its anterior fibers MUSCLE SPASM, TENSION, ATROPHY
are antagonistic to its posterior fibers during internal and (Liebenson 1996, Walsh 1 992)
external rotation of the humerus. Interestingly, these same
fibers become synergists in the movement of lateral abduc Muscles are often said to be short, tight, tense or in spasm;
tion of the humerus. Hence the role that various fibers play, however, these terms are often used very loosely.
38 C L I N I C A L A P P LI CATI O N O F N E U R O M U S C U LA R TEC H N I Q U E S : T H E U P PER B O DY
Muscles experience either neuromuscular, viscoelastic or Muscle fibers housing trigger points have been shown to
connective tissue alterations or combinations of these. A have different levels of EMG activity within the same
tight muscle could have either increased neuromuscular functional muscle unit.
tension or connective tissue modification (for example, Hyperexcitability, as shown by EMG readings, has been
fibrosis) that results in it palpating as tight. demonstrated in the nidus of the trigger point, which is
It is worthwhile differentiating between three commonly situated in a taut band (that shows no increased EMG
used terms: contraction, spasm and contracture. With activity) and has a characteristic pattern of reproducible
regards to skeletal muscles, each of these produces a short referred pain (Hubbard & Berkoff 1993, Simons et aI 1999).
ening or increase in tension of a muscle. However, they are When pressure is applied to an active trigger point, EMG
unique in many ways. activity is found to increase in the muscles to which sen
sations are being referred ('target area') (Simons 1994).
A contracture differs from a contraction in that it is invol
CONTRACTION (TENSION WITH EMG E LEVATION , untary and that activation of the myofibrils is prolonged
VOLUN TARY) in the absence of ac tion potential activity (MacIntosh et al
Muscle tension, usually with shortening, that denotes the 2006, Simons et aI 1999).
These types of 'physiologic' contractures are differenti
normal function of a muscle.
Electromyographic (EMG) activity is increased in these a ted from the 'pathologic' contractu res associated with
cases. permanent shortening of muscles produced by excessive
Contraction is voluntary, not obligatory, i.e. one can vol growth of fibrous tissue, such as seen in Duchenne mus
untarily relax a contraction if desired. cular dystrophy (MacIntosh et aI 2006).
While contraction usually produces movement of the
joint(s) on which the muscle acts, it can also contract to INCREASED STR E TCH SENSITIVITY
produce stability in a moving joint, as a result of anxiety
Increased sensitivity to stretch can lead to increased mus
or for postural purposes.
cle tension.
This can occur under conditions of local ischemia, which
SPASM (TENSION WITH E MG ELEVATION, have also been demonstrated in the nidus of trigger
INVOLUN TARY) points, as part of the 'energy crisis' "vhich, it is hypothe
sized, produces them (Mense 1993, Mense et al 2001,
Muscle spasm is a neuromuscular phenomenon relating Simons 1994) (see Chapter 6) .
either to an upper motor neuron disease or an acute reac Many free nerve endings in group III (smallest myeli
tion to pain or tissue injury. nated) and IV (non-myelinated) afferent fibers are sensi
Electromyographic (EMG) activity is increased in these tive to pressure or stretch (MacIntosh et al 2006) and
cases. would likely be affected by the degree of ischemia within
Spasm is involuntary, i.e. one cannot voluntarily relax a the muscle.
spasm. These same afferents also become sensitized in response
Examples include spinal cord injury, reflex spasm (such as to a build-up of metabolites (MacIntosh et al 2006) when
in a case of appendicitis) or acute Iwnbar antalgia with sustained mild contractions occur, such as occurs in pro
loss of flexion relaxation response (Triano & Schultz 1987). longed slumped sitting (Johansson 1991).
Long-lasting noxious (pain) stimulation has been shown Mense (1993) and Mense et al (2001) suggest that a range
to activate the flexion withdrawal reflex (Dahl et aI 1992) . of dysfunctional events emerge from the production of
Using electromyographic evidence Simons (1994) has local ischemia that can occur as a result of venous con
shown that myofascial trigger points can 'cause reflex gestion, local contracture and tonic activation of muscles
spasm and reflex inhibition in other muscles, and can by descending motor pathways.
cause motor incoordination in the muscle with the trig Sensitization (which, in all but name, is the same phenom
ger point'. enon as facilitation, as discussed more fully in Chapter 6)
involves a change in the stimulus-response profile of neu
rons (Mense et aI 2001), leading to a decreased threshold as
CONTRACTUR E (TENSION OF MUSCLES
well as increased spontaneous activity of types III and IV
WITHOUT EMG E LE VATION , INVOLUN TARY)
primary afferents.
Increased muscle tension can occur without a consis Schiable & Grubb (1993) have implicated reflex dis
tently elevated EMG. charges from (dysfunctional) joints in the production of
Contracture is involuntary, i.e. one cannot voluntarily such neuromuscular tension. Liebenson (2006) notes that
relax a contracture. 'joint inflammation or pathology initiates a complex neu
An example is trigger points, in which muscle fibers fail romuscular response in the dorsal horn of the spinal cord,
to relax properly. resulting in flexor facilitation and extensor inhibition' .
2 M uscles 39
According to Janda (199 1 ), and agreed to by Liebenson Type I (postural or aerobic) fibers hypertrophy on the
(2006), neuromuscular tension can also be increased by symptomatic side and type II (phasic or anaerobic) fibers
central influences due to limbic dysfunction. atrophy bila terally in chronic back pain patients
(Fitzmaurice et aI 1992) .
VISCOELASTI C INFLU ENCE
In a traditional test of prone hip extension it is difficult to This was in contrast to subjects without low back pain
identify overactivity of the lumbar erector spinae or ham who showed that contraction of transversus abdominis
strings as substitutes for an inhibited gluteus maximus. precedes contraction of the muscles involved in limb
Tests developed by Janda are far more sensitive and allow movement (Hodges & Richardson 1996) .
us to iden tify muscle imbalances, faulty (trick) movement The upper and deep cervical flexor muscles (type II, pha
patterns and joint overstrain by observing or palpating sic) have been shown to lose their endurance capacity in
abnormal substitution during muscle-testing protocols. For subjects with neck pain and headache (Watson & Trott
example, in a prone position, hip extension should be initi 1993) .
ated by gluteus maxim us. If the hamstrings undertake the When testing for activity in these deep flexor muscles, it
role of prime mover and gluteus maximus is inhibited, this has been found that patients w i th neck pain tend to sub
is easily noted by palpating activity wi thin each of them as stitute with the superficial flexor muscles (sternocleido
movement is initiated. mastoid and scalenes) to achieve the desired position of
Similar imbalances can be palpated and observed in the the neck (Ju1l 2000).
shoulder region where the upper fixators dominate the The posterior suboccipital muscles, which control the
lower fixa tors by inhibiting them, which results in major position of the head, have been shown to atrophy in
neck and shoulder stress. These patterns have major reper patients with chronic neck pain (McPartland et al 1997).
cussions, as will become clear when crossed syndromes, The synergistic function of these muscles may be lost so
and Janda's functional assessment methods, are outlined in that other muscles, such as upper trapezius and levator
Chapter 5 (Janda 1978) . scapulae, substitute for the suboccipital muscles during
As Sterling et al (2001) explain: functional movements. This is confirmed by studies that
have reported increased activity in these muscles in
Musculoskeletal pain potentially produces many changes in
people with neck pain (Bansevicius & Sjaastad 1996) .
motor activity. Some of these changes can be explained by
peripheral mechanisms in the muscles themselves and by These examples offer insights into the adaptive capacity of
mechanisms within the central nervous system. Certainly, the musculoskeletal system when faced with problems of
pain has a potent effect on motor activity and control. pain, overuse and disuse. There is clear evidence that some
The dysfunction that occurs in the neuromuscular sys muscles respond by becoming inhibited and/or by losing
tem in the presence of pain is extremely complex. In addition stamina, while others shorten.
to the more obvious changes, such as increased muscle activ
ity in some muscle groups, and inhibition of others, more JOINT IM PLICATIONS
subtle anomalous patterns of neuromuscular activation
seem to occur . . . Loss of selective activation and inhibition When a movement pattern is altered, the activation
of certain muscles that perform key synergistic functions, sequence, or firing order of different muscles involved in a
leading to altered patterns of neuromuscular activation, and specific movement, is disturbed. The prime mover may be
the ensuing loss of joint stability and control, are initiated slow to activate while synergists or stabilizers substitute
with acute pain and tissue injury. However, these phenom and become overactive. When this is the case, new joint
ena persist into the period of chronicity and could be one stresses will be encountered. Sometimes the timing
reason for ongoing symptoms. sequence is normal yet the overall range may be limited due
to joint stiffness or antagonist muscle shortening. Pain may
well be a feature of such dysfunctional patterns.
Exa m p l es
Pain may lead to inhibition or delayed activation of spe WHEN SHOUL D PAIN AND DYSFUNCTION
cific muscles or muscle groups involved in key synergis BE LEFT ALONE?
tic functions. This seems to most commonly occur in the
deep local muscles that perform a synergistic function to Splinting (spasm) can occur as a defensive, protective,
control joint stability (Cholewicki et aI 1997). involuntary phenomenon associated with trauma (fracture)
EMG has been used to detect selective fatigue of lumbar or pathology (osteoporosis, secondary bone tumors, neuro
multifidus, as opposed to other erector spinae muscles genic influences, etc.). Splinting-type spasm commonly dif
(Roy et aI 1989). fers from more common forms of contraction and
U1trasonography was used by Hides et al (1994) to identify hypertonicity because it often releases when the tissues that
a marked atrophy of lumbar multifidus ipsilateral to the it is protecting, or immobilizing, are placed at rest.
patients' symptoms. These changes remained even after When splinting remains long term, secondary problems
the patients had ceased to report pain (Hides et aI 1996). may arise in associated joints (e.g. contractures) and bone
A delay of contraction of transversus abdominis was (e.g. osteoporosis) . Travell & Simons (1983) note that,
noted in subjects with low back pain when they per 'Muscle-splinting pain is usually part of a complex process.
formed limb movements (Hodges & Richardson 1999) . Hemiplegic and brain-injured patients do identify pain that
2 M uscles 41
depends on muscle spasm'. They also note 'a degree of mas it is tight and consider that, in some circums tances, it is
seteric spasm which may develop to relieve strain in trigger offering beneficial support to the 51} or that it is reducing
points in its parallel muscle, the temporalis'. low back stress (Simons 2002, Thompson 2001). It is possible
Travell & Simons (1983) note a similar phenomenon in to conceive similar supportive responses in a v ariety of set
the lower back: tings, including the shoulder joint when lower scapular fix
a tors have weakened, thus throwing the load onto other
In patients with low back pain and with tenderness to pal muscles (see discussion of upper crossed syndrome in
pation of the paraspinal muscles, the superficial layer tended Chap ter 5).
to show less than a normal amount of EMC activity until
the test movement became painful. Then these muscles
showed increased motor unit activity or 'splinting' . . . This
SOMATIZATION - MIND AND MUSCLES
observation fits the concept of normal muscles 'taking over'
(protective spasm) to unload and protect a parallel muscle
It is entirely possible for musculoskeletal symptoms to
that is the site of significant trigger point activity.
represent an unconscious attempt by the patient to entomb
their emotional distress. As most cogently expressed by
Recognition of this degree of spasm in soft tissues is a mat
Philip Latey (1996), pain and dysfunction may have psy
ter of training and intuition. Whether attempts should be
chological distress as their root cause. The patient may be
made to release, or relieve, what appears to be protective
somatizing the distress and presenting with apparently
spasm depends on understanding the reasons for its exis
somatic problems (see Chapter 4).
tence. If splinting is the result of a cooperative a ttempt to
unload a painful but not pathologically compromised struc
ture, in an injured knee or shoulder for example, then treat
BUT HOW IS ONE TO KNOW?
ment is obviously appropriate to ease the cause of the
original need to protect and support. If, on the other hand, Karel Lewit (1992) suggests that, 'In doubtful cases, the
spasm or splinting is indeed protecting the struc ture it sur physical and psychological components will be distin
rounds (or supports) from movement and further (possibly) guished during the treatment, when repeated comparison
serious damage, as in a case of advanced osteoporosis for of (changing) physical signs and the pa tient's own assess
example, then it should clearly be left alone. ment of them will provide objective criteria'. In the main, he
suggests, if the patient is able to give a fairly p recise
description and localization of his pain, we should be reluc
BENEFICIALLY OVERACTIVE MUSC L E S
tant to regard it as 'merely psychological'.
Van Wingerden et al (1997) report that both intrinsic and In masked depression, Lewit suggests, the reported
extrinsic support for the sacroiliac joint (51]) derives, in part, symptoms may well be of vertebral pain, particularly
from hamstring (biceps femoris) status. Intrinsically, the involving the cervical region, with associated muscle ten
influence is via the close anatomic and physiological rela sion and 'cramped' posture. As well as being alerted by
tionship between biceps femoris and the sacrotuberous lig abnormal responses during the course of treatment to the
ament (they frequently attach via a strong tendinous link). fact that there may be something other than biomechanical
They state: 'Force from the biceps femoris muscle can lead causes of the problem, the history should provide clues. If
to increased tension of the sacrotuberous ligament in vari the masked depression is treated appropriately, the verte
ous ways. Since increased tension of the sacrotuberous liga brogenic pain will clear up rapidly, he states.
ment diminishes the range of sacroiliac joint motion, the In particular, Lewit notes, 'The most important symp tom
,
biceps femoris can play a role in stabilization of the SI} (Van is disturbed sleep. Characteristically, the patient falls asleep
Wingerden et al 1997; see also Vleeming 1 989). normally but wakes within a few hours and cannot get back
Van Wingerden et al (1997) also note that in low back to sleep'. Pain and dysfunction can be masking major psy
pain patients forward flexion is often painful as the load on chological distress and awareness of it, how and when to
the spine increases. This happens whether flexion occurs in cross-refer should be part of the responsible practitioner's
the spine or via the hip joints (tilting of the pelvis). If the skills base.
hamstrings are tight and short, they effectively prevent Muscles cannot be separated, in reality or intellectually,
pelvic tilting. 'In this respect, an increase in hamstring ten from the fascia that envelops and supports them. Whenever
sion might well be part of a defensive arthrokinematic it appears we have done so in this book, it is meant to high
reflex mechanism of the body to diminish spinal load.' light and reinforce particular characteristics of each. When
If such a state of affairs is long standing, the hamstrings it comes to clinical applications, these structures have to be
(biceps femoris) will shorten (see discussion of the effects of considered as integrated units. As muscular dysfunction is
stress on postural muscles, p. 25), possibly influencing being modified and corrected it is almost impossible to con
sacroiliac and lumbar spine dysfunction. The decision to ceive that fascial structures are not also being remodeled.
treat a tight hamstring should therefore take account of why Some of the quite amazingly varied functions of fascia are
42 CLI N I CA L A P P L I CATI O N O F N E U R O M U S C U L A R TECH N I Q U E S : TH E U P P E R B O DY
detailed in Chapter 1 . In this chap ter we have reviewed In the next chapter, as we review the myriad reporting
some of the important features of muscles themselves, their sta tions embedded in the soft tissues in general and the
structure, function and at least some of the influences that muscles in particular, it becomes clear that muscles are as
cause them to become dysfunctional, in unique ways, much an organ of sense as they are agents of movement and
depending in part on their fiber type. stability.
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45
Chapter 3
PROPR I O CEPTIO N
taste, hearing, touch and balance), proprioception provides Butler and Moseley (2003) seek to clarify the concept of
information solely on the status of the internal body. The nociceptors (pain sensors) when they say:
information is derived from neural reporting stations (affer
We don't actually have 'pain receptors', or 'pain pathways'
ent receptors) in the muscles, the skin, other soft tissues and
or 'pain centers'. However, there are some neurons that
joints, independent of vision, and is combined with input
respond to all manner of stimuli, if those stimuli are suffi
from the vestibular apparatus. The term 'proprioception'
cient to be dangerous to the tissue. Activation of these spe
was first used by Sherrington in 1907 to describe the sense
cial neurons sends a prioritized alarm signal to [the] spinal
of position, posture and movement. Janda (1996) states that
cord, which may send it towards the brain.
it is now used ('not quite correctly') in a broader way, 'to
describe the function of the entire afferent system'. Whether a message sent by a nociceptor is actually per
Schafer (1987) describes proprioception as 'kinesthetic ceived as pain depends on many factors, perhaps the most
awareness' relating to 'body posture, position, movement, important being the interpretation given to the message by
weight, pressure, tension, changes in equilibrium, resistance the brain. This is discussed further in Chapter 7 where we
of external objects, and associated stereotyped response pat examine the phenomenon of pain.
tems'. In addition to the unconscious data being transmitted Lewit has shown that altered function can produce
from the proprioceptors, Schafer lists the sensory receptors as: increased pain perception, and that this is a far more com
mon occurrence than pain resulting from direct compres
Mechanoreceptors, which detect deformation of adjacent sion of neural structures, such as that which produces
tissues. These are excited by mechanical pressures or dis radicular pain when the sciatic nerve is compressed.
tortions and so would respond to touch or to muscular Lewit (1985) suggests that there is seldom a need to explain
movement. Mechanoreceptors can become sensitized fol pain by actual mechanical irritation of nervous structures, as in
lowing what is termed a 'nociceptive barrage' so that they the root-compression model. It would be a peculiar conception
start to behave as though they are pain receptors. This of the nervous system (a system dealing with information)
would lead to pain being sensed (reported) centrally in that would have it reacting, as a rule, not to stimulation of its
response to what would normally have been reported as receptors but to mechanical damage to its own structures.
movement or touch (Schaible & Grubb 1993, Willis 1993). Lewit offers as examples of the reflex nature of much pain
chemoreceptors, which report on obvious information perception: referred pain from deeper structures (organs or
such as taste (gustation) and smell (olfaction), as well as ligaments) which produce radiating pain, altered skin sensi
local biochemical changes such as CO2 and O2 levels. tivity (hyperalgesia) and sometimes muscle spasm. These
Taste buds and olfactory epithelium, rich with receptor reflex referrals are discussed later in this chapter in the con
cells, allow distinction among a wide range of chemical text of somatosomatic and viscerosomatic reflexes. Even true
stimuli. Information obtained is transmitted to the limbic radicular pain (for example, resulting from disc prolapse)
system, a portion of the brain that can respond to emo usually involves stimulation of nociceptors that are present
tion and thought (Butler & Moseley 2003). in profusion in the dural sheaths and the dura rather than
thermoreceptors, which detect modifications in tempera direct compression that would produce paresis and anesthe
ture, such as when something hot or cold is applied to the sia (loss of motor power and numbness) but not pain.
skin, as well as changes in the immediate climate. These Pain derives from irritation of pain receptors, and where
are also used in palpation of tissue temperature varia this results from functional changes (such as inappropriate
tions and are most dense on the hands and forearms (and degrees of maintained tension in muscles), Lewit suggests
the tongue). the most appropriate descriptive term would be 'functional
electromagnetic receptors, which respond to light entering pathology of the motor system'.
the retina.
nociceptors, which register pain. The word nociception
FASCIA AND PROPRIOCEPTION
actually means 'danger reception'. These receptors can
become sensitized when chronically stimulated, leading Bonica (1990) suggests that fascia is critically involved in
to a drop in their threshold (see notes on facilitation, proprioception and that, after joint and muscle spindle
Chapter 6, p. 105). This is thought by some to be a process input is taken into account, the majority of remaining pro
associated with trigger point evolution (Korr 1976). prioception occurs in fascial sheaths (Earl 1965, Wilson
polymodal receptor (PMR), a type of nociceptor responsive 1966). Staubesand (1996) confirms this and has demon
to mechanical (e.g. acup uncture), thermal (moxibustion) strated that myelinated sensory neural structures exist in
and chemical stimuli. Its sensory terminals are free nerve fascia, relating to both proprioception and pain reception.
endings and exist in various tissues throughout the body. The various neural reporting organs in the body provide a
Research suggests that these pain receptors may play a constant source of information feedback to the central nerv
significant part in the evolution of trigger points, and are ous system, and higher centers, as to the current state of
also capable of being used to modify pain (Kawakita et al tone, tension, movement, etc. of the tissues housing them
2002). PMR is discussed further in Chapter 6. (Travell & Simons 1983, 1992, Wall & Melzack 1991). It is
3 Reporting stations and the brain 47
Box 3.1 Neurotrophic influences t"vo-way traffic along neural pathways, is arguably at least as
important as the passage of impulses with which we usually
I rvin Korr (Korr 1 967, 1 986) spent half a century investigating the associate nerve function.
scientific backg round to osteopathic methodology and theory.
Some of his most im portant work related to the role of neu ral
structures in the delivery of trophic substances. The various REFLEX MECHAN ISMS
patterns of stress that are covered in the next chapter are
capable of d rastically affecting this axoplasmic transportation.
Korr states: As Schafer (1987) points out, 'The human body exhibits an
astonishingly complex array of neural circuitry'. Among
These 'trophic' proteins are thought to exert long-term influences
on the developmental, morphologic, metabolic and functional
these are receptors, reflex arcs and mechanisms that com
qualities of the tissues - even on their viability. Biomechanical municate from outside the muscular system.
abnormalities in the musculoskele tal system can cause trophic A receptor (proprioceptor, mechanoreceptor, etc.) resides
disturbances in ot least two ways: (7) by mechanical deformation on the cell surface or within the cytoplasm and is composed of
(compression, stretching, angUla tion, torsion) of the nerves, which
structural protein molecules. It binds to a specific factor, such
impedes axonal transport; and (2) by sustained hyperactivity of
neurons in facilitated segments of the spinal cord [see discussion
as a neurotransmitter, by which it is stimulated as follows.
of this phenomenon in Chap ter 6J which slows axonal transport
An afferent impulse travels, via the central nervous system,
and which, because of metabolic changes, may affect protein
synthesis by the neurons. It appears that manipula tive treatment
to a part of the brain that we can call an integrative center.
would alleviate such impairments of neurotrophic function. This integrative center evaluates the message and, with
influences from higher centers, sends an efferent response.
The manufactu ring process of macromolecules for transportation
This travels to an effector unit, perhaps a motor endplate,
takes place in nerve cells, is packaged by the Golgi apparatus and
transported along the neural axon to the target neurons (Ochs Et and a response occurs.
Ranish 1 969). The speed of transportation along axons is
sometimes remarkably swift at the rate of up to half a meter per
Additionally, the basic reflex arcs, which control much of
day (although m uch slower than the 1 20 meters per second of the body's 'immediate reaction' responses, can be summa
actual neural transmission) (Ochs 1 9 75). rized as follows (Sato 1992).
Once the macromolecu les reach their destination, where they
influence the development and maintenance of the tissues being A sensory receptor (or proprioceptor, mechanoreceptor,
supplied, a return transportation of materials for reprocessing etc.) is stimulated.
com mences. When there is interference in axonal flow (because An afferent impulse travels via a sensory neuron to the
of com pression, etc.) the tissues not receivin g the trophic spinal cord.
material degenerate and a build-up of axoplasm occu rs, forming
The sensory neuron synapses with an interneuron, which,
a swel ling (Schwartz 1 980).
Korr ( 1 98 1 ) has shown that w h en a m uscle is denervated by in turn, synapses with the motor neuron to send an effer
injury and atrophies, it is the interruption of trophic substances ent response, without any intervention by the brain.
which causes this rather than loss of neural impulses (see This travels to an effector unit, perhaps a motor endplate,
notes on rectus capitis posterior minor denervation following and a response occurs (see Box 3.2).
whiplash, p. 294).
Research has shown that when the neural supply to a postural Reflex mechanisms extend beyond the musculoskeletal sys
(predominantly red fiber) m uscle is su rgically altered, so that it tem. It is possible to further characterize the reflex mecha
receives neurotrophic material originally destined for a phasic nisms that operate as part of involuntary nervous system
(white fiber) muscle, there is a transformation in which the
postural muscle can become a phasic m u scle (and vice versa)
function as follows.
based on the trophic material it receives. This suggests that Somatosomatic reflexes, which may involve stimuli from
genetic expression can be neurally mediated. The axoplasm tells
sensory receptors in the skin, subcutaneous tissue, fascia,
the muscle what its function is going to be (Guth 1 968).
striated muscle, tendon, ligament or joints, producing
reflex responses in segmentally related somatic struc
tures - for example, from one such site on the body to
important to realize that the traffic between the center and the another segmentally related site on the body. Such
periphery in this dynamic mechanism operates in both direc reflexes are commonly triggered by manual therapy tech
tions along efferent (away from the CNS and brain) and affer niques (during application of compression, vibration,
ent (toward the CNS and brain) pathways. Any alteration in massage, manipulation, application of heat or cold, etc.).
normal function at the periphery (such as a proprioceptive Somatovisceral reflexes, which involve a localized somatic
source of information) leads to adaptive mechanisms being stimulation (from cutaneous, subcutaneous or muscu
initiated in the central nervous system, and vice versa loskeletal sites) producing a reflex response in a segmen
(Freeman 1967). tally related visceral structure (internal organ or gland)
It is also important to reahze that it is not only neural (Simons et aI1999). Such reflexes are also commonly trig
impulses that are transmitted along nerve pathways, in both gered by manual therapy techniques (during application
directions, but also a host of important trophic substances. of compression, vibration, massage, manipulation, appli
This process of the transmission of trophic substances, in a cation of heat or cold, etc.).
48 CLI N ICAL A PPLI CATIO N O F N EU RO M U S C U LA R TEC H N IQ U ES : TH E U PPER B O DY
.
@y Lacrimal gland
. ... .
- .. .... . . . . . ,
..
.. ..
Eye
Gray rami
communicantes
.. . .
C1
.. .
. . . ... . 1.........
. .
..
. . . ...
Parotid gland
. . .
..
.
.
. .
..
.
. .
Sublingual gland
--
Larynx
Trachea
Bronchi
Lungs
T1
Heart
.
:: -o>;r-
::.::: --
_-: G re
;;;
::: a ter thora . Sl'h
Innervation to arrector -.:::.::::.::.:::.::.::.:
-- C/c $pl.
___
pili muscles,vascular
-....
--- q"f]lc
...
smooth musde and
.. . . fI7
sweat glands of skin
--...;::..."c9I)...c9
.
.
..
.
: . : .: : t
Iadder
. .b
..
Gray ramus communicans
.U Bile ducts
"
.
Pancreas
. .... .
While ramus communicans Aortiroreoal
. . t' . ,
. Kidneys
-.:.::.:===,
v--.;;;:=---+---<.., .. .
.
.:..:: : . :)!/
Intestines
;.
..
Descending colon
. ... -..,./ Sigmoid colon
.
mesenlenc
.
.
.
9i Rectum
---- P9'"::,:'b
.
Inlener S:
::
S1 --
Preganglionic fibres
hy :::
plexus
nc ":: : 1UJ Extemal genitalia
F ig u re 3.1 A EtB : Co rd level of organ i n n ervation via (A ) sympathetic nervous system an d (B) parasympathetic nervous system. Drawn after
N etter (2006) .
Viscerosomatic reflexes, in which a localized visceral (inter the intensity of the visceral stimulus. Obvious examples of
nal organ or gland) stimulus produces a reflex response in this include right shoulder pain in gallbladder disease and
a segmentally related somatic structure (cutaneous, subcu cardiac ischemia producing the typical angina distribution
taneous or musculoskeletal) (Fig. 3.1). It has been sug of left arm and thoracic pain. Giamberardino (2005) notes
gested that such reflexes, feeding into the superficial that visceral pain can affect the somatic tissues in the area
structures of the body, can give rise to trigger points of referral for months or even years, and long after the vis
and/or dysfunction in the somatic tissues (De Sterno 1977, ceral problem has been resolved .
Giamberardino 2005, Simons et al 1999). Balduc (1983) Viscerocutaneous reflex, in which organ dysfunction stim
reports that these reflexes are intensity oriented, which is uli produce superficial effects involving the skin (includ
to say that the degree of reflex response relates directly to ing pain, tenderness, heightened sensitivity to heat,
3 R eporting stations and the brain 49
Medulla
. Lacrimal gland
oblongala -'-
. :::: (
:::
.
'
.
..
/
Eye
.
..
..
Parotid gland
Submandibular gland
Sublingual gland
Larynx
Trachea
Bronchi
Lungs
Pulmonary plexus
T1 --
Heart
Stomach
Liver
Gallbladder
Bile ducts
Pancreas
Kidneys
L1 --
Intestines
Descending colon
Sigmoid colon
Inferior Rectum
hypogastric
1
S1 -_
S2
Urinary bladder
S3 Prostate
---- Preganglionic fibres
External genitalia
B
Fig u re 3.1 (Continued)
touch or pinprick, etc.) Examples of this include itch pat coronary heart disease plus gallbladder calculosis, for
.
terns and heightened skin sensitivity associated with the instance, may experience more frequent attacks of angina
referral pattern of an organ. and biliary colic than patients with a single condition,
Viscerovisceral reflex in which a stimulus in an internal organ based upon the partially overlapping (T5) afferent path
or gland produces a reflex response in another segmentally ways from the heart and gallbladder. Women with both
related internal organ or gland Giamberardino (2005) dysmenorrhea and irritable bowel syndrome (IBS) tend to
.
places particular importance on 'visceroviscero hyperalge complain of more intense menstrual pain, intestinal pain
sia, an augmentation of pain symptoms due to the sensory and referred abdominal/pelvic hyperalgesia than do
interaction between two different internal organs that women with only one of these conditions. She suggests
share at least part of the afferent circuitry. Patients with that treatment of one visceral condition may improve
50 CLINICAL A PP LICATIO N OF N EU RO MU S C U LAR TEC H N IQ U ES : THE U PPER B O DY
symptoms from another. It should be noted, however, that Afferent messages are received centrally from somatic,
such pathologies, layered one over the other, often present vestibular (ears) and visual sources, all reporting new
a complex symptomatology and are difficult to diagnosis data and providing feedback for requested information.
a clear cause for each symptom may never be proven. To If all or any of this information is excessive, noxious or
compound the situation, prolonged visceral afferent bar inappropriately prolonged, sensitization (see notes on
rage into the CNS may produce long-term sensitization facilitation, Chapter 6, p. 108) can occur in aspects of the
that results in hyperalgesia, trophic changes and somatic central control mechanisms, which results in dysfunc
pain that is deceptive, and may delay appropriate treat tional and inappropriate output (Mense et al 2001,
ment, unless the viscera are fully considered. Russell 2001).
The limbic system of the brain can also become dysfunc
Whether such reflexes have bidirectional potential is tional and inappropriately process incoming data, leading
debated. Some research suggests that a visceral problem to complex problems, such as fibromyalgia (Goldstein
can exhjbit in a specific dermatomal segment via a viscero 1996) (see Box 3.4).
cutaneous reflex (Giamberardino 2005) and that stimulation The entire suprasegmental motor system, including the
of the skin could have a distinct effect on related visceral cortex, basal ganglia, cerebellum, etc., responds to the
areas via a cutaneovisceral reflex. afferent data input with efferent motor instructions to
Schafer (1987) makes the very important observation the body parts, with skeletal activity receiving its input
that, 'The difference between somatovisceral and visceroso from alpha and gamma motor neurons, as well as the
matic reflexes appears to be only quantitative and to be motor aspects of cranial nerves.
accounted for by the lesser density of nociceptive receptors As noted in Chapter 2, any alteration in pH, for example
in the viscera'. This can best be understood by means of when respiratory alkalosis follows overbreathing, modi
Head's law, which states that when a painful stimulus is fies neural function, which can include speeding reflexes,
applied to a body part of low sensitivity (such as an organ) reducing thresholds (such as pain) and allowing sensiti
that is in close central connection (the same segmental sup zation to occur more easily (Chaitow et aI2002).
ply) with an area of higher sensitivity (such as a part of the
soma), pain will be felt at the point of higher sensitivity Schafer (1987) sums up the process:
rather than where the stimulus was applied.
Whether a person is awake or asleep, the brain is constantly
bombarded by input from all skin and internal receptors.
LOCAL RE FLEXES
This barrage of incoming messages is examined, valued, and
translated relative to a framework composed of instincts,
A number of mechanisms exist in which reflexes are stimu experiences and psychic conditioning. In some yet to be dis
lated by sensory impulses from a muscle leading to a covered manner, an appropriate decision is arrived at that is
response being transmitted to the same muscle. Examples transmitted to all pertinent muscles necessary for the
include the stretch reflexes, myotatic reflexes and the deep response desired. By means of varying synaptic facilitation
tendon reflexes. and restraints within the appropriate circuits, an almost
The stretch reflex is a protective mechanism in which a limitless variety of neural integrntion and signal transmis
contraction is triggered when the annulospiral receptors in sion is possible.
a muscle spindle are rapidly elongated. Concurrently there
are inhibitory messages transmitted to the motor neurons of The sum of proprioceptive information results in specific
the antagonist muscles inducing reciprocal inhibition, with responses.
simultaneous facilitating impulses to the synergists.
Motor activity is refined and reflex corrections of move
If enough fibers are involved the threshold of the Golgi
tendon organs will be breached, leading to the muscle 'giv ment patterns occur almost instantly.
A conscious awareness occurs of the position of the body
ing way'. This is a reflex process known as autogenic inhibi
tion (Ng 1980). and the part in space.
This body awareness in the brain relates to the presence
there of a 'virtual body', a homunculus ('little man'), a
'sensory map' of the brain, that is aware of the spatial
CENTRAL INFLUENCES
location of the parts, and that responds to messages of
Sensory information received by the central nervous system distress (danger) that may be interpreted as pain (Butler
can be modulated and modified both by the influence of the & Moseley 2003).
mind and changes in blood chemistry, to which the sympa The more neurons a particular part of the body has to
thetic nervous system is sensitive (see notes on carbon dioxide represent it in the brain, the more attention the message
influences on neural sensitivity, Chapter 4, p. 77). Whatever receives, with the hands, face, tongue and genitals being
local biochemical influences may be operating, the ultimate highly represented, compared, for example, with the rest
overriding control on the response to any neural input of the head or the chest. This is discussed in more detail
derives from the brain itself. in Chapter 7, particularly in relation to phantom pain.
3 Reporting stations and the brai n 51
Some important structures involved in this i nternal information The pacinian corpuscle. This is found in periarticu lar connective
highway, which may under given circumstances be involved in the tissue and adapts rapidly. It triggers discharges, and then ceases
production or maintenance of pain (LaMotte 1992), are listed below. reporting in a very short space of time. These messages occur
Ruffini end-organs. Found within the joint capsu le, around the successively, d u ring motion, and the CNS can, therefore, be aware of
joints, so that each is responsible for describing what is happening the rate of acceleration of movement taking place in the area. It is
over an angle of approximately 15' with a deg ree of overlap sometimes called an acceleration receptor.
between it and the adjacent end-organ. These organs are not easily Skin receptors are responsive to touch, pressure and pain and are
fatigued and are progressively recruited as the joint moves, so that involved in primitive responses such as withdrawal and g rasp
movement is smooth and not jerky. The prime concern of Ruffini reflexes.
end-organs is a steady position. They are also to some extent Cervical receptors, especially relative to the suboccipital
concerned with reporting the direction of movement. m usculature (see notes on rectus capitis posterior minor, p. 292),
Golgi end-organs. These, too, adapt slowly and continue to in teract with the labyrinthine (ear) receptors to maintain balance
discharge over a lengthy period. They are fou nd in the ligaments and an appropriate positioning of the head in space.
associated with the joint. Unlike the Ruffin i end-organs, which respond There are other end-organs, but those described above can be seen
to muscular contraction that alters tension in the joint capsule, Golgi to provide information on the present status, position, direction and
end-organs can deliver information independently of the state of rate of movement of any muscle or joint and of the body as a whole.
muscular contraction. This helps the body to know just where the joint Muscle spindle. This receptor is sensitive and complex (Macintosh
is at any given moment, irrespective of muscular activity. et al 2006).
Slow-adapting joint receptors (above) have a powerful
It detects, evaluates, reports and adjusts the length of the muscle
modu lating influence on reflex responses (for example, in the
in which it lies, setting its tone.
sacroiliac joint) and seem to have the ability to produce long-lasting
Acting with the Golgi tendon organ, most of the information as
influences, either in maintaining dysfunction or in helping in its
to m uscle tone and movement is reported.
resolution (if pressure/stress on them can be normalized). Direct joint
Spindles lie paral lel to the m uscle fibers and are attached to
manipulation (Lefebvre et al 1993) can have just such an effect or, as
either skeletal m uscle or the tendinous portion of the m uscle.
Lewit has shown, so can normalization of joint function by less
Inside the spind le are fibers that may be one of two types. One is
direct means. Lewit (1985) emphasizes this by saying :
described as a 'nuclear bag' fiber and the other as a chain fiber.
The basic [soft tissue] techniques . . . are very gentle and are also very In different muscles, the ratio of these internal spindle fibers differs.
effective for mobilization, using muscular facilitation and inhibition, In the center of the spindle is a receptor called the annu lospiral
i.e. the inherent forces of the patient. It is most unfortunate that in receptor (or primary ending) and on each side of this lies a 'flower
the minds of most people, physicians and laymen alike, manipula tion spray receptor' (secondary ending).
is tantamount to thrusting techniques - techniques that should The primary ending discharges rapid ly and this occurs in response
rather be the exception. to even small changes in muscle length.
box continues
52 C L I N ICAL A P P L I CAT I ON OF N EU R OM U SCULA R TEC H N I QUES: TH E UPPER B ODY
The secondary ending compensates for this, because it fires The activities of the spindle appear to provide information as to
messages only when l a rger changes in m uscle length have length, velocity of contraction and changes in velocity (Gray's
occurred. Anatomy 2005). How long is the m uscle, how quickly is it changing
The spind le is a 'length comparator' (a lso called a 'stretch recep length and what is happening to this rate of change of length?
tor') and it may discharge for long periods at a time.
Within the spind l e there a re fine, intrafusal fibers which a lter the Go/gi tendon receptors. These structures indicate how hard the
sensitivity of the spind le. These can be a l tered without any actual m uscle is working ( whether contracting or stretching ) since they
change taking place in the length of the m uscl e itself, via a n reflect the tension of the m uscle, rather than its length. If the
independent g a m m a efferent supply t o t h e intrafusal fibers. This tendon organ detects excessive overload it may cause cessation of
has im plications in a variety of acute and ch ronic problems. fu nction of the m uscle to prevent damage. This produces relaxation.
In order to appreciate some of the profound influences that Proprioception and pain
proprioceptive function offers and the devastating effect
Proprioceptive signals from these suboccipital mus
disturbance of this function can produce in terms of pos
tural stability and pain, a particular example is summarized cles may also serve as a 'gate' that blocks nocicep
below involving rectus capitis posterior minor. tor (pain fiber) transmission into the spinal cord
and higher centers of the central nervous system (Wall
1989).
RECTUS CAPITIS POSTERIOR MINOR (RCPMin)
According to the gate theory of pain, large-diameter
RESEARCH EVIDENCE
(A-beta) fibers from proprioceptors and mechanorecep
In head extension, the posterior atlas arch maintains a tors enter the spinal cord and synapse on interneurons in
mid-position between the occiput and the axis. In forward the dorsal horn of the spinal cord.
3 R eporting stations and th e brain 53
box continues
3 Reporting stations a n d the brain 55
Goldstein ( 1 996) has described many chronic health conditions. 3. Genetica lly predetermined susceptibility to viral infection
including chronic fatigue and fibromyalgia syndromes (CFS. FMS). as affecting the neurons and g lia. 'Persistent CNS viral infections
neurosomatic disorders. q uoting Yu nus ( 1 994) who says they are . . . the
cou ld a lter production of transmitters as well as cel l ular
commonest grou p of il l nesses for which patients consult physicians: mechanisms:
Neurosomatic disorders are ill nesses which Goldstein suggests are 4. Increased susceptibility to environmental stressors due to reduction
caused by 'a complex interaction of genetic. developmental and in neural plasticity (resulting from all or any of the causes listed in
environmenta l factors'. often involving the possibility of early 1 -3 above). This might include deficiency in glutamate or nitric
physical. sexual or psychological abuse (Fry 1 993). Symptoms emerge oxide (NO) secretions, which results in encoding new memory.
as a result of 'impaired sensory information processing' by the neural 'Neural plasticity' capacity may be easily overtaxed in such individu
network (including the bra i n). Examples given a re of light touch als which. Goldstein suggests, is why neurosomatic patients often
being painful. mild odors producing nausea. walking a short distance develop their problems after a degree of increased exposure to envi
being exhausting. climbing stairs being like going u p a mou ntain. ronmental stressors such as acute infection. sustained attention.
reading something lig ht ca using cog nitive impairment - all of which exercise. immunization. emergence from anesthesia. trauma. etc.
examples a re true for many people with CFS/FMS.
Goldstein is critical of psychological approaches to treatment of Goldstein ( 1 996) describes the limbic system and its dysreg ulation
such conditions. apart from cog nitive behaviour therapy. which he thus.
.
suggests ... may be more appropriate. since coping with the
vicissitudes of these ill nesses. which wax and wane u n predictably. is 1 . The limbic system acts as a regu lator (integrative processing) i n
a major problem for most of those afflicted'. He claims that most t h e b ra i n with effects on fatigue, pain. sleep. memory. attention.
major medical journals concerned with psychosomatic medicine weight. appetite. libido, respiration. temperatu re, blood pressure.
rarely discuss neu robiology and 'apply the concept of somatization mood. immune and endocrine function.
to virtually every topic between their covers' (Hudson 1 992. Yunus 2. Limbic function dysreg u lation influences a l l or any of these fu nc
1 994). tions and systems.
The four basic influences on neurosomatic i l lness are. he believes. 3. Regulation of autonomic control of respiration derives from the
as follows. limbic system and major abnormalities (hyperventilation tenden
cies. irregu l a rity in tida l volu me, etc.) in breathing function a re
1 . Genetic susceptibility, which can be strong or weak. If only a noted in people with chronic fatigue syndrome. along with abnor
weak tendency exists. other factors a re needed to influence the mal responses to exercise (including failure to find expected lev
trait. els of cortisol increase. catecholamines. g rowth hormone,
2. If a child feels unsafe between birth and puberty. hypervigila nce somatostatin. increased core temperatu re, etc.) (Gerra 1 993,
may develop and interpretation of sensory input will a lter. Goldstein Et Daly 1 993. G riep 1 993, M u nschauer 1 99 1 ) .
box continues
56 C LI N I CA L A P P L I CATI O N O F N E U R O M U SC U LA R TECH N I QU E S : T H E U P PE R B O DY
Box 3.4
glucocorticoid elevation
(Hanbauer 1 992) (so affecting fatigue), descending pain inh ibi
various key sites in the brain produce neurohumoral changes
tion processes, sleep induction and even m enstrual problems.
potentially influencing almost any part of the body or its
' Female patients with CFS/FMS usually have premenstru a l exacer functions.
bations of their symptoms. Most of the symptoms of late luteal
phase dysphoric diso rder [premenstrual syndrome) a re sim ilar to
those of CFS, and it is l i kely that this d isorder has a l imbic etiol Figure 3.5 Schematic representation of a l l ostasis. Reprodu ce d
ogy sim ilar to CFS/FMS' (Iadecola 1 993). w i t h permission from Chaitow (2003a).
box continues
3 Reporting stations a n d the bra i n 57
happening, either because of i nherited tendencies or because of nutritional approaches. Goldstein h a s offered us insights and his own
early developmental (physical or psychological) insul t(s), to which solutions. Not everyone w i l l necessarily accept these sol u tions but
additional multiple stressors have been added. His sol ution is a the i l l u mination of the highly com plicated mechanisms i nvolved,
biochemical (drug) modification of the i m balances he iden tifies as which he offers, is to be commended.
key features of this situation. It is also worth reflecting on the possible effects, on predisposed
Alternative approaches might attempt to modify behavior or to mechanisms, of whiplash-type i nj u ries, as d iscussed in this cha pter.
a lter other aspects of the complex d isturbances, possibly using
totality of information that is received, rather than individual papers offering glimpses of what may be going on in the
pieces of information from particular reporting stations. apparently never-ending pain states.
Should any of this mass of information be contradictory and Dommerholt (2004a,b) has examined one such syndrome
actually conflict with other information being received, what CRPS (chronic regional pain syndrome, previously known
then? If conflicting reports reach the cord from a variety of as reflex sympathetic dystrophy). He notes that, 'It is
sources simultaneously, no discernible pattern may be recog likely that CRPS is a disease of the central nervous sys
nized by the CNS (see Korr 's discussion below and Box 3.3). In tem, but at the same time there are numerous indications
such a case no adequate response would be forthcoming and that point to peripheral inflammatory processes, abnor
it is probable that activity would be stopped and a protective mal sympathetic-afferent coupling, and adrenoreceptor
co-contraction ('freezing', splinting) spasm could be the result. pathology. It is plausible that there are multiple simulta
neous processes that contribute to the development of
Sensitization CRPS' (Dommerholt 2004a) .
Dommerholt (2004b) acknowledges that when attempt
W hen pain persists past the time that an injury should
ing to treat such conditions, while physical (manual)
have healed, a process of central sensitization may have
therapy may be useful, there is no research evidence to
occurred.
validate its efficacy. There is certainly no general prescrip
Similarly, if pain, instead of reducing in the area involved
tion as to what will help most in any of the widespread
over time, gradually spreads, sensitization is a probable
pain conditions listed above. However, Dommerholt sug
cause.
gests that (and the authors of this text agree) : 'Therapy [of
Sensitization is also the likely mechanism if pain inten
CRPS] should include at least general range of motion
sity increases for no apparent reason.
exercises, inactivation of myofascial trigger points, desen
The process of sensitization involves the dorsal horn of
sitization interventions, aquatic physical therapy, posture
the spinal cord and/or the brain becoming increasingly
training and movement retraining.'
easily irritated, with its threshold reduced.
A process known as wind-up, and another known as long
In later chapters all of these options will be explored, along
term potentiation (see Box 3 .5) may result in a degree of
with nutrition, stress management and emotional well
sensitization and chronic pain, such as allodynia, where
being, all of which can also be influential to these conditions.
even a light stimulus provokes extreme pain (Kandel
et al 2000, Van Griensven 2005).
Commonly, when central sensitization occurs, move
NEURAL OVERLOAD , ENTRAPMENT AND
ments become limited because of the pain and a degree
CROSSTAL K
of anxiety and 'pain behavior' starts, in which activities
are reduced to avoid an increase in pain. Korr (1976) discusses a variety of insults that may result in
The sorts of conditions that might have these characteris increased neural excitability, including the triggering of a
tic may carry labels such as fibromyalgia, chronic fatigue barrage of supernumerary impulses to and from the cord
syndrome, somatoform pain disorder, myofascial pain that can result in 'crosstalk', in which axons may overload
syndrome, non-specific neuropathic pain . . . and many and pass impulses to one another directly. Muscle contrac
others, depending on who made the diagnosis, who tion disturbances, vasomotion, pain impulses, reflex mech
offered the 'label' . anisms and disturbances in sympathetic activity may aU
Aspects of the mechanisms described i n Box 3.4, a s well as result from such behavior, due to what might be relatively
in Box 3.5, may be involved in central sensitization, with slight tissue changes (in the intervertebral foramina, for
altered biochemistry as a feature, possibly relating to early example), possibly involving neural compression or actual
childhood stresses (biochemical and/or psychological). entrapment.
The fact is that complex chronic pain syndromes appear In addition, Korr states that normal patterned transmis
to have multiple possible causes, and the processes sion from the periphery can be jammed when any tissue is
involved remain unclear - despite mountains of research disturbed, whether bone, joint, ligament or muscle. These
58 C LI N I CA L A P P L I CATI O N OF N E U R O M U SC U LA R T E C H N I Q U E S : T H E U P P E R B O DY
factors, combined with any mechanical alterations in the tis debated. Some take a pOSition that this is a minimal effect
sues, are the background to much somatic dysfunction. (Lederman 1997), while others suggest a strong, if tempo
Korr summarizes the picture as follows: rary, influence that allows for an easier stretch of previ
These are the somatic insults, the sources of incoherent and ously shortened structures (Lewit 1985). In Chapter 9 new
meaningless feedback, that cause the spinal cord to halt nor research evidence is described that helps to explain just
mal operations and to freeze the status quo in the offending what does happen following an isometric contraction as
and offended tissues. It is these phenomena that are used in MET and other soft tissue manipulation tech
detectable at the body surface and are reflected in disorders niques such as 'hold-relax' and 'contract-relax-antagonist
of muscle tension, tissue texture, visceral and circulatory contract'.
Positional release techniques (PRT) - muscle spindles are
function, and even secretory junction; the elements that are
so much a part of osteopathic diagnosis. influenced by methods which take them into an 'ease'
state and which theoretically allow them an opportunity
Goldstein (1996) offers a more complex scenario in which the to 'reset' and reduce hypertonic status. Jones' (1995) 'strain
brain itself (or at least part of it) becomes hyperreactive and and counterstrain' and other positional release methods
starts to miSinterpret incoming information (see Box 3.4). use the slow and controlled return of distressed tissues to
the position of strain as a means of offering spindles a
MANIPULATING THE REPORTING STATIONS chance to reset and so normalize function. This is particu
larly effective if they have inappropriately held an area in
There exist various ways of 'manipulating' the neural
just such protective splinting.
reporting stations to produce physiological modifications in
Direct inf luences can be achieved, for example, by means
soft tissues.
of pressure applied to the spindles or Golgi tendon
Muscle energy technique (MET) - isometric contractions uti organs (sometimes termed 'ischemic compression' or
lized in MET affect the Golgi tendon organs, although the 'inhibitory pressure', equivalent to acupressure method
degree of subsequent inh ibition of muscle tone is strongly ology) (Stiles 1984).
Proprioceptive manipulation (applied kinesiology) is possi
STRENGTHEN ble (Walther 1988). For example, kinesiological muscle
tone correction utilizes two key receptors in muscles to
achieve its effects. A muscle in spasm may be helped to
relax by the application of direct pressure (using approx
imately 2 1bs or 0.5 kilos of pressure) away from the belly
of the muscle, in the area of the Golgi tendon organs,
and/or by the application of the same amount of pres
sure toward the belly of the muscle, in the area of the
muscle spindle cells (Fig. 3.6).
c WEAKEN
The precise opposite effect (i.e. temporary toning or
strengthening of the muscle) is achieved by applying
pressure away from the belly, in the muscle spindle
region, or toward the belly of the muscle in the tendon
A = Golgi tendon organs B = belly of muscle C = muscle spindle
organ region.
F ig u re 3.6 Proprioceptive m a n i pu l a t i o n of m u scles as described i n The mechanoreceptors in the skin are very responSive to
the text. Reproduced with pe rmission from Ch aitow (2003b). stretching or pressure and are, therefore , easily influenced
Box 3:5
Van Griensven (2005, p . 64) explains t h e processes th at occur It is in teresting to note that wind-up develops whether a person is
in the dorsal horn that can lead to central sensitization and extreme conscious or not. A person undergoing surgery may develop long
pain : lasting sensitization of the dorsal horns supplying the operation
site with sensory nerves, even though they are under general
Wind-up is a phenamenon that has been observed in laboratory anaesthetic.
settings. When a C fibre is stimulated repeatedly at a relatively high Long-term potentiation is thought to be the result of wind-up and
frequency. it continues to depolarize even when stimulation has other forms of persistent nociceptive stimulation. The bombardment
ceased. The spontaneous firing can take a lang time to fizzle out and of the secondary neuron with glutamate opens more ion channels in
it can be main tained by successive stimulatian. In ather wards, its membrane than when stimulation is of shorter duration and lower
although it takes in tense and high frequency stimula tion for a C intensity. The result is an ever-increasing calcium influx into the sec
fibre to go in to a state of wind up, it requires much less to main tain . . . ondary cell, which makes it even more exitable.
box continues
3 R eporting stations and t h e brain 59
Presynaptic
Dorsal
horn
Tissue
Presynaptic
Dorsal
horn
receptors
opened
Postsynaptic Tissue
Note: It may be useful to refer to the discussion of facititation in Chapter 6 to compare the similarities and d i ffere nc es between t h i s phenomenon a n d centra l
faci l i tation.
by methods which rub them (e.g. massage), apply pres reprogramming proprioceptive information (Chaitow &
sure to them (NMT, reflexology, acupressure, shiatsu, DeLany 2002, Liebenson 2006).
etc.), stretch them or 'ease' them (as in osteopathic func
tional technique, see Chapter 9).
The mechanoreceptors in the joints, tendons and liga THERAPEUTI C REHABI LITATI O N U SING
ments are influenced to varying degrees by active or pas REFLEX SYSTEMS
sive movement including articulation, mobilization,
adjustment and exercise (Lederman 1997). V ladimir Janda has researched and developed ways in which
Sensory motor stimulation, using a variety of tools (see reeducation of dysfunctional patterns of use can best be
below), may activate afferent pathways as a means of achieved, using our knowledge of neural reporting stations - a
60 C L I N I C A L A P P L I CAT I O N OF N E U R O M U SC U LA R TECH N I QU E S : T H E U P P E R B O DY
'sensory motor' approach Ganda 1996). There are, he states, trampolines and many others, including balance exercises,
two stages to the process of learning new motor skills or such as Tai Chi (see Volume 2, Chapter 2) . The principles of
relearning old ones. this approach are based on the work of Bobath & Bobath
(1964) who developed motor education programs for chjJ
1. The first is characterized by the learning of new ways of dren w i th cerebral pa lsy. A program of reeducation of sen
performing particular functions. This involves the cortex sory motor function can apparently double the speed of
of the brain in conscious participation in the process of muscle contraction, significantly improving general and
skill acquisition. As this process proceeds, Janda says, 'the postural function (Bullock-Saxton et aI 1993) .
brain tries to minimize the pathways and to simplify the
regulatory circuits', speeding up this relatively slow
means of rehabiJita tion. However, he warns, 'If such a
motor program has become fixed once, i t is difficult, if not C O N C LU S I O N
impossible, to change it. This calls for other approaches'.
2. The speedier approach to motor learning involves bal A n appreciation o f the roles o f the neural reporting stations
ance exercises tha t a ttempt to assist the proprioceptive helps us in our understanding of the ways in which dys
system and associated pa thways relating to posture and functional adaptive responses progress, as they evolve out
equilibrium. Janda (1996) informs us that, 'From the of patterns of overuse, misuse, abuse and disuse.
pOint of view of afference, recep tors in the sole of the Compensatory changes that emerge over time or as a result
foot, from the neck muscles, and in the sacroiliac area of adapta tion to a single tra uma tic event are seen to have a
have the main proprioceptive influence' (Abrahams logical progression. We will focus on these pa tterns in the
1977, Freeman et a1 1965, Hinoki & Ushio 1975). next chapter. There we will take both a broad and a local
view of compensations and adaptations to the normal
Aids to stimulating the proprioceptors in these areas (gravity) and abnormal (use patterns or trauma) stresses of
include wobble boards, rocker boards, balance shoes, mini life and how these impact our remarkably resilient bodies.
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63
::::::oJ
Chapter 4
ADAPTING TO STRESS
Alarm phase Aching muscles
Different activities
place the body under
different kinds of
stress. It is how we Postural changes, shoulders slumped,
adapt to the stresses Strengthening muscles in dominant arm head pushed forwards
Changes
that determines how Increased heart strength Possible changes to eyesight as eye muscles
we are affected by adapt to long periods focused on screen
them. These two
examples show the
two paths taken during
Regular movement
the adaptation phase - Adaptation Lack of awareness
and postural
the planned adaptation phase of changes
path leads to recovery
without injury or
damage; unplanned
adaptation leads to Improvement of
breakdown and the strength and
Recovery or Injury or strain, No long-term Repetitive strain
development of coordination
breakdown e.g. tennis elbow damage injury
particular problems. No injury or tissue
damage
Figure 4.1 Examples of appropriate and inapp ropriate responses to stress. Redrawn after Peters (2005).
syndrome (GAS) as being composed of three distinct changes that occur when particular load is applied to, or par
stages: ticular demands are made of, body areas (Norris 2000a,b).
Selye demonstrated that stress results in a pattern of adap
the alarm reaction when initial defense responses occur
tation, individual to each organism. He also showed that
('fight or flight')
when an individual is acutely alarmed, stressed or aroused,
the resistance (adaptation) phase (which can last for
homeostatic (self-normalizing) mechanisms are activated.
many years, as long as homeostatic - self-regulating -
However, if the alarm status is prolonged or if adaptive
mechanisms can maintain function)
demands are excessive, long-term, chronic changes occur and
the exhaustion phase (when adaptation fails) where
these are almost always at the expense of optimal functional
frank disease emerges.
integrity.
GAS affects the organism as a whole, while the local adaptation When assessing or palpating a patient or a dysfunctional
syndrome (LAS) goes through the same stages but affects area, neuromusculoskeletal changes can often be seen to
localized areas of the body. For example, imagine the tissue represent a record of the body's attempts to adapt and adjust
response to digging the garden, chopping wood or playing to the multiple and varied stresses that have been imposed
tennis after a period of relative inactivity - an 'acute adap upon it over time. The results of repeated postural and trau
tive response' would result with accompanying stiffness and matic insults over a lifetime, combined with the somatic
aching, followed by resolution of the stress effects after a few effects of emotional and psychological origin, will often
days. Imagine the same activity repeated over and over present a confusing pattern of tense, shortened, bunched,
again, in which adaptive ('training') responses would result, fatigued and, ultimately, fibrous tissue (Chaitow 1989).
leading to chronic tissue responses involving hypertrophy,
possible shortening, strengthening and so on. Anyone who
regularly trains by running or lifting weights will recognize POSTURE, RESPIRATORY FUNCTION AND
this seguence. The body, or part of the body, responds to THE ADAPTATION PHENOMENON
the repetitive stress (running, lifting, etc.) by adapting to the
needs imposed on it. It gets stronger or fitter, unless the Some of the many forms of soft tissue stress responses that
adaptive demands are excessive, in which case it would affect the body include the following (Barlow 1959,
ultimately break down or become dysfunctional (see Basmajian 1974, Dvorak & Dvorak 1984, Janda 1982, 1983,
Fig. 4.1). The acronym SAID (specific adaptation to imposed Korr 1978, Lewit 1985, Simons et a11999, Travell & Simons
demand) has been coined to illustrate this process of the 1992).
4 Causes of musculoskeletal dysfunction 65
]
areas of muscles, leading to tendon and attaclunent inflam The chronic adaptive changes that develop in such a sce
mation and the development of periosteal pain. nario lead to the increased likelihood of future acute exacer
Compensatory adaptations evolve, leading to habituaL bations as the increasingly chronic, less supple and less
'built-in' patterns of use emerging, as the CNS learns to resilient biomechanical structures attempt to cope with
compensate for modifications in muscle strength, length additional stress factors resulting from the normal demands
and functional behavior. of modern living.
Abnormal biomechanics result, involving malcoordination For example, Bakker et al (2003) have reported that not
of movement (with antagonistic muscle groups being only do musculoskeletal tissues weaken from overuse or
either hypertonic or weak - for example, erector spinae disuse, but also that the actual shape of the vertebrae and
tightens while rectus abdorninis is inhibited and weakens). the intervertebral discs, as well as the ligaments, adapt and
The normal firing sequence of muscles involved in par adjust to the type of load imposed. This is clearly an exam
ticular movements alters, resulting in muscle substitu ple of a specific adaptation to imposed demand (Conroy &
tion and additional strain (Janda 1982, 1983). Earle 2000) and is supported by Wolff's law (see Chapter 1).
Joint biomechanics are directly influenced by the accu The degree of physiological musculoskeletal adaptation -
mulated influences of such soft tissue changes and can that causes changes to both function and structure - is largely
themselves become significant sources of referred and determined by the magnitude of the load, as well as the use,
local pain, reinforcing soft tissue dysfunctional patterns or misuse, to which the spine is put.
(DeFranca 2006, Schaible & Grubb 1993). Wall den (2000) has described such adaptation sequences
Deconditioning of the soft tissues becomes progressive as a in slightly different terms, identifying both the rate of tissue
result of the combination of simultaneous events involved damage (micro trauma) and the rate of tissue repair as key fea
in soft tissue pain, 'spasm' (hypertonic guarding), jOint tures in the rate of advance toward adaptation exhaustion:
stiffness, antagonist weakness, overactive synergists, etc.
Across the life-span of an organism, or of a tissue, the rate of
Progressive evolution of localized areas of hyperreactivity
repair slowly declines, whilst the rate of cumulative micro
of neural structures occurs (facilitated areas) in paraspinal
trauma to the organism/tissue increases. The point at which
regions or within muscles (myofascial trigger points) (see
the rate of trauma exceeds the rate of repair is the point at
Chapter 6).
which the organism/tissue fails. If repair mechanisms are
In the region of these trigger points (see discussion of
optimal, the organism or tissue should realize its genetic
myofascial triggers, p. 97) a great deal of increased neu
potential. If repair mechanisms are impaired or overloaded,
rological activity occurs (for which there is EMG evi
potential is not realized, and adaptation will fail.
dence) that is capable of adversely influencing distant
tissues (Hubbard 1993, Simons 1993, Simons et aI1999). This observation highlights a need to focus on both reduction
Energy wastage, due to unnecessarily sustained hyper of microtrauma as well as enhancement of repair potentials
tonicity and excessively active musculature, leads to gen (nutrition, etc.).
eralized fatigue as well as to a local 'energy crisis' in the
local tissues (see trigger point discussion, p. 97).
AN EXAMPLE OF 'SLOW' ADAPTATION
More widespread functional changes develop - for exam
ple, affecting respiratory function and body posture - with Consider the cumulative effects of a leg-length imbalance.
repercussions on the total economy of the body. Using data on leg-length inequality, obtained by accurate
Induction of muscle hypertonicity is part of the alarm and reliable x-ray methods, Knutson (2005) fOlmd the preva
reaction of the flight/fight alarm response. In the pres lence of anatomic leg length inequality to be 90%. The evi
ence of a constant neurological feedback of impulses to dence suggested that, for most people, anatomic leg-length
the CNS/brain from neural reporting stations indicating inequality does not appear to be clinically significant until the
heightened arousaL there will be increased levels of psy magnitude reaches approximately 20mm (74").
chological arousal and a reduction in the ability of the Janda (1988) has described the sequence of adaptive
individual, or the local hypertonic tissues, to relax effec changes, resulting from the presence of a significant degree of
tively. This will consequently result in reinforcement of leg shortness, that culminate in back, head, neck and facial
hypertonicity. pain. This is summarized in Chapter 5 (p. 84).
Functional patterns of use of a biologically unsustainable Over time, adaptational modifications may progress from
nature will emerge, probably involving chronic muscu the production of soft tissue changes to evidence of dysfunc
loskeletal problems and pain. tion (e.g. low back pain) and the evolution of actual patho
logical changes. For example, Gofton & Trueman (1971)
At this stage, restoration of normal function requires thera found a strong association between leg length and unilat
peutic input which addresses both the multiple changes eral osteoarthritis (OA) on the side of the anatomically long
that have occurred, and the need for a reeducation of the leg. They noted that all subjects with this type of OA 'had
individual as to how to use his body, to breathe and to carry led healthy active lives prior to the onset of hip pain' and
himself in more sustainable ways. few subjects were aware of any difference in leg length.
4 Causes of musculoskeletal dysfunction 67
They also point out that this form of OA has its onset picture of health. From the shoes we wear to the seats we sit
around the age of 53, but acknowledge that many people upon, to the awkward positions we assume in the work
with precisely this anatomic asymmetry failed to develop environment, daily activities have perhaps the most pro
an arthritic hip, suggesting that factors other than the leg found impact. Further discussion of the myriad of static and
length disparity are also important. dynamic influences is found in Volume 2 of this text.
This underscores the importance of the context in which
these mechanical adaptations are being processed by the tis
sues under stress - with some joints becoming arthritic and
MAKING SENSE OF THE PIC TURE
others not.
It may be useful to ask what the other variables were that
Motor control is a key component in injury prevention and
allowed some people with significant leg length discrepan
loss of motor control involves failure to control joints, com
cies to avoid arthritic changes and others to develop
monly due to incoordination of the agonist/antagonist mus
them: Nutritional? Genetic? Gender? Weight? Occupation?
cle coactivation (McGill 1998).
Other?
According to Panjabi (1992), three subsystems work
together to maintain spinal stability:
to compensating patterns of use, with reduction in muscle of this subsystem can be reduced by injury (or by
force and possible wasting, often observed in backache hypermobility).
patients. If uncorrected, such altered patterns of use inevitably the muscle subsystem (active). This subsystem can be
lead to the development of habitual motor patterns and even impaired by deconditioning and inhibition (for example, by
tually to structural modifications. overactive antagonists, or the presence of trigger points),
The possible adaptational sequelae to trauma may include: and can be enhanced by strength training.
modified proprioceptive function due to alteration in Anything that interferes with any aspect of these features
mechanoreceptor behavior of normal motor control may contribute to dysfunction
inhibition of joint afferents influencing local muscle func and pain.
tion, possibly involving the build-up of metabolic In the discussion below, attention will be given to various
by-products, if joint damage has occurred core elements of the evolution of musculoskeletal dysfunc
altered motor patterns resulting from higher center res tion - including musculoskeletal stress resulting from pos
ponses to injury, possibly involving a sense of insecurity tural, emotional and respiratory causes. These three factors
and the development of protective behavior patterns, interface with each other and reinforce any resulting dys
resulting in actual structural modification, such as mus functions. As will become clear in these descriptions, there
cle wasting is a constant merging and mixing of fundamental influences
associated non-painful reflexogenic responses to pain, on health and ill health. In trying to make sense of a
and also to injury (Hurley 1991). patient's problems, it is frequently clinically valuable to
cluster etiological factors. One model that the authors find
useful divides negative influences into:
WHAT OF ADAPTATION TO HABITS OF USE?
biomechanical (congenital, overuse, misuse, trauma, dis
Habits of use, as well as the close environment that comes in use, etc.)
intimate contact with the body, can have profound effects biochemical (toxicity, endocrine imbalance, nutritional
on tissue tone, flexibility and behavior. Prolonged periods of deficiency, ischemia, inflammation, hydration)
distorted or strained positioning that is often involved in psychosocial (anxiety, depression, unresolved emotional
professional or leisure activities may produce shortened states, somatization, etc.).
and/or weakened, fibrotic, indurated or, in some other way,
dysfunctional tissues. Stresses being loaded onto these Obviously some of these features are inborn, while others are
already compromised tissues that would not have been acquired. Some are easily modified and some are extremely
harmful to normal tissue may result in injury. difficult to change.
Everything that comes in contact with the body, or to Part of the practitioner/ therapist'S role is to help to identify
which the body must conform, is important in the overall what can be most easily modified by treatment or altered
68 C L I N I CA L A P P L I CATI O N OF N E U R O M U S C U LA R TE C H N I Q U E S : THE U P P E R B O DY
behavior - say inhibited or overtight muscles - and the rea result of the CO2 imbalance caused by this breathing
sons for these changes, as well as helping to improve func pattern, or might possibly be breathing in this way because
tion so that the stress load can be better handled (postural of a predisposing anxiety (Chaitow et al 2002, Timmons
and breathing rehabilitation, balance training, etc.). 1994).
The usefulness of this approach is that it allows a focus to
be brought to factors that are amenable to change via (for Interventions that reduce anxiety will help all associated
example): symptoms and these could involve biochemical modifi
cation (herbs, drugs), stress coping approaches (includ
manual methods, rehabilitation, reeducation and exer ing breathing rehabilitation) or psychotherapy.
cise, all of which influence biomechanical factors Interventions that improve breathing function, probably
nutritional or pharmaceutical tactics, which modify bio involving easing of soft tissue distress (including deacti
chemical influences, and vation of trigger points) and/or joint restrictions, as well
psychological approaches, which deal with psychOSOCial as breathing retraining, should significantly help to
influences. reduce symptoms associated with musculoskeletal dys
function.
In truth, the overlap between these causative categories is
so great that in many cases interventions can be randomly The most appropriate approach will be the one that most
selected since, if effective, all will (to some degree) modify closely deals with causes rather than effects and which
the adaptation demands, or will enhance self-regulatory allows for long-term changes that will reduce the likelihood
functions sufficiently for benefit to be noted. of recurrence. Biochemistry, biomechanics and the mind are
seen in this example to be inextricably melded to each other.
In other examples, etiological influences may not always be
EXAMPLE
as clearly defined; however, they will almost always impact
Consider someone who is habitually breathing in an upper on each other.
chest mode, the stress of which will place adaptive The theme of respiratory influence on musculoskeletal
demands on the accessory breathing muscles, with conse dysfunction is explored further, later in this chapter. Before
quent stiffness, pain, trigger point activity (particularly in that, a summary of postural and emotional influences will
the scalenes) and joint involvement. This individual will prepare us for a more comprehensive understanding of one
probably display evidence of anxiety (see below) as a direct of the most important body processes - respiration.
The interacting influences of a bio che mical, biomechanical and psychosocial nature (overuse, misuse, e.g. hyperventilation
a negative emotional state (e.g. depression) produces specific biochemical changes, and structures)
Figure 4-3 Biochemical, biomechanical and psychosocial influences on health. Reproduced with permission from Chaitow (2003).
4 Causes of musculoskeletal dysfunction 69
EMOTIONAL CONTRACTIONS
Also sphincters and hollow organs can be held tight until whereas, in vomiting, it remains in total contraction through
numb. He gives as examples the muscles that surround the out each eliminative wave. Between waves of vomiting the
genitals and anus as well as the mouth, nose, throat, lungs, breathing remains in the inspiratory phase, with upper chest
stomach and bowel. panting. Transversus is slack in this phase. Latey suggests
When considering the 'middle fist', Latey concentrates that often it is only muscle fatigue that breaks cycles of
his attention on respiratory and diaphragm function and laughter/weeping/vomiting.
the many emotional inputs which affect this region. He dis The clinical problems associated with 'middle fist' dys
counts as a popular misconception the idea that breathing is function relate to distortions of blood vessels, internal organs,
produced by contraction of the diaphragm and the muscles autonomic nervous system involvement and alteration in
that raise the rib cage, with exhalation being simply a relax the neuroendocrine balance. Diarrhea, constipation and colitis
ation of these muscles. He states, 'The even flow of easy may be involved, but more direct results relate to lung and
breathing should be produced by dynamic interaction of ... stomach problems. Thus, bronchial asthma is an obvious
two sets of muscles'. example of 'middle fist' fixation.
The active exhalation phase of breathing is instigated, he There is a typical associated posture with the shoulder
suggests, by the following muscles. girdle raised and expanded as if any letting go would pre
cipitate a crisis. Compensatory changes usually include very
1. Transversus thoracis which lies inside the front of the taut, deep neck and shoulder muscles (see Janda's upper
chest and attaches to the back of the sternum, \vhile fan crossed syndrome description, discussed in Chapter 5)
ning out inside the rib cage and then continuing to the (Janda 1983).
lower ribs where the fibers separate. This forms an inverted In treating such a problem, Latey starts by encouraging
'V' below the chest. This muscle, Latey says, has direct function of the 'middle fist' itself, then extending into the
intrinsic abilities to generate all manner of uniquely pow neck and shoulder muscles, while encouraging them to relax
erful sensations, with even light contact sometimes pro and drop. He then goes back to the 'middle fist'. Dramatic
ducing reflex contractions of the whole body or of the expressions of alarm, unease and panic may be seen. The
abdomen or chest. Feelings of nausea and choking and patient, on discussing what they feel, might report sensa
all types of anxiety, fear, anger, laughter, sadness, weep tions of being smothered, drowned, choked, engulfed or
ing and other emotions may be displayed. He discounts crushed.
the idea that the muscle's sensitivity is related to the
'solar plexus', suggesting that its closeness to the internal
'UPPER FIST' FUN CTION S
thoracic artery is probably more significant since, when it
is contracted, it can exert direct pressure on the artery. He The 'upper fist' involves muscles which extend from the
believes that physiological brea thing has, as its central thorax to the back of the head, where the skull and spine
event, a rhythmical relaxation and contraction of this join, and extends sideways to include the muscles of the
muscle. Rigidity is often seen in the patient with 'middle shoulder girdle. These muscles therefore set the relative
fist' problems, where 'control' dampens the emotions positions of the head, neck, jaw, shoulders and upper chest
that relate to it. and, to a large extent, the rest of the body follows this lead (it
2. The other main exhalation muscle is serratus posterior was F.M. Alexander (1932) who showed that the head-neck
inferior, which runs from the lower thoracic and upper relationship is the primary postural control mechanism). This
lumbar spine and fans upwards and outwards over the region, says Latey, is 'the center, par excellence, of anxieties, ten
lower ribs, which it grasps from behind to pull them sions and other amorphous expressions of unease'.
down and inwards on exhalation. These two muscles In chronic states of disturbed 'upper fist' function, he
mirror each other and work together. Latey states that it asserts, the main physical impression is one of a restrained,
is common to find a static overcontracture of serratus overcontrolled, damped down expression. The feeling of the
posterior inferior, with the underlying back muscles in a muscles is that they are controlling an 'explosion of affect'.
state of fibrous shortening and degeneration, reflecting Those experiences that are not allowed free play on the face
'the fixity of the transversus, and the extent of the emo are expressed in the muscles of the skull and the base of the
tional blockage'. skull. This is, he believes, of central importance in problems of
headache, especially migraine. Says Latey, 'I have never seen
a migraine sufferer who has not lost complete ranges of facial
'MIDDLE FIST' FUN CTIONS
expression, at least temporarily'.
Latey reports that laughing, weeping and vomiting are three
emotional 'safety valve' functions of 'middle fist' function,
Effects of 'upper fist' patterns
used by the body to help resolve internal imbalance. Anything
stored internally that cannot be contained emerges explo The mechanical consequences of 'upper fist' fixations are
sively via this route. In laughing and weeping, there is a many and varied, ranging from stiff neck to compression fac
definite rhythm of contraction/relaxation of transversus tors leading to disc degeneration and facet wear. Swallowing
4 Causes of musculoskeletal dysfunction 71
and speech difficulties are common, as are shoulder dys the scope of this text. However, it is important to consider
functions including brachial neuritis, Reynaud's syndrome emotional influences, particularly those that are most
and carpal tunnel problems. impacting.
Latey states: What are the backgrounds to feelings that Latey conjures
up in his 'clenched fist' model of physical contraction and
The medical significance of 'upper fist' contracture is mainly
congestion - of being stressed, pressured, tense, anxious?
circulatory. Just as 'lower fist' contraction contributes to
Without doubt, there are probably as many different back
circulatory stasis in the legs, pelvis, perineum and lower
grounds as there are people affected. However, some common
abdomen, so may 'upper fist' contracture have an even more
elements seem likely, and most of these have become familiar
profound effect. The blood supply to the head, face, special
to us through the popular media - with 'life events' and
senses, the mucosa of the nose, mouth, upper respiratory
'type A personality' being among the most obvious.
tract, the heart itself and the main blood vessels are con
trolled by the sympathetic nervous system and its main
'junction boxes' (ganglia) lie just to the front of the verte Life events
brae at the base of the neck.
Holmes & Rahe (1967) studied some 5000 people who had
Thus, headaches, eye pain, ear problems, nose and throat as recently been ill, inquiring into the 'events' that had taken
well as many cardiovascular troubles may contain strong place over the previous 12 months. Using questionnaires that
mechanical elements relating to 'upper fist' muscle contrac listed both major events, such as 'death of a spouse' (100
tions. Latey reminds us that it is not uncommon for cardio points or 'life crisis units'), 'divorce' (60 points), as well as
vascular problems to manifest at the same time as chronic minor ones such as 'moving house' (15 points) and 'taking a
muscular shoulder pain (such as avascular necrosis of the minor loan' (10 points), they were able to demonsh'ate a
rotator cuff tendons) and that the longus colli muscles are cumulative effect.
often centrally involved in such states. If the 'score' resulting from the 50 or so questions totaled
He looks to the nose, mouth, lips, tongue, teeth, jaws and 250 or more, an 80% risk of serious illness within 2 years
throat for evidence of functional change related to 'upper was suggested. Different scores carried with them varying
fist' dysfunction, with relatively simple psychosomatic percentages of risk, although it was recognized that people
disturbances underlying these. Sniffing, sucking, biting, had different degrees of stress susceptibility, meaning that
cheWing, tearing, swallowing, gulping, spitting, dribbling, for some people a far lower score than 250 might suggest
burping, vomiting, sound making and so on are all signifi significant risk.
cant functions which might be disturbed acutely or chroni The attractiveness of the model constructed by Rahe &
cally. These patterns of use can all be approached via Holmes was that it illustrated the cumulative effect of a
breathing function. number of minor stresses as having the same potential to
When all the components of the 'upper fist' are relaxed, the cause harm (if not adequately adapted to) as major events.
act of expiration produces a noticeable rhythmical move This is a concept that Selye (1956) had identified in his
ment. The neck lengthens, the jaw rises slightly (rocking the model of the general adaptation syndrome. It also allowed
whole head), the face fills out, the upper chest drops. When a rough and ready picture of vulnerability. However, a
the patient is in difficulty [ may try to encourage these number of provisos need to be made in relation to the accu
movements by manual work on the muscles and gentle racy of the 'life event' model.
direction to assist relaxed expiration. Again, by asking the 1. Correlation does not prove cause. In other words, because
patient to let go and let feelings happen, I encourage resolu many people had become ill within a certain time of a
tion. Specific elements often emerge quite readily, especially major, or a number of minor, stress events, this did not
those mentioned with the 'middle fist', the need to vomit, prove that the stresses caused the illness, only that there
cry, scream, etc.
was a probable link.
Note: More detail of Latey's perspective regarding 'lower 2. The way the scale was created did not allow for individ
fist' function is presented in Volume 2 of this book, which ual variations in the way people respond to the stresses
deals with the lower body. affecting them.
3. Nevertheless the questionnaire and scale offers a relatively
simple way of scoring the amount of stress people are
BEHAVIOR AN D PERSON ALITY ISSUES
suffering, suggesting their current risk of becoming ill.
In this segment, focus will be on the everyday contributory
states ('anxiety', 'tension' and 'stress') that add to muscu
Type-A personality
loskeletal distress, arising from a background of what may
be termed exaggerated emotional states. The authors have Within the framework of behavior and personality, as it
deliberately avoided discussion of the potential biomechani relates to how stress is handled, the now (in)famous Type-A
cal influences of true psychological illness as they lie beyond personality is a major feature.
72 C L I N I CAL A P P L I CATI O N OF N E U R O M USCU LAR TECHN I Q U ES : THE U P P E R B O DY
to achieve more and more in less and less time' (Booth There is (justifiably) intense debate regarding the question
Kewley & Friedman 1987). This is the 'workaholic' individual, of the intentional induction of 'emotional release' in clinical
feverishly working to deadlines, often - as Norman Cousins settings in which the therapist is relatively untrained in
(1979) showed - with a tendency to cardiac disease (Booth psychotherapy.
Kewley & Friedman 1987).
If the most appropriate response an individual can cur
There is unlikely to be an easy ability to relax, and if exer
rently make to the turmoil of their life is the 'locking
cise is taken it is also likely to be with great intensity. A car
away' of the resulting emotions into their musculoskele
toon of a patient speaking to his doctor sums up the nature
tal system, what is the advisability of unlocking the emo
of the true Type-A individual: 'I am learning to relax doctor,
tions that the tensions and contractions hold, especially
but I want to relax better and faster ... in fact I want to be at
when the practitioner has no training and the patient has
the cutting edge of relaxation as quickly as possible. '
no skills with which to handle those emotions?
The bodyworker attempting t o relax the muscles o f a
If there exists no current ability to mentally process the
Type-A patient is fighting an uphill battle, unless an internal
pain that these somatic areas are holding, are they not
awareness of the problem is achieved, accompanied by
best left where they are until counseling or psychother
behavior modification.
apy or self-awareness leads to the individual's ability to
reflect, handle, deal with and eventually work through
Hard iness the issues and memories?
What are the advantages of triggering a release of emo
But there are healthy Type-As, just as there are people who
tions, manifested by crying, laughing, vomiting or what
cope adequately and actually seem to suffer little ill-effect
ever - as described by Latey and others - if neither the
physically or mentally, even though they endure severe
individual nor the therapist can then take the process to a
overload of 'life events'. This appears to be because they
healthier position?
carry the attributes of what has been termed 'hardiness'
(Kobassa 1983, Maddi & Kobassa 1984). In the experience of one of the authors (LC) there are indeed
The key 'hardiness factors' that increase a person's patients whose musculoskeletal and other symptoms are
resilience to stress and prevent burnout are commitment, patently linked to devastating life events (torture, abuse,
control and challenge. If an individual has a strong commit witness to genocide, refugee status and so on) to the extent
ment to him/ herself; and believes that he /she is in control that extreme caution is called for in addressing obvious
of the choices in life (internal locus of control); and if change symptoms for the reasons suggested above.
4 Causes of musculoskeletal dysfu nction 73
What would emerge from a 'release'? How would the stress can hav on associated tissues, starting with diaphrag
person handle it? The truth is that there are many examples matic weakness.
in modern times of people whose symptoms represent the
The main factors which determine the maintenance of the
end result of appalling social conditions and life experiences.
abdominal viscera in position are the diaphragm and the
Healing may require a changed life (often impossible to envis
abdominal m uscles, both of which are relaxed and cease to
age) or many years of work with psychological rehabilitation,
support in faulty posture. The disturbances of circulation
and not interventions that address apparent symptoms,
resulting from a low diaphragm and ptosis may give rise to
which may be the merest tips of large icebergs.
chronic passive congestion in one or all of the organs of the
The contradictory perspective to these questions suggests
abdomen and pelvis, since the local as well as general
that there would not be a 'spontaneous' release of 'emotional
venous drainage may be impeded by the failure of the
baggage' unless the person was able to intellectually and
diaphragmatic pump to do its full work in the drooped body.
emotionally handle whatever emerged from the process.
Furthermore, the drag of these congested organs on their
This is indeed a debate without obvious resolution. The
nerve supply, as well as the pressure on the sympathetic
authors feel it worthy of exposure in this context but cannot
ganglia and plexuses, probably causes many irregularities
offer definitive answers. These questions are intended to be
in their function, varying from partial paralysis to over
thought-provoking. It is suggested that each patient and
stimulation. All these organs receive fibers from both the
each therapist/practitioner should reflect on these issues
vagus and sympathetic systems, either one of which may be
before removing (however gently and however temporarily)
disturbed. It is probable that one or all of these factors are
the defensive armoring that life may have obliged vulnera
active at various times in both the stocky and the slender
ble individuals (almost all of us at one time or another) to
anatomic types, and are responsible for many functional
erect and maintain. It may be that, in some circumstances, an
digestive disturbances. These disturbances, if continued
individual's 'physical tensions' may be all that are prevent
long enough, may lead to diseases later in life. Faulty body
ing him/her from fragmenting emotionally.
mechanics in early life, then, becomes a vital factor in the
It is important to differentiate between the skill to pro
production of the vicious cycle of chronic diseases and pres
voke an emotional release and the skill to adequately
ents a chief point of attack in its prevention . . . In this
process the resulting emotional instability. Many trainings
u pright position, as one becomes older, the tendency is for
teach the skills to provoke emotional release, but few offer
the abdomen to relax and sag more and more, allowing a
any training whatsoever in appropriate steps to resolution.
ptosic condition of the abdominal and pelvic organs unless
Practitioners who practice 'emotional release' techniques
the supporting lower abdominal muscles are taught to con
are responsible for also acquiring training, skills and proper
tract properly. As the abdomen relaxes, there is a great ten
licensure to ensure safe handling of the patient's emotional
dency towards a drooped chest, with narrow rib angle,
state, regardless of whether the emotional release courses
forward shoulders, prominent shoulder blades, a forward
provided those skills as part of the training.
position of the head, and probably pronated feet. When
At the very least we should all learn skills that allow the
the human machine is out of balance, physiological func
safe handling of 'emotional releases' that may occur with
tion cannot be perfect; muscles and ligaments are in an
out deliberate efforts to induce them. And we should have a
abnormal state of tension and strain. A well-poised body
referral process in place to direct the person for further pro
means a machine working perfectly, with the least amount
fessional help.
of muscular effort, and therefore better health and strength
As a first-aid approach, should such an event occur dur
for daily life.
ing or following treatment, emphasis should be on initiat
ing calm, and this may best be achieved through slow Note how closely Goldthwaite mirrors the picture Janda
breathing, focusing on the outbreath. The patient should be paints in his upper and lower crossed syndrome and 'pos
allowed to talk if he/she wishes but, unless adequately ture and facial pain' descriptions (see Chapter 5, p. 84).
h'ained, the practitioner should avoid any attempt to advise Also note the descriptions of faulty body mechanics, a.nd
or to try to 'sort out' the patient's problems. The focus should try to imagine that same individual standing in a balanced
be on helping the patient through the crisis to a state of calm manner while breathing in a slow, deep, relaxed way. The
before offering an appropriate referral. idea of normal postural or respiratory (or almost any other
physiologic) function emerging from an unbalanced and
crowded, anatomically compromised structure, is far-fetched
POSTURAL IM B A LANC E AND THE at best.
DIAPHRAGM (Goldthwa ite 1 945) Goldthwaite, in his description above, speaks of 'the fail
ure of the diaphragmatic pump' being able to do its work in
Goldthwaite, in his classic 1930s discussion of posture, links a 'drooped body'. This highlights one of the key elements
a wide array of health problems to the absence of balanced required to normalize posture and breathing pattern disor
posture. Clearly, some of what he hypothesized remains ders. There is a need not only to encourage (and teach if
conjecture but we can see j ust how much impact postural possible) better brea thing and postural habits, but also to
74 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S C U LA R TE C H N I Q U E S : T H E U P P E R B O DY
focus attention on the drooped and crowded structures that upon neural circuits that are shared by pathways that medi
will, over time, have become compromised - and which will, ate autonomic control, vestibuloautonomic interactions and
unless appropriately treated (loosened, stretched, mobilized, anxiety:
etc.), be virtually unable to improve their function.
A key measure of good posture is optimal balance. The core of this circuitry is a parabrachial nucleus network,
consisting of the parabrachial nucleus . . . a site of conver
BALAN CE gence of vestibular information processing, and somatic and
visceral sensory information processing, in pathways that
Maintaining body balance and equilibrium is a primary role appear to be involved in avoidance conditioning, anxiety,
of functionally coordinated muscles, acting in task-specific and conditioned fear.
patterns, and this is primarily dependent on normal motor
control (Winters & Crago 2000). At its simplest, balance depends on optimal motor control,
Without doubt, balance largely depends on adequate and motor control depends on coordinated neurological
proprioceptive input, as discussed in Volume 2, Chapter 2. direction. Feelings of anxiety - such as can be triggered by
Without a steady flow of proprioceptive information (deriv breathing pattern disorders - or imbalances such as those
ing from the eyes, inner ear, muscles and joints of the entire described above (also see notes on deconditioning below),
body) reaching the higher centers, balance is going to be result in poor motor control, unbalanced body function, and
compromised. the likelihood of malcoordinated use patterns. Resultant
Balaban & Theyer (2001) have examined the neurological adaptations lead to shortening of postural muscles, inhibi
basis for links between balance control and anxiety, based tion of phasic muscles and the evolution of trigger points.
Body goes on
alert (the 'fight
or flight' response)
4.6 Negative health infl uences of a dysfunctional breathing pattern such as hyperventilation. Reproduced with permission from
F i g u re
Peters et a I (2002).
4 Causes of musculoskeletal dysfunction 75
These thoughts offer an example of the meeting poin t of The products of this process, which is more extreme in
mind and body - where biochemistry, biomechanics and deconditioned individuals, include the b uild-up of acids,
the mind interact seamlessly. Here we can see emotions such as lactic and pyruvic acids (Fried 1987) . As lactate
(anxiety, for example) influencing function (brea thing), aCCLUTIulates in muscle cells and the bloodstream, pH reduces
while at the same time being aware tha t the reverse is also and this triggers a homeostatic retention of bicarbonate
true, that an habitual breathing pa ttern can trigger anxiety. (part of renal function) in an attempt to balance the increasing
Whichever way round this cause-and-effect cycle goes, the acidity. This, in turn, stimula tes the brea thing rate, causing
end result is - a series of disturbed neurological and func CO2 levels to drop again, resulting in symp toms of brea th
tional patterns, operating in a biochemically compromised lessness (dyspnea) and fatigue. And the fluctua ting cycle
system, where pH is unbalanced and calcium and magne continues to repeat i tself (Lum 198 1 ) .
sium reserves are seriously affected. Out of this environment According t o Nixon & Andrews ( 1996) the outcomes of
emerges the likelihood (virtual certainty) of disturbed bal these events in a decondi tioned individual include:
ance, increased sympa thetic arousal, sensitized neurons,
loss of muscle mass (due partly to poor protein synthesis)
muscular distress, trigger point activity, fatigue and pain
decreased ability to use energy substra tes efficiently
(Chaitow et al 2002).
decreased neurom uscular transmission
These complications from respiratory influences are wor
decreased efficiency in m uscle fiber recrui tment, with
thy of the following deeper investigation.
indications of disruption of normal motor con trol being
apparent (Wittink & Michel 2002).
RESPIRATORY IN F LUENCES Nixon & Andrews (1996) summa rized the emerging symp
toms tha t result from overbrea thing in a decondi tioned
Breathing dysfunction is seen to be at least an associated individual as follows:
factor in most chronically fatigued and anxious people, and
Muscular aching at low levels of effort
almost aU people subject to panic a ttacks and phobic behavior,
Restlessness and heightened sympathetic activity
many of whom also display multiple musculoskeletal symp
Increased neuronal sensitivity
toms. In modern inner cities in particular and early 21st
Constriction of smooth muscle tubes (e.g. vascular, respi
century existence in general, there exists a vast expression
ratory and gastrointestinal) tha t can accompany the basic
of respiratory imbalance, as seen in paradoxical brea thing,
symptom of inability to make and sustain normal levels
upper chest breathing and chronic hyperventilation (Aust &
of effort.
Fischer 1997, Cholewicki & McGill 1996, Hodges et aI 200 1 ) .
A s a tendency toward upper chest brea thing becomes In practice this means tha t pa tients who are not aerobically
more pronounced, biochemical imbalances occur when fi t are the most likely individuals whose motor con trol will
excessive amounts of carbon dioxide (C02) are exhaled, be impaired, and who will be most vulnerable to muscle
leading to relative alkalosis, which automatically produces and joint - particularly the spine - dysfunction (Panjabi
a sense of apprehension and anxiety. This condition of res 1992).
piratory al kalosis frequently leads to panic a ttacks and pho
bic behavior, from which recovery is possible only when
RESP I RATORY EN TRAIN MEN T AN D CORE
breathing is normalized (King 1988, Lum 198 1 ) .
STABILITY ISSU ES
Since carbon dioxide is one of the major regulators of
cerebral vascular tone, any reduction due to hyperventilation Diaphragm and transversus abdominis tone are well estab
patterns leads to vasoconstriction and cerebral oxygen defi lished as key features in the provision of core stability (Panjabi
ciency. Whatever oxygen there is in the bloodstream then 1992). There is evidence tha t increased intraabdominal pres
has a tendency to become more tightly bound to its hemo sure (lAP), even with limited participa tion of the abdominal
globin carrier molecule, leading to decreased oxygenation or back muscles, augments the stability of the spine (Hodges
of tissues. All this is accompanied by a decreased threshold et al 2001, 2005).
of peripheral nerve firing. Recent data confirm that the activity of the diaphragm
occurs in association with tasks tha t challenge the stabi lity
of the spine (Hodges & Gandevia 2000a,b, Hodges et al
E F FECTS OF RESPIRATORY AL KALOSIS IN A
1997). When, however, a challenge occurs that ma kes pos
DECON DITION ED IN DIVIDUAL
tural/stabilizing demands on the diaphragm at the same
Oxygen is a necessary ingredient of ATP (energy) production time that respiratory demands are occurring, it is the stability
in normal tissues. However, when respiratory alkalosis occurs, element that s uffers.
the activation of anaerobic energy pathways starts (anaero Using a 1 0% CO2 gas mixture to elevate breathing, McGill
bic glycolysis - the p roduction of energy in the relative et al (1995) demonstrated that reduction in the support offered
absence of oxygen), leading to an accumulation of incom to the spine by the muscles of the torso may occur if there is a
pletely oxidized products of metabolism (Fried 1987). load challenge to the low back combined with a breathing
76 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S C U LA R TE C H N I Q U E S : TH E U P P E R B O DY
I shoulder girdle
3. Temporal headaches
4. Painful legs
5. Whole body expresses
'Tetany, muscle spasm, 'Sympathetic dominance - dilated 'Increased neuronal activity
tension - cannot relax in
paresthesia pupils, dry mouth, sweaty palms, gut speeding spinal reflexes as well
any position
Increased neuronal irritability and digestive dysfunction, abdominal (initially) as heightened pain
Reduced blood flow to brain, bloating, tachycardia perception + photophobia,
limbs and heart + hyperacusis
'foggy brain'
Cold extremities
'all these symptoms are increased during progesterone phase of menstrual cycle ..... Chest pain
Anxiety, apprehension (sense
of mild panic)
Depressed cortical activity
Vasomotor instability, blurring
Increased circulating histamines of consciousness and vision
make allergic reaction more Loss of cortical inhibition results
violent and possibly more likely in emotional lability
Figure 4.7 Negative health infl uences of a dysfunctional breathing pattern such as hyperventilation.
N EURAL REPERCUSSI ON S most likely to be affected and these are also common sites for
active myofascial trigger points (Timmons 1994).
Loss of CO2 ions from neurons during moderate hyperven
tilation stimulates neuronal activity, while producing mus Painful muscular contractions (,nodules') develop and
cular tension and spasm, speeding spinal reflexes as well as are easily felt in the nape of the neck, anterior chest and
producing heightened perception (pain, photophobia, hyper shoulder girdle.
acusis) - all of which are of major importance in chronic pain Temporal headaches centered on painful nodules in the
conditions. \A/hen hypocapnia is more severe or prolonged parietal region are common.
it depresses neural activity until the nerve cell becomes Sympathetic dominance is evident by virtue of dilated
inert. pupils, dry mouth, sweaty palms, gut and digestive dys
What seems to occur in advanced or extreme hyperventi function, abdominal bloating and tachycardia.
lation is a change in neuronal metabolism; anaerobic glycol Allergies and food intolerances are common due to
ysis produces lactic acid in nerve cells, while lowering pH. increased circulating histamines.
Neuronal activity is then diminished so that in extreme
hypocapnia (reduced levels of CO2), neurons become inert.
BIOMECHAN ICAL CHAN GES IN RESPONSE TO
Thus, in the extremes of this clinical condition, initial hyper
UPPER CHEST BREATHI N G
activity gives way to exhaustion, stupor and coma (Lum
1981). \"ihereas Goldthwaite (1945), Janda ( 1 982) and others point
to the collapse of normal posture leading inevitably to
changes which preclude normal breathing function, Garland
TETANY (1994) presents the picture in reverse, suggesting that it is the
functional change of inappropriate breathing (e.g. hyper
According to Stedman's Medical Dictionary (2004) tetany is
ventilation or upper chest patterns of breathing) that ulti
characterized by muscle twitches, cramps and cramping of
mately modifies structure. It was Garland who coined the
the hands and feet and, if severe, may include laryngospasm
memorable phrase 'where psychology overwhelms physi
and seizures. These findings reflect irritability of the central
ology' to describe the changes which occur.
and peripheral nervous systems, which may result from
Garland describes the somatic changes that follow from a
low serum levels of ionized calcium or, rarely, magnesium.
pattern of hyperventilation and upper chest breathing:
A reduced degree of CO2 resulting in excessive alkalinity
can also produce this effect. A degree of visceral stasis and pelvic floor weakness will
In tetany that is secondary to alkalosis (excessive alkalin develop, as will an imbalance between increasingly weak
ity), muscles which maintain 'attack-defense' mode (hunched abdominal muscles and increasingly tight erector spinae
shoulders, jutting head, clenched teeth, scowling) are those muscles.
78 C L I N I C A L A P P L I CAT I O N OF N E U R O M U S C U LA R T E C H N I Q U E S : T H E U P P E R B O DY
Fascial restriction from the central tendon of the Remember that thefunctional status of the diaphragm is prob
diaphragm via the pericardial fascia, all the way up to the ably the most powerful mechanism of the whole body. It not
basiocciput, will be noted. only mechanically engages the tissues of the pharynx to the
The upper ribs will be elevated and there will be sensi perineum, several times per minute, but is physiologically
tive costal cartilage tension. indispensable to the activity of every cell in the body. A work
The thoracic spine will be disturbed by virtue of the lack ing knowledge of the crura, tendon, and the extensive ramifi
of normal motion of the articulation with the ribs and cation of the diaphragmatic tissues, graphically depicts the
sympa thetic outflow from this area may be affected. significance of structural continuity and functional unity. The
Accessory muscle hypertonia, notably affecting the sca le wealth of soft tissue work centering in the powerful mecha
nes, upper trapezius and levator scapulae, will be palpa nism is beyond compute, and clinically it is very practical.
ble and observable.
Fibrosis will develop in these muscles as will myofascial
trigger points (see pp. 65-66). The cen1ical spine will ADDITIONAL EMOTIONAL FACTORS AND
become progressively more rigid, with a fixed lordosis MUSCULOSKELETA L DYS FUNCTION
being a common feature in the lower cervical spine.
A reduction in the mobility of the 2nd cervical segment Use of electromyographic techniques has shown a statis
and disturbance of vagal ou tflow from this region is tical correlation between unconscious hostility and arm
likely. tension as well as leg muscle tension and sexual distur
bances (Shagass & Malmo 1954).
Although not noted in Garland's list of dysfunctions, the Wolff (1948) proved that the majority of patients with
other changes which Janda has listed in his upper crossed headache showed 'marked contraction in the muscles of
syndrome (see p. 82) are likely consequences, including the the neck . . . most commonly due to sustained contrac
potentially devasta ting effects on shoulder function of the tions associa ted with emotional strain, dissatisfaction,
altered position of the scapulae and glenoid fossae as this apprehension and anxiety'.
pattern evolves. Barlow (1959) sums up the emotion/ muscle connection
Also worth noting in relation to breathing function and thus:
dysfunction are the likely effects on two important muscles,
not included in Garland's description of the dysfunctions Muscle is not only the vehicle of speech and expressive gesture,
resulting from inappropriate breathing patterns, quadratus but has at least a finger in a number of other emotional pies -
lumborum and iliopsoas, both of which merge fibers with for example, breathing regulation, control of excretion, sexual
the diaphragm. functioning and, above all, an influence on the body schema
Since these are both postural muscles, with a propensity through proprioception. Not only are emotional attitudes, say,
to shortening when stressed, the impact of such shortening, of fear and aggression, mirrored immediately in the muscle,
uni- or bilaterally, can be seen to have major implications but also such moods as depression, excitement and evasion
for respiratory function, whether the primary feature of have their characteristic muscular patterns and postures.
such a dysfunction lies in diaphragmatic or muscular A comprehensive review by Linton (2000) of over 900
distress. studies involving back and neck pain concluded that
Among possible stress factors that will result in shorten psychological factors play a significant role, not only in
ing of postural muscles is disuse. When upper chest breath chronic but also in the etiology of acute pain - particu
ing has replaced diaphragmatic breathing as the norm, larly in the process of transition to chronicity. 'Stress, dis
reduced diaphragmatic excursion results and consequent tress or anxiety as well as mood and emotions, cognitive
reduction in activity for those aspects of quadratus l umbo functioning, and pain behavior, all were found to be
rum and psoas which are integral with it. Shortening (of significant in the analysis of 913 potentially relevant
any of these) would likely be a result of this disuse pattern. articles.'
Garland concludes his listing of soma tic changes associ
ated with hyperventilation: 'Physically and physiologically We must not ignore the influence of emotion on muscu
[all of] this runs against a biologically sustainable pattern, loskeletal dysfunction at our (and our patients') peril.
and in a vicious cycle, abnormal function (use) alters nor
mal structure, which disallows return to normal function.'
Garland also s ugges ts tha t counseling (for associa ted SELECTIVE MOTOR UNIT INVOLVEMENT
anxiety or depression, perhaps) and breathing retraining (Waersted et a l 1 992, 1 993)
are far more likely to be successfully initiated if the biome
chanical componen t(s), as outlined, are appropriately The effect of psychogenic influences on muscles may be
treated. more complex than a simplistic 'whole' muscle or regional
Pioneer osteopathic physician Carl McConnell (1962) involvemen t. Researchers at the Na tional Institute of
reminds us of wider implications of respiratory dysfunction. Occupational Health in Oslo, Norway, have demonstrated
4 Causes of musculoskeletal dysfu nction 79
J
that a small number of motor units, particularly muscles, The researchers report tha t similar observa tions have been
may display almost constant, or repeated, activity when noted in a pilot study (Waersted et aI 1992).
influenced psychogenical ly. In their study normal individu The implications of this information are profound since
als performing reaction time tasks were evaluated, creating they suggest tha t emotional stress can selectively involve
a 'time pressure' anxiety. Using the trapezius muscle as the postural fibers of muscles, which shorten over time when
focus of attention, the researchers were able to demonstrate stressed (Janda 1983). The possible 'metabolic crisis' sug
low-amplitude levels of activity (using surface EMC) even gested by this research has strong parallels with the evolu
when the muscle was not being employed. They explain tion of myofascial trigger pOints as suggested by Wolfe &
this phenomenon as follows. Simons (1992), a topic which will be discussed in greater
detail in later chapters.
In spite oflow total activity level ofthe muscle, a small pool of
low-threshold motor units may be under considerable load for
prolonged periods of time. Such a recruitment pattern would
be in agreement with the 'size principle' first proposed by CONC LUSION
Henneman (1957), saying that motor units are recruited
according to their size. Motor units with type I [postural] We have observed in this cha pter evidence of the negative
fibers are predominant among the small, low-threshold units. influence on the biomechanical components of the body, the
If tension-provoking factors [anxiety, for example] are f e r muscles, joints, etc., of overuse, misuse, abuse and disuse,
quently present and the subject, as a result, repeatedly whether of a mechanical (posture) or psychological (depres
recruits the same motor units, the hypothesized overload may sion, anxiety, etc.) na ture. We have also seen the interaction
follow. This can possibly result in a metabolic crisis and the of biomechanics and biochemistry in such processes, with
appearance of type I fibers with abnormally large diameters, breathing dysfunction as a key example of this. In the next
or 'ragged-red' fibers, which are interpreted as a sign of mito chapter we will explore some of the patterns which emerge
chondrial overload. (Edwards 1 988, Lnrsson et a1 1 990) as dysfunction progresses.
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81
Chapter 5
Patterns of dysfunction
This involves ga thering evidence, and then interpreting Pectoralis major and minor
it in the context of the processes of which the individual is Upper trapezius which all tighten
currently part. How tight, loose, weak, bunched, flaccid, Levator scapulae and shorten
symmetrical, balanced, sensitive or painful the tissues are Sternocleidomastoid
can tell a potent story - but we have to add the words, the while
explana tions. Lower and middle trapezius all weaken
Interpretation of the evidence emerges from the sensations Serra tus anterior and rhomboids
that we perceive with our hands, and to which we add the
As these changes take place they alter the relative posi
descriptors that add color and pattern to the story. The thera
tions of the head, neck and shoulders as follows.
peutic choices that emerge from the patient's symptoms, his
tory and the evidence that tests, palpation and assessment 1. The occiput and C1 and C2 will hyperextend, with the
offer are a crucial part of the therapeutic encounter. head being translated anteriorly. There will be weakness
From the accumulated evidence we need to identify what of the deep neck flexors and increased tone in the suboc
it is tha t the individual is adap ting to, the background to the cipital musculature.
presenting symptoms. Inappropria tely focusing on symp 2. The lower cervicals down to the 4th thoracic vertebra will
toms ra ther than on trying to understand the bigger contex be posturally stressed as a result.
tual picture, and then using this to frame stra tegies tha t 3. Rotation and abduction of the scapulae occur as the
encourage self-regulation, is likely t o retard recovery. increased tone in the upper fixators of the shoulder (upper
Intervention calls for therapeutic choices tha t reduce adap trapezius and levator scapulae, for example) causes them
tive demands and / or enhance adaptive capacity - so allow to become stressed and shorten, inhibiting the lower fixa
ing self-regulation to operate more efficiently, while tors, such as serratus anterior and the lower trapezius.
simultaneously preventing exacerbations and recurrences. 4. As a result the scapula loses its stability and an al tered
When a chain reaction develops, in which some muscles direction of the axis of the glenoid fossa evolves, result
shorten (postural, type I) and others weaken (phasic, type ing in humeral instability that involves additional leva tor
II), predictable patterns involving imbalances emerge. Czech scapulae, upper trapezius and supraspinatus activity to
researcher Vladimi r Janda MD ( 1982, 1 983) describes two of maintain functional efficiency.
these, the upper and lower crossed syndromes, as follows.
These changes lead to cervical segment strain, the evolution
of trigger points in the stressed structures and referred pain
to the chest, shoulders and arms. Pain mimicking angina
UPPER CROSSED SYNDROME (FIG. 5.1)
may be noted, plus a decline in respiratory efficiency.
The solution, according to Janda, is to be able to identify
The upper crossed syndrome, also known as the shoulder
the shortened structures and to release (stretch and relax)
neck or proximal crossed syndrome (Liebenson 2006),
these, followed by reeducation toward more appropriate
involves the following basic imbalance.
function. This key underlying pattern of dysfunction will be
found to relate to a great many of the painful conditions of
the neck, shoulder and arm, all of which will be considered
in later chap ters. \Nha tever other local trea tment these
receive, consideration and reform of patterns, such as the
upper crossed syndrome, must form a basis for long-term
rehabilitation.
Figure 5.1 Upper crossed syndrome (after Janda). Reproduced with The result of this chain reaction is to tilt the pelvis for
permission from Chaitow (1996). ward on the frontal plane, while flexing the hip joints and
5 Patterns of dysfunction 83
exaggerating lumbar lordosis. LS-Sl will have increased The solution for these common pa tterns is to identify both
likelihood of soft tissue and joint distress, accompanied by the shortened and the weakened structures and to set about
pain and irritation. An additional stress feature commonly normalizing their dysfunctional status. This might involve:
appears in the sagittal plane in which:
deactivating trigger points within them or whi ch might
Quadra tus lumborum shortens be influencing them
while normalizing the short and weak muscles with the objec
Gluteus maximus and medius} weaken tive of restoring balance. This may involve purely soft tis
sue approaches or be combined with osseous adjustment/
When this 'la teral corset' becomes unstable the pelvis is
mobilization .
held in increased elevation and is accentuated when walk
ing. This instability results in LS-Sl stress in the sagittal Such approaches should coincide with reeducation of pos
plane, which leads to lower back pain. The combined ture and body usage, if results are to be other than short term.
stresses described produce instability at the lumbodorsal
j unction, an unstable transition pOint at best.
LAYER (STRATIFICATION) SYNDROME
The piriformis muscles are also commonly involved. In
(FIG. 5.3)
10--20% of individuals, the right piriformis is penetrated
by either the peroneal portion of the sciatic nerve or, rarely,
The layer (stratification) syndrome is a combination of upper
by the whole nerve (the incidence of this is greatly increased
and lower crossed syndromes. According to Janda et al
in individuals of Asian descent) (Kuchera & Goodridge 1997).
Piriformis syndrome can therefore produce direct sciatic pres
Muscle hypotrophy Muscle hypertrophy
sure and pain (but not beyond the knee) (Heinki ng et aI 1997).
Arterial involvement of piriformis shortness can produce
ischemia of the lower ex tremity and, through a relative fix
ation of the sacrum, sacroiliac dysfunction and pain in the
hip. Dural dysfunction is also possible when sacral mechan Cervical erector spinae
Upper trapezius
ics are distorted in this way as the deformations place ten Levator scapulae
sion and torsion on the dural tube.
An almost inevitable consequence of a lower crossed
syndrome pattern is that stresses will translate superiorly, Lower stabilizers
thereby triggering or aggrava ting the upper crossed syn of the scapula
drome pattern outlined above. We can once again see how
the upper and lower body interact with each other, not only Thoracolumbar
functionally but dysfunctionally as well. erector spinae
Lumbosacral
erector spinae
Gluteus
maximus
Figure 5.2 Lower crossed syndrome (after Janda). Reproduced with Figure 5.3 Layer (stratification) syndrome. Reproduced with
permission from Chaitow (1996). permission from Juli Et Janda (1987).
84 CLINICAL A P PLICATION OF NEUROMUSCULAR TECHNIQUES: T HE U P PER BODY
(2006), this has a poor prognosis for rehabilitation 'because assessed for the role they might be playing in the person's
of the fixed muscle imbalance patterns at the central nerv pain and restriction condi tions and certainly before these
ous system level'. can be successfully and appropriately treated. Various pro
tocols will be ou tlined in later chap ters that can assist in this
form of functional assessment.
elastic limits, beyond which it will break down or fail to narmal aI', in same cases, nat at all. Hence the arder in which
compensate (leading to decompensation). Grieve rightly muscles can tract is altered, as is caardinatian. The mast
reminds us that while attention to specific tissues incrimi characteristic feature, hawever, is substitutian, altering the
nated in producing symptoms often gives excellent short entire pattern. This change is particularly evident if the
term results, 'Unless treatment is also focused toward weak muscle is the aganist. If, hawever, the neutralizers
restoring function in asymptomatic tissues responsible for and/ar fixatars are weak, the basic pattern persists but there
the original postural adapta tion and subsequent decom is accessary matian; if the antagonists are weak, the range of
pensation, the symptoms will recur'. matian is increased. (Vasilyeva & Lewit 1996)
An example of Vasilyeva & Lewit's findings, relating specif
ically to a shortened upper trapezius, includes the follow
RECOGNIZING DYSF UNCTIONA L PATTERNS ing observations.
With a short upper trapezius muscle the a ttachments will
Vasilyeva & Lewit (1996) have cataloged observable changes deviate as follows, causing the listed changes.
in m uscle, elevating the art of inspection to a higher level.
The occipital bone will be pulled caudoventrally and
They state:
slightly laterally, causing the head to deviate forward
Because muscular imbalances manifest in individual mus and to the side, with rotation to the opposite side, leading
cles and therefore (primarily) in certain regions, but are fol to craniocervical lordosis.
lowed by compensatory reactions in other areas that restore There will be pull on the spinous processes adding to
balance, it is most important to determine which muscle(s) sidebending and rotation to the opposite side. In com
and which region are primarily affected and where compen pensation, scoliosis will develop at the cervicothoracic
sation is taking place. j unction, to the ipsilateral side, with increased kyphosis.
There will be relative fixation of the cervical and upper
Among the main criteria examined when assessing for pat
thoracic spine with increased mobility at the craniocervi
terns of imbala nce, for example in an extremity joint, are the
cal and cervicothoracic junctions.
following.
The acromion will be pulled craniomedially, leading to
Can the movement be carried out in the desired direction? the clavicle and acromion devia ting craniomedially, pro
Is the movement smooth and of constant speed? ducing compression of the clavicle at the sternal articula
Does the movement follow the shortest path? tion, with compensation involving sidebending at the
Does the movement involve the full range? shoulder girdle toward the opposite side, with rota tion to
the ipsila teral side.
The decision as to which muscles are probably implicated
when abnormal responses are noted is based on the The motor patterns during shoulder abduction, which will
following. be disturbed with a shortened upper trapezius, include the
following.
Dysfunction of agonists and synergists when the direc
tion of movement is abnormal. There will be a shearing between the clavicle and scapula
Neutralizer muscles are implicated if precise motion is at the acromioclavicular joint.
missing. The head and cervical spine w ill move into extension,
If movement is other than smooth, antagonists are ipsilateral flexion and contralateral rotation.
implicated. The shoulder girdle will displace superiorly on tha t side.
Wha t happens if the main culprits in disturbed motor pat Observation may also alert the practitioner to the presence
terns are shortened muscles? of a crossed syndrome - pelvis tilted anteriorly, protruding
abdomen, increased thoracic kyphosis, head thrust for
The shortened muscle is also hyperactive as a rule. Its irrita
ward, rounded shoulders, etc. But which muscles, specifi
tion threshold is lowered and therefore it contracts sooner
cally, among the many involved, are demonstrating relative
than normal, i.e. the order in which muscles contract in the
shortness or weakness or both? Testing is needed and this
normal pattern is altered. If, therefare, the aganist is shart
can involve functional tests (below), as well as a ssessment
ened, the relationship to' the synergists, neutralizers, fixa
of length and strength. A munber of these tests will be
tars and antaganists is aut af balance and the lacal pattern,
detailed in the text a ssociated with particular regions and
i.e. the direction, smoothness, speed and range af matian, is
joints later in the book.
disturbed in a characteristic way. (Vasilyeva & Lewit 1996)
What happens if the main culprits in disturbed motor pat
terns are weak muscles? EXCESSIVE MUSCULAR TONE
The threshold of irritation in the weakened muscle is raised Muscle tone (residual muscle tension) is the continuous,
and therefare, as a rule, the muscle can tracts later than passive partial contraction of muscles. It helps maintain
5 Patterns of dysfunction 87
posture and is often even present during REM sleep. It The limitation of range of motion of a muscle is estimated
depends physiologically on two factors: the basic viscoelastic clinicaUy by slowly extending the muscle until it reaches
properties of the connective tissues associated with the mus a barrier of increasing tension, which could be because of
cle and/ or the degree of activation of the contractile appara increased viscoelastic tension, spastici ty, physiological
tus of the muscle Oanda et a12006, Simons & Mense 1 998). con tracture or fibrosis. vVhen this test shows increased
Janda et al (2006) discuss the importance yet difficulties range of motion (hypermobility) it suggests decreased
of differen tial diagnosis since each condi tion requires a dif muscle tone or laxity of ligamentous and capsular con
ferent type of treatment: nective tissues.
A 'flapping test' for assessing hypo- and hypertonia is
In the former [viscoelastic properties], we speak about muscle
performed by 'grasping the fingertips of the extended
tightness, stiffness, loss of flexibility or extensibility (length)
arms and rhythmically shaking them up and down to see
and in the latter [contractile properties], it is a real increase
how loose or how stiff the muscula ture of each extremity
of muscle contractile activity such as in spasmodic torticol
is'. With progressively more rapid movements, the exam
lis or trismus . . . Clinically, resting muscle tone presents a
iner can estimate the resonant frequency of each limb .
combination of both situations (contractile and viscoelastic
Proximal-distal and bilateral differences are noted.
properties) . . . However, measuring muscle tone objectively
The Wartenberg pendulum test: This simple but extremely
presents a dilemma. Tests of viscoelasticity involve measure
useful test is performed with the relaxed patient sitting
ments of the velocity of motion, viscosity, thixotropy, and
on the edge of the table with legs hanging freely over the
resonant frequency when load is gradually applied. Tests of
edge. The examiner lifts both legs to the horizontal posi
contractile activity are far simpler in tlUlt EMG can be used;
tion (knees straight) and then releases them, observing
however, this is not without inherent difficulties, as in trig
their movement as they swing freely. A normal leg
ger points where only small loci in the muscle show
swings in smoothly decreasing arcs. However, overreac
increased electrical activity. The degree of muscle stiffness
tive reflex activity reduces the number and smoothness
in relaxed subjects can be seen therefore to include both vis
of oscillations of an affected limb, while muscular hypo
coelastic tone and muscular contractile factors.
tonia gradually decreases the amplitude of the arcs.
Regardless of the source, excessive muscular tone is undesir
able since it interferes with normal physiological function Hannon (2006) has revisited this simple test which was ini
ing as well as being wasteful of energy. Yet, it is important to tially developed in the early 1 950s by Wartenberg (1951).
differentiate - through palpa tion of the layers of tissue Hannon suggests tha t this test can be used to evaluate exces
(skin, fascia, fat, muscle fibers, etc.) and inspection of pos sive, Lmnecessary tension in the quadriceps, which offers
ture, patterns of movement and gait analysis - as much as is evidence of what he terms 'underlying "parasitic" muscular
subjectively and objectively possible to determine as the effort' tha t represents a current inability for the individual
cause for the increased tone. to relax the muscles involved. Hannon notes tha t patellar
tension is often seen in the asymptomatic individual, and,
in fact, 'it is rare to find adults able to fully relax the patella
SIMPLE FUI\ICTIONAL TESTS FOR ASSESSING a t will'.
EXCESS MUSCULAR TONE The patient is in a Sitting position with the legs hanging
Simons & Mense (1 998) define resting muscle tone as the vertically.
'elastic and/or viscoelastic stiffness in the absence of con The leg under examination is passively ex tended to 45
, and then released.
tractile activity (motor unit activity and / or contracture) .
Lakie et al (1980) concluded tha t there was no reduction in The pendular movement of the leg is observed and
tone as a resu lt of surgical anesthesia and therefore tha t the documented.
elastic tone of normal resting muscle must be caused by i ts In a relaxed state approximately 10 cycles of elliptical
viscoelastic properties in the a bsence of muscle contractile pendulum swings will occur. 'The classic observa tion is
activity. In clinical practice muscle tone is measurable as the number of cycles accrued before the leg comes to rest.'
stiffness, which is the resistance to passive movement.
This simple test has been applied to the study of aging mus
Studies in 1 998 (Simons & Mense) and 2001 (Mense &
cle responsiveness, cerebral palsy, fibromyalgia, spinal cord
Simons) led the authors to suggest the following simple
injury and vertebral conditions (Fowler et al 2001, Le
methods for evaluating muscle ' tone':
Cavorzin et al 200 1 , Wachter et aI1 996) .
The compliance (compressibility) of a muscle is assessed Hannon notes that even
clinically by pressing a finger into it or by squeezing i t excess muscular effort since tension in the hip rota tors turns
between the fingers to determine how easily i t i s indented the femur either internally or externally. This deviates the
and how 'springy' it is. The less easily it is indented, and shin from the vertical in the frontal plane. The trajectory of
the more it tends to return to i ts original shape, the more the foot during the oscilla tion of the swinging knee, shin pos
stiff (elastic) it is. ture and extraneous effort all offer additional informa tion.
88 CLINICAL A P PLICATION OF NEUROMUSCULAR TEC HNIQUES : THE U P PER BODY
"
I
,
,
, ,
I I
I I
I
,
I
I I
\ I
\ \
\ \
\, ....
A B (i) (ii)
Figure 5.4 A: Wartenberg pendulum test. Sitting, the patient's leg is extended to 45. The leg is released and the pendular swing is observed
and documented. B: Resting shin position. Observation of resting shin posture may identify subtle muscle tension. A slanted shin in the
frontal plane suggests hip rotator tension. A sagittal slant points toward tension in the knee flexors or extensors. C: Extraneous exertion and
passive knee movements. The knee is moved passively to help the patient notice extraneous effort. At fi rst, use only the smallest of
movements. Watch for shudderi ng and stiffness. D: Elliptical versus l inear foot trajectory. In the picture, the shin appears l i ke a swinging
shaft hanging from a hook. If the hook also rolls, as does the femur, the freely moving shin w i l l reflect both the swinging and ro l l i ng
movements. Relaxed pelvic rotators, hamstrings and quadriceps muscles allow the swinging foot to travel an ell iptical path. Tensing the hip
rotators restricts travel to a linear trajectory. Tensing the other muscles reduces the extent of the swing. Reproduced with permission from
Hannon (2006).
Janda has developed a series of assessments - functional A key aspect of Janda's functional assessments relates to
tests - that can be used to show changes that suggest imbal the proposed firing sequence of muscles when particular
ance, via evidence of over- or underactivity. Some of these actions (e.g. hip ex tension, hip abduction) are performed.
are ou tlined below. Jull & Janda (1987) observed that the firing order of the
key muscles for hip/ leg ex tension should be as follows: first
the ipsilateral hamstrings, followed by ipsilateral glu teus
F UNCTIONAL SCREENING SEQ UENCE maximus, and then contrala teral lumbosacral erector
spinae, ipsila teral lumbosacral erector spinae, contralateral
Janda (1996) and Janda et al (2006) have claimed that altered thoracolumbar erector spinae and finally ipsila teral thora
movement patterns can be tested as part of a screening columbar erector spinae.
examina tion for locomotor dysfunction. In general, obser Janda (1982) described the hamstrings and gluteus max
vation a lone is said to be all that is needed to determine imus as prime movers in prone hip extension, with the erec
the al tered movement pattern. However, light palpation tor spinae stabilizing the spine and pelvis.
may also be used if observa tion is difficult due to poor light Based on EMG studies, Vogt & Banzer (1997) disagreed,
ing, a visual problem or if the person is not sufficiently and suggested that the firing pa ttern for prone hip exten
disrobed. sion should be: ipsilateral erector spinae, followed by ipsi
Although some of these tests relate directly to the lower lateral hamstring, contrala teral erector spinae, tensor fascia
back and limb, their relevance to the upper regions of the latae and finally gluteus maximus.
body should be clear, based on the interconnectedness of The usefulness and accuracy of some of these tests has been
body mechanics, as previously discussed. brought into question by research that shows inconsistency
5 Patterns of dysfunction 89
in some of the purported firing patterns (see description In the test (below) it is suggested that both the movement
below), when groups of asymptomatic individuals were pattern, as well as the timing sequence, should be observed .
tested. The question is also raised as to how accurate palpa
tion methods can be when the difference in firing between
specific muscles may be as little as 30 milliseconds (Lehman PRONE HIP (LEG ) EXTENSION (PLE) TEST
et aI2004). (FIG. 5.5)
The answer to at least some of the objections involves a
Purpose: To assess for the presence of true or false hip exten
weakness in the research in which asymp tomatic individuals
sion, as well as to check for coordinated firing pa tterns dur
are the subjects used in the studies. This factor alone ensures
ing hip extension. Janda did not encourage the palpa tion
that the population being studied fails to match pa tients
approach described below be performed simul taneously
who will be seen clinically - who by definition are unlikely
with the observations, and suggested tha t it interfered with
to be asymptomatic.
normal function. Instead he encouraged observation first,
Lehman et al note that 'In this current study the only con
as described, and suggested tha t ii palpation is carried out
sistent finding between subjects was tha t 13/14 subjects
during the test, this should be after first evalua ting the
fired the gluteus maximus last [on prone leg extension].'
movement pa tterns by observation alone.
In Janda's observation, this finding would be most likely
to occur when gluteus maximus is inhibited, probably due
to excessive tone/ activity in the erector spinae group. Since Observation with palpation
this is a very common clinical presenta tion in symptomatic
The person lies prone and the practitioner stands to the
individuals, it is reasonable to assume tha t many asympto
side at waist level with the cephalad hand spanning the
matic individuals have similar imbalances prior to the onset
lower lumbar musculature and assessing erector spinae
of symptoms. This is acknowledged by the researchers
activi ty bila terally.
who state:
The caudad hand is placed so that the heel lies on the
[We were] unable to identify what is truly an abnormal pat gluteal muscle mass with the fingertips on the hamstrings.
tern of muscular activation. While the participants included The person is asked to raise the leg into extension as the
in this study had no current symptoms they may still have practi tioner assesses the firing sequence.
dysfunctional motor activation patterns, which have not The normal activation sequence is said to be (1) gluteus
presented symptomatically. Future studies should look at maximus, (2) hamstrings, followed by (3) erector spinae
the relationship between activation patterns and the onset of contrala teraL then (4) ipsilatera l. (Note: As discussed
future dysfunction. It should also be noted that the PLE test above, not all researchers or clinicians agree with this
is also used to assess the movement kinematics of patients. sequence. Some believe the hamstrings should fire first,
This paper only investigated muscle onset timing and did or that there should be a simultaneous contraction of
not assess movement kinematics. The PLE test may still be hamstrings and gluteus maxim us.)
a valid test for assessing movement dysfunction, however, If the hamstrings and / or erectors take on the role of
no work has been done to assess this possibility. glu teus as the prime mover, they w ill become shortened
90 CLINICAL A P PLICATION OF NEUROMUSCULAR TECHNIQUES: THE U P PER BODY
(see notes on postural and phasic muscle response to TRUNK FLEXION TEST (FIG. 5.6)
stress and overuse in Chapter 2).
The person is supine with arms extended and reaching
Janda says, 'The poorest pattern occurs when the erector
toward the knees, which are flexed with feet flat on table.
spinae on the ipsilateral side, or even the shoulder girdle
The person is asked to maintain the lumbar spine against
muscles, initiate the movement and activation of gluteus
the table and to slowly lift the head, then the shoulders
maximus is weak and substantially delayed . . . the leg lift
and then the shoulder blades from the table.
is achieved by pelvic forward tilt and hyperlordosis of
Normal function is represented by the ability to raise the
the lumbar spine, which undoubtedly stresses th.is
trunk until the scapulae are clear of the table without the
region' .
feet lifting or the lower back arching.
Abnormal function is indicated when the feet (or a foot)
Kinesthetic aspect of the test lift from the table or the low back arches, before the
scapulae are raised from the table. This indicates psoas
When the hip extension movement is performed there
overactivity and weakness of the abdominals.
should be a sense of the lower limb 'hinging' from the hip
j oint. Note: It may be helpful for the practitioner to slide his hand
If, instead, the hinge seems to occur in the lumbar spine, under the patient's lower back prior to testing to directly
the indication is tha t the lumbar spinal extensors have feel the lifting of the lumbar spine since this movement may
adopted much of the role of gluteus maximus and that not be readily visible on some patients.
these extensors (and probably hamstrings) will have
shortened.
HIP ABDUCTION TEST (FIG. 5.7)
Morris et al (2006) observe tha t the test is positive (i.e. the
Purpose: To screen for the dynamic stability or instability of
pattern is dysfunctional) if:
the lumbopelvic region during hip abduction.
1. significant knee flexion of the ipsilateral leg occurs, sug
The person lies on the side, ideally with head on a cush
gesting overactiva tion of the hamstrings
ion, with the upper leg straight and the lower leg flexed
2. there is delayed or absent ipsila teral gluteus maximus
contraction. Th.is is considered a very important finding
3. the presence of false hip extension is observed. This is
demonstrated when the pivot point (hinge) of the leg
extension during the initial 10 occurs totally or in part a t
the sacroiliac region, instead of totally a t the h i p joint
4. lowering of the flank occurs on either side, suggesting
rotation due to poor lumbopelvic functional stability
5. early contraction takes place at the periscapular muscu
lature, strongly suggesting a chronic functional low back
instability. This is most frequently observed on the con ------ -----
tralateral side. This finding suggests that recruitment of
the upper torso muscula ture has occurred during the hip
extension movement pattern in order to expedite the Figure 5.6 Trunk flexion test. If feet leave the surface or back
process. arches, psoas shortness is indicated. Reproduced with permission
from ehaitow (1996).
at hip and knee, for balance. The uppermost (straight) leg The person is asked to let the arm being tested hang
should rest on the lower leg, the hip of which should be down and to flex the elbow to 90 with the thumb point
flexed to 45 while knee should be flexed to 60. It is ing upward.
important for the patient's upper leg to remain in line The person is asked to slowly abduct the arm toward the
with the torso. horizontal.
The practitioner, who is observing, not palpating, stands A normal abduction will include eleva tion of the shoul
in front of the person and toward the head end of the table. der and/ or rotation or superior movement of the scapula
The person is asked to slowly raise the leg into abduction. only after 60 of abduction.
Normal is represented by pure hip abduction to 45. Note: Abnormal performance of this test occurs if elevation of
The leg should abduct to 20 withou t in ternal or external the shoulder, rotation, superior movement or winging of
rotation or any hip flexion. There should be no ipsilateral the scapula occurs within the first 60 of shoulder abduc
pelvic 'hip hike' (cephalad elevation). A slight initial con tion, indicating levator and / or upper trapezius as being
traction of the lumbar erector spinae or quadratus lum overactive and shortened, while lower and middle trapez
borum may be observed. This is considered to represent a ius and serra tus anterior are inhibited and are therefore
normal isometric stabilizing contraction . weak.
Abnormal is represented by:
1. hip flexion during abduction, indicating tensor fascia
Variation 1
lata (TFL) shortness, and / or
2. the thigh externally rotating during abduction, indi The person performs the abduction of the arm as described
ca ting piriformis shortness, and/ or above and the practitioner observes from behind.
3. 'hip hiking', indicating quadratus lumborum short A 'hinging' should be seen to take place at the shoulder
ness (and probable gluteus medius weakness), and/ or joint, if upper trapezius and levator are normal.
4. posterior pelvic rotation, suggesting short antagonis
tic hip adductors.
Variation 1
Before the test is performed the practitioner (standing
behind the sidelying patient) lightly places the fingertips
of the cephalad hand onto the lateral margin of quadratus
lumborum while also placing the caudad hand so that the
heel is on gluteus medius and the fingertips on TFL.
If quadratus lumborum is overactive (and, by definition,
shortened - see p. 34), it will fire before gluteus and pos
sibly before TFL.
The indica tion would be tha t quadratus (and possibly
TFL) had shortened and tha t gluteus medius was inhib
i ted and weak.
A
Variation 2
When observing the abduction of the hip, there should be
a sense of 'hinging' occurring at the hip and not at waist
level.
If there is a definite sense of the hinge being in the low
back/ waist area the implica tion is the same as in varia
tion 1 - that quadra tus is overactive and shortened, while
glu teus medius is inhibited and weak.
,.
SEATED ASSESSMENT (J a n d a 1 9 8 2 )
1. The patient places a hand on the upper abdomen and
another on the upper chest. The practitioner observes the
hands as the pa tient inhales and exhales normally several
"
"
I times. If the upper hand (chest) moves superiorly rather
than anteriorly, and moves significantly more than the
hand on the abdomen, this suggests a dysfunctional
\
'upper chest' pattern of brea thing (see Fig. 14. 1 0, p. 553).
2. The practitioner stands behind and places both hands
gently over the upper trapezius area, fingertips resting
on the superior aspect of the clavicles. As the patient
B ------ inhales the practitioner notes whether the hands move
Figure 5.9 N eck flexion test. A: Normal flexion. B: Abnormal flexion significantly superiorly. If they do, the scalenes are
('chin poking' ) . sugges ting shortness of SCM. Reproduced with overworking, indicating stress and therefore possible
permission from Chaitow ( 1 996). shortening.
------ .----
5 Patterns of dysfunction 93
3. The practi tioner stands or crouches facing the pa tient the lower rib cage, fingers wrapping posteriorly along
who is seated on the edge of the treatment table and the rib shafts. The tissues are then tested for their rota
places the hands on the patient's lower ribs, one on each tional preference, by easing the superficial tissues and
side with fingers wrapping to the posterior surface, and the ribs in a rotational manner, right and then left. Ideally,
notes whether there is lateral excursion of the hands on a symmetrical degree of rota tion should be noted.
inhala tion to evaluate symmetry of movemen t.
4. Standing to the side the practitioner observes the spinal
SID ELYING ASSESSME NT
contours as the patient fully flexes. If there a re obvious
'flat' a reas of the spine (suggesting inability to flex fully), Quadratus lumborum is tested for shortness by direct pal
especially in the thoracic region, this may indicate rib pation (see Volume 2) and/or by use of the functional
restrictions at those levels. assessment described earlier in this chap ter. Quadratus
lumborum is connected to the diaphragm (via a fascial
encasement tha t becomes the lateral arcuate ligament)
SUPI NE ASSESSMENT
(Palastanga et al 2002) as weJ l as to the 12th rib (via d irect
1 . The brea thing pattern is observed. Does the abdomen attachmen t). QL may be involved in breathing dysfunction,
move forward on inhala tion, or does the upper chest particularly when there is reduced lower rib excursion.
inappropriately move first while the abdomen retracts? If
the latter, breathing retraining is called for, as this is a
PRONE ASSESSMENT
paradoxical breathing pattern.
2. Is there a normal observable lateral excursion of lower ribs? 1 . The so-called 'breathing wave' is observed - there should
3. Assessmen t should be performed for shortness of all res be a continuous wave from the base of the spine to the
piratory muscles available in the supine position, includ neck on deep inhalation (Lewit 1 999). If movement starts
ing the following tha t are either involved in respiration above the sacrum (common), or if regions of the spine
or which - if shortened - could interfere with normal res move as a 'block' instead of in a sequential wave-like man
pira tory function: pectoralis major, latissimus dorsi, ster ner, this can be noted as the current representation of a
nomastoid, psoas (since this merges with the diaphragm). dysfunctional pattern, as it involves thoracic spinal move
4. The practitioner stands at waist level while facing the ment. Areas moving en bloc are commonly those areas that
head and places the hands fully extended on each side of were observed not to flex fully in the seated assessmen t.
2. The practitioner can now palpate and evaluate for trigger Box 5.2 Trigger point chains (Hong 1 994)
point activity in muscles available in the prone pOSition
tha t are associated with respiration or which - if short When key trigger points were deactivated, Hong noted that
ened - could interfere with normal respiratory function. trigger points in d istant areas, which had previously tested as
active, became inactive.
The findings from these assessments point toward what is
necessary in therapeutic or rehabilita tion terms as part of Deactivated trigger Inactivated associated triggers
breathing retraining (Chaitow et al 2002).
Sternocleidomastoid Tem pora lis, masseter, digastric
Upper tra pezius Tem pora lis, masseter, splenius,
TRIGGER POINT CHAINS (Mense 1 993, Patterson semispinalis, levator scapulae,
1 976, Simons et al 1 999, Trave l l Et Si mons 1 992) rhomboid minor
Sca len ii Deltoid, extensor carpi radia lis,
As compensatory postural patterns emerge, such as Janda's extensor digitorum com munis
crossed syndromes which involve distinctive and (usually) Splenius ca pitis Tem pora lis, sem ispinalis
easily identifiable rearrangements of fascia, muscle and
Supraspinatus Deltoid, extensor carpi radialis
joints, it is inevitable that local, discrete changes should also
evolve within these distressed tissues. Such changes include Infraspinatus Biceps brachii
areas that, because of the particular stresses imposed on Pectoralis minor Flexor carpi rad ial is, flexor carpi
them, have become irrita ted and sensitized. u l na ris, first dorsal interosseous
If particular local condi tions apply (see Chapter 6), these Latissimus dorsi Triceps, flexor carpi u l naris
irritable spots may eventually become hyperreactive, even
Serratus posterior Triceps, latissimus d orsi, extensor
reflexogenically active, and mature into major sources of
su perior digitorum communis, extensor carpi
pain and dysfunc tion. This form of dysfunctional adapta ulnaris, flexor carpi u l naris
tion can occur segmentally (often involving several adjacent
Deep paraspinal Gluteus maximus, medius, m i n imus;
spinal segments) or in soft tissues anywhere in the body (as
muscles (L5-Sl ) piriformis, hamstrings, tibialis,
myofascial trigger points). The activation and perpetuation peroneus longus, soleus,
of myofascial trigger points now becomes a focal point of gastrocnemius
even more adaptational changes. Quadratus l umborum Gl uteus maximus, medius, m i n imus;
Clinical experience has shown tha t trigger point 'chains' piriformis
emerge over time, often contributing to predictable patterns
Piriformis Hamstrings
of pain and dysfunction. Hong (1994), for example, has
shown in his research that deactivation of particular trigger H amstri ngs Peroneus longus, gastrocnemi us,
soleus
points (by means of injection) effectively inactivates remote
triggers (see Box 5.2). In the next chapter the trigger point
phenomenon will be examined in some detail.
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Edi.nb urgh body balance more in chronic low back subjects that in healthy
Chai tow L 2004 Breathing pa ttern disorders, motor control and low subjects? Clinical Biomechanics 1 7:548-550
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Chaitow L, Bradley D, Gilbert C 2002 Multidisciplinary approaches patella (part 1 ) . Journal of Bodywork and Movement Therapies
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Cho l ewick i ) , Silfies S 2005 Clinical biomechanics of the lumbar Heinking K, Jones III J M, Kappler R 1997 Pelvis and sacrum.
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Fowler E, Ho T, Nwigwe A, Dorey F 2001 The effect of quadriceps Hong C-Z 1994 Considerations and recommendations rega rding
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Gray's anatomy for students 2005 Churchill Livingstone, Janda V 1982 Introduction to functional pathology of the motor sys
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------- --
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Janda V 1988 Muscles and cervicogenic pain syndromes. In: Grant Mense S, Simons D 2001 Muscle pain: lmderstanding its nature,
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Komendantov G 1945 Proprioceptivnije reflexi glaza i golovy u cle tone as related to clinical muscle pain. Pain 75( 1 ) : 1-17
krolikov. Fiziologiceskij Zurnal 31 :62 Simons D, Travell L Simons L 1999 Myofascial pain and dys fLU1c
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97
Chapter 6
Trigger points
In their second edition, Simons et al (1999) present an analyzed and in some instances refuted previous research
explanation as to the way they believe myofascial trigger into the area of myofascial trigger points, some of which
points form and why they form where they do. Combining they assert was poorly designed
information from electrophysical and histopathological suggested future research direction and design.
sources, their integrated trigger point hypothesis appears to
Simons et al (1999) present evidence which suggests that
be based solidly on current understanding of physiology
what they term 'central' trigger points (those forming in the
and function. Additionally, the authors have:
belly of the muscle) develop almost directly in the center of
validated their theories using research evidence the muscle's fibers, where the motor endplate innervates it
cited older research (some dating back over 100 years) as at the neuromuscular junction (Fig. 6.1). They postulate the
referring to these same mechanisms (see Box 6.1 for a following.
brief historical summary)
Box 6.1 Historical research into chronic referred muscle pain (Baldry 1993, Cohen Et GibbOns 1998, Simons 1988, 2004, Straus
1991, Van Why 1994)
F Va l l eix 1 841 Treatise on neuralgia. Paris (never substa ntiated) and suggested that pa i n sensations
Noted that when certa i n pa i nfu l points were pal pated they pro emanati n g from nod u l es cou ld be due to nerve pressure (now
d uced shooting pai n to other reg ions (neurolgia). H e also reported d iscounted).
that diet was a precipitating factor in the development of th e Sir William Osler 1 909 Principles and practice of medicine.
painfu l aching symptoms of the back and cervical reg ion. Appleton, New York
Johan Mezger, mid-1 9th century (Haberl ing W 1 93 2 Johan Georg Considered the pa infu l aspects of muscular rheumatism (myalgia)
Mezger of Amsterdam. Founder of modern scientific massage. to i nvolve 'neuralgia of the sensory nerves of the muscles'.
Medical Life) W Tel l i n g 1 91 1 Nodular fibromyositis - an everyday affliction and
Dutch physicia n, developed massage techniques for treating 'nod its identity with so-called muscular rheumatism. Lancet
u l es' and ta ut cord-l i ke bands associated with this condition. 1 :154- 1 58
T I nman 1 858 Remarks on myalgia or muscular pain. British Ca l l ed the condition ' nodular fibromyositis.
Medical Jou rnal 407-408 :866-868 L Llewellyn, A Jones 1 9 1 5 Fibrositis. Rebman, New York
Was able to clearly state that radiating pa i n in these conditions Broadened the use of the word ' fibrositis' to include other condi
(myalgia) was independent of nerve routes. tions including gout.
Uno Helleday 1 876 Nordiskt Medicinkst Arkiv 6 Et 8 (8) A Schmidt 1 9 1 8 Muskelrheumatismus (Myalgiej. Marcus Et
Swedish physician d escribed nod u l es as part of 'chron ic myitis'. Webers Verlag, Bonn
H Strauss 1 898 Kl i n ische Wochenschrift 3 5 :89-91 Book on muscular rheumatism, myalgia.
German physician distinguished between palpable nodules and F Albee 1 927 Myofascitis - a pathological explanation of any
'bands'. apparently dissimilar conditions. American Jou rnal of Surg ery
I Adler 1 900 Muscular rheumatism. Medical Record 57:529-535 3:523-533
Identified cli nical phenomena characteristic of MTrPs as muscular Ca l l ed the condition 'myofascitis.
rheumatism. F Gudzent 1 93 5 Testunt und heilbehondlung von rheumatismus
A Cornelius 1 903 Narben und Nerven. Deutsche M i l i ta ra rztlische und gicht mid specifischen allergen. Deutsche Medizinsche
Zeitschrift 32:657-673 Wochenschrift 61 :901
German physician who demonstrated the pain-i nfl uencing fea German physician noted that chron ic 'muscular rheumatism' may
tures of tender points and n od u l es, i nsisti ng that the rad iating at times be allergic in orig i n and that removal of certai n foods
pathway was not determi ned by the course of nerves. H e a lso from the diet resulted in clinical improvement.
showed that external i nfluences, i ncluding climatic, emotional or M Lange 1 931 Die Muskelharten (Myogelosenj. J F Lehmann's
physical exertion, cou ld exacerbate the a l ready hyperreactive Verlag, Mu nchen
neural structu res associated with these conditions. Cornelius First trigger poi nt manual.
also d iscussed these pain phenomena as being d ue to reflex C H u nter 1 933 Myalgia o f the abdominal wall. Canadian Medical
mechanisms. Association Journal 28:1 57-1 61
A M u l ler 1 9 1 2 Untersuchungsbefund am rheumatische erkronten Described referred pa i n (myalgia) resulting from tender points sit
muskel. Zeitschrift Kl i n ische Medizin 74:34-73 uated i n the abdominal musculature.
German physician who n oted that to identify n od u l es and bands J Edeiken, C Wolferth 1 936 Persistent pain in the shoulder region
req u i red refined palpation skills, aided, he suggested, by l ubricat following myocardial infarction. American Journal of Med i cal
ing the skin. Science 191 : 20 1 -210
Sir William Gowers 1 904 Lumbago: its lessons and analogues. Showed that pressure applied to tender points i n scapula region
British Medical Jou rnal 1 : 1 1 7- 1 21 muscles cou ld reproduce shou lder pa in already bei ng experienced.
Suggested that the word fibrositis be used, believing erroneously This work i nfl u enced Janet Travel l - see bel ow.
that inflammation was a key feature of 'muscular rheumatism'. Sir Thomas Lewis 1 938 Suggestions relating to the study of
Lecture, National Hospital of Nervous Diseases, London. somatic pain. B ritish Medical Jou rnal 1 :321 -325
Ralph Stockman 1 904 Causes, pathology and treatment of chronic A major researcher into the phenomenon of pa i n in general,
rheumatism. Edinburg h Med i ca l Jou rnal 1 5 : 1 07-1 1 6, 223-225 charted severa l patterns of pa in referral and suggested that
Offered support for Gowers' suggestion by reporting finding Kel lgren (see below). who assisted him in these studi es, conti nue
evidence of inflammation i n con nective tissue i n such cases the resea rch.
box continues
6 Trigger points 99
J Kellgren 1938 Observations on referred pain arising from muscle. trial ingestion of allergenic foods or inhalation of house dust
Clinical Science 3 :17 5 -190 extract or particu lar hydrocarbons, with rel ief of symptoms often
Identified (in patients with 'fibrositis' and 'myalgio' ) many of the being achieved by avoidance of a l l ergens. Randolph reports that
features of our current understanding of the trigger point phe severa l of his patients who achieved rel ief by these means had
nomenon, incl ud ing consistent patterns of pain referra l - to dis previously been d iagnosed as having 'psychosomotic rheumatism'.
tant muscles and other structures (teeth, bone, etc.) from pain James Mennel l 1 9 52 The science and art of joint manipulation,
points ('spots') in muscle, l iga ment, tendon, joint and periosteal vol 7. Churchi l l , London
tissue - which could be obliterated by use of novocaine British physician described 'sensitive areas' which referred pain.
injections. Recommended treatment was a choice between manipu lation,
A Reichart 1938 Reflexschmerzen auf grund von myoglosen. heat, pressure and deep friction. He a l so em phasized the impor
Deutsche Medizinische Wochenschrift 64 :823 -824 tance of diet, fluid intake, rest, the possible use of cold and pro
Czech physician who identified and charted patterns of distri bu caine injections as well as suggesting cupping, skin rol l ing,
tion of reflex pain from tender points (nodu les) in particu lar massage and stretching in norma lization of' fibrositic deposits'.
muscles. Janet Travel l (and S Rinzler) 19 52 The myofascial genesis of pain.
M Gutstein 1 938 Diagnosis and treatment of muscular rheuma Postgrad uate Medicine 11 :425-434
tism. British Journal of Physical Medicine 1 :302-321 B u i lding on previous research and fol l owing her own detailed
Refugee Polish physician working in Britain who identified that in studies of the tissues involved, coined the word 'myofascial',
treating muscular rheumatism, manual pressure applied to tender adding it to Steind ler's term to produce 'myofascial trigger points'
(later ca l led 'trigger') points produced both local and referred and fina l ly ' myofascial pain syndrome'. Between 1 942 and 1 993,
symptoms and that these referra l patterns were consistent in Janet Travel l authored four books and more than 1 5 papers on
everyone, if the original point was in the same location. He deac TrPs; however, it was this paper that introduced referra l patterns
tivated these by means of injection. His other papers publ ished for 32 m u scles. Only one paper prior to her 1 983 book had a
between 1 938 and 1 9 51 identified the cond ition with 11 different minor mention of a loca l twitch response.
names, including common rheu matism, idiopathic mya lgia, rheu I Neufeld 1 9 52 Pathogenetic concepts of 'fibrositis' - fibropathic
matic mya lgia, myalgia, muscu lar sciatica, fibrositis, a m uscle dis syndromes. Archives of Physical Medicine 3 3 :363 -369
ease and non-articu lar rheumatism (see below as Gutstein-Good Suggested that the pain of 'fibrosistis-fibropathic syndromes' was
and as Good). due to the brain misinterpreting sensations.
A Steindler 1 940 The interpretation of sciatic radiation and the F Speer 1954 The allergic-tension-fatigue syndrome. Pediatric
syndrome of low back pain. Journal of Bone and Joint Surgery Clinics of North America 1 :1029 -1 037
22:28-34 Called the cond ition the 'allergic-tension-fatigue syndrome' and
American orthopedic surgeon who d emonstrated that novoca ine added to the pain, fatigue and general sym ptoms previously rec
injections into tender points located in the low back and g l uteal ognized (see Randolph above) the observation that edema was a
regions cou l d relieve sciatic pain. H e ca lled these points 'trigger feature, especially involving the eyes.
points'. Janet Travell (see below) was infl uenced by his work and R Gutstein 1 9 5 5 Review of myodysneuria (fibrositis). American
popularized the term 'trigger points'. Practitioner 6 :570-577
M Gutstein-Good 1 940 (sa me person as M Gutstein above) Called the cond ition' myodysneurio'.
Idiopathic myalgia simulating visceral and other diseases. Lancet R Nimmo 1 9 57 Receptors, effectors and tonus: a new approach.
2:3 26 -3 28 Journal of the National Chiropractic Association 27( 1 1 ) :21
Ca lled the cond ition 'idiopathic myalgio'. After many years of research, which paralleled chronologically that
M Good 1 941 (same person as M Gutstein and M Gutstein-Good of Travell, he described his concept of 'receptor-tonus technique',
above) Rheumatic myalgias. The Practitioner 1 46 :1 67 -1 74 involving virtua l ly the same mechanisms as those eventually
Ca lled the cond ition ' rheumatic myalgio'. described by Travell Et Simons (1 983a) but with a more manual
James Cyriax 1 948 Fibrositis. British Medical Journal 2:251 -255 emphasis. 'I have found that a proper degree of pressure, sequential ly
Believed that chronic muscle pain derived from nerve im pinge applied, causes the nervous system to release hypertonic muscle:
ment due to d isc degeneration. 'It [pressure on dura mater] has M Kel ly 1 962 Local injections for rheumatism. Medical Journal of
misled clinicians for decades and has given rise to endless m isd i Austra lia 1 :45 -50
agnosis; for these areas of "fibrositis", "trigger points", or "mya l Austra l ian physician who carried on Kellgren's concepts from the
gic spots", have been regarded as the primary lesion - not the early 1 940s, diagnosing and treating pain (rheumatism) by means
resu lt of pressure on the dura mater' (Cyriax J 1 962 Textbook of of identification of pain points and deactivating these using
orthopaedic medicine, vol 1, 4th edn. Cassell, London). injections.
P Ell man, D Shaw 1 9 50 The chronic 'rheumatic' and his pains . M Yunus et al 1981 Primary fibromyalgia (fibrositis) clinical study
Psychosomatic aspects of chronic non-articular rheumatism. of 50 patients with matched controls. Seminars in Arthritis and
Anna ls of Rheumatic Disease 9 :341 -3 57 Rheumatism 1 1 :1 51 -1 71
Suggested that because there were few physical manifestations First popu larized the word 'fibromyalgio'.
to support the pain cla imed by patients with chronic muscle pain, Janet Travel l , David Simons 1 983 Myofascial pain and dysfunc
their cond ition was essentially psychosomatic (psychogenic tion: the trigger point manual vol 7. Wi l l iams and Wilkins,
rheumatism): 'the patient aches in his l i mbs because he aches in Balti more
his mind'. The definitive work (with vol u me 2, 1 99 2) on the subject of
Theron Randolph 1 9 51 Allergic myalgia. Journal of Mich igan myofascial pain syndrome (MPS).
State Med ical Society 50:487 K Lewit, D Simons 1 984 Myofascial pain: relief by post-isometric
This lead ing American clinical ecologist described the cond ition relaxation. Archives of Physical Medicine and Rehab i l i tation
as allergic myalgia and demonstrated that widespread and 6 5 :4 52-456
severe muscle pain (particularly of the neck region) could be Czech neurologist Karel Lewit described his simple manual treat
reproduced 'at will under experimental circu mstances' following ment of MTrPs, and later emphasized joint dysfunction in MTrPs
box continues
1 00 C L I N I C A L A P P L I C AT I O N O F N E U R O M U S C U L A R T EC H N I QU ES: T H E U P P E R B O DY
[
with suggestions as to joi n t mobilization, and later developed Showed that many 'tender points' in fibromyalgia are i n
va luable concepts of cha ins of MTrPs. rea l ity latent trigger poi nts. He believes t h a t MPS and FMS
David Si mons 1 986 Fibrositis/fibromyalgia: a form of myofascial are d istinctive syndromes but are 'closely related'. States that
trigger points? American Journal of Med icine 81 (Su ppl 3A):93 -98 many people with MPS progress on to develop fibromyalgia.
American physician who collaborated with Travel l in a joint study C-Z Hong 1 994 Electrophysical characteristics af localized twitch
of MPS and who a lso conducted his own studies i nto the con nec responses in responsive taut bands of rabbit skeletal muscle.
tion between myofascial pain syndrome and fibromyalgia syn Journal of Musculoskeletal Pain 2(2) :1 7-43
drome, finding a good deal of overlap. This physiatrist pioneered studi es focusing on identifying taut
M Margoles 1 989 The concept of primary fibromyalgia. Pain bands of MTrPs.
3 6 :391 -39 2 D Simons, J Travel !, L Simons 1999 Myofascial pain and dysfunc
States t h a t most patients w i t h fibromyolgio demonstrate n umer tian: the trigger point manual, vol 1: upper half of body, 2nd edn.
ous active myofascial trigger points. Wi l l iams & Wilki ns, Baltimore
R Bennett 1 990 Myofoscial pain syndromes and the fibromyalgia This second edition, with emphasis on sig nificant research con
syndrome. In: Fricton R, Awad E (eds) Advances in pain research ducted in the 1 5 years since the first edition, altered the founda
a n d therapy. Raven Press, New York tional platform of trigger poi nt theories and trea tment.
Excess acetylcholine
release
-""'---
Depol arization
;;;
:;
=;=d==-==::=';5d
Cal cium release
=f'=I:::=+=1 '$ Sarcomere
contracture
Compression of vessels
Dysfunctional endplate activity occurs (commonly asso As the endplate keeps producing ACh flow, the actin/
ciated with a strain), which causes acetylcholine (ACh) to myosin filaments slide to a fully shortened position (a
be excessively released at the synapse, often associated weakened state) in the immediate area around the motor
with excess calcium. endplate (at the center of the fiber).
The presence of high calcium levels apparently keeps the As the central sarcomeres shorten, they begin to bunch
calcium-charged gates open and the ACh continues to be and a contracture 'knot' forms.
released, resulting in localized ischemia. This knot is the 'nodule' that is a palpable characteristic
The consequent ischemia involves an oxygen/nutrient of a trigger point (Fig. 6.2).
deficit that, in turn, leads to a local energy crisis and As this process occurs, the remaining sarcomeres of that
inadequate adenosine triphosphate (ATP) production in fiber (those not btffiching) are stretched, thereby creating
the immediate area. the usually palpable taut band that is also a common trig
Without available ATP the local tissue is unable to remove ger point characteristic.
(active transport) the calcium ions that are 'keeping the Attachment trigger points may develop at the attachment
gates open', thereby allowing continued release of Ach. sites of these shortened tissues (periosteal, myotendinous)
Removing the superfluous calcium requires more energy where muscular tension provokes inflammation, fibrosis
than sustaining a contracture, so the contracture remains. and, eventually, deposition of calcium.
The resulting muscle fiber contracture (involuntary,
without motor potentials) is distinctly different from a This model is explored in greater depth later in this chapter,
contraction (voluntary, with motor potentials) and spasm since it represents the most widely held understanding as to
(involuntary, with motor potentials). the etiology of myofascial trigger pOints. Other models exist
The contracture is apparently sustained by the chemistry which attempt to explain the trigger point phenomenon,
at the innervation site, not by action potentials from the including the facilitation concept (below) and the ideas
spinal cord. and methods developed by Raymond Nimmo DC (1981)
6 Trigger poin ts 101
Trigger point complex are released to act on vessels and nerves locally. These
include catec holamines, serotonin, histamine, bradykinin
Taut band Nodule and prostaglandins. Among their effec ts, these substances
A cause vasodilation and vascular permeabili ty, often resu lt
ing in local edema. As edema increases, arterial and venous
vessels are compressed, resulting in a vicious cycle that
further reduces blood supply and sensitizes nociceptors.
Research also shows that when pain receptors are stressed
(mechanically or chemically) and are simultaneously exposed
to elevated levels of adrenaline, their discharge rate increases,
i .e. a greater volume of pain messages is sent to the brain
(Kieschke et al 1988).
\tV-hen the blood supply to a muscle is fully inhibited,
pain is not usually noted until that muscle is asked to con
tract, at which time pain is likely to be noted within 60 sec
B
Contraction onds (Mense et aI2001). This is the phenomenon that occurs
knot
in intermittent claudication. The precise mechanisms are
open to debate but are thought to involve one or more of a
number of processes, including potassium ion build-up, the
lack of oxidation of metabolic products and the release of
Normal algesic substances. Previous concepts of lactate accumula
fibers tion have now been discarded as a maj or factor in ischemic
muscle pain since it is considered to be an ineffec tive activa
tor of muscle nociceptors, although it may have a combined
action with other substances (Mense et aI2001). Further, lac
Figure 6.2 ARB : Tension produced by central trigger point (CTrP) tate (or lactic acid) accumulation following rigorous exer
can result in localized inflammatory response (attachment trigger
cise does not appear to be the cause of delayed onset muscle
point, ATrP). Adapted from Simons et al (1 999).
soreness (12-24 hours) since concentrations rapidly
decrease within 1 hour following cessation of exercise
(Khalsa 2004).
(discussed below) . Before examining these, it will be useful Pain receptors are sensitized when under ischemic condi
to investigate a key element of myofascial trigger point tions (i t is thought) due to the release of algesic substances
development and dysfunction - ischemia. such as bradykinin, a chemical mediator of inflammation.
This has been confirmed by the use of drugs that inhibit
bradykinin release, allowing an active ischemic muscle to
ISCHEMIA AND MUSCLE PAIN remain relatively painless for longer periods of activity
(Oigiesi et aI1975). When ischemia ceases, pain receptor acti
Ischemia can be simply described as a state in which the vation persists for a time and, conceivably, indeed probably,
current blood supply is inadequate for the current physio contributes to sensitization (facilitation) of such structures, a
logical needs of tissue. The causes of ischemia can be patho phenomenon noted in the evolution of myofascial trigger
logic, as in a narrowed artery or thrombus, or anatomic, as points (discussed further below).
in particular hypovascular areas of the body, such as the Although ischemic muscles may remain painless LUltil
region of the supraspinatus tendon 'between the anastomo asked to contract, trigger points in muscle may refer pain
sis of the vascular supply from the humeral tuberosity and even when the muscle is not being actively used. The term
the longitudinally directed vessels arriving from the muscle's 'essential pain zone' describes a referral pattern that is pres
belly' (Tullos & Bennet 1984), or as a result of a sequence of ent in almost every person when a particular trigger point is
events such as occurs in trigger point development outlined active. Some trigger points may also produce a 'spillover
above. Compression of blood vessels or blockage of blood pain zone' beyond the essential zone, or in place of it, where
flow by any means can result in ischemia and excitation of the referral pattern is usually less intense (Simons et aI1999).
nociceptors. These target zones should be examined, and ideally pal
The development of ischemia in muscles can be immedi pated, for changes in tissue 'density', temperature, hydrosis
ate, such as results when trauma occurs, or can be slow and and other characteristics associated w ith satellite trigger
insidious, such as that associated with postural adaptation. point formation (as discussed later in this chapter).
Pain receptors are stimulated (and become sensitized) by Trigger point activity itself may also induce relative
prolonged intense muscular contraction when biological ischemia in the 'target' tissues (Baldry 1993, Simons et aI1999).
substances, known as vasoneuroactive substances (VNS), The mechanisms by which this occurs remain hypothetical
1 02 C LI N I CA L APPLICAT I O N OF N E U RO M U SCULAR T E C H NIQU ES: T H E U P PER B O DY
but may involve a neurologically mediated increase in tone in sidelying sleeping posture, may lead to relative ischemia
in the trigger point's reference zone (target tissues). According under the acromion process (Brewer 1979). These are pre
to Simons et al (1999) these target zones are usually periph cisely the sites most associated with rotator cuff tendinitis,
eral to the trigger point, sometimes central to the trigger calcification and spontaneous rupture (Cailliet 1991), as
point and, more rarely (27%), the trigger point is located well as trigger point activi ty.
within the target zone of referral. This is more than informa Additionally, a number of shoulder and neck muscles,
tional as it translates to a significant clinical application: if including levator scapulae, anterior and middle scalenes, tri
the practitioner is treating only the area of pain and the ceps brachii and trapezius, target the supraspinatus area as
cause is myofascial trigger points, he is 'in the wrong spot' their referred zone and can produce not only pain but also
nearly 75% of the time! autonomic and motor effects, including spasm, vasoconstric
Any appropriate manual treatment, movement or exer tion, weakness, loss of coordination and loss of work toler
cise program that encourages normal circulatory function is ance in the target tissues (Simons et aI1999). Due to weakness
likely to modulate these negative effects and reduce trigger and loss of coordination, the person may adapt by improp
point activity. It is important to note, however, that when erly using these and other muscles with resultant damage to
tissues containing (particularly active) trigger points are the tissues (see patterns of dysfunction, Chapter 5).
exercised prior to the deactivation of the trigger points, the
referred pain is often provoked or increased . Therefore, a
general protocol suggests that manual palpation, examina TRIGGER POINT CONNECTION
tion for and treatment of trigger points, would precede the
Mense (1993) describes the hypothesized evolution of a trig
start of exercise therapy. After treatment of trigger points
ger point, clearly similar to the Simons et al (1999) model.
and elongation of the taut bands housing them, a condi tion
ing program can be implemented to help prevent reactiva A muscle lesion leads to the rupture of the sarcoplasmic
tion. A degree of normal function may return when the soft reticulum and releases calciumfrom the in tracellular stores.
tissue's Circulatory environment is improved and the stress The increased calcium concentration causes sliding of the
producing elements, whether of biomechanicaL biochemi myosin and actin filaments; the result is a local contracture
cal and/ or psychosocial origin, are reduced or removed. (myofilamen t activation without electrical activity) that has
Increased lymphatic flow, which is enhanced by light high oxygen consumption and causes hypoxia. An addi
gliding strokes and other forms of tugging on the skin sur tionalfactor may be the traumatic release of vasoneuroactive
face, such as that created by manual lymph drainage tech substances (for example, bradykinin), which produce local
niques (Chikly 2001 , Wittlinger & Wittlinger 1982), will edema that in turn compresses venules and enhances the
assist in draining the waste materials that accumulate ischemia and hypoxia. Because of the hypoxia-induced drop
within the ischemic tissues, while altering the local cellular in ATP concentrations, the function of the calcium pump in
chemistry and reducing neuroexcitation. Many massage the muscle cell is impaired, and the sarcoplasmic calcium
techniques drain lymphatic wastes; however, some are concentration remains elevated. This perpetuates the con
designed to dynamically induce lymph movement and tracture.
drainage (Chikly 1996, 2001, Wittlinger & Wittlinger 1982) .
Use of these specialized techniques, especially in a system The presence of oxygen deficit at the heart of the trigger
atic protocol that addresses opening the primary pathways point has been confirmed, according to Mense:
of lymph flow in a particular order, may greatly enhance the Measurements of the tissue p02 with microprobes show that
conditions of the in terstitial fluids surrounding the cells. oxygen tension . . . is extremely low. Thus, the pain and
Such movement may also i ncrease the flow of nutrients to tenderness of a trigger point could be due to ischemia
the area, thus improving the cells' physiological status. induced release of bradykinin and other vasoneuroactive
substances which activate and/or sensitize nociceptors.
(Bruckle et a1 1990)
ISCHEMIA AND TRIGGER POINT EVOLUTION
The original 'lesion' could have been the result of any of the
Hypoxia (apoxia) involves tissues being deprived of ade multiple etiological and maintaining factors (overuse, mis
quate oxygen. This can occur in a number of ways, such as use, abuse, disuse) outlined in the overview of stress and
in ischemic tissues where circulation is impaired, possibly the musculoskeletal system in Chapter 4. It could be the
due to a sustained hypertonic state resulting from overuse result of a gross trauma, such as a blow, sudden elongation
or overstrain. The anatomy of a particular region may also (as in whiplash) or laceration, occurring recen tly or even
predispose it to potential ischemia, as described above in years before. It could also be the result of sustained emo
relation to the supraspinatus tendon. Additional sites of rel tional distress, with its influence on somatic structures, or of
ative hypovascularity include the insertion of the infra the effects of hormonal imbalance, specific nu tritional defi
spinatus tendon and the intercapsular aspect of the biceps ciencies, aJlergic (or sensitivity) reactions or increased levels
tendon. Prolonged compression crowding, such as is noted of toxic material in the tissues (see Chapter 4).
6 Trigger points 1 03
the heart of a trigger point (its taut band) until it touched the Figure 6.3 ARB : An in-vivo microanalytical technique for measuring
band. At each small stage of the needle's penetration of the the local biochemical milieu of human skeletal muscle. TP1, t rigge r
tissues, samples were taken of the tissue fluids. point 1 . Reproduced with permission from Shah et al (2005).
The same region of upper trapezius was penetrated by
the needle and samples taken, in the three people without
In a personal communication (2004), the lead researcher
trigger points, to compare the nature of the fluids extracted.
reported that pH levels returned to normal almost instantly
In this way multiple samples, from the three groups,
when the taut band was released, i.e. when the biopsy nee
were obtained and could be compared.
dle touched it, as did levels of oxygen.
Analytes removed and tested showed that concentra
Commenting on this research, Simons (2006) stated:
tions of protons (H+), bradykinin, calcitonin gene-related
'Remarkably, and unexpectedly, the clinical distinction
peptide, substance P, tumor necrosis factor, serotonin and
betvveen active and latent MTrPs was sharply distinguished
norepinephrine were significantly higher in the active group
by the concentration of these stimulants of nociception.' (See
than either of the other two groups (p < 0.01). Additionally,
also notes on needle electromyography later in this chapter.)
pH was significantly lower in the active group than the
other tvvo groups (p < 0.03).
To summarize the most important findings: ISCHEMIA AND FIBROMYALGIA
SYNDROME (FMS)
People with active trigger points had a very much lower
pain threshold than the other individuals studied.
It has been suggested that the origin of the pain noted in
The tissues surrounding active trigger points had much
fibromyalgia may also derive in large part from muscular
higher levels of substances such as bradykinin, norepi
ischemia (Heruiksson 1999).
nephrine and substance P than those with latent, or no,
The rationale for this observation can be summarized as
trigger points.
follows:
The level of acidity (pH) of the tissues in the region of the
active trigger points was very much greater (i.e. there The pathophysiology of the chronic muscular pain and
was lower pH) than the others tested. tenderness of FMS is not fully understood, but seems to
1 04 C L I N I CA L A P P L I CATI O N OF N E U R O M U S C U LA R T EC H N IQ U ES: T H E U PP E R B O DY
A B
C D
Figure 6.4 Doppler evaluation of intersegmental muscle (ISM) during static contraction in (A) healthy control subject and (B) FM patient,
showing typical no or small vessel perfusion. I n (el. after the administration of ultrasound contrast media, the muscular tissue vascularity is
clearly seen in the control subject. Differently in (D) the I SM of an FM patient shows no detectable flow during contraction. Note, however,
that normal muscular vascularity is seen in the non-contracting deltoideus muscle in the upper right-hand corner. Reproduced with
permission from Elvin et al (2006).
Among the research into the connection between myofascial trigger 3. Researchers at Oregon Health Sciences U n iversity studied the
point activity and fibromyalgia are the fol lowing: history of patients with FMS and fou nd that over 80% reported
that prior to the onset of their genera l ized symptoms they
1. Yu nus ( 1 993) suggests that 'Fibromyalgia and myofascial pai n
suffered from reg i onal pa i n problems (which almost always
syndrome (MPS) [trigger point-derived pain] share several com
involved trigger poi nts). Physical tra u ma was cited as the major
mon features [and] it is possible that MPS represents an incom
cause of their pre-FMS regi ona l pain. Only 1 8% had FMS
plete, reg ional or early form of fibromyalgia syndrome since many
which started without pri or reg iona l pain (Burckhardt
fibromya lgia patients give a clear history of l ocalized pain before
1 995).
developing generalised pain:
4. Research at UCLA has shown that injecting active trigger
2. Granges & Littlejohn (1 993) i n Austra l i a have researched the
poin ts with the pa in-killing agent xyl ocaine produced marked
overlap between trigger points and the tender poi nts in
benefits in FMS patients in terms of pain rel ief and reduction of
fibromyalgia and come to several conclusions, including:
stiffness but that this is not rea lly sig nifica ntly a pparent for a t
'Tender points i n FMS represent a diffusely diminished pain thresh least a week after t h e injections. FMS patients reported more
old ta pressure while trigger points are the expression of a local local soreness foll owing the injections than patients with only
musculoskeletal abnormality' myofascial pain but improved after this settled down. Th is rein
'It is likely that trigger points in diffuse chronic pain states such as forces the opi nion of many practitioners that myofascial trigger
FMS '" contribute only in a limited and localized way to decreasing points contribute a large degree of the pai n being experienced in
the pain threshold to pressure in these patients: FMS (H ong 1 996).
5. Travell & Simons (1992) are clearly of this opi n i on, stating 'Most
'Taken individually the trigger points are an important clinical
of these [fibromya lgia] patients would be l ikely to have specific
finding in some patients with FMS with nearly 700;0 of the FMS
myofascial pain syndromes that would respond to myofascial
patients tested having at least one active trigger point:
therapy:
'Of those FMS patients with active trigger points, around 60%
reported that pressure on the trigger 'reproduced a localized and
familiar {FMS] pain:
FMS AND MYOFASCIAL PAIN the cause of facilitation may be the result of organ dysfunc
tion as explained below (Ward 1997).
Having noted a clear connection between ischemia and It has long been hypothesized in osteopathic medicine as
myofascial pain, as well as a well-supported proposed link well as chiropractic care that organ dysfunction will result
betvveen ischemia and fibromyalgia, it would be useful to in sensitization and, ultimately, facilitation of the paraspinal
refer to Box 6.2 which looks at some of the suggested structures at the level of the nerve supply to that organ. The
relationships betvveen fibromyalgia and myofascial pain term viscerosomatic reflex is well established to describe
syndromes. the consequences of this situation. If, for example, there
is any form of cardiac disease, there will be a 'feedback'
toward the spine of impulses along the same nerves that
FACILITATION - SEGMENTAL AND LOCAL supply the heart and the muscles alongside the spine in the
(Korr 1976, Patterson 1976) upper thoracic level (T2, T3, T4 as a rule) served by the same
neural segments will become hypertonic. If the cardiac
Neural sensitization can occur by means of a process known problem continues, the area will become facilitated, with
as facilitation. There are two forms of facilitation: segmental the nerves of the area, including those passing to the heart,
(spinal) and local. If we are to make sense of soft tissue dys becoming sensitized and hyperirritable. Electromyographic
function, we should have an understanding of facilitation. readings of the muscles alongside the spine at this upper
Facilitation occurs when a pool of neurons (premotor thoracic level would show this region to be more active than
neurons, motoneurons or, in spinal regions, preganglionic the tissues above and below it. The muscles alongside the
sympathetic neurons) is in a state of partial or subthreshold spine, at the facilitated level, would be hypertonic and
excitation. In this state, a lesser degree of afferent stimula almost certainly painful to pressure. The skin overlying this
tion is required to trigger the discharge of impulses. facilitated segmental area will alter in tone and function
Facilitation may be due to sustained increase in afferent (with increased levels of hydrosis as a rule) and will display
input, aberrant patterns of afferent input or changes within a reduced threshold to electrical stimuli.
the affected neurons themselves or their chemical environment. Research into the ability of osteopathic diagnostic meth
Once established, facilitation (sensitization) can be sustained ods to accurately identify such dysfunction has been carried
without the involvement of central nervous system activity. out and evaluated (Kelso et aI1980). Between 1969 and 1972
It is the example of neurons maintained in a hyperirritable over 6000 patients admitted to Chicago Osteopathic Hospital
state, due to an altered biochemical status in their local envi were part of a clinical investigation. Visual and palpatory
ronment, that appears to come closest to the situation occur observations made by attending osteopathic physicians were
ring in trigger point behavior. On a spinal segmental level recorded and analyzed in relation to the health problems
106 C L I N ICAL A P P L I CAT I O N O F N E U R O M USCU LA R T EC H N I Q U ES : T H E U P P E R B O DY
L
of the patients. The findings showed a clear link between stasis and edema, structural bodywork to reduce postural
the spinal area, diagnosed by the examining practitioner as stress and relaxation techniques of biofeedback, hypnother
being involved, and the corresponding diseased organs of apy or psychotherapy to reduce the number of signals from
the patient. The conclusion was: 'The somatic findings in higher centers of the central nervous system.
over 6,000 cases of hospital patients support the osteopathic In assessing and treating somatic dysfunction, the phe
theory of viscero-somatic (internal organs and the body) nomenon of segmental facilitation should always be borne in
relationships.' mind, since the causes and treatment of these facilitated seg
In a separate study doctors at Riverside Osteopathic ments may lie outside the scope of practice of many practi
Hospital in Trenton, Michigan, investigated the existence of a tioners and can easily be overlooked. In many instances,
viscerosomatic reflex that could be easily detected and which appropriate manipulative treatment can help to 'destress'
correlated with the presence of atherosclerotic coronary facilitated areas. However, when a somatic dysfunction con
artery disease. Eighty-eight consecutive patients, each sug sistently returns after appropriate therapy has been given, the
gesting coronary disease, underwent cardiac catheterization. possibility of organ disease or dysfunction is a valid consider
Within 1 week of this, each patient in tum was given stan ation and should be ruled out or confirmed by a physician.
dard osteopathic musculoskeletal evaluation (pain, range of
movement, soft tissue texture, etc.) by an examiner unaware
of the results of the cardiac catheter probe. TRIGGER POINTS AND ORGAN DYSFUNCTION
The results showed a correlation between coronary ath Conditions that lie outside obvious musculoskeletal dys
erosclerosis and abnormalities of range of motion and soft function may at times have trigger points as a primary fea
tissue texture in the 4th and 5th thoracic and the 3rd cervi ture. Selected examples include the following.
cal intervertebral segments.
Once facilitation of the neural structures of an area has
occurred, all associated target structures (connective tissue, C h ro n i c prostatitis
muscle, bone, blood vessels, skin, sweat glands and internal Chronic prostatitis involving non-bacterial urinary difficul
organs) can be adversely affected. Any additional stress of ties, accompanied by chronic pelvic pain (involving the per
any sort that impacts the individual, whether emotional, ineum, testicles and penis), has been shown in a study at
physical, chemical, climatic, mechanical - indeed, absolutely Stanford University Medical School to be capable of being
anything that imposes adaptive demands on the person as a treated effectively using trigger point deactivation together
whole and not just this particular part of their body - leads with relaxation therapy (Anderson et aI2005).
to a marked increase in neural activity in the facilitated seg The researchers pOint out that 95% of chronic cases of
ments and not in the rest of the normal, 'unfacilitated' spinal prostatitis are unrelated to bacterial infection and that
structures. Different types of problem are associated with myofascial trigger points, associated with abnormal muscu
facilitated segments at specific levels - for example, T9/ 10 lar tension in key muscles, are commonly responsible for
(gallbladder), T12/L l (kidney) and L5 (urogenital). the symptoms.
Korr (1976) has called such an area a 'neurological lens' The I-month study involved 138 men, and the results
since it concentrates neural activity to the facilitated area, so produced marked improvement in 72% of the cases, with
creating more activity and also a local increase in muscle 69% showing significant pain reduction and 80% improve
tone at that level of the spine. Similar segmental (spinal) ment in urinary symptoms. The study noted that:
facilitation occurs in response to any organ problem, affect
ing only the part of the spine from which the nerves supply TrPs in the anterior levator ani muscle often refer pain to the
ing that organ emerge. Other causes of segmental (spinal) tip of the penis. The levator endopelvic fascia lateral to the
facilitation can include stress imposed on a part of the spine prostate represents the most common location ofTrPs in men
through injury, overactivity, repetitive patterns of use, poor with pelvic pain . . . myofascial TrPs were identified and
posture or structural imbalance (short leg, for example). pressure was held for about 60 seconds to release [described
Korr (1978) tells us that when subjects who have had as myofascial trigger point release technique MFRT].-
facilitated segments identified were exposed to physical, Specific physiotherapy techniques used in conjunction with
environmental and psychological stimuli similar to those MFRT were voluntary contraction and releaselhold-relax/
encountered in daily life, the sympathetic responses in contract-relax/reciprocal inhibition, and deep tissue mobi
those segments were exaggerated and prolonged. The dis lization, including stripping, strumming, skin rolling and
turbed segments behaved as though they were continually effleurage.
in, or bordering on, a state of 'physiologic alarm'.
The explanation for the success of this approach remains
Therapeutically, any approach that reduces sensory input
hypothetical, according to Anderson et al, who have out
or interrupts the self-perpetuating activity of that facilitated
lined possible mechanisms as follows:
segment is helpful. Therapeutic intervention can include
massage, soft-tissue manipulation to relax the muscles, struc Pathways in neurogenic inflammation, especially between
tural manipulative therapy to mobilize the area, reduction of the central and peripheral nervous and endocrine systems
6 Trigger points 107
with effects on immunomodulatory mechanisms, will most The protocol of treatment was a s follows:
likely provide a pathophysiological explanation for CPPS. It
10 intravaginal massages using the Thiele technique by one
seems intuitive that central sensitization probably represents
of three qualified women's health nurse practitioners. The
the basis for hyperalgesia and allodynia in many of these
technique consisted of massage from origin to insertion
men (McCracken & Turk 2002). We must await elucidation
along the direction of the muscle fibers with an amount of
of these biochemical pathways and develop an understand
pressure tolerable to the subject. The motion was performed
ing of the role of pro-inflammatory and other cytokines. Our
10 to 15 times during each session to each of the following
treatment modality is based on the psychophysiological
muscles in order: coccygeus, iliococcygeus, pubococcygeus,
explanation of painful muscle TrPs being initially activated
and obturator internus. At the practitioner 's discretion, 1 0
by infection, trauma or emotions. Our protocol includes the
t o 15 seconds of ischemic compression was applied t o trigger
release of myofascial TrPs, which tends to recreate patient
points. A typical treatment lasted fewer than 5 minutes.
symptoms and behavior modification to relax profoundly the
Each massage was scheduled at least 2 days apart to allow
pelvic muscles and modifij the habit offocusing tension in
for any inflammation or discomfort from the previous ses
the pelvic floor while under stress . . . Our premise is that, in
sion to subside. Patients received two massages per weekfor
addition to releasing painful myofascial TrPs, the patient
a period of 5 weeks.
must supply the central nervous system with new informa
tion or awareness to progressively quiet the pelvic floor.
Interst i t i a l cystitis, dysp a re u n i a a n d sacro i l i a c
dysfu n cti o n
Interstiti a l cystitis
A link between the sort of symptoms treated in the previous
Using similar trigger point deactivation methods, Weiss examples, as well as dyspareunia (painful intercourse) and
(2001) has reported the successful amel ioration of symp sacroiliac dysfunction, was noted in a study conducted in
toms in patients with interstitial (i.e. 'unexplained') cystitis Philadelphia (Lukban et al 2001). Sixteen patients with inter
using myofascial release. stitial cystitis were evaluated (1) for increased pelvic tone and
Holzberg et al (2001) showed the effectiveness of trans trigger point presence, and (2) sacroiliac dysfunction. The
vaginal Theile massage on high-tone pelvic floor muscula study reports that in all 16 cases SI joint dysfunction was
ture in 90% of patients with interstitial cystitis. Describing identified. Treatment comprised direct myofascial release,
the technique, Holzberg et al note: joint mobilization, muscle energy techniques, strengthening,
stretching, neuromuscular reeducation and instruction in an
Subjects underwent a total of 6 intravaginal massage ses
extensive home exercise program. The outcome was that
sions using the Theile 'stripping technique'. This technique
there was a 94% improvement in problems associated with
encompasses a deep vaginal massage via a 'back and forth'
urination, and 9 of the 16 patients were able to return to pain
motion over the levator ani, obturator internus, and piri
free intercourse. The greatest improvement seen is related to
formis muscles as well as a myofascial release technique
frequency symptoms and suprapubic pain. There was a
whereas a trigger point was identified, pressure was held for
lesser improvement in urinary urgency and nocturia.
8 to 12 seconds and then released.
A similar improvement trend was observed in the IBS LOCAL FAC I LITAT I O N I N MUSCLES
patient group (53% IBS-free initially, 78% at 6 months, 72% at
Baldry (1993) explains:
12 months). All 18S-free patients were LVAS-free at 6 months.
The conclusion was that the LVAS symptoms may be Palpable myofascial bands are electrically silent at rest.
cured or alleviated in 72% of the cases at 12 months with However, when such a band is 'plucked' with a finger . . . a
one to two sessions, and that since most of 18S pa tients ben transient burst of electrical activity with the same configu
efited from such treatment, it is logical to suspect a mutual ration as a motor unit's action potentials may be recorded
etiology and to screen for LVAS in all such patients. (Dexter & Simons 1981). It is undoubtedly this electrical
What we can learn from these selected examples is tha t hyperactivity of motor and sensory nerve fibers at myofas
the influence of active trigger points is to be found beyond cial trigger points that is responsible for the so-called local
the obvious ones of interference in muscle and joint func twitch response, a transient contraction of muscle fibers
tion and the production of pain, and actually extends to vis which may be seen or felt . . . It is also neural hyperirritabil
ceral function (bladder and bowels in these examples). It is ity which causes both myofascial and non-myofascial trig
also clear from the research reported above that mainstream ger points to be exquisitely tender to touch . . . The amount
medical scientists are focusing attention on these phenom of pressure required to produce this is a measure of the
ena, and are employing skillfully applied manual method degree of irritability present.
ology, such as that outlined in this text, in successfully
treating these conditions. A similar process of facilitation occurs when particularly
vulnerable sites of muscles (a ttachments, for example) are
H OW TO RECOGN IZE A FACI LITATED S P I N AL overused, abused, misused or disused in any of the many
AREA ways discussed in Chapter 4. Localized areas of hypertonic
ity may develop, sometimes accompanied by edema, some
A number of observable and palpable signs indicate an area times with a stringy feel but always with sensitivity to
of segmental (spinal) facilitation. pressure. Many of these tender, sensitive, localized, facili
Beal (1983) tells us that such an area will usually involve tated areas contain myofascial trigger points, which may, in
two or more segments unless traumatically induced, in part, derive from this facilita tion process.
which case single segments are possible. Myofascial trigger points are not only painful themselves
The paraspinal tissues will palpate as rigid or board-like. when palpated but can also transmit or activate pain (and
With the person supine and the palpating hands under other) sensations some distance away in 'target' tissues.
the paraspinal area to be tested (practitioner standing at Leading researchers into pain Melzack & Wall (1988) have
the head of the table, for example, and reaching under stated that there are few, if any, chronic pain problems that
the shoulders for the upper thoracic area), any ceiling do not have trigger point activity as a major part of the pic
ward 'springing' attempt on these tissues will result in a ture, perhaps not always as a prime cause but almost
distinct lack of elasticity, unlike more normal tissues always as a maintaining fea ture. Similar to the facilitated
above or below the facilitated area (BeaI 1983) . areas alongside the spine, these trigger points will become
more active when stress, of whatever type, makes adaptive
Grieve ( 1986), Gwm & Milbrandt (1978) and Korr (1948)
demands on the body as a whole, not just on the area in
have all helped to define the palpable and visual signs that
which they lie. A number of factors that play a role in trig
accompany facilitated dysfunction.
ger point activation and perpetuation are discussed within
A gooseflesh appearance is observable in facilitated areas this chapter.
when the skin is exposed to cool air, as a result of a facil When a trigger point is mechanically stimulated (by
itated pilomotor response. compression, needling, stretch or other means) it will refer
A pa lpable sense of 'drag' is noticeable as a light touch or intensify a referral pattern (usually of pain) to a target
contact is made across such areas, due to increased sweat zone. An active trigger point refers a pattern that the person
production resulting from facilitation of the sudomotor recognizes as being a part of their current symptom picture.
reflexes. When a la tent trigger point is stimulated, it refers a pattern
There is likely to be cutaneous hyperesthesia in the related that may be unfamiliar to the person or an old pattern they
dermatome, as the sensitivity is increased (facilitated). used to have and have not had for a while (previously
An 'orange peel' appearance is noticeable in the subcuta active, reverted to latent) (Simons et al 1 999). All the same
neous tissues when the skin is rolled over the affected characteristics that denote an active trigger point (as
segment, because of subcutaneous trophedema. detailed in this chapter) may be present in the latent trigger
There is commonly localized spasm of the muscles in a point, with the exception of the person's recognition of their
facilitated area, which is palpable segmentally as well as active pain pattern. The same signs as described for seg
peripherally in the related myotome. This is likely to be mental facilitation, such as increased hydrosis, a sense of
accompanied by an enhanced myotatic reflex due to the 'drag' on the skin, loss of elasticity, etc., can be observed and
process of facilitation. palpated in these localized areas as well.
6 Trigger poi nts 1 09
J
tion), a given stressor may trigger less of an alarm; however, nodules occur as a result of an increased production of this
Selye insists that adaptation to one agent is acquired normally occurring substance, or a decrease in degradation,
at the expense of resistance to other agents. That is, as or a change in its quality?'
one accommodates to a given stressor, other stressors may Awad therefore identifies edema as a part of the etiology
require lower thresholds for eliciting the alarm reaction. Of of the trigger point, based on his analysis of the content of
considerable importance is Selye's observation that concomi the tissue. Non-traumatic reduction of fluid levels and acid
tant exposure to several stressors elicits an alarm reaction at ity, perhaps involving lymphatic drainage or traditional
stress levels that individually are subthreshold. That is, one massage techniques, as well as improved oxygenation,
third the dose of histamine, one-third the dose of cold, one should therefore decrease nociceptive sensitization, some
third the dose offormaldehyde, elicit an alarm reaction equal thing neuromuscular therapy has as a primary objective.
to a fill! dose of any one agent. (Bold italics added)
In short, therefore, as adaptation to life's stresses and stres NIM MO'S R E C E PTOR-TONUS TECHNIQU ES
sors continues, thresholds drop and a lesser load is required [ S c h n e i d e r e t al 2 00 1 )
to produce responses (pain, etc.) from facilitated structures,
Raymond Nimmo DC (1904-1986) developed an under
whether paraspinal or myofascial.
standing of musculoskeletal pain syndromes that paralleled
The concept that emotional stress could be one of the fac
that of Janet Travell (1901-1997), whose work he admired
tors was supported by the research of McNulty et al (1994),
(Cohen & Gibbons 1998). Nimmo arrived at a different
which suggests a mechanism by which emotional factors
(from Travell) understanding of the way in which trigger
influence muscle pain. Fourteen subjects were evaluated by
points (he called these 'noxious generative points') evolve
needle electromyography in a trapezius myofascial trigger
and of how to treat them. He held to a model in which
point and simultaneously in adjacent non-tender trapezius
increased muscle tone was the major feature initiating the
muscle fibers during a control condition (forward count
triggers via the effect they had on neural receptors. He saw
ing), a stressful condition (mental arithmetic) and resting
the trigger as an abnormal reflex arc.
baselines. The authors noted:
Excessive levels of muscle tone could result from repeti
Based on recent data implicating autonomic in nervation in
tive or prolonged influence of stressors ('insults'), such as
muscle function, we hypothesized that the trigger point
cold, trauma, postural strain, etc., acting on them and
would be more responsive than the adjacent muscle to psy
causing projection of impulses through the posterior root
chological stress. The results showed increased trigger point
to the gray rnatter of the cord.
electromyographic activity during stress, whereas the adja
Here the highly excitatory internuncial neurons produce
cent muscle remained electrically silent . . . This may have
a prolonged motor discharge, increasing muscle tone.
significant implications for the psychophysiology of pain
If there were a 'malfunction' in this feedback system
associated with trigger points.
(resulting, Nimmo suggested, from insults such as 'acci
dents, exposure to cold drafts or from occupations requir
ing prolonged periods of postural strain'), hypermyotonia
VARYING VIEW POINTS ON TRIGGER POINTS could result, leading to even greater afferent input to the
cord and amplification of additional efferent impulses to
AWA D ' S ANA LYSIS OF TRIGG ER POINTS the muscles.
This state of abnormally increased tone could become
In 1973, Awad examined dissected muscle fascicles (approx
part of a self-perpetuating cycle, involving involuntary
imately 1 cm wide and 2 cm long) from muscle 'nodules' .
sympathetic activity, with reflex 'spillover' causing vaso
Under a light microscope, i n eight o f the 1 0 specimens (dif
constriction, retention of metabolic wastes and pain.
ferent people), large amounts of 'amorphous material' were
noted between muscle fascicles. This was shown to com Nimmo's treatment approach was based on releasing the
prise acid mucopolysaccharides (with high water-binding hypertonic status of the muscles ('I found that a proper
1 10 C LI N I CA L A P P L I CATI O N O F N E U RO M U SC U LA R T EC H N I Q U E S : T H E U P P E R B O DY
degree of pressure sequentially applied causes the nervous not intimately related to muscle spasm (Johnson 1 989) . This
system to release a hypertonic muscle') (Nimmo 1981). He concept has been strongly encouraged by commercial inter
called his approach 'receptor-tonus' technique (Nimmo ests in pharmaceutical antispasmodic d rugs.
1957) and it has had a major influence on modern neuro Mense et al (2001 ) point out: 'Physiologic studies show
muscular therapy (DeLany 1 999). A 1993 review of current that muscle pain tends to inhibit, not facilitate, reflex con
chiropractic adj ustive techniques found that just over 40% tractile activity of the same muscle.' Even though it may feel
of chiropractors currently utilize Nimmo's approach on a tense, a painful muscle commonly shows no EMC activity.
regular basis (NBCE 1993). Additionally, not all muscle spasms (as identified by EMC)
A series of articles originally published from 1 958 to 1976 are painful.
in Nimmo's own newsletter, The Receptor, or in Digest of
Chiropractic Economics, was republished as a collection by
Schneider et al (2001). In their text, comments are embed FIBROTIC SCAR TISSUE H Y POT HESIS
ded as footnotes in the original articles in an attempt to Although there may be a few cases where scar tissue is
update some material to more current concepts. found within the taut bands of trigger points, scar tissue is
not commonly found in biopsies of tender nodules, accord
ing to Mense et al (2001, p. 261 ). They suggest that if the TrP
IM PROVE D OX YGENAT I ON AND REDUCED
exists for an extended period of time, chronic fibrotic
TRIGGER POINT PAIN - AN E X A M PL E
change may eventually evolve; however, this is not pre
New Zealand physiotherapist Dinah Bradley (1 999), an dictable and rapid resolution of the palpable band with spe
expert in breathing rehabilita tion, identifies key trigger cific TrP treatment argues against that explanation.
points in her patients, in the intercostals and upper trapez
ius as a rule, at the outset of their course of breathing reha
bilitation. She asks patients to ascribe a value, out of 1 0, to MUSCLE S PINDLE H Y POT HESIS
the trigger point when under digital pressure, before they Some theorists oppose the most widely accepted concepts
commence their exercise and treatment program (during of trigger point formation, those being an integrated
which no direct treatment is given to the trigger points hypothesis, as presented by Simons et al (1999) (discussed
themselves) and periodically during their course, as well as more fully below). Hubbard & Berkoff (1993) and Hubbard
at the time of discharge. (1 996) point to a dysfunctional muscle spindle as the source
Bradley states: of TrP EMC activity. They dismiss the possibility of poten
I use trigger point testing as an objective measurement. tials arising from motor endplates since they believe that
Part of [the patient's] recovery is a reduction in muscu the activity is not localized enough to be generated in the
loskeletal pain in these overused muscles. I use a numeric endplate, and does not have the expected waveform mor
scale to quan tify this. Patients themselves feel the reduction phology nor the expected location.
in tension and pain, a useful subjective marker for them, Simons et al (1999) and Mense et al (2001 ) both contradict
and an excellent motivator. these three assertions, offering a thorough discussion of the
location of active loci and their distribution within the end
This use of trigger points, in which they are not directly plate zone, the nature of spike activity, the lack of concentra
deactivated but are used as monitors of improved breathing tion of muscle spindle concentration in the endplate zone
function, highlights several key points. where TrPs are found, and current information on wave
1. As breathing function and oxygenation improve, trigger form morphology. Additionally, Simons et al (1999, p. 80)
points become less reactive and painful. give the following four reasons that question the validity of
2. Enhanced breathing function also represents a reduction a muscle spindle hypothesis.
in overall stress, reinforcing the concepts associated with 1. If the conclusions that these potentials arise from dys
facilitation - that as stress of whatever kind reduces, trig functional muscle spindles is correct, then Wiederholt's
ger points react less violently. [1970] comprehensive EMC, histological and pharmaco
3. Direct deactivation tactics are not the only way to handle logical study reached an erroneous conclusion and elec
trigger points. tromyographers ever since have been misled. It may be
4. Trigger points can be seen to be acting as 'alarm' signals, difficult to convince the electromyographic community
virtually quantifying the current levels of adaptive that what they have identified as endplate potentials are
demand being imposed on the individual. really muscle-spindle potentials . . .
2. The presence of action potentials originating at an end
plate that was also the site of a TrP active locus was illus
PAIN-SPAS M - PAIN CYCLE
trated [within the cited text] . . . These are motor endplates
The old concepts of pain-spasm-pain have been aban of extrafused fibers. The type of needle used would be
doned due to overwhelming evidence that muscle pain is mechanically unable to penetrate the capsule of a muscle
6 Trigger points 111
spindle to reach an intrafusal motor endplate. Muscle excludes the. possibility of a non-muscular origin of the
spindles usually lie in loose coTmective tissue. pathology. They suggest that the characteristics of the pain
3. The demonstration that the spikes from a TrP active locus from trigger points are not distinguishable from neural pain,
can propagate at least 2.6 cm along the taut band pre and that a primary neurological cause is a much more likely
cludes a muscle-spindle intrafusal-fiber origin. This dis explanation for the local and referred sensations of myofascial
tance is twice the total length of a human spindle and four pain. To date, no neurophysiologic studies have confimled or
times the half-fiber distance measured in this experiment. denied these claims. Routine nerve conduction testing has not
4. In addition, the clinical effectiveness of Botulinum A identified any abnormalities, but may be lacking the sensitiv
toxin injection for the treatment of myofascial TrPs sup ity to do so.
ports the endplate hypothesis.
Mense et al (2001) comment on the concepts presented by
A further short discussion of EMG needling of trigger GlUU1. (1980) and, more recently, a similar discussion by Chu
points is offered later in this chapter. (1995). 'There is much clinical evidence that compression of
Although discussion of needle penetration methodology, motor nerves can, at times, activate and perpetuate the pri
abnormal endplate noise and other associated information mary TrP dysfunction at the motor endplate. Conversely, TrPs
is beyond the scope of this text, the authors acknowledge its are commonly activated by an acute muscle overload that is
importance and refer the readers to the above mentioned unrelated to a compressive neuropathic process. Neuropathy
work of Simons et al (1999) and Mense et al (2001). can be, but is not always, a major activating factor.'
Some theorists point to a neurological cause as primary and Simons et al (1999) combine two widely accepted theories
trigger points as secondary phenomena (Gunn 1997, (energy crisis theory and motor endplate hypothesis) into an
Quintner & Cohen 1994). integrated hypothesis of trigger point formation. This
Huguenin (2004) explains: approach suggests a polymodal model and implies that
there is not a single cause for trigger point formation, but
Gunn (1997) suggested a radiculopathic model for muscular rather a cascade of steps that may occur and a variety of
pain and states that 'myofascial pain describes neuropathic influences that help determine activation and perpetuation.
pain that presents predominantly in the musculoskeletal sys The energy crisis theory (Bengtsson et a1 1986, Hong 2000,
tem' (p. 1 2 1). The radiculopathic model is based on all dener Simons et al 1999) suggests that trauma, repetitive use or
vated structures exhibiting super sensitivity. From clinical increased neural input (see facilitation discussion earlier in
observations, GUHll (1 997) states that neuropathic nerves this chapter) increases calcium release in the inunediate area
are most commonly found at the rami of segmental nerves, surrounding the motor pOint, resulting in prolonged short
and therefore represent a radiculopathy. If neural injury or ening of the central sarcomeres and the formation of a taut
compression and partial denervation are the site of origin of band of myofascial tissue. This also results in compromised
this pathology, he believes that it helps to explain the lack of circulation (reduced oxygen and nutrients) in the local area
pathology seen in muscle and the sensory, motor, and auto with subsequent failure to produce adequate ATP to initiate
nomic changes seen in myofascial pain syndromes. relaxation of the tissues. As metabolic wastes accumulate,
Gunn (1 997) suggests that myofascial pain most often sensitization of nociceptors occurs as well as direct stimula
relates to intervertebral disc degeneration with nerve root tion of sensory nerves by pressure from taut tissues. While
compression or angulation due to reduced intervertebral this theory is plausible, there are no definitive studies to
space and resultant paraspinal muscle spasm. This is show that it is the cause of trigger point formation.
described as a form of neuropathy. This neuropathy then The motor endplate hypothesis points to the fact that the
sensitises structures in the distribution of the nerve root, motor nerve synapses with a muscle cell at the motor end
causes distal muscle spasm, and contributes to other degen plate (mid-fiber region in most muscles). Needle EMG studies
erative changes in tendons and ligaments within its distri (Hubbard & Berkhoff 1993) have found that fibers containing
bution that are then perpetuated by the ongoing muscle trigger points produce characteristic electrical activity (end
shortening. Therefore, this theory is not only used to explain plate noise - EPN) when properly measured at the motor end
trigger point formation, but also conditions such as plate zone (Simons 2001, Simons et aJ 2002). EPN (previously
tendinopathy and en thesopathy. referred to as spontaneous electrical activity or SEA) (Simons
Based on his theories, Gunn (1 997) proposes that long last 2004) is thought to represent an increased rate of release of
ing pain relief requires needle treatment to the shortened acetylcholine (ACh) from the nerve terminal and to result in
paraspinal muscles in order to reduce nerve root compression, action potentials being propagated a small distance along the
as well as to trigger points more local to the site of perceived muscle cell membrane. This may cause activation of a few
pain. Quintner & Cohen (1 994) argued that the reasoning contractile elements, resulting in some degree of muscle
behind traditional trigger point teaching is circular and shortening (Simons 1996).
112 CLI N I CA L A P P L I CATI O N O F N E U RO M U S C U LA R T E C H N I Q U E S : T H E U P P E R B O DY
[
practi tioner stays ever mindful of the existence of this rela Box 6.3 Trigger point activating factors
tionship, successful reduction of TrP referral patterns can be
thwarted. Primary activating factors i nclude:
Key TrPs are primary TrPs, but not all primary TrPs persistent m uscu la r contraction, strai n or overuse (emotional
become key TrPs. Satellite TrPs are not primary TrPs since or physical cause)
they develop associated with a key TrP, and not as a result trauma (local inflammatory reaction)
of d irect activation by overload or overuse. adverse environmental conditions (cold, heat, damp, draughts,
Hong & Simons (1992) have reported on over 1 00 sites etc.)
prolonged immobility
involving 75 patients in whom remote trigger points were
febri le i l l n ess
inactivated by means of injection of key triggers. The details systemic biochemical i mbalance (e.g. hormonal, n utritional).
of the key and satellite triggers, as observed in this study,
Secondary activating factors include (Baldry 1 993):
are listed below.
compensating synergist and antagonist m uscles to those
housing primary triggers may develop triggers
sate l l ite triggers evolve i n referral zone (from pri mary triggers
Key trigger Satell ite triggers or visceral disease referral, e.g. myocardial infarct).
Right lower
Left lower molars Pharynx and larynx molars
Side of tongue
Heart Central portion
Tip of tongue Pharynx and larynx of left diaphragm Heart
Mesentery and
Spleen Right kidney
intestines
Renal pelvis and renal pelvis
Right ovary and ureter
Rectum and trigone Uterine cervix
and tube
Bladder fundus region of bladder
Bladder trigone
A B
Figure 6.S Pai n referred from viscera. A : Anterior view. B : Posterior view. Adapted from Rothstein et al ( 1 99 1 ).
the skills required to identify and treat myofascial dysfunc Practitioners should be able to identify:
tion. To date, no definitive, reliable method of imaging trig
ger points or laboratory test is available to assist in the
bony structures
diagnosis of a trigger point (Simons 2004). Manual palpa
individual muscles (where possible)
tion and physical examination, combined with a thorough
palpable thickenings, bands and nodules within the
case history, remains the diagnostic standard.
myofascial tissues.
BAS IC S KILL REQUIREMENTS Additionally, knowledge of fiber arrangement and the short
When designing and conducting clinical studies relating to ened and stretched positions for each section of each muscle
soft tissue dysfunction, it is important that the examiners be will allow the practitioner to apply the techniques in such a
experienced and well trained in those palpation skills and way as to obtain accurate and reliable results. Knowledge of
protocols required to accurately assess the tissues. Those (or accessible charts showing) trigger point reference zones
who are inexperienced (recent graduates or students, for will offer greater accuracy.
example) or experienced practitioners with insufficient Simons et al (1 999) discuss diagnostic criteria for identi
training in the specific techniques required may well fall fying a trigger point:
short of the skills needed to apply technique-sensitive
strategies. This is especially true of those applying manual taut palpable band
techniques, since palpa tion skills take time and practice to exquisite spot tenderness of a nodule in the taut band
perfect. Experienced practitioners who are trained to pal recognizable referral pattern (usually pain) by pressure
pate for, and identify, specific characteristics that form part on a tender nodule (active with familiar referral or latent
of research criteria (see below) will offer the most useful with unfamiliar referral)
and valid findings (Simons et aI 1999). painful limit to full stretch range of motion.
116 C L I N ICAL A P P L I CAT I O N O F N EU R O M USCU LAR TECH N I Q U E S : T H E U P PER B O DY
L
ULTRASOUND
1 . 200 asymptomatic Air Force recruits aged 1 7-35 demon Visual imaging of the local twitch response (LTR) provides
strated trigger points i n 54% of 100 females and 45% of 100 objective evidence tha t an LTR has been provoked. While it
males tested (Sola et al 1 95 1 ) . may be clinically practical to use ultrasound, the practitioner
2 . Triggers c a n occur i n a n y myofascial tissue but the most com
monly identified trigger points are found i n the u pper trapez would still need to provoke the LTR. This would involve nee
ius and quadratus lumborum (Travel l Et Simons 1 983b). ('A dle penetration or the development of snapping palpation
latent trigger point in the third finger extensor may be more skills . Snapping palpation is a difficult technique to master
common' Simons et al 1 999.) and is not applicable to many of the muscles. However, when
3. I ncidence of primary myofascial syndromes noted in 85% of it is possible to do so, this method provides non-invasive
283 consecutive chronic pain patients and 55% of 1 64
chronic head/neck pain patients (Fishba i n et al 1 986, Fricton supporting evidence that a trigger point has been found.
et al 1 985).
4. Most common trigger point sites are :
belly o f m uscle, close t o motor point SURFACE EL ECTRO MYOGRA P H Y
close to attach ments
referred spasm to other muscles. With well-designed stud takes more than 4 kg of pressure to produce pain, the point
ies, this may provide evidence that trigger points increase does not count in the tally. Without a measuring device, such
responsiveness and fatigability and delay. recovery of the as an algometer, there would be no means of standardizing
muscle. pressure application. An algometer is also a useful tool for
training a practitioner to apply a standardized degree of pres
sure when treating and to 'know' how hard they are pressing.
ALGOMETER USE FOR RESEARC H AND CLINICAL
Use of a hand-held algometer is not really practical in
TRAINING
everyday clinical work but this becomes an important tool if
When applying digital pressure to a tender point in order to research is being carried out, as an objective measurement of
ascertain its status (Does it hurt? Does it refer? etc.), it is a change in the degree of pressure required to produce symp
important to have some way of knowing that pressure being toms. The research by Hong and colleagues as to 'which
applied is Wliform. The term 'pressure threshold' is used to treatment method is most successful in treating trigger
describe the least amount of pressure required to produce a points' reported on later in this chapter, utilized algometer
report of pain and / or referred symptoms. It is obviously readings before and after treatment and could not usefully
useful to know whether pain and /or referral symptoms have been carried out without such an instrument.
occur with 1, 2, 3 or however many kilograms of pressure An electronic algometer that fits over the thumb allows
and whether this degree of pressure changes before and recording of pressures applied to obtain feedback from the
after treatment or at a subsequent clinical encOlmter. patient and to register the pressure being used when pain
In diagnosing fibromyalgia, the criteria for a diagnosis levels reach tolerance. A lead from the algometer connects
depend upon 11 of 18 specific test sites testing as positive to a computer, giving precise readouts of the amount of
(hurting severely) on application of 4 kg of pressure pressure being applied during assessment or treatment
(American College of Rheumatologists 1990) (Fig. 6.6). If it (Fryer & Hodgson 2005) (Figs 6.7 and 6.8).
Taut band----,-C"-'
\\--.1\/
I
Diarrhea, dysmenorrhea
Diminished gastric motil ity
Vasoconstriction and headache
Dermatographia
Proprioceptive d isturbance, d izziness
Excessive maxillary sinus secretion
Loca l ized sweating
t
Cardiac a rrhythmias (especia l ly pectora l is major triggers)
Gooseflesh
Ptosis, excessive lacrimation
Conjunctival reddening
I
j' l\
Box
The sca lenes (anterior, i n particular) can ent ra p structures
passing through the thoracic inlet.
This is aggravated by 1 st rib (a nd clavicu lar) restriction (which
can be caused by triggers in a nterior and middle scalenes).
Scalene trigger points have been shown to reflexively suppress F i g u re 6. 1 0 Testi n g skin a n d fascial m o b i l ity bi laterally as loca l
lymphatic duct peristaltic contractions in the affected tissues a re taken toward the e lastic e n d of ra nge.
extremity.
Triggers i n the posterior axil lary folds (subscapularis, teres
major, latissimus dorsi) i nfluence lymphatic d ra inage affecting
upper extremities and breasts (Travel l Et Simons 1 992). as inflammation and ischemia. Trigger point activity is
Similarly, triggers i n the anterior axillary fol d (pectoralis
likely in areas of greatest 'difference'
m i nor) can be implicated i n lymphatic dysfu nction affecti ng
the breasts (lin k 1 98 1 ) . movement of skin on fascia - resistance to easy gliding of
skin on fascia indicates general locality of reflexogenic
activity, i.e. possible trigger point (Lewit 1992), and can
indicate lymphatic congestion which may be contribut
muscle is considered, which places the predictable zone ing to the etiology
of central trigger point location much further distally on local loss of skin elasticity - can refine localiza tion of site
the upper arm than it would be if the tendons were of trigger poin ts, as can ex tremely light single-digit
included. stroking, which seeks to locate a 'drag' sensation (evi
Muscles with tendinous inscriptions (tendinous bands dence of increased hydrosis in and under the skin),
traversing muscles which divide them into sections, such which offers pinpoint accuracy of location
as occurs in rectus abdominis) will have an endplate digital pressure (angled rather than perpendicular) into
zone within each section. the suspected tissues seeks confirmation of active trigger
The fiber arrangement of all underlying and overlying or latent trigger points (Kuchera & McPartland 1997).
tissues should be considered when approaching layers of
Trigger point deactivation possibilities, which will be exam
muscles with manual assessment so as to include all of
ined in later sections of this book, include (Chaitow 1996b,
them.
Kuchera & McPartland 1997) :
Additional palpation skills may be used to discover the inhibitory soft tissue techniques (previously called
presence of trigger points, facilitated tissue and myofascial ischemic compression, now referred to as trigger point
restrictions (Figs 6.10 and 6.11). These skills require practice pressure release) including neuromuscular therapy!
before accuracy is reliable; however, once developed, they massage
are clinically valuable. They include (Chaitow 1996a): chilling techniques (cryospray, ice)
acup uncture, injection, etc. (dry or wet needling)
off-body scan (manual thermal diagnosis); which offers positional release methods
evidence of variations in local circulation, probably muscle energy (stretch) techniques (including both pas
resulting from variations in tone, as well as factors s uch sive and active forms of isometric contraction)
6 Trigger points 121
plus active ROM and interferential current as well as can powerfully release the contractures and teach the person
myofascial release technique, are most effective for easing new skills for maintaining the release. Little long-tenn bene
MTrP pain and increasing cervical ROM. fit is derived from the mechanical release alone. At-home
stretches, changes in usage and a ttention to other perpetuat
When precise palpation and release techniques are combined ing factors will alter the conditions that have helped build the
with elongation of the tissues (stretching), the combination trigger points and help prevent them from recurring.
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1 25
Chapter 7
primary focus on reorganization and repair of damaged tis chronic pain what are known as wind-up type mechanisms
sues. The coordinated achievement of these processes, and long-term potentiation (LTP) play roles in neuroplastic
influenced by a plethora of biochemical mediators, occurs ity to cause hyperalgesia and allodynia. Wind-up is a pro
under the general heading of 'inflammation' although, as gressive increase in the magnitude of the C-fiber evoked
will become clear in this chapter, not all the processes under response. This may also produce some characteristics of
that heading involve actual inflammation. Inflammation central sensitization, including expansion of the receptive
that is not confined to myofascial tissues is discussed later fields and enhanced responses to C-fiber stimulation (Li
in this chapter. et aI1999).
These homeostatic adaptations usually take place in an Abnormal processing allows transmission of signals
orderly mcumer, although the stages involved can vary along the central nervous system pathways, independent of
quite considerably in temporal terms, depending on the sta the degree of nociception that is occurring in the periphery.
tus of the individual and associated conditions (hygiene, for The term central sensitization refers to an increase in spinal
example). There are three stages of inflammation (Toumi & cord neuronal excitability and a decrease in threshold. In
Best 2003), commonly referred to as the acute response (lag) simple terms, the perceived pain may be greater than the
phase, the regeneration phase and finally, if all is going well, injury would seem to warrant, due to increased sensitivity
the remodeling phase (Liebenson 2006). of the nervous system itself, or of the part of the brain regis
The healing process needs to involve capillary repair and tering the pain messages - virtually as though the 'volume'
new growth, proliferation of fibroblasts, deposition of colla has been turned inappropriately high.
gen and scar tissue formation. It is always worth reminding
ourselves that these types of inflammatory process are usu
MECHANISMS OF CHRONIC PAIN
ally beneficial and have a great healing potential.
Chronic pain is characterized by an abnormal sensitivity
that may be due to generation of pain in response to low
PAIN PROGRESSION threshold mechanoreceptive A-fibers that normally gener
ate innocuous sensations (Woolf & DoubeI1994).
For the individual to become aware of pain, peripheral noci
A decrease in non-nociceptive input may lead to pain by
ceptors (afferent neurons that respond to noxious stimuli)
a deafferentation mechanism, sometimes described as
need to be activated (Davis 2001). These then stimulate neu
'burning, raw, or searing' or as a 'tingling, numb sensation'
rons in the spinal cord (Carr & Goudas 1999). At the cord
(Tasker & Dostrovsky 1989).
level, pain signals may be both transmitted to the brain, as
Changes in spinal sensory processing may occur without
well as being modified. Specific areas of the brain, such as
changes in blood flow (Andrews et a11999) or actual inflam
the thalamus and brains tern, receive the nociceptive infor
mation (Alfredson et al 1999) (see details of this in discus
mation and have the ability to initiate descending inhibition.
sion of tendon pain below). Mediated by low-threshold
Following joint or muscle injury, the spinal cord processes
mechanosensitive afferents projecting to sensitized dorsal
painful information and influences inflammatory responses
horn neurons, the nociceptive processes are qualitatively
(Dickenson et al 1997). The chemicals that are released in
altered in patients with chronic myofascial pain (Bendtsen
response to injury include potassium (from damaged cells),
et al 1996). Patients suffering from chronic whiplash syn
serotonin (from platelets), bradykinin (from plasma), hista
drome (Johansen et a11999) and patients with fibromyalgia
mine (from mast cells), prostaglandins (PGE2, from dam
(Sorensen et al 1998) have a generalized central hyperex
aged cells), leukotrienes (from damaged cells) and substance
citability of the nervous system, representative of central
P (SF, from primary afferent fibers) (Purves et aI1996).
sensitization.
Inflammation increases the sensitivity of the neural recep
There is ample evidence that indicates diin m ished
tors, both in the periphery and in the central nervous sys
endogenous opioid (i.e. self-generated pain modulating) sys
tem, by altering the membrane properties of nociceptors,
tems with chronic pain (Bruehl et al 1999). The functional
permitting a higher discharge frequency, and contributing to
result is hyperalgesia and spontaneous pain associated with
hyperalgesia by activating synapses that are usually inactive
tissue injury. Pain can also be biochemical in origin, even in
(Djouhri & Lawson 1999, Li & Zhou 1998). Inflammatory
apparently normal structures. Chemical mediators involved
pain and the sensitization of peripheral nociceptors can be
in nociceptive processing include neuropeptides, such as
very rapid and may involve non-neuronal cells such as mast
dynorphin, substance P and calcitonin gene-related peptide,
cells, neutrophils, fibroblasts, and macrophages (Mendell
and excitatory amino acids, such as NMDA (N-methyl
et al 1999, Mense et aI2001).
D-aspartic acid that mimics glutamate) (Dubner & Ruda 1992,
Khan et aI2000). Patients suffering from chronic whiplash syn
drome, for example, may have a generalized central hyperex
SENSITIZATION
citability from a loss of tonic inhibitory input (disinhibition)
Chronic pain can be due to tissue injury, nervous system and/or an increase in excitatory input (partially chemically
injury, or both (Woolf et al 1998). In the development of induced) contributing to dorsal horn hyperexcitability. This
7 The internal environment 127
may lead to dysfunction of the motor system. The aim of discussion, which the authors of this text find unfortunate,
treatment should be not only to relieve pain but also to since its application in the acute stage would be most
allow for proper proprioception (Parkhurst & Burnett 1994). appropriate as an inflammatory mediator.
A fascinating link between emotion, endogenous chemical The risks of the use of antiinflammatory medication, and
pain modulation and levels of chronic pain experienced has alternatives, are discussed later in this chapter. As will be
been identified. For example, individuals chronically defi seen in Chapter 13, a variety of neuromuscular approaches,
cient in endogenous opioid activity appear to have less abil including attention to the activities of active myofascial trig
ity to inhibit emotions and physiological arousal, resulting in ger points and to manual release of increased muscular ten
a strong and overtly expressive style of anger management. sion, offer alternative and complementary choices.
This suggests that chronically low levels of opioid activity
may be a common factor underlying development of both
GLUTAMATE: A CONTRARY VIEW OF THE CAUSE
the way anger is expressed (i.e. violently) and elevated pain
OF TENDON PAIN
sensitivity (Bruehl et a12002, Gregg & Siegel 2001).
But what if 'epicondylitis' - as described by Hume et al (2006)
above - is inaccurate and the painful problem does not
An elbow example involve an inflammatory process after all?
Surprisingly, it appears that the actual causes of chronic
A standard medical view of the adaptive sequence, and the
tendon pain remain unknown, and even though tendon
correct terminology associated with painful and inflamed
biopsies commonly show no inflammatory activity, anti
joint tissues as they move from acute to chronic dysfunc
inflammatory medications are nevertheless commonly
tion, are encapsulated in the description of elbow injuries
used. Wilson & Best (2005) note that:
by Hume et al (2006). They remind us that the incidence of
epicondylar injuries in those sports associated with over
head or repetitive arm actions (baseball, for instance) are Histologic descriptions of tendinopathies have demonstrated
frequent and often severe. disordered collagen arrangement together with increased
proteoglycan ground substance and neovascularization. It is
Acute elbow injury that results in inflammation should unclear if these chronic degenerative changes are preceded
be termed epicondylitis, commonly the result of valgus consistently by an acute inflammatory response; therefore,
forces with medial distraction and lateral compression. the designation of tendon pain as 'tendonitis' may be a mis
The more chronic stage of epicondylosis develops over a nomer. The terms 'tendinopathy' and '[tendinosisl' are more
longer period of time due to repetitive forces leading to appropriate and should be used to describe these clinical enti
structural changes in either epicondylar tendon. What the ties in the absence of biopsy-proven histopathologic evidence
patient feels, epicondylalgia, refers to elbow pain at either ofacute inflammation, particularly in patients who have had
the medial or lateral epicondyle relating to tendinopathy symptoms for more than a few weeks.
of the common flexor or extensor tendon origins at these
points. In other words, the suffix use of -itis or -osis is dependent
upon the stage of inflammation, acute versus chronic,
Pain in such settings is usually associated with gripping, respectively.
resisted wrist extension and certain movements, such as in A process of intratendinous microdialysis was employed
tennis and golf, hence the common terms 'tennis elbow' (lat by Scandinavian researchers (Alfredson 2005) to investigate
eral epicondylitis) and 'golfer's elbow' (medial epicondylitis). human tendons. They found normal prostaglandin E2 (PGE2)
Standard medical attention of corticosteroids and elbow levels and no proinflammatory cytokines, in people with
straps may be used for treatment; however, as Hume et al chronic painful tendinosis (Achilles' and patellar). These
make clear, there is 'very limited prospective clinical or exper findings show that there is no PGErmediated intratendi
imental evidence for their effectiveness'. Therefore, Hume nous inflammation, at least in the chronic stage of these
et al assert that, 'the most effective modalities of treatment conditions.
are probably rest (the absence of painful activity) combined However, the neurotransmitter glutamate (a potent mod
with cryotherapy in the acute stage', followed by anti ulator of pain in the central nervous system and its most
inflammatory medication, heat (ultrasound) and cortisone profuse excitatory neurotransmitter) has been found in
injections, as well as rehabilitation exercises. W hile the abundance in painful human tendons (Alfredson et al 2001,
authors of this text agree that this approach would allow the Alfredson 2005). Microdialysis of these tissues has shown
natural transition from the acute to the regeneration and significantly higher glutamate levels in chronic painful
remodeling phases of recovery, it is suggested that cortisone tendinosis (Achilles' and patellar), compared with pain
injections be considered only when all other measures have free normal control tendons. Although the importance of
failed and only if treatment of trigger points, joint mobility these findings is not yet clear, they do suggest that anti
and habits of use have been thoroughly addressed. inflammatory strategies may frequently be less than useful
Lymphatic drainage was apparently not considered in this in such conditions.
1 28 C L I N ICAL A P P LICAT I O N OF N E U R O M U S CULAR TEC H N I QUES: T H E U P PER B O DY
Injury cycle which are, in fact, degenerative. In such conditions there may
be scant evidence of the beneficial influences of inflammation.
TIlis 'mistaken identity' may occur, he notes, in Achilles ten
dinitis and patella tendinitis, a view that is evidence based
(Kann us 1997).
'Evidence . . . suggests that degenera tive tendon changes
are evident in one third of the healthy urban population aged
35 or more.' Hunter (1998) reports that, at biopsy, degenera
tive changes (e.g. calcifying tendinopathy) may be found
and that, without inflammation, there will be no stimulus to
healing.
Joints and ligaments
Effusion
If inflamma
modifies it is likely to reduce the level of perceived pain. It is
important to keep in mind that although inflammation is
Deconditioned Appropriate care
Neglect or adverse Positive treatment
unpleasant it is a vitally important process in repairing (or
outcomes outcomes defending against) damage, irritation or infection. Therefore
antiinflammatory strategies (use of cryotherapy, medication,
nutritional approaches, etc.) need to aim at a limited degree of
reduction, rather than total elimination of this process, during
the acute phase following tissue inj ury.
Excessive scarring Minimal scarring
Intraarticular adhesions Regeneration As noted in this chapter, a major fea ture of localized
Extraarticular adhesions Repair inflammation involves prostaglandins and leukotrienes
Continued pain No pain
Loss of function Full strength
(Djupsjobacka et aI1994). These are largely dependent upon
Loss of range Full range the presence of arachidonic acid, which the body manufac
Loss of power (atrophy) Hypertrophy
tures mainly from a nimal fats. Reducing animal fat (meat,
Tendency to reinjure Normal movement patterns
Negative psychological effects No psychological residue poultry, dairy) intake cuts down levels of the enzymes tha t
help produce arachidonic acid (Donowitz 1985).
Figure 7.2 Sc he m a tic representation of the injury cycle.
Cold-water fish oil, on the other hand, provides anti
inflammatory eicosapentenoic acid (EPA), which interacts
with the metabolites of arachidonic acid to soften i ts effects
in the inflammatory process (Terano et a l 1986) . Five to ten
movement therapies even in the face of some types of dis 1 000 mg EPA capsules daily are commonly taken to main
comfor t. tain a reduction - but not elimination - of vital inflamma
Liebenson (2006, p. 21) expla ins this shift in clinical tory processes (Moncada 1 986) .
thinking: Antiinflammatory (proteolytic) enzymes, often derived
from plants, have a gentle but substantial antiinflammatory
A paradigm shift from a traditional biomedical model to a
influence. These include bromelaine, which comes from the
biopsychosocial one has taken firm hold in a spine field. The
pineapple stem (not the fruit), and papain from the papaya
biopsychosocia/ approach teaches us that the old adage 'let
plant. It is necessary to ensure around 2-3 g of one or the
pain be your guide' can actually reinforce illness behavior
other are taken (bromelaine seems to be more effective)
such as fear-avoidance behavior. The more modern report of
spread through the day, away from meal times, as part of an
findings reassures patients that they do not have a disease
antiinflammatory, pain-relieving strategy (Cichoke 1981,
(tumor, infection, and fracture) and that staying active will
Taussig 1988, Walker et al 2002, Werbach 1991). These veg
actually speed recovery. Learning that pain does not always
etable enzymes can be taken before events, such as a
warn of impending harm or damage can empower patients
mara thon, to reduce subsequent tissue damage.
to remain active to avoid disability, and prevent the transi
Seaman (2006) suggests that potassium and magnesium
tion from acute to chronic pain.
are significantly important nu trients, generally overlooked,
and tha t each could provide substantial antiinflammatory
benefits as well as valuable pH influences. Deficiencies of
DIFFERENCE BETWEEN DEGENERATIVE AND
either are critical factors in the development of chronic inflam
INFLAMMATORY PROCESSES
mation. Glucose u tilization is impaired and glycogen stores
Hunter (1998), quoted above, makes a clear distinction reduced when potassium is deficient, resulting in hypoxia,
between many conditions previously labeled as inflanunatory muscle weakness, cramps and pain. Magnesium (Mg) is
1 30 C L I N ICA L A P P L ICAT I O N OF N E UR O M U S CULAR T E C H N I Q U E S: T H E U P P ER B O DY
necessary for ATP synthesis and mitochondrial fW1ction, and WHAT ABOUT ANTIINFLAMMATORY
profoW1dly influences potassium homeostasis. Deficiencies MEDICATION?
in Mg may be associated with neurogenic inflammation, a
Steroidal (e.g. cortisone) and non-steroidal antiinflammatory
generalized nervous system hyperexcitability and height
drugs (NSAIDs) are among the most widely used medica
ened peripheral and central nociceptive activity (Seaman
tions, prescribed and over the cOW1ter (OTC). Although there
2006). The importance of maintaining adequate levels of
may be a place for the use of these, based on clinical experi
magneSium is supported by Jing et al (1995), who link low
ence and the widely reported dangers of many of these drugs
dietary and serum Mg to the development of cardiovascular
(e.g. the COX-2 inhibitors such as rofecoxib (VIOXX), recalled
disease, atherosclerosis, hypertension and diabetes. With
in September 2004), the authors of this text are strongly of the
appropriate changes in diet, adequate intake of potaSSium
opinion that other, potentially less harmful, methods should
may be acquired through foods such as fruits, vegetables
be used in preference, whenever possible.
and nuts. However, it is usually necessary to supplement
The words of researchers who are strongly in favor of the
Mg since dietary sources alone may not resolve the issue
use of antiinflammatory medication state the case for using
(Seaman 2006).
such drugs with caution. For example, Ehrlich (2004) states:
Barbagallo et al (2003) point to the intimate relationship
of Mg to insulin, and insulin's modulating effects on the
Pain remains the leading reason for which patients con
shift of Mg into intracellular space. They also note:
sult their doctors.
Intracellular Mg concentration has also been shown to be Pain also motivates over-the-counter sales of analgesic
effective in modulating insulin action (mainly oxidative medicines, to be taken orally or even transcutaneously.
glucose metabolism), offset calcium-related excitation Prescription medicines usually follow attempts at self
contraction coupling, and decrease smooth cell responsiveness medication that fail to achieve the desired results.
to depolarizing stimuli. A poor intracellular Mg concentra Acute pain usually subsides spontaneously but medi
tion, as found in non insulin-dependent diabetes mellitus cines are needed W1til that occurs; in arthritic conditions
(NIDDM) and in hypertensive patients, may result in a especially osteoarthritis - antiinflammatory drugs work
defective tyrosine-kinase activity at the insulin receptor best in short-term administration for flares that aggravate
level and exaggerated intracellular calcium concentration. chronic but tolerable pain.
Both events are responsible for the impairment in insulin In cases of chronic pain that exceeds the level of easy tol
action and a worsening of insulin resistance in noninsulin erance, antiinflammatory drugs can reduce the pain to
dependent diabetic and hypertensive patients . .. . [It] may tolerable levels more effectively than simple analgesics
play a key role in modulating insulin-mediated glucose and narcotic combinations.
uptake and vascular tone. Wefurther suggest that a reduced The non-steroidal antiinflammatory drugs (NSAIDs) are
intracellular Mg concentration might be the missing link among the most useful medicines providing an array of
helping to explain the epidemiological association between drugs that differ chiefly in time of onset of action, dura
NIDDM and hypertension. tion of action and persistence in the blood.
The benefit they provide is pain amelioration; none is
As to diet and inflammation, Seaman (2006) suggests:
curative.
A diet that is pro-inflammatory will increase the inflamm.a The risks are well known and do not differ greatly
tory potential of cells and tissues, and the outcome is likely to among the drugs; unwanted gastrointestinal (GI) effects
be the phenotypic expression of a disease or syndrome related are the most common, but the skin, kidneys, liver and
to inflammation such as pain, arthritis, cancer, heart disease, blood forming organs may also be affected. [emphasis
diabetes, Alzheimer disease, and most other chronic degener added]
ative diseases ... we can craft a diet that is rich in foods that
are known to be anti-inflammatory . . . such a diet would be
free of simple carbohydrates because they drive hyperinsu CONTROLLED SCARRING - FRICTION AND
linemia and the expression of syndrome X . Calories would
. . PROLOTHERAPY
be restricted to inhibit an increase in fat stores which serve as
Treatment that deliberately mildly inflames the structure
a depot of inflammation and a promoter of syndrome X.
may, in such cases, be seen to offer a therapeutic stimulus.
He concludes that dietary focus would be similar to the Controlled friction carefully applied to such structures
hW1ter-gatherer diet, Mediterranean-like diet and the poly could induce a mild inflammatory response and assist in
meal, suggesting that food choices would include fish, grass achieving this. Methods such as crossfiber friction, as advo
fed lean meats, omega-3 eggs, fruits, vegetables, nuts, olive oil cated by Cyriax (1962), could be selectively useful in such
and minimal grains, coupled with eating less and exercising settings. In the case of the induction of a deliberate inflam
more. Dietary and lifestyle changes, such as those discussed matory response, antiinflammatory measures, such as those
by Richard & Richards (2003) offer a similar approach (see discussed above, should be delayed until desired outcomes
hormonal discussion later in the chapter). have been achieved.
7 The internal environ ment 1 31
In some situations, particularly those involving substan chronic, low-grade, systemic inflammation that becomes
tialligamentous damage, prolotherapy might also be a useful self-perpetuating. Seaman (2006) explains:
tool. Prolotherapy involves the placement of a prolific agent
(dextrose), which is injected at the attachment site of ligament Tumor necrosis factor-a: (TNF), one of many pro-inflamma
or tendon to bone . The resultant localized inflammation in ton) C1)tokines, is released by both white cells and adipocytes,
this weak area increases blood supply and nutrient flow, and as individuals gain additional fat, there's an increased
thereby stimulating tissue repair. Mooney (2003) observes: release of adipocyte-derived TNF, which serves to inhibit
'The concept of creating scar to offer tissue stability goes back insulin receptor activity that leads to insulin resistance
to Hippocrates' advice for using a hot poker for chronically (Fernandez-Real & Ricart 2003, Grimble 2002). As insulin
cUslocating shoulders.' Various sclerosant agents have been resistance develops, it promotes glycosylation of proteins and
used since the 1800s to treat varicose veins, hemorrhoids and DNA, enhances free radical formation (Preuss et al 2002),
hernias non-surgically. A general surgeon named Hackett, and leads to an upregulation of inflammatory protein pro
having recognized the potential for injected agents to duction (Evans et al 2002), and through these mechanisms,
strengthen ligaments, started performing this procedure in insulin resistance will lead to a worsening of inflammation,
the 1950s. He changed the procedure name to proliferant ther which leads to a vicious cycle of chronic inflammation
apy rather than sclerosant treatment because of the more pos (Fernandez-Real & Ricart 2003).
itive implication of enhancing tissue strength through new (See also the hormonal discussion below.)
tissue rather than changing it by scar. Richards & Richards (2003), in Mastering Leptin, explain
this process in greater detail, simplifying complex concepts,
such as a triad of leptin, insulin and adrenaline resistance.
WHEN INFLAMMATION BECOMES GLOBAL 'The concept of fat as a storage place has been transformed
to fat as a major endocrine organ, such as the thyroid gland,
It is important to consider that the inflammatory process adrenal glands, and sex glands.' In actuality, the picture is
seen in the patient may be more systemically oriented, i.e. a much bigger than the statement implies.
generalized proinflammatory state that leads to chronic
inflammation. Diet-related metabolic imbalances (such as
insulin resistance, a prediabetic state, and free radical mech HORMONAL INFLUENCES
anisms) are implicated as a driving force in systemic inflam Hormones are the chemical messengers to and from the
mation, which has far-reaching consequences on practically
brain, cells, glands and organs, forming a complex commu
all organs and systems in the body. nication system that drives respiration, reproduction,
Seaman (2006) notes: growth, digestion, energy production and usage, and prac
tically all functions of the human body. Concentration levels
. . . inflammation is part of the healing process; however,
of hormones in blood and extracellular fluid are crucial
chronic inflammation represents lack of tissue healing and
factors in health that regulate innumerable physiological
actually, promotes ongoing tissue damage. Cancer, heart
effects. Concentration levels are determined by the:
disease, hypertension, Alzheimer disease, endometriosis,
osteoarthritis, rheumatoid arthritis, diabetes, aging, rate of production
osteoporosis, chronic obstructive pulmonary disease, and rate of delivery, and
menopause are examples of conditions that developed and rate of degradation and elimination.
exist as a consequence of chronic inflammation and this is
likely the case for chronic musculoskeletal pain. When hormone concentrations are either too high or too
low disease almost always results.
He further notes that these metabolic imbalances occur In the few years since its discovery, leptin has been linked
simultaneously, are interrelated, and appear to have a cumu to influences on body weight, insulin levels, cardiovascular
lative effect. He implicates free radicals, inappropriate ratios health, reproductive function, sexuality, immune function,
of omega-6 to omega-3 fatty acids, deficiencies of potassium adrenal function, effects of stress, bone health, cancer and
and magnesium, and related pH disorders as primary cul inflammation. Research regarding leptin is still in its infancy,
prits in the development of chronic inflammation. He sug although it was the focus of over 4200 scientific papers
gests that single interventions, such as taking individual between 1995 and 2003 (Tenenbaum 2003). With new infor
supplements of magnesium or vitamin E, will not have an mation regarding hormones and other chemical communi
appreciable effect, and that a broader approach will likely be cators (such as cytokines) emerging almost daily, there are
needed, including significant changes in dietary habits. obvious challenges for most physicians to stay current with
These diet-related metabolic imbalances, as also dis the information load. Hormonal imbalances in general, and
cussed by Haffner et al (1992), are usually referred to as leptin, adrenaline and insulin dysfunction in particular,
'syndrome X', which is directly linked to hyperinsulinemia appear to play significant roles in widespread damage,
and/or insulin resistance. It is apparently promoted by a destruction and devastation in health and in the lives of
1 32 CL I N ICAL A P PL I C AT I O N OF N E U R O M U SC U L A R T EC H N I QU ES: T H E U P P E R B O DY
those who suffer with them, making it critical to have a While they may be secreted directly into the bloodstream,
baseline understanding of their interface. they may also move by circulation or diffusion to their tar
Although we normally think of hormones as being pro get cell, which may be nearby or in a distant organ or tissue.
duced by endocrine glands (Box 7.1), they are also pro Once they reach their target cells, the hormones combine
duced by most organ systems and tissue types in the body. with their receptors to complete the signal, which might
Endocrine glands are ductless glands that secrete specific messenger 6. adrenocorticotropin (ACTH) - governs the nutrition. growth
molecules called hormones that are released directly into the and function of the adrenal cortex
bloodstream and travel to target organs, upon which they act. 7. somatotropin - promotes body growth. fat mobilization and
Conversely, exocrine glands (salivary, sweat and digestive glands) secrete inhibition of glucose utilization
products that are passed outside the body. While both are important, 8. melanotropin - causes dispersion of melanin. which results in
the endocrine system as a whole works in parallel with the nervous darkening of the skin
system to control growth and maturation along with hom eostasis. 9. oxytocin and prolactin- stimulated at the end of pregnancy
Each hormone's shape is specific and can be recognized by the to induce labor and prepare the breasts for milk production,
corresponding hormone receptors on the target cells. Some respectively.
hormones are supplied in antagonistic pairs that have opposing
The thyroid gland produces thyroid hormones that regulate
effects on the target o rgans. For example, insulin lowers blood sugar
metabolism, including body temperature and weight, as we l l as
levels whereas glucagon raises it. Hormonal regulation (balance and
calcitonin, which helps regulate calcium (see Box 7.2).
hom eostasis) usua l l y depends on feedback loops.
The parathyroid glands play a significant role in the regulation of
Endocrine-related problems include overproduction of a hormone,
the body's calcium balance.
underproduction of a hormone and non-functional receptors that cause
The pancreas has two functions: functioning as a ducted
target cells to become insensitive to or unable to utilize hormones.
(exocrine) gland, it secretes digestive enzymes into the small
Functions controlled by hormones include:
intestine; as a ductless (endocrine) gland its islets of Langerhans
activities of certain organs secrete insulin and glucagon to regulate blood sugar levels.
growth and development The adrenal glands, located one on top of each kidney, consist of
reproduction two parts that work hand-in-hand with the hypothalamus and
sexual characteristics pituitary gland. The outer cortex secretes corticosteroids such as
usage and storage of energy cortisone, wel l known as being antiinflam matory. The medulla
levels of fl uid, salt and sugar in the blood. secretes epinephrine, norepinephrine and other similar 'stress'
hormones that respond in fight or flight situations as well as to
More than 50 human hormones have been identified and are
caffeine or low blood sugar. Several steroid hormones are also
categorized into general classes (groups) by chemical structure, not
produced by the adrenal glands, classified in the fol lowing cate
function. These include:
gories: mineralocorticoids (electrolyte balance), glucocorticoids
steroid hormones - l ipids derived from cholesterol; these include (breakdown of fats and proteins) and sex hormones.
sex hormones (such as testosterone, estradiol, progesterone) and The gonads or sex organs secrete sex hormones. While both sexes
adrenal steroids (such as cortiso l) make some of each of the hormones, typically male testes secrete
amines - derived from the amino acid tyrosine; secreted from the primarily androgens (including testosterone) and female ovaries
thyroid and the adrenal medu l l a make estrogens and progesterone.
peptide hormones -secreted b y the parathyroid, pituitary, heart, The pineal gland is stimulated by the optic nerves. It secretes
stomach, liver and kidneys melatonin, which promotes sleep. It also affects reproductive,
eicosanoids - derived from po l yunsaturated fatty acids; the prin thyroid and adrenal cortex functions. In some animals, melatonin
cipal groups of hormones of this class are prostaglandins, prosta affects skin pigmentation.
cyclins, leukotrienes and thromboxanes. The thymus gland is l ocated in the upper part of the chest and
produces T lymphocytes (white blood cells that fight infections
The gla nds and destroy abnormal cel l s).
The pituitary gland is considered the ' master gland'. H owever, it
In addition to the above listed classic endocrine organs, many other
should be borne in mind that the hypothalamus secretes hor
cells in the body secrete hormones. Among these are the adipose cells,
mones that stimul ate or suppress the rel ease of hormones in the
which were previously thought to only provide a storage site. In recent
pituitary gland, in addition to controlling water balance, sl eep,
years, much has come to light regarding hormonal production by
temperature, appetite and blood pressure. Together, the hypothal
adipocytes, thereby establishing adipose as a true endocrine organ
amus and pituitary gland control many other endocrine functions
(Kershaw Et Flier 2004) (see Box 7.3). If defined broadly, the term
and secrete a number of hormones, including:
'hormone' can also include all secreted chemical messengers, which
1. fol licl e-stimulating hormone (FSH) - stimulates deve lopment means virtual ly all cells can be considered part of the endocrine system.
and m aturation of a fo l l icle in one of a woman's ovaries Though this discussion has appeared to simplify endocrinology,
2. luteinizing hormone (LH) - causes ovulation and the forma the study of the endocrine system remains one of most complex
tion of a corpus luteum information. It is important to bear in mind that there are no cell
3. antidiuretic hormone (ADH) - helps regulate water excretion types, o rgans or processes that are not influenced - usual l y
by the kidneys and blood pressure profoundly - b y hormone signaling. Often multiple hormones are
4. enkephalins and endorphins (opiates) - serve to deaden pain acting in relation to each other. Although many hormones are
receptors known, there is no doubt that others remain to be discovered. And of
5. thyrotropin - thyroid stimulating hormone those that we know to exist, little is ful ly understood.
7 The i n ternal environment 1 33
then trigger a succession of secondary actions within the issues of underactive thyroid, which is undoubtedly linked
celi, with a cascade effect being common. to myofasciaf trigger point formation (Simons et al 1999)
\lVhile it is certainly not within the scope of this text to and fibromyalgia (Chaitow 2003, Lowe 2000). Box 7.3 dis
include an in-depth discourse on hormonal issues, those cusses the significant impact of leptin resistance and its rela
that are of primary concern to chronic myofascial pain tionship to insulin resistance and adrenaline resistance. Box
patients demand discussion. Box 7.2 is dedicated to the 7.4 outlines key concepts in the relation between adipose
The most common symptoms of underactive thyroid function a re: Functional h ypoth yroidism
Another method of eva l uating subclinical sluggish thyroid activity is
depression
by a fu nctional test developed by Barnes Et Ga lton ( 1 976), which
d ifficulty in losing weight
measures thyroid hormone's effect on the body rather than looking
dry skin
solely at blood thyroid hormone levels. This is achieved by measuring
musculoskeletal symptoms
a person's resting metabolic rate, w h ich is control led by the thyroid
headaches
gland, by ta king an axil lary temperature prior to getting out of bed
lethargy or fatigue
t h ree mornings i n a row. An average temperature below
memory problems
36.55C/97.8F i s suggestive of hypothyroidism. Barnes Et Galton
menstrual problems
found that measuring basa l body temperature was a good way of
hyperl ipidemia
assessing basal metabolic rate and thus the body's response to
recurrent infections
thyroid hormones, reg a rd l ess of their blood level. When employi ng
sensitivity to cold.
this test, the incidence of hypothyroidism is a surprising 25%
(Barnes Et Galton 1 976).
Different forms of u nderactive thyroid function
Pizzorno Et M u rray (2005, p 1 793-1 794) report:
The hormones of the thyroid gland regu late metabolism, therefore a
deficiency of thyroid hormones ca n affect virtually a l l bod i ly Functional tests show a far greoter incidence of low thyroid than
functions. blood tests largely because typical blood tests meosure thyroxine (T4),
Pizzorno Et Murray (2005, p. 1 79 1 - 1 793) report: which accounts for 90% afthe hormone secretion by the thyroid.
However. the form that affects the cells the most is T3 (triiodothyro
Deficiency of thyroid hormone may be due to lack of stimulation by
nine), which cells make from T4. lf the cells cannot convert T4 to the
the pituitary gland, defective hormone synthesis, or impaired cellular
four-times-more-active T3, a person can have normal levels of thyroid
conversion of T4 to T3. The pituitary gland regulates thyroid octivity
hormone in the blood yet be thyroid deficient.
through the secretion of thyroid-stimulating hormone (TSH). The
combination of low thyroid hormone and elevated TSH blood levels 'Wilson's syndrome' is a name used for the condition i n w h ich
usually indicates defective thyroid hormone synthesis, which is subcl in ica l hypothyroidism is thought to be associated with deficient
defined as primary hypothyroidism. When TSH and thyroid hormone peripheral conversion ofT4 to T3 ( Ba novac et al 1 985).
levels are both low, the pituitary gland is responsible for the low
Cellular resistance to th yroid hormone
thyroid function, a situation termed secondory hypothyroidism.
An u nderstanding is emerging of another fo rm of hypothyroid ism,
Normal blood thyroid hormone and TSH blood levels combined with
a genetically acq u i red condition in which cel ls become resista nt
low functional thyroid activity (as defined by a low basal metabolic
to the infl uence of the hormone, known as thyroid hormone
rate) suggest cellular hypothyroidism {sometimes called 'cellular
resistance syndrome. This problem is characterized by elevated
resistance}.
free thyroid hormone levels and partial resistance to this at
Most estimates on the rate of hypothyroidism are based on the lev
the cel lular level (Chatterjee et al 1 99 1 ) . This condition is said
els of thyroid harmanes in the blaad ... Using blood levels of thyroid
to be far more widespread than is genera l ly thought (Krysiak
hormones as the criteria, it is estimated that between 1 0;0 and 4% of
et al 2006).
the adult population have moderate to severe hypothyroidism, and
another 10% to 12% have mild hypothyroidism. The rate of hypothy
roidism increases steadily with advancing age. Clinical symptomato l ogy of hypothyroid ism (from any
ca u se )
Metabolic
Causes of hypothyroidism General decrease in the rate of util ization of fat, protein and car-
Overt h ypothyroidism bohydrate
About 95% of a l l cases of overt hypothyroid ism a re primary. In the Moderate weight gain
past, the most common cause of hypothyroidism was iodine Sensitivity to col d weather (demonstrated by cold hands or feet)
deficiency; however, this cause is now rare in the USA due to the Cholesterol and triglyceride levels are increased
wide use of iodized table salt. Ca pil lary permeability and slow lymphatic drainage
affecting 2-7% of adults (Evans 2003). Nails become thin and brittle, often with transverse g rooves
Psychological (Gold et al 198 1) Sou rces of zinc include seafood (especia l ly oysters), beef, oat
Depression, along with wea kness and fatigue meal, chicken, l iver, spinach, n uts and seeds.
Difficulty concentrating and forgetful Copper is found in l iver and other organ meats, eggs, yeast,
beans, nuts a n d seeds.
Muscular and skeletal (Krupsky et a1 1 987)
The best sources of the B vitamins are yeast, whole g ra ins and
Muscle weakness and joint stiffness
l iver.
Muscle and joint pain, as wel l as tenderness (Hochberg et a l
The best source of selenium is Brazil nuts, especially those that
1 976)
are u nshelled at the time of purchase.
Cardiovascular Orga nica lly g rown foods shou l d be recom mended due to their
Atherosclerosis due to the increase in cholesterol and trig lyc- higher levels of trace minerals (Liel et a I 1 996).
erides
Hypertension Supplementation (Be rry Et Larsen 1 992, Choudhury et a l
2003, Oeshpande e t a l 2002)
Other common manifestations
Zinc: 25 mg/day
Shortness of breath
Copper: 5 mg/day
Constipation
Selen i u m : 200 /lg/day
I mpa i red kid ney function
Vitamin C: 1 -3 g/day in d ivided doses
Vitamin E: 400 I U/day
Diet
The diet for i nd ividuals with hypothyroid function should be low in
Exercise
goitrogens and high in foods rich in the trace minera ls needed for
I nvigorating activity such as water sports, avoidance of overheated
thyroid hormone production and activation (see l ist below).
environments, and cold hydrotherapy can stim ulate thyroid function
Goitrogens (to be l i m ited) include brassica fam i ly foods (turnips,
(Lennon et al 1 985).
cabbage, ca u l iflower, broccoli, brussel sprouts, rutabagas, mustard
Thyroid dysfu nction is relatively com mon in adu lts and can be a
greens, radishes, horseradishes), cassava root, soybeans, peanuts,
major feature in muscu loskeletal dysfu nction and pain, including
pine nuts and m i l let. When eaten, these foods should be cooked to
encou raging the presence of active trigger poi nts. Standard medical
break down their goitrogenic constituents.
thyroid hormone replacement is one therapeutic option, others
Sou rces of iodine include sea fish, sea vegetables (kelp, d u lse, include consulting someone who is either a licensed naturopathic
a rame, h ijiki, nori, waka me, kombu) and iod ized sa lt. practitioner or traditional Chinese medicine practitioner.
Box 7.3 Leptin and other chemical i nfl uences in systemic i nflam mation
Note: The fol lowing details a re pa rt of newly emerging information characterized by a g roup of metabolic risk factors in one person. It
regard ing a d ipose tissue as an endocrine organ . Much of the presents with a cascade of d isorders (abdominal obesity,
research on leptin and other newly d iscovered hormones is sti l l in its dysl ipidemia, prothrombotic state, hypertension, insu lin resistance
infancy. While the authors of this text a re intrigued with the and a proinflammatory state) that together render fa r greater
concepts d iscussed i n this box, they caution that the d ieta ry card iovascul a r (CV) risk than any of its i nd ivid ual factors. The main
suggestions might not be right for everyo ne, such as for professional featu res of this condition i nclude i ncreased visceral adipose tissue
ath letes, diabetics and others with advanced patholog ies that may (VAT) mass, d isplayed as an inflated waistline, a pple-shaped figure
requ i re additional food intake beyond that suggested. We have (android body type) and increased systemic infla mmation (Berg Et
chosen to i nclude this i n formation on using natural methods to Scherer 2005).
obtain hormonal bal ance d u e to our interest in seeing research Ell iott (2007) notes:
va l idation regarding the suggested eating pattern as a possible
Regional body {fat} composition has been linked to heart disease,
sol ution fo r endocrine and other systemic dysfu nctions.
stroke, diabetes mellitus, hypertension, endometrial cancer, peptic
Once thought to be an inert tissue mainly devoted to energy
ulcers, non-alcoholic hepatitis, ga/l bladder disease, Cushing 's syn
storage, wh ite adi pose tissue (WAT) is now known to be an active
drome, polycystic ovaries, menstrual disorders, Werner's syndrome,
participant in reg u lating physiological and pathologica l processes,
psychosocial problems, and other health risks (Lean 2003, Janssen
including i m m un ity and inflam mation (Ju ge-Aubry et al 2005). WAT
et aI 2002). These established correlations are among the many good
a lso plays a primary role in the development of a triad of hormonal
reasons to measure body composition.
i m ba l ance (Ieptin resistance, adrena line resistance, insu lin
resistance) with a cascade of endocrine interfaces that have Si nce many of these conditions a lso mask, or present with,
sign ificant health consequences. Weight gain in the a bdominal myofascial pain symptoms, and since central obesity a lso has
region is a primary indicator of accu mulation of WAT that is postural i m pl ications, it is suggested that an awareness of central
associated not only with these hormonal d isorders, but a lso with obesity and syndrome X is i m portant for all manual practitioners.
high risks of developing ca rd iovascu l a r disease. Waist circu mference (WC) measurement has long been
Central obesity has been shown to be associated with various determ ined as a simple indicator of abdominal visceral adi pose mass
morbidities that have collectively emerged as 'synd rome X', a and its related CV risk (Pou liot et al 1 994), with obesity defined as a
precipitator of cardiovascular d isease. The American Heart waist circu mference of 40 inches ( 1 0 1 .6 cm) or g reater in men and
Association (2007) defines syndrome X as a metabolic syndrome 35 i nches (88.9 cm) or greater in women. Elliott (2007) has discussed
Box 73 (continlled) .
'. .
the pros and cons of a nu mber of methods for measu ring body A primary purpose of the hormone leptin is to coordinate the meta
composition and ag rees that the WC measurement, when performed bolic, endocrine and behavioral responses to starvation (Wilding
correctly, can be a simple, inexpensive and accurate gauge that the 2007J. This hormone has a powerful influence on the subconscious
practitioner as well as the patient ca n util ize. mind that is programmed by the genetic survival level, completely
While measu ring at a specific level with consistency a mong taking over eating patterns if the circumstances from its point of view
practitioners is challenging (especi a l ly with the moderately obese, dictate that it should. . . . When a person gets thrown out of natural
whose waistline is certai nly not obvious), Ell iott (2007) suggests balance [homeostasis}, the brain does not sense leptin levels correctly,
that, with proper t raining, individuals should be able to self-measure literally building up resistance to the hormone. This problem steadily
WC at a point half way between the inferior su rface of the ribs and gets worse as a person gets older.
the top of the i l iac crest. This assessment would have a n initial va lue
Kershaw & Flier (2004) explore leptin's effects beyond energy
in determ ining excess of WAT. Periodic remeasuring can also be
homeostasis. They docu ment that it:
val uable as a n obvious indicator of changes associated with
compliance or fa i l u re in fol lowing a prescribed hea lth improvement regulates neuroendocrine function and traditional endocrine
prog ram. systems
While a trim waist l i ne and decreased cardiova scular risk are fine decreases hypercortisolemia by inh ibiting cortisol (a hormone
goa ls for many reasons, WAT contributes fa r more infl uences to keenly associated with stress)
consider in health. Fantuzzi (2005) notes that WAT produces both normalizes suppressed thyroid hormone
pro- and antiinflammatory factors, including adipokines (cytoki nes, accelerates puberty and interfaces i n reproductive function
cell-signaling proteins, such as leptin, adiponectin and resistin) as has d i rect effects via peripheral leptin receptors in the ova ry,
well as other chemicals, such as tumor necrosis factor-a l pha (TNF-a) testis, prostate and placenta
and interleu kin 6 ( I L-6) (see below for deta i ls on these). 'The cu rrent assists in reg u lation of i m m u ne function, hematopoiesis (blood
view of adipose tissue is that of an active secretory organ, sending cell formation), angiogenesis (blood vessel development) and
out and responding to signals that modulate a ppetite, energy bone development
expenditure, insu l i n sensitivity, endocrine and reproductive systems, influences sympathetic nervous system (SNS) activities, and
bone metabolism, and inflammation and i m m u n ity: decreases bone mass indirectly via activation of the SNS.
To begin to consider the influences of WAT and its associated
Budak et a l (2006) h i g h l ig h t yet a nother point. 'Leptin and g h re l i n
chemical soup, let us explore some of the hormones produce by WAT.
[a n appetite sti m ulator] a n d other adi pose tissue-secreted hormones
For instance, adi pocytes (fat cells) secrete a n u mber of substances
have significant effects on reproduction. Acting through the brain,
(Havel 2002) that play crucial roles in the development of type 2
these hormones may serve a s links between adipose tissue and the
diabetes, obesity and atherosclerosis (Rei l ly & Rader 2003). A close
reproductive system to supply and regu late energy needs for normal
look at one of these, leptin hormone, will begi n to offer a g l impse
reproduction and pregnancy:
as to the wide-ranging conseq uences that these hormones can have
As part of a complex com m u n ication system , energy ma intenance
on health.
system and even as an a ppetite reg u lator, leptin and its affi liate
The many faces of leptin hormone hormones keep the machi nery run n i ng smooth ly and fuel burning
First discovered in 1 994, leptin hormone may very we l l be the most efficiently. However, modern l ife, including magnified stress, excess
important hormone realized to date. Though first thought to signal food ava i labil ity and consumption of excessive carbohydrates a n d
satiety (hu nger satisfaction), peripheral actions of leptin a re now inappropriate fats, has strained these systems. A breakdown in
known to interface i n insu l i n biosynthesis a nd, with leptin receptors com m u nication ensues and, for many, a cascade of serious health
present on the pancreas, in pancreatic secretion (Feh mann et al consequences develops.
1 997). In return, i nsu l i n stimu lates leptin secretion from adipose
When a good plan goes bad - hormonal resistance
tissue (Havel 2002, Trayh u rn et al 1 999), establishing a hormonal
This system probably worked well in the years of hunting and
regu latory feedback loop, the 'adi po-insular axis' (Seufert 2004).
gathering, when food su ppl ies were erratic - the body stored when
Crucial to surviva l and fundamental core level energy, leptin is
there was plenty so that it cou l d take from the stores when there
now known to be secreted by wh ite adipose tissue that is found
was less. However, today, when there a re food supplies on every
primarily on the abdomen, thighs and buttocks, a nd to have a
corner, the body often may not have even digested (let a lone burned
regulatory effect on a n u m ber of other hormones, including thyroid,
u p) the previously eaten food before more is consumed. Cutler et al
adrenal, pancreatic and sex hormones (Havel 2000, Wauters et a l
(2003) suggest that extra ca lories from snacking a re the weight gain
2000). I t plays a n i m porta nt part in body weight regu lation, eating
cul prit, reporting a 60% rise in the average n u mber of daily snacks
behavior and reproduction by acting on the central nervous system
since the early 1 970s. While one study (Field et al 2004) reports that
a nd target reproductive organs (Budak et al 2006).
snack intake in children may be less influential on their weight than
One of leptin's primary jobs is to com m u nicate with the
the moth er's weight or the child's d ietin g status, Howarth et al
hypothalamus as to how m uch fat is stored in the body. This, in turn,
(2006) show that i n both younger and older a du lts 'eating frequency
can affect the metabolic rate for burning this 'stored fuel'. If working
was positively associated with energy intake, and eating more than
normal ly, leptin levels rise when enough food has been consumed ,
three times a day was associated with being overweight or obese'.
which signals t h e brain to stop eating and increase metabol ism.
When leptin levels drop because food is not being consu med, Key triad in systemic problems
appetite is stimu lated. If food is sti l l not consu med (incl uding The triad of leptin, adrenal ine and insu l i n resistance i nterface to
when meals a re volu ntarily skipped) and leptin levels continue to create an overweight consequence, with gain being pri mari ly in the
d rop, this eventua lly signals metabolism to slow down and conserve middle - in the company of da ngerous cardiovascular and diabetic
body fat. consequences as a bdominal and visceral a d i pose tissue m ushrooms.
Richards & Richards (2005) indicate that this is part of a U nlocking this triad requ i res a n u n derstanding of how these
primitive mechanism. hormonal resistances develop and how they interface.
When food is available, it heads to fat cells to Leplin resistance occurs in overweight people.
zy.r- replenish depleted reserves The brain thinks there is not enough fat in
storage and conlinues to fill fat cells with fuel
are high enough and there Food heads for fat storage,
is plenty of fuel in storage, resulting in excess fal in the body
fat will stop being stored
and melabolic rate will Higher than
Fig u re 7.3 The deve l o p m e n t of leptin resistance. A : Leptin fu nction w h en food i s a va i l a b l e. B : Leptin resistance associated with
ove rweig ht. Drawn after Richards 8: R i c h a rds (2005).
Leptin resistance high levels of adrena line and the eventual development of reduced
Fad d iets, eating d isorders and other problems ( e.g. continual sym pathetic sensitivity by the fat cel ls ( adrenaline resistance)
sympathetic a rousal ) m ay confuse the metabolic system and ( Rayner 8: Trayhurn 2001 ). Over time, the changes in metabolism
interfere with normal com m u nication (Ha l le 8: Persson 2003, produce abdom inal weight gain in both genders, as well as thigh and
Tenenba u m 2003). Breakdowns occur in signaling and the hip weight gain in females, chronic fatigue, sleep problems,
hypotha lam us, which relies on an accurate perception of leptin to ca rdiovascular distress and a host of other changes. This additional
set the meta bolic rate, develops a resistance to the signa ls. Although adi pose, as mentioned previously, contributes further to leptin
the leptin levels may be high, the signal to stop eating simply does resistance.
not get through to the brain, the cornerstone of leptin resistance.
This results in overeating and frequent snacking in an attempt to Insulin resistance and the type of food consumed
q uiet the 'false hunger' pains. Not only is the a mount of food and frequency of eating l i nked to
Bodosi et a l (2004) note that leptin levels rise with the inta ke of leptin levels, the type of food consumed is also important. High
food and 'suggest a strong relationsh ip between feeding and the g lycemic index foods cause increased production of insulin, resulting
di urnal rhythm of lepti n, and that feed ing a lso fu ndamenta l ly in an i mbalance of these two hormones that normally have a
mod u lates the d i u rnal rhythm of g h relin', a concept also supported balancing effect on each other. Once leptin levels a re elevated and
by Howarth et al (2006). Richa rds 8: Richards (2005) suggest that leptin resistance develops, insulin resistance is not far behind, with
even with a sma l l amount of food, constant snacking and the leptin playing a primary role a s a mediator of insulin secretion (Va n
resultant consistently elevated leptin release a re powerful cu lprits in Gaal et al 1 999) and insul i n as a prominent regulator of leptin's
the development of l eptin resistance. expression i n the fat cel l (Spiegelman 8: Fl ier 2001 ).
Once leptin resistance is estab lished, the hypothalamus no longer Richards 8: Richards (2005) depict this vicious cycle of hormonal
receives the signals from the hormone, which is stil l being produced resistance.
and, in fact, exists i n high levels i n the blood. When the bra in
[The] brain cannot sense leptin, so it keeps metabolism slow and calo
becomes resistant to the signals, the food being consumed is sent to
ries heading for storage. The pancreas cannot sense leptin, so it keeps
storage.
making excess insulin, setting the stage for insulin resistance. " .
Adrenaline resistance Excess insulin production leads to insulin resistance throughout the
The brain's contin u a l attempts to sti m u late meta bolism by using body. as well as erratic or no energy from food. ". The normal nervous
adrenal ine, cou pled with the excessive adrena line being released as a system signal to simulate fat cell metabolism is no longer received by
result of the constant stresses of daily l ife, can resul t in constant fat cells. This causes weight gain, especially in the abdominal area,
box continues
7 The i nternal enviro n ment 1 37
the type of weight most associated with cardiovascular disease and resistance of adrenaline, insu l i n and leptin, TNF-a and inter
reproductive organ cancer. leukin-6 (I L-6) act as the 'glue' that keeps them locked, producing
This fat, in turn, produces more l eptin, thereby keeping the vicious a proinflammatory state. They note that d u ring insu l i n resistance,
cycle intact. TNF-a tends to match exaggerated insu l i n levels, d i rectly pro
pelling insu l i n resistance. Additional ly, ' Excess TNFa contributes
The leptin-hormonal interface to cancer, heart d isease, arthritis and n u merous other problems
With leptin receptor sites on the l iver, kidney, ovary, adi pose and by provoking a highly i nflammatory state of a ffairs'.
gastrointestinal tract, one can readily see that leptin's interface is Interleukin-6 (IL-6) is a proinfl a m matory cytokine involved in
broad reaching. It has a d i rect effect on a n umber of other hormones acute phase response to tra u ma as well as the inflammatory
and cytokines as well as the ones discussed a bove. As the reader response to stress. If stress is chronic, a general systemic infla m
considers the fol lowing l ist that only touches on a few of the many mation can result. Yudkin et a l (2000) suggest that I L-6, I L- 1 and
other chemica l s evident in this cascade, it should be borne in mind TNF-n are intimately involved in the progression of atherosclerosis.
that each of these chemicals plays a vital role i n health, as well as a They further note 'circulating I L-6 sti m u la tes the
significant position in the development of disease. There are no 'bad hypothalam ic-pituita ry-adrenal (HPA) axis, activation of which is
g uys' or 'good guys' when in a ppropriate levels. They form a team, associated with central obesity, hypertension and insu l i n resist
where their significance is based on interdependence and interface. a nce. Thus we propose a role for I L-6 in the pathogenesis of coro
nary heart d isease (CHO) t h rough a com bination of a utocrine,
Adiponectin (AD), which is involved in regu lation of g lucose and
paracri ne and endocrine mechanisms. Long-chain omega-3 oi ls,
metabolism of fatty acid, appears to help reduce insu l i n resist
such as found i n fish oil, borage oil and flax oil, can significantly
ance (Ou ntas et al 2004). Levels of this hormone are i nversely
reduce TN F-n and I L-6 (Simopoulos 2002), thereby reducing the
correlated with body mass index, being decreased in obesity and
inflammatory immune signals that lock i n leptin-resistance
in type 2 diabetes (Duntas et a l 2004). Adiponectin seems to act
overeating.
as a n antiinflammatory molecul e (Fantuzzi 2005) and appears to
Nuclear factor kappa-B (N FIi:B) is activated at times of stress to
be controlled, at least in part, by leptin (H uypens 2007). I n
d i rect cells as to which proteins to m a ke to meet the immediate
research that studied obese children and adolescents with a
needs of the stressful situation. Without this d i rection, cells
chronic, general ized inflam matory reaction, AD appeared to be
would be h ig hly intolerant of any type of stress. It also responds
the best indicator of metabolic syndrome, and thus the higher
to cytokines, free rad icals, ultraviolet rad iation and infections by
risks of cardiovascula r d isease associated with it (Gilard i n i et al
bacteria or vi ruses. Excessive production of NF,.,:B has been linked
2006).
to cancer, autoim m une d isease and septic shock, among other
Cortisol, an antiinflammatory stress-related hormone secreted by
cond itions. I n the majority of serious health problems excessive
the adrenal cortex, is norm a l ly highest in the morning and lowest
levels of N FIi:B and TN F-a coexist, such as that noted in a lcohol
at night, d u ring sleep. I t is released i n response to stress and has
l iver inflam mation (Hill et a l 2000). Silymarin (milk th istle herb)
a n effect on blood sugar levels and blood pressure, and can sig
can directly lower the production of N Ft.: B (Manna et al 1 999).
nificantly influence metabol ism. In non-stressfu l circu mstances,
Ghrelin, a hormone stim u lated by N PY and agouti, and produced
both cortisol and leptin fol low a 24-hour rhythm that is genera l ly
in the stomach (and to some degree in the small intestine, pan
reciproca l, with one rising as the other fa lls (inverse circadian
creas and thyroid), rises when blood l evels of leptin and glucose
rhythm) (Leal-Cerro et al 2001 ). The peak for l eptin is between
fa l l , sti m u lating a ppetite. It u sually increases before m eals and
midnight and 2 a.m. and for cortisol is about 6 a.m. Cortisol is not
decreases after food is consumed (Shi iya et a l 2002). I t signals
under the control of leptin. However, it can, as part of the stress
the anterior pituitary gland to secrete g rowth hormone and per
response, 'turn up the volu me' of leptin in fat cells (N ishiyama
forms antagon istically to leptin when they are both functioning
et a l 2000), leading to l eptin resistance and a l l that goes with it.
norm a l ly. A recent study (Taheri et a l 2004) showed that elevated
Neuropeptide y (N PY), a neurotransmitter found in the b rain and
g h relin levels were observed in participants who had short sleep
autonomic system, plays a significant role in energy balance.
d u ration. The a uthors concluded that this is l ikely to 'increase
Being the key h unger signal in the brain, it is countered by leptin
a ppetite, possibly explaining the increased BMI observed with
when both are working normally. As leptin rises, N PY fa l ls, signal
short sleep d u ration. I n Western societies, where chronic sleep
i ng satiety. I n leptin resistance, N PY levels stay elevated, resulting
restriction is com mon and food is widely ava i lable, changes in
i n a lack of satisfaction with food, constant hunger and resultant
a ppetite regulatory hormones with sleep curta ilment may con
overeating. N PY interfaces with dopam ine, serotonin, agouti, h is
tribute to obesity:
tamine and other chemicals in varying ways that have a high
impact on this craving cycle.
Other consequences of this hormonal cascade
Agouti, a gene signal that is regulated by ca lcium i ntake, pro
Other studies have shown significant i m pact of leptin, g h relin and
motes a ppetite. It ampl ifies the production of l eptin (Claycombe
many of these chemica l factors. Only a few a re mentioned here to
et al 2000) and blocks the ability of the hypothalamus to sense it,
show the d iverse i nfl uences that have been revealed.
thereby sti m ulating food i ntake while a lso slowing down metabo
l ism. Richards 8: Richards (2005) a g ree and suggest that: 'Extra W u rst et al (2006) note that 'elevated leptin levels a re associated
calci u m intake can cool off this agouti gene, and thereby remove with a lcohol craving in patients suffering from a lcoholism.
a stressor that enha nces the production of excessive leptin and Furthermore, g h relin l evels seem to be increased d u ring a lcohol
rei nforces h igher levels of N PY causing food cravings: abstinence'. Kiefer et a l (200 1 ) indicate that a lcohol craving may
Tumor necrosis factor-alpha (TNF-a) is produced by the WAT be mod u lated by leptin and verified a positive association
(Sewter et al 1 999) and, when at normal levels, is a powerful between elevated leptin plasma levels and craving for alcohol
cancer-destroying com pound as well as a major reg u lator in the d u ring early alcohol withdrawal. It is possible that by lowering
inverse relationship between adiponectin and leptin (Huypens leptin levels to norma l, recovery from alcohol addiction might be
2007). Richards 8: Richards (2005) explain that in the triad of supported.
box continues
1 38 CLI N I CA L A P PL I CAT I O N OF N E U RO M U SC U LA R T EC H N I Q U E S : TH E U P P E R B O DY
[
Box 7 .3 ( n ued)
Note that thickening of the i ntima and media (layers of the vessel
Plaque rupturelthrombosis wal ls) of the common and internal carotid artery are visible with
high-resolution u ltrasonography.
box continues
7 The i nternal enviro nment 139
transport as assessed with in vivo, in vitro, and in situ models of the stomach and easily decrease overal l caloric consumption.
the BBB. Fat-free m i l k and intra l ipid, a sou rce of vegetable Rule 4 : Eat a breakfast containing protein. This helps set the hor
trig lycerides, were without effect: monal cycles for the day and for the night. CompromiSing this
Banks & Farrell (2003) documented leptin transport rates across can have hormonal effects d u ring the day and into the nig ht, d is
the BBB in obese a nd thin m ice, an i mportant factor in leptin turbing sleep. Weigle et al (2005) have shown that an i ncrease in
resistance. I n regards to the obese m ice, they report: 'With mod dietary protein from 15 to 30% of energy produced a sign ificant
erate reductions in body weight, the leptin transport rate weight loss, presumably 'mediated by increased central nervous
increased to levels seen in thin m ice. These results show that the system leptin sensitivity'.
obesity-related defects in leptin transport across the BBB are Rule 5 : Reduce the overall amount of carbohydrates eaten. U n l ess
acquired and that they can be reversed with reductions in body one is a l ready on a low carbohydrate plan, cha nces a re too many
weight induced by either fasting or leptin treatment: They note carbohydrates are routinely consumed. Regarding carbohydrate
that short-term fasting resulted in a good outcome and that influences, Garg et al ( 1 992) note: 'Compared with the low
longer fasts inhibit the leptin transporter. carbohydrate d iet, the high-carbohydrate diet caused a 27.5%
increase in plasma trig lycerides and a similar i ncrease in [very low
Ti ming is everything density lipoprotein) cholesterol levels; it a lso reduced levels of
Th is d iscussion is a simpl istic overview of the complex metabolic HDL cholesterol by 1 1 Ofo:
distu rbances that lead to, or w h ich a re i nvolved in, a plethora of
chronic d iseases. It does not begin to cover the m u ltitude of Exercise has been shown to i m prove insulin resistance (Boga rdus
chemica l interactions involved. The chemica l imbalances have et a l 1 984). Additionally, the fol lowing provides evidence that
consequences that are far-reaching, both in daily l ife and in the fu l l va rious forms of nutritional support m i g ht be beneficial.
life cycle. To fu lly u nravel t h e complexities is overwhel ming and to Melatonin, a hormone produced a t night that has a n effect on
develop a recuperative plan might appear a l most impossible. Not so, sleep, has been shown to decrease circu lating leptin levels (Kus
say Richards & Richards (2005). et a l 2004). I t can be taken at bedtime by those who a re
Timing is everything. Our bodies are either regulated by a harmonic experiencing sleep d isturbance or who have other evidence of
symphony. a heavy-metal tune, or somewhere in between. Biological leptin resistance.
rhythms are the guiding force of human metabolism and natural bal A diet rich in fish oil (omega-3 fatty acids) has been shown to
ance. They are the essence underlying communication in the body. A reduce plasma leptin (Beltowski 2005).
person either feels in sync or out of balance. . . . Hormones are impor Carnosine (a combination of the amino acids beta-al a n i ne and
tan t communication signals in the body that seek to coordinate the h istidine), a non-protein com ponent of brain tissue, is found i n
body's ability to stay in sync and meet the extra demands or pressures. relatively high amou nts i n m uscle; it helps t o protect t h e brain
As a person begins to have problems, the body is thrown out of sync, cel ls from the damage of stress (Kang et al 2002) and has been
and timing is off. shown to stop the effects of excess adrena line on the kidneys
(Niijima et a l 2002).
In Mastering Leptin, Richards & Richards (2005) define a simple plan Calcium helps to decrease agouti, a close associate of N PY, w hich
to help rega in normal leptin levels and, thereby, balance the together block thyroid function, even though common thyroid
hormonal cascade discussed above. Although this plan may not be tests might appear normal (Fekete et a l 2002).
ideal for everyone, it is presented here for the majority who w i l l
Vitamin 0 is a powerful inh ibitor of leptin secretion (Menendez
benefit from i t s use. The fou ndation of their p l a n conta ins five et al 2001 ) as well as a cofactor in calcium absorption.
cardinal rules, which they emphasize are a l l necessary to fol low.
Pantethine (a coenzyme form of vita m i n B51. a fat metabolizer,
Brea king a ny of the ru les can lead to a setback for one or severa l can help lower LDL cholesterol, raise HDL cholesterol and lower
days. They are summarized as:
triglycerides (McRae 2005).
Rule 1 : Never eat after din ner, not even a snack or g l a ss of wine Conjugated l inoleic acid (CLA), one of the most vigorously
or j uice. Al low 1 1 - 1 2 hours between d inner and breakfast. researched n utrients in the world, shows considerable evidence in
Generally finish eating dinner at least 3 hours before bed. This its ability to reduce cancer, hardening of the a rteries and body
ru le is designed to al low leptin, melatonin, cortisol and other fat, and prevent the development of diabetes (Belury 2002).
chemicals to balance during the night. Night-eating syndrome Acetyl-L-ca rnitine (ALC) before bed encourages the hypothalamus
individuals have abnormal hormonal patterns apparently associ to sti mulate growth hormone during sleep. Research has a lso
ated with nocturnal eating (Geliebter 2001). shown ALC to be effective in reducing leptin resistance (lsso et a l
Rule 2 : Eat three meals a day. Allow 5-6 hours between meals. 2002) and i n helping t h e bra i n sense t h e true a mount o f leptin.
Timing is crucial so that insulin levels can drop, glucagon (pro
Richards & Richards clearly point to the importance of lifestyle
d uced by the l iver) can rise and fat metabolism ca n kick in. If this
management. In addition to suggesting adequate sleep, good food
occurs a couple of hours before more food is eaten, fats stores
choices and fol lowing the five ca rdinal rules, they a lso note:
can be util ized until the next food is eaten. Snacking between
meals sends the insu l i n back up and fat stores rema in u ntapped. Stress is the wild card variable that magnifies any weakness in a per
Snacks are, therefore, to be avoided. Portions are estimated as son's brain chemistry. If the weakness is on the dopamine side, crav
protein the size of the palm of the hand, carbohydrates to match ings are for calorie-laden and salty foods. The subconscious goal is to
that amount, a nd vegetables a s desired except peas, carrots and have an energetic feeling of metabolic drive. If the weakness is on the
corn, which are taken in moderation. serotonin side, cravings are for carbohydrates. The subconscious goal
Rule 3: Do not eat large meals. Eat slowly and, if overweight, always is to have a relaxed state of feelings or more pleasant mood.
try to finish a meal when slightly less than full. Eating slowly al lows When the overall natural balance in a person's life is not good, then
time for hormonal signals to reach the brain before overeating there is much less tolerance for stress. A person is likely to experience
occurs. Smal ler meals allow for better digestion, do not overstretch the cravings based on brain chemistry imbalance triggering stress
box continues
1 40 C L I N ICAL A P P L I CAT I O N O F N E U R O M U S C U LA R T EC H N I Q U E S : T H E U P P E R B O DY
eating, in turn causing a disruption in fuel utilization. This leads to hormonal resistances, a simple th ree square meals a day might not
leptin resistance, insulin resistance, and adrenaline resistance, a path only be beneficial to weight reduction, but a lso to ca rdiovascular
of increased fatigue and bad moods no matter what is eaten. and pancreatic health.
The authors of this text suggest that this newly brea king
As is evident with this host of information (that only begins to tap information on endocrinology is of crucial benefit to manual
into the latest data on hormonal influences) , biochem istry can be practitioners since many of their patients u ndoubtedly present with
significantly infl uenced not only by what we eat, but also by when these conditions. The fu l l role that these inflammatory processes
and how m uch we eat, the proportions or fats, carbohydrates and play in myofascial pain, chronic fatigue, fibromya lgia and trigger
proteins, our exercise habits and our sleep patterns. For those who point formation remains to be clearly defined, yet, hopeful ly, their
have a l ready developed a thick waist and potentially the triad of relevance in chronic pain syndromes is apparent.
Box 7.4 Key concepts i n the relation between adipose result of marked or repetitive muscular tension dragging
tissue and infl a m mation (Fantuzzi 2005) on the attachment and the evolution of periosteal pain
points (Lewit 1992)
Cells the joint, which can become restricted and overapproxi
Macrophages a re a normal component of adipose tissue mated, to the extent that osteoarthritic changes can result
Obesity is associated with increased n u m bers of macrophages from the repeated microtrauma of shortened and unbal
in a d ipose tissue
anced soft tissue structures
Obesity is associated with the presence of activated
macrophages in adipose tissue overapproximation of joint surfaces due to soft tissue
There is a cross-ta l k between adipocytes and lymphocytes in shortening, leading to uneven wear and tear, as for exam
lymph nodes ple when the tensor fasciae latae structure shortens and
crowds both the hip and lateral knee joint structures
Molecu les
neural irritation, which can be produced spinally or along
Adipocytes produce many factors mod u lating i m m u nity and
inflam mation the course of the nerve, as a result of chronic muscular con
Leptin exerts mostly proinflammatory and i m m u ne-potentiat tractions. These can involve disc, facet and general spinal
ing effects mechanical faults (Korr 1976), fascial arcades (Simons et al
Adi ponectin exerts mostly antiinflammatory effects 1999, p. 733) and bone-related enclosures, such as the
greater sciatic foremen (Travel! & Simons 1992, p. 191)
D iseases
Low adiponectin levels in type 2 diabetes a re a possible link to variations in pain threshold - possibly to do with percep
insu l i n resistance tion (Melzack 1 983) and memory (Sandklihler 2000) -
Obesity seems to be associated with asthma, but the mecha which can make all these factors more or less significant
nism is u n known and obvious.
Severa l conditions are associated with a ltered adi pokine levels,
but the sign ificance of this observation is unclear The research into tendon-related pain discussed earlier
should not lead to an assumption that inflammation is not
an important issue in many of these areas of pain. On the
tissue and inflammation. The endeavor to build a founda contrary, there are, for example, high levels of inflammatory
tion of understanding of the enormous role these and other cytokines (inflammatory mediators such as prostaglandins
hormones play in health and homeostasis may very wel! and leukotrienes) in facet joint tissue associated with
result in a practical paradigm shift in the treatment of degenerative lumbar spinal disorders.
myofascial syndromes and other conditions .
Inflammatory cytokines have a higher concentration rate in
lumbar spinal canal stenosis than in lumbar disc herniation.
Research findings suggest that inflammatory cytokines in
MUSCLES, JO INTS AND PAI N
degenerated facet joints may also relate to the cause of pain
in degenerative lumbar disorders (Igarashi et aI 2004).
Where pain exists in tense musculature (in the absence of
other pathology), Barlow (1959) suggests that it results from: There is a progression of normal muscle to one that is in
painful, chronic distress (Baldry 2005) commonly involving:
the muscle itself through some noxious metabolic product
('factor P') (Lewis 1942) or an interference in blood circula initial or repetitive trauma (strain or excessive use)
tion due to spasm, resulting in relative ischemia (see below leading to
for more recent research into pain generation concepts) release of numerous chemical mediators capable of acti
the muscular insertion into the periosteum, such as that vating, sensitizing or arousing nociceptors, such as kinins,
caused by an actual lifting of the periosteal tissue as a pro inflammatory and antiinflammatory cytokines,
7 The internal environment 1 41
prostanoids, lipooxygenases, neurotrophins and other understanding and modifying the processes involved, which
growth factors, neuropeptides, nitric oxide, histamine, might includ e:
serotonin, proteases, excitatory amino acids, adrenergic
altering sources of external biomechanical overload (pos
amines and opioids (Coutaux et al 2005)
ture, habits of use in da ily life including work and leisure
subsequent sensitization of A-delta and C (Group I V )
activities, etc.)
sensory nerve fibers with involvement o f the brain (lim
cognition and modification of abnormal illness behavior
bic system and the frontal lobe). Pain signals are gener
improvement of normal function via self-applied
ated by peripheral sensory organs (nociceptors), which
strengthening, stretching, fitness training, balance and
are endings of small-diameter nerve fibers responsive to
coordination-enhancing strategies.
the tissue environment.
As these patterns are appropriately being addressed, func
These chemical mediators may act in combination, or at a tional rehabilitation of the motor system, through appropri
given time in the inflammatory process, to produce subtle ate treatment and exercise, should be ongoing. When
changes that result in increased sensitivity and pain (hyper reading the sections of this book that focus most on the
algesia or allodynia). treatment aspects of neuromuscular pa in and dysfunction,
We can see in the following example a manifestation of the reader should bear in mind the essential need for the
an adaptive response by the nervous system, as well as the person's active participation in the recovery process.
mind of the individual, to a long-standing stressor, pain. In
this sequence pain is associated with a spinal strain but the
model holds true elsewhere. These features lie at the heart REFLEX EFFECTS OF MUSCULAR PAIN
of the transition from an acute to a chronic pain syndrome.
Liebenson ( 1996) highlights the fact that muscular pain pro
Adaptation occurs to a painful event involving altered duces not just increased stiffness and tension but inhibition
biomechanics. as well. He quotes from research that has demonstrated:
The demands on local functional capacity may be in acute back pain, localized areas of the multifidus mus
exceeded by such changes, leading to tissue fatigue, as the cle show signs of unilateral wasting in association with a
processes of hysteresis and creep evolve (see Chapter 1 on single dysfunctional vertebral segment (Hides et a1 1994)
fascia, for details of these phenomena). as a result of chronic back pain, type I multifidus fibers
In order to maintain accurate proprioception, type I and (postural) hypertrophy on the symptomatic side, while
type II afferents are stimulated. type 1I fibers (phasic) atrophy bilaterally (Stokes et al
The firing from muscle spindle, joint mechanoreceptor 1992)
and Golgi tendon organ afferents helps the adapting tis reciprocal inhibition occurs in the abdominal muscles
sues avoid failure. when erector spinae are excessively 'stiff ' and they
These receptors are adaptive and therefore cease to dis become spontaneously stronger again (without rehabili
charge if the adaptation process continues for a lengthy tation exercises) when the overactive erector spinae are
period . stretched (Janda 1 978)
Ultimately, however, as in all stress situations, adaptive myofascial trigger points in upper trapeZius inhibit the
capacity is exhausted and a painful, chronic situation functional activity of the lower trapezius muscle
slowly emerges. (Headley 1993)
. At this stage, inflammatory processes commence (see more deltoid inhibition occurs as a result of myofascial trigger
detail on inflammation in this chapter), as does stimulation point activity in the supraspinatus muscle (Simons 1993).
of non-adaptive types III and IV nociceptive afferents lead
ing to protective mechanisms that immobilize the area . McPartland et al (1997) hypothesize a cycle initiated by
Immobilization is appropriate in acute injury situations chronic somatic dysfunction, resulting in muscle atrophy
but can become memorized and influence the evolution and reduced proprioceptive output from atrophied suboc
toward chronic behavior. cipital muscles.
Biomechanical insult (trauma, overuse, strain), biochem Barker et al (2004) show evidence of coex isting atrophy
ical alterations (inflammation), facilitation of pain of psoas and multifidus and an association between
related pathways, and, finally, neuromuscular decrease in the cross-sectional analysis of multifidus and
adaptation evolves. If continued biomechanical insult is duration of symptoms .
not avoided, abnormal illness behavior develops, and Danneels et al (2004) showed evidence that only the mul
deconditioning occurs. Inadequate neuromuscular adap tifidus (and only at the lower endplate of L4) was found to
tation and chronic pain with central nervous system be statistically smaller than other lower back muscles in
involvement (corticalization) can result . cross-section analysis. They suggest tha t:
Rehabilitation from the adverse effects of such a pain . . . atrophy may be the consequence of LBP [Lower back pain]:
cycle requires the individual to be actively involved in after the onset of pain and possible long-loop inhibition of the
1 42 CLI N I CA L A PP L I CATI O N OF N EU RO M USCU LA R T E C H N I QU ES : T H E U PP E R B O DY
multifidus a combination of reflex inhibition and substitution In this form of dysfunction, the joint (segment of the spine)
patterns of the trunk muscles may work together and could is seen to be the maintaining factor in a soft tissue manifes
cause a selective atrophy of the multifidus. Since this muscle tation of pain. However, Dvorak & Dvorak also see altered
is considered important for lumbar segmental stability, the mechanics in a vertebral unit as causing 'reflexogenic
phenomenon of atrophy may be a reason for the high recur pathological change of the soft tissue, the most important
rence rate of LBP being the "myotendinoses", which can be identified by pal
pation'. Many experts, including Lewit, cited above, would
argue that soft tissue changes frequently precede the altered
vertebral states, as a result perhaps of poor posture and pat
SOURCE OF PAIN
terns of overuse. 'It is in chronic pain patients that mobility
of fascia is frequently impaired; in such cases, joint (spinal)
IS IT REFLEX OR LOCAL?
mobility is as a rule restored by moving the fascia. It also
Palpation of an area that the person reports to be painful follows that unless we restore normal mobility of the fascia,
will produce increased sensitivity or tenderness if the pain muscle and joint dysfunction will recur' (Lewit 1996).
is originating from that area . If, however, palpation pro The reader may reflect on the fact that, in these examples,
duces no such increase in sensitivity, then the chances are the same phenomena are being observed (pain and joint
strong that the pain is being referred from elsewhere. dysfunction) and quite different interpretations as to cause
But where is it coming from? If the pain is indeed coming and effect are being ascribed. Do the soft tissues determine
from a myofascial trigger point, knowledge of the distribu and maintain the joint restriction and the pain that follows?
tion patterns of probable trigger point target zones (see Or does the joint restriction produce and maintain the soft
Chapter 6) can allow for a swift focusing on suitable sites to tissue changes and the pain that follows? Or are both ele
search for an offending trigger. Unless the pattern is a result ments (joint and soft tissue) so intermeshed in their func
of combinations of several trigger point referrals, the pat tional roles that this separation is artificial? The authors of
terns distributed by trigger points are fairly predictable and this text take the view, based on clinical experience, that the
well documented by research (Simons et aI 1999). soft tissues hold the primary role most of the time, but not
always.
RADICULAR PAIN
ARE THE REFLEXES NORMAL? WHAT IS THE
The discomfort could, however, be a radicular symptom SOURCE OF THE PAIN?
coming from the spine. 'When pain is being referred into a
limb due to a spinal problem, the greater the pain distally The referred pain may not be from either a trigger or the
from the source, the greater the index of difficulty in apply spine itself. Kellgren (1938, 1939) showed that: 'The superfi
ing quickly successful treatment', suggests Grieve (1984) . cial fascia of the back, the spinous processes and the
Dvorak & Dvorak (1984) state: 'For patients with acute supraspinous ligaments induce local pain upon stimula
radicular syndrome there is little diagnostic difficulty, tion, while stimulation of the superficial portions of the
which is not the case for patients with chronic back pain. interspinous ligaments and the superficial muscles results
Some differentiation for further therapy is especially impor in a diffused (more widespread) type of pain'.
tant, although not always simple.' Noting that a mixed clin Clearly ligaments and fascia must therefore also be
ical picture is common, they then say: 'when testing for the considered as sources of referred pain and this is made
radicular syndrome, particular attention is to be paid to the clearer by Brugger (1960), who describes a number of syn
motor disturbances and the deep tendon reflexes. When dromes in which altered arthromuscular components pro
examining sensory radicular disorders, the attention should duce reflexogenic pain. These syndromes are attributed to
be towards the algesias. ' painfully stimulated tissues (origins of tendons, joint cap
Dvorak & Dvorak have charted a multitude of what they sules and so on) producing pain in muscles, tendons. and
term 'spondylogenic reflexes' that derive primarily from overlying skin.
intervertebral joints. The palpated changes are character As an example, irritation and increased senSitivity in the
ized as: region of the sternum, clavicles and rib attachments to the
sternum, through occupa tional or postural strain, will cause
... painful swellings, tender upon pressure and detachable pain in the intercostal muscles, scalenes, sternocleidomas
with palpation, located in the musculofascial tissue in topo toid, pectoralis major and cervical muscles. The increased
graphically well-defined sites. The average size varies from tone in these muscles and the resultant stresses that they
0.5 cm to 1 cm and the main characteristic is the absolutely produce may lead to spondylogenic problems in the cervi
timed and qualitative linkage to the extent of thefunctionally cal region, with further spread of symptoms. Overall, this
abnormal position (segmental dysfunction). As long as a dis syndrome can produce chronic pain in the neck, head, chest
turbance exists, the zones oj irritation can be identified, yet wall, arm and hand (even mimicking heart disease)
disappear immediately after the removal of the disturbance. (Brugger 1960).
7 The internal environment 1 43
DIFFERENTIATING BETWEEN SOFT TISSUE AND Examples .of a joint assessment involving compression
J OINT PAIN are described by Blower & Griffin ( 1984) for sacroiliac dys
function. They showed that pressure applied over the lower
Several simple screening tests have been proposed by
half of the sacrwn or over the anterior superior iliac spines
Kaltenborn (1980).
were diagnostic of sacroiliac problems (possibly indicating
1. Does passive stretching (traction) of the painful area ankylosing spondylitis) if pain was produced in the sacnun
increase the level of pain? If so, it is probably of soft tis and buttocks. Soft tissue dysfunction would not produce
sue origin (extraarticular). painful responses with this type of compression test.
2. Does compression of the painful area increase the pain? If Note: Lwnbar pain is not significant if it occurs on sacral
so, it is probably of joint origin (intraarticular) involving pressure, as this action causes movement of the lumbosacral
tissues belonging to that anatomic jOint. joint, as well as some motion throughout the whole lumbar
3. If active (controlled by the person) movement in one direc spine.
tion produces pain (and/or is restricted), while passive
(controlled by the operator) movement in the opposite
NEUROPATHIC PAIN (Co rd e rre 1 9 9 3 , M e rskey 1 9 8 8 ,
direction also produces pain (and/or is restricted), the con
N a c h e m so n 1 9 9 2 )
tractile tissues (muscle, ligament, etc.) are implicated.
Resisted movement tests, the principles of which are Neuropathic pain is defined as a chronic pain condition that
described below, can confirm the accuracy of this proposal. occurs or persists after a primary lesion or dysfunction of
4. If active movement and passive movement in the same the peripheral or central nervous system. Traumatic injury
direction produce pain (and/or restriction), joint dys of peripheral nerves also increases the excitability of noci
function is probable. This can be confirmed by use of ceptors in and around nerve trunks and involves neuro
traction and compression (and gliding) of the joint. genic inflammation at the nerve terminals. As a result
nociceptors and injured nerve fibers release excitatory neu
Resisted tests are used to assess both strength of, and
rotransmitters at their synaptic terminals (such as L-gluta
painful responses to, muscle contraction. These tests
mate) and substances that trigger cellular changes in the
involve producing a maximal contraction of the suspected
central nervous system (Zieglgansberger et al 2005). This is
muscle while the joint is kept immobile, somewhere near
what is currently thought to be an aspect of what happens
the middle of its range. No joint motion should be allowed
in the local environment of the pain receptors involved in
to occur during the contraction. If it is painful, contractile
neuropathic pain.
tissues are implicated in the painful problem.
Liebenson (2006) has commented on neuropathic pain
These resisted tests are done after test 3 (described
and central sensitization in the spectrum of musculoskeletal
above) to confirm a soft tissue dysfunction rather than a
dysfunction. He notes:
joint involvement. Before performing the resisted test, it is
wise to perform the compression test (2 above) to clear any Pain casts a long shadow in the nervous system. Pain can be
suspicion of joint involvement. 'learned' in the nervous system so that it is maintained inde
Cyriax (1962) adds to this the following thoughts. pendent of injury, pathology, expectations, or dysfunction.
Such pain is called neuropathic and is an important unrec
If, on resisted testing, the muscle seems strong and is also ognized dimension of the chronic problem. Failure to appre
painful, there is no more than a minor lesion/dysfunc ciate when pain has become conditioned will lead to an
tion of the muscle or its tendon. overemphasis on coincidental structural pathology, func
If it is weak and painful, there is a more serious tional deficits, and psychosocial factors.
lesion/dysfunction of the muscle or tendon. Neuropathic pain is centrally maintained and therefore
If it is weak and painless, there may be a neurological does not require peripheral sources of painful irritation or
lesion or the tendon has ruptured. injury. Typically, it arises as a result of a prolonged, inten
A normal muscle tests strong and pain free. sive bombardment from peripheral nociceptive pathways.
However, because of central sensitization, altered processing
It is suggested that all these statements be tested on condi
of input from secondary neurons (after exiting the dorsal
tions of known etiology.
horn) occurs so that pain can be experienced in the absence
In many instances soft tissue dysfunction accompanies
of peripheral injury, inflammation, or irritation. The most
(precedes or follows) joint dysfunction. Joint involvement is
obvious example of this is a phantom limb pain where the
less likely in the early stages of soft tissue dysfunction than
painful source is not present, but the central pathways that
(for example) in the chronic stages of muscle shortening. It
carried nociceptive information are not inhibited, so that
is hard to conceive of joint conditions, acute or chronic,
even non-noxious stimuli are interrupted as painful!
without accompanying soft tissue involvement. The tests
described above will offer a strong indication as to whether The concept of sensitization and facilitation has been dis
the major involvement in such a situation is of soft tissue or cussed in Chapter 6. A similar, but more complex mechanism
osseous in nature. is proposed by those researchers and clinicians who advocate
1 44 C LI N I CA L A P P LICAT I O N O F N EU RO M U S C U LA R T EC H N I Q U E S : T H E U PP E R B O DY
Mercury is a h i g h ly reactive, neurotoxic metal with widely Lorscheider et al ( 1 995) voice a strong opinion question ing the
recognized toxic properties at high dose, i ncluding paresthesias, safety of amalgam fi l l ings:
cerebellar ataxia, dysarthria and constriction of the visual fields
During the past decade medical research has demonstrated that
(Needleman 2006). Medicine is aware of its lethal effects and has
{mercury] Hg is continuously released as vapor into mouth air; then it
eliminated it as a disinfectant and antibiotic, and has abolished its
is inhaled, absorbed into body tissues, oxidized to ionic Hg, and finally
use in contact lens solutions. It bioaccumulates in the envi ronment
covalently bound to cell proteins. Animal and human experiments
and is disposed of as a biohazardous waste. I n recent years, the
demonstrate that the uptake, tissue distribution, and excretion of
American Public Hea l th Association, the Ca l ifornia Medical
amalgam Hg is significan t, and that dental amalgam is the major
Association, and Hea l th Care Without Harm have a l l cal led for the
con tributing source to Hg body burden in humans. Current research
elimi nation of putting any mercu ry in the human body (Watson
. on the pathophysiological effects of amalgam Hg has focused upon
2001).
the immune system, renal system, oral and intestinal bacteria, repro
Mercu ry is an element that cycles through several different
ductive system, and the central neNOUS system. Research evidence
chemica l forms throughout the environment, exposing l iving
does not support the notion of amalgam safety.
organisms to its potential effects in the process. Although there may
be a latent period of weeks or months after exposure, paresthesias of After a thorough d iscussion of research and pathophysiology
the circumoral a rea a nd hands and feet, visu a l -field constriction and associated with mercury toxicity, they conclude:
ataxia a re some of the symptoms reported in adults who have had
Although human experimental evidence is incomplete at the present
mercury exposure. Lorscheider et a l ( 1 995) d isclose that the brain i s
time, the recent medical research findings presented herein strongly
t h e primary target tissue; however, reproductive, i m m u n e , renal, ora l
contradict the unsubstantiated opinions pronounced by various den
and intestinal bacteria may also be affected and reg ional destruction
tal associations and related trade organizations, who offer assurances
of neurons in the visual cortex and cerebellar g ranule cells may be
of amalgam safety to dental personnel and their patients without
revea led in neuropatholog ical exa mination.
providing hard scien tific data, including animal, cellular and molecu
lar evidence, to support their claims.
Environmental exposure
Modern industrial activity, especially fossi l fuel combustion and A word of caution in wa rranted to the reader who is driven by this
waste incineration, is responsible for a n estimated threefold increase information to request immediate removal of all mercury-laden fillings.
in environmental mercury levels in this century a lone (Bender Et The process of amalgam removal carries with it inherent risks of
Williams 1 999). The major source of non-occu pational exposure is potentially generating substantially more mercury vapor than if the
dietary intake of methyl mercu ry, with fish and seafood being the fillings were left alone. Significant protection of the patient (rubber
main culprits because of their propensity to concentrate mercury dams, air tubes, etc.) during the removal process as well as chelation of
from the water (Clarkson et al 2003). Through dietary intake and the mercury load prior to and after removal is required. It would be
other sources, mercury is present at low concentrations in many practical to question the chronic pain patient regarding any dental
tissues. procedures that may have exposed the patient to mercury vapor with in
the year prior to the onset of chronic pain, particularly when the pai n is
Dental sources of unknown etiology. There is often a latent period of weeks or months
Dental amalgam fillings are composed of a number of metals, between exposure and the onset of symptoms (Clarkson et al 2003).
including silver, tin, copper and a trace a mount of zinc, m ixed with
approximately 50% mercury. Since amalgam fi l l ings were first Vacci n e sou rces
introduced, the assumed health risks of mercury have been a source Contributing to such exposures a re pharmaceutical prod ucts
of controversy a nd debate, often labeled as the 'amalgam wa rs'. Part i ncl uding some vaccines that contai n thiomersal (formerly a n d stil l
of the controversy revolves around whether the degree of mercury commonly known i n t h e United States as thimerosa l), a mercury
vapors produced by aging amalgam fil li ngs releases significant derived preservative in use since the 1 930s, which is composed of
enough mercu ry to be a health risk. 49.6% mercury by weight in the form of ethyl mercury (Steuerwald
Recogn izing that the inhaled dose from a malgams might be sma l l et a l 2000).
a n d that t h e potential ra mifications o f mercury exposure from dental
sou rces a re inconclusive, Clarkson et a l (2003) point out: 'No da nger' from vaccine sources message
One study (Pichichero et a l 2002) suggests that administration of
Nevertheless, amalgam fillings are the chiefsource of exposure vaccines conta ining thiomersa l does not seem to raise blood
to mercury vapor in the general population (WHO 1990). Brain, concentrations of mercury above safe va l ues in infa nts, claiming that
blood, and urinary concentrations correlate with the number ethyl mercury seems to be e l i m i nated from blood rapidly, via the
of amalgom surfaces present. It has been estimated that stools, after admi nistration of thiomersa l i n vaccines. The a u thors of
10 amalgam surfaces would raise urinary concentrations by this text q uestion whether there is a ny 'safe' level of ethyl m e rcury.
1 M of mercury per liter. roughly doubling the background
concentrations (Kingman et al 1998). Higher urinary concentrations If 'safe' why has this prod uct been withdrawn?
are found in persons who chew a great deal. ... The removal of Although thiomersal has recently been removed from most children's
amalgam fillings can also cause temporary elevations in blood vaccines, it is sti l l present in flu vaccines g iven to pregnant women,
concentrations (Molin et al 1990), since the process transiently the elderly and to ch i l d ren in developing cou ntries. I t is h a rd to
increases the amount of mercury vapor inhaled. What are the health imagine why its use should have been curta i led if there is 'no
risks from such exposures? Cases ofpoisoning from inhalation of mer danger'. Experts maintain that preservative-free vaccines a re not
cury vapor have been recognized for centuries (Ramazzini 1 964). always a n option and that a preservative should a lways be used in
Severe cases are characterized by a triad of intentional tremor. gin multidose vials to prevent bacterial and fu ngal contam ination, and
givitis, and erethism. Erethism consists of bizarre behavior such as multidose vials a re as yet the only option in many parts of the
excessive shyness and even aggression. developing world (Pless Et Risher 2000).
box continues
1 46 C L I N I CA L A P PLICAT I O N O F N E U RO M U S C U LA R T E C H N I QU ES : T H E U P P E R B O DY
Possible n utritional protection treatment has been to a pply chelating agents in an attempt to
As noted, environ mental methyl mercury has been shown to be extricate the mercury. Another option is utilization of the body's own
highly neurotoxic, especially to the developing bra i n (James et al detoxification mechanisms - for example. the endogenous enteric
2005). Because mercury has a high affin ity for thiol (su lfhydryl (SH)) bacteria. High-dose probiotics have been suggested as a n adjuva n t
g roups, the thiol-conta ining a ntioxida nt, g lutathione (GSH), provides for detoxification protocols w i t h an emphasis on u s e in autistics
the major i ntracel lular defense against mercury-induced (Brudnak 2002).
neu rotoxicity. Pretreatment with the n utrients 1 00 M g l u tathione or
N-acetylcysteine (NAC) (but not methioni ne) has been shown to Caution regarding use of probiotics when mercu ry is
produce a significant increase in intrace l l u l a r GSH. present
Stud ies suggest that since ora l bacteria. yeast (such as Candida) and
Possible probiotic protection? probiotics a l l methylate mercu ry. any contact between them should
Autism is a developmental disease characterized by a spectrum of be m i n im ized. This may explain some adverse reactions reported by
symptoms ra nging from decreased verbal skil l s and social parents a n d patients who have used probiotics to correct dysbiosis or
withdrawal , to repetitive behavior and violent outbursts. I t has been fungal overgrowth (Heintze et a 1 1 983. Rowland et a1 1 975. Yannai
suggested that the etiology of autism may involve m u ltiple loci, and et a l 1 99 1 ) . It is therefore suggested that i t is important to attempt
many different theories exist (Blaxi l l et a l 2004). One theory is that to e l iminate mercury first. before high-dose use of probiotics. via
envi ronmentally acquired mercury may be the cul prit since it is heavy metal detoxification. chelation a nd/or careful ly protected
capable of exerting neurolog ical effects on the brain. A standard amalgam replacement.
in relation to a patient's history and / or symptom picture and small amounts in food. William Pardridge, MD (1979) illus
should be considered as potentially part of the chronic pain trated that ' . . . dietary glutamate does not enter the brain
profile. because the blood-brain barrier maintains a transport sys
Endogenous neurotoxins include those tha t at normal tem for acidic amino acids, such as glutamate, to effectively
levels may act as an excitatory neurotransmitter, but when exclude circulating glutamate from the brain'. Pard ridge
in excess can cause tissue damage. For instance, when con also showed that the levels of brain glutamate do not rise or
centration levels of glutama te, a primary neurotransmitter fall with changes in plasma glutamate levels.
in the brain, reach critical levels, the neuron kills i tself by a Additionally, the American College of Allergy, Asthma
process called apoptosis. This process of excitotoxicity, as it is and Immunology (ACAAI 1991), after reviewing the litera
aptly named, may also be involved in stroke, traumatic ture on MSG, food allergy and safety, concluded that MSG
brain injury and diseases of the CNS, such as multiple scle is not an allergen and reaffirmed its safety as a food ingre
rosis, Alzheimer disease, fibromyalgia, Parkinson's disease, dient. More recently, Simon (2000) conducted a well
and Huntington's disease (Kim et al 2002, Smith et aI 200l ). designed, double-blind, placebo-controlled study of 65
Glutamate (glu tamic acid) is one of the 20 amino acids that subjects with chronic urticaria. None of the subjects exhib
make up proteins and is a non-essential amino acid, since it i ted positive reactions to doses of 2.5 g of MSG.
can be syntheSized in the body. It is a key molecule in cellular In the face of continued public interest and consistent
metabolism as the most abundant excita tory neurotransmitter denial by researchers tha t MSG is the cause of food-related
in the nervous system and is believed to be involved in cogni symptoms, the FDA contracted the Federation of American
tive functions such as learning and memory. In appropriate Societies for Experimental Biology (FASEB), a body of inde
amounts and present in a wide variety of foods, glutamic acid pendent scientists dedicated to safety concerns, to review
is responsible for the fifth human sense of taste, umami available scientific data surrounding MSG. FASEB (1995)
(Box 7.6), which accompanies sweet, sour, salty and bitter conclusions follow, extracted from the U .S. Food and Drug
(Halpern 2002). In excess, glutamic acid triggers excitotoxicity, Administration (FDA) website in regards to monosodium
which can cause neuronal damage and, eventually, cell death. glutamate (MSG).
In i ts free form, i.e. when it is not bound to another amino
The agency asked FASEB to address 18 questions dealing
acid, such as in protein, it has a flavor-enhancing effect in
with:
foods. Monosodium glutamate (MSG), the sodium salt of
glutamic acid, is commonly used in the food industry to 1.the possible role of MSG in eliciting MSG symptom
enhance flavor. It has long been suspect by consumers as complex
the cause of a bizarre array of symp toms, often reported 2. the possible role of dietary glutamates in forming brain
after consumption of oriental food, hence the name lesions and damaging nerve cells in humans
'Chinese restaurant syndrome'. Since MSG is a product tha t 3. underlying conditions that may predispose a person to
is widely consumed throughout the world, i t h a s been the adverse effects from MSG
focus of much research for many years. 4. the amount consumed and other factors that may affect
However, research does not point to MSG as a culprit in a person's response to MSG
causing a neurotoxic effect in the brain when consumed in 5. the quality of scientific data and previous safety reviews.
_._- -------------------------------
. . .
. . ' <i . , '. , .,..
4
The fol lowing letter, titled What's in a Name? Are MSG and Umami individual tastants a re not described as del icious. In isolation, the
the Same? was written by Bruce Halpern (2002) while associated taste of neither NaCI nor MSG is del icious. I n similar fash ion,
with the Departments of Psychology and Neurobiology and Behavior, naturally occu rring tastants, such as potassium ch loride or
Uris Hall, Cornell University. phosphate salts, amino acids l ike g lycine, a rg i nine and alanine, and
The Japanese word "umami" has a long past. It was a l ready in use nucleotides such as adenosine 5' -monophosphate, taken alone, are
during the Edo period (Tokugawa Shogunate) of Ja panese h istory, not described as delicious. However, these same tastants, com bined
which ended in 1 868 (Mason, 1 993). I n Japa nese, "umami" often in appropriate proportions with NaCI and g l utamic acid (or MSG),
connotes a cogn itive category (Ya maguchi and Ninomiya, 1 998) of yield the flavor of boi led crab (Konosu et a/ 1 987), and may be
taste, or perhaps flavor, with defin itions that include del iciousness, characterized as delicious, perhaps with reports of "umami".
flavor, rel ish, gusto and zest (I noue, 1 983). In effect, the Ja panese
word "umami" can denote a rea lly good taste of somethi ng-a taste References
or flavor that is an especia lly appropriate exemplar of the flavor of Backhouse, A.E. ( 1 978) Japanese taste terms. Unpublished doc
flavor has a shorter h istory. In 1 909 Dr Kikunae I keda reported defa u ltfriday.html (cited August 24).
the isolation of meta l lic salts of g lutamic acid from a brown kelp Halpern, B.P. ( 1 997) Psychophysics of taste. I n Beauchamp, G.K.
[tang le, genus Laminaria (Guiry, 2002), "konbu" or "kombu" in and Ba rtoshu k, L.M. (edsl. Tasti n g and Sme l l i ng. Handbook of
Japanese] commonly used in Japanese cuisine, and recog nition that Perception and Cognition, 2nd edn. San Diego, CA, Academic
the (mono) sod i u m sa lt of g l u tamic acid imparted a fa m i l iar and Press, pp. 7 7 - 1 23.
highly desirable flavor to foods (I keda, 1 909; M u rata et a/ 1 985). Halpern, B.P. (2000) Gl utamate and the flavor of foods. J. Nutrit.,
Dr Ikeda noted that the flavor coul d be described as del icious, n ice or 1 30,9 1 OS -91 4S.
pa latable ("umai" in Japa nese). I t seemed to h i m to be related to his Halpern, B.P. (2002) Taste. In Pash ler, H. (series ed.) and Yantis, S.
impressions when he ate meat or bonito (dried marine fish flakes; (vol. ed.l. Stevens' Handbook of Experimental Psychology, Vol. 1 .
"katsuobushi" in Japa nese), and was based u pon a taste that differed Sensation and Perception, 3 rd edn. New York, W i ley, pp. 653-690.
from genera l ly recogn ized basic tastes. He accepted the suggestion Ikeda, K. ( 1 909) New seasonings. J. Tokyo Chem. Soc., 30,820-836
that this taste could tempora rily be ca lled "umami". In a later [in J apanese].
publ ication, i n Engl ish (Ikeda, 1 91 2), he chose to use the description I keda, K. ( 1 9 1 2) On the taste of the salt of g lutamic acid. In
unpleasant. and as bitter, salty or soapy (Yamaguchi, 1 998; Ha lpern, Tokyo, Tuttle.
2000, 2002). However, when MSG is added in low concentrations to Konosu, S., Yamaguchi, K. and Hayash i, T. ( 1 987) Role of extrac
a ppropriate foods, the flavor, pleasantness and acceptabil ity of the tive components of boi led crab in prod ucing the characteristic
food increases (Hal pern, 2000). These differences illustrate the flavor. I n Kawamura, Y. and Kare, M.R. (eds), Uma m i : a Basic
d istinction between the taste of a single tasta nt and the effects Taste. New York, Dekker, pp. 23 5-253.
upon flavor of tasta nts in a food (Lawless, 1 996). Lawless, H.T. ( 1 996) Flavor. I n Friedman, M.P. and Ca rterette, E.C.
MSG is a tastant, as is sa lt (NaCI). We ca n study transduction (edsl. Cog nitive Ecology. San Diego, CA, Academic Press,
mechanisms for NaCI or MSG, and peri pheral and central g ustatory pp. 325-380.
neural responses, in a particu lar species, while recog nizing that the Mason, P. ( 1 993) H istory of Japa nese Art. New York, Abrams.
gustatory mechanisms and responses discovered in one species may M u rata K., Shimosato, S., I nayama, Y., Ifuka, H., Nagam u ra, S.,
be q u i te different from those in a nother (Hal pern, 2002). For human Suzuki, H., Suzuki, M. and Shiga, M. ( 1 985) Ten Japa nese g reat
responses to NaCl, we ta lk about sal t taste, or saltiness. I n similar inventors. http://www.jpo.go.jp/shoukaie/judaie.htm (cited July
fashion, for MSG i t is appropriate to speak of g l u ta mate taste, a s 1 2, 2002).
Dr I keda did (I keda, 1 9 1 2). Flavor, derived from human descriptions Yamaguchi, S. ( 1 998) Basic properties of umami and its effects on
of foods and beverages, depends upon mixtures of tastants (and food flavor. Food Rev. I nt., 1 4, 1 39- 1 76.
odorants) but represents aspects that emerge from the array of Yamaguchi, S., and Ninomiya, K. ( 1 998) What is umami? Food
tastants and odorants, and their matrix (Hal pern, 1 997). I n general, Rev. I nt., 1 4, 1 23 - 1 38.
FASEB held a 2-day meeting and convened an expert panel numbness in the back of the neck, radiating to the arms
that thoroughly reviewed all the available scientific litera and back
ture on this issue. tingling, warmth and weakness in the face, temples,
upper back, neck and arms
FASEB concluded the following key findings: facial pressure or tightness
chest pain
An unknown percentage of the population may react to
headache
MSG and develop MSG symptom complex, a condition
nausea
characterized by one or more of the following symptoms:
rapid heartbeat
burning sensation in the back of the neck, forearms and bronchospasm (difficulty breathing) in MSG-intolerant
chest people with asthma
1 48 C L I N I CA L A PPLICAT I O N O F N E U RO M U SC U LA R T E C H N I Q U E S : T H E U PP E R B O DY
[
described for multiple chemical sensitivity is not new and Hyperventilation is the extreme of a breathing pattern
perhaps this is not a new phenomenon. disorder, although respiratory alkalosis commonly occurs in
individuals who have not reached that extreme. Since prog
MCS etiology is hotly debated, with some professions
esterone is a respiratory accelerator, this condition seems to
believing tha t it is a physical illness, some as a chemical
affect mainly females (Loeppky et al 2001), particularly
(irritant or toxic) injury and others convinced tha t it is psy
those in the postovulation stages of the menstrual cycle
chosomatic. Although the patients are unsure of the ca use,
when progesterone levels rise (Damas-Mora et aI 1980).
what is usual ly presented is that exposure to chemical irri
Foster et al (2001 ) point out that respiratory alkalosis is an
tants precipitates the (sometimes disabling) symptoms.
extremely common and complicated problem affecting vir
Regardless of the pa thogenesis of this condition, avoidance
tually every organ system in the body, producing as it does
of further exposure to irritants is a number one priority.
multiple metabolic abnormalities, including changes in
Magill & Suruda (1998) note:
potassium, phosphate and calcium balance, and the devel
Several theories have been advanced to explain the calise of opment of a mild lactic acidosis. There are many cardiac
MCS, including allergy, toxic effects and neurobiologic sensi effects of respira tory alkalosis, including tachycardia and
tization. There is insufficient scientific evidence to confirm a ventricular and a trial arrhythmias, as well as ischemic and
relationship between any of these possible causes and symp non-ischemic chest pain. In the gastrointestinal system there
toms. Patients with MCS have high rates of depression, anx are changes in perfusion, motility and electrolyte handling.
iety and somatoform disorders, but it is unclear if a causal Due to the circulatory changes induced by alkalosis
relationship or merely an association exists between MCS (including constriction of blood vessels and the Bohr effect)
and psychiatric problems. Physicians should compassionately body tissues tend to become ischemic and this encourages
evaluate and care for patients who have this distressing con increased sensitization, as well as the evolu tion of trigger
dition, while avoiding the use of unproven, expensive or points (Mogyros et a1 1 997, Seyal et aI 1998).
potentially harmful tests and treatments. The first goal of
management is to establish an effective physician-patient
DECONDITIONING AND UNBALANCED
relationship. The patient's efforts to return to work and to a
BREATHING
normal social life should be encouraged and supported.
Because the deconditioned indiv idual relies more on anaer
obic metabolism for energy supply, such changes are far
EFFECTS OF pH CHANGES TH ROUGH
more likely to occur in people who are out of cond ition,
BREATHING
who do not perform regular aerobic exercise. In such indi
Despite being critical in healthcare in general, and in body v iduals respiratory alkalosis leads to an accumula tion of
work in particular, the biochemical and pathophysiological incompletely oxidized products of metabolism, due to the
ramifications of the widespread feature of disturbed breath activa tion of anaerobic energy pathways (Nixon &
ing are not generally appreciated, recognized or evaluated Andrews 1996). The products of the anaerobic pathway are
by healthcare providers. Probably the most important bio acids, such as lactic acid and pyruvic acid (Fried 1987) . This
chemical change deriving from disturbed breathing pat leads to accumulation of lactate in muscle cells and the
terns results from al tered blood pH, the effects of which bloodstream, and a reduction in pH, which encourages
range from reduced pain thresholds to altered motor con bicarbonate retention, resulting in increased CO2 produc
trol, sympathetic arousal, disturbed balance, reduced oxy tion, a more rapid breathing rate and perpetuation of the
genation of tissues and smooth muscle constriction with adapta tion cycle described above.
potential influence on fascial tone (Hastreite et al 2001), as Outcomes of deconditioning include:
well as overuse of key muscles associated with respiration
1. loss of muscle mass
(Chaitow 2004).
2. decreased ability to use energy substra tes efficiently
3. decreased neuromuscular transmission
A L KALOSIS AND THE BOHR EFFECT 4. decreased efficiency in muscle fiber recrui tment with
indications of disruption of normal motor control being
An increased brea thing rate, such as occurs in obvious hyper
apparent (Wittink & Michel 2002).
ventilation, can increase the rate of carbon dioxide (C02)
exhalation so that it exceeds the rate of its accumulation in Nixon & Andrews (1996) have summarized the emerging
the tissues. This produces respira tory alkalosis, which is symptoms resulting from overbrea trung in a deconditioned
characterized by the decrease in CO2 and an increase in pH individual as follows: 'Muscular aching at low levels of
(above the norm of 7.4) (Pryor & Prasad 2002). effort; restlessness and heightened sympathetic activity;
Due to the Bohr effect, respiratory alkalosis induces increased neuronal sensitivity and constriction of smooth
smooth muscle (and therefore vascular) constriction, thereby muscle tubes (e.g. vascular, and gastrointestinal) can
decreasing blood flow, as well as inhibiting transfer of oxygen accompany the basic symptom of inability to make and sus
from hemoglobin to tissue cells (Pryor & Prasad 2002). tain normal levels of effort.'
1 50 C L I N I CA L A P P L I CATI O N O F N E U R O M U S C U L A R TEC H N I QU E S : T H E U P P E R B O DY
These adaptation sequences may lead to physiologically The correction of this conunon pH imbalance is breathing
unsustainable adaptive changes that result in chronic retraining, as discussed in Volume 2, Chapter 7, and
myofascial and joint problems, almost inevitably including Chapter 14 of this text.
trigger point development.
As Litchfield (2003) explainS: CAFFEINE 1 1\1 I TS VARIOUS FORMS
Hypocapnia is the result of over-breathing behavior, the mis Caffeine, as found in tea, coffee, cola, chocolate and in many
match of breathing rate and depth. Its consequence is an medications, may very well be the most widely used (and
increased level of pH, or respiratory alkalosis, which may have accepted) neuroactive drug in the world, being consumed
profound immediate and long-tenn effects that trigger, exacer by a majority of the adult popula tion in most countries. It
bate, and/or cause a wide variety of emotional, perceptual, cog does not appear to in troduce any major social problems,
nitive, attention, behavioral, and physical deficits that may and may, in fact, improve social interactions. Unlike smok
seriously impact health and performance. Although thefunda ing, it does not appear to directly pollute the environment
mental importance of CO2 in body chemistry regulation is of others and has not been definitively linked to a potential
common knowledge to any pulmonary or acid-base physiolo health hazard of the consumer (as have both alcohol and
gist, it remains virtually unknown by most healthcare practi smoking). Evidence shows that tea and coffee may, in fact,
tioners, health educators, breathing trainers, and laypeople. have significant health benefits (Box 7.7).
Caffeine in general has a bad press. Is this justified by research or d o Epidemiological research evidence presented by H igdon Et Frei
potential benefits outweigh t h e possible ha rmful effects o f excessive (2006) suggests that: ..coffee consumption may help prevent
.
stimulation deriving from caffeine intake? Or is the possible h a rm several chronic diseases. including type 2 diabetes mellitus.
resulting from consumption of caffeine-rich beverages (tea. coffee. Parkinson's d isease and liver d isease (cirrhosis a nd hepatocellular
cola. chocolate) more related to the oils. added sugar a nd/or carcinoma)'. They caution. however. that:
a rtificial sweetening?
Some groups, including people with hypertension, children, adoles
Not all a nswers a re clear as yet. but since - apart from water -
cents. and the elderly. may be more vulnerable to the adverse effects
tea and coffee consumption represents the g reatest source of l i q u id
of caffeine. In addition, currently available evidence suggests that it
i ntake for most people it is important for practitioners to have as
may be prudent for pregnant women to limit coffee consumption to 3
clear an overview as possible.
cups/day providing no more than 300 mg/day of caffeine to exclude
Siddi q u i et a l (2006) confirm the vast intake of tea. and clarify
any increased probability of spontaneous abortion or impaired fetal
some key points: Tea. next to water. is the most widely consumed
growth.
beverage in the world. Depending u pon the level of fermentation. tea
can be categorized into three types: g reen (u nfermented). oolong
(pa rti a l ly fermented). and black (highly to fu l ly fermented). In Prevention of chronic d isease by tea
genera l . g reen tea has been found to be superior to black and oolong Zhu et al (2006) state the case for tea as fol lows:
tea i n terms of antioxidant and hea lth promoting benefits: Herbal During the period 1982-2002, 691 research papers related to tea and
teas that contai n no caffeine are not considered in this section. health have been published in 290 Chinese journals. These studies
showed that tea and tea constituents have various biological activi
General advice and cautions regarding caffeine
ties and suggested that tea drinking might be beneficial to human
inta ke
health. Tea has potential in the prevention or adjuvant treatment of
Caffeine is probably the most freq uently ingested pha rmacologica l ly
several diseases including cancer, cardiovascular diseases and
active substance in the world. It is found in common beverages
(coffee. tea. soft drin ks). in prod ucts containing cocoa or chocolate. obesity.
and in med ications. The possibility that caffeine ingestion adversely Detai led m u ltid iscipli nary research on the effect of tea. and the
affects human health was investigated based on reviews of associated tea polyphenols. has led to major advances on the
(pri mari ly) publ ished human studies obtained through a underlying mechan isms.
comprehensive l iterature search. Based on the data reviewed. it was In most stud ies. g reen and black tea have similar effects.
concluded that for the healthy adult popu lation. moderate daily including the fol lowing.
caffeine intake at a dose level up to 400 mg (3-4 cups) per day. is
not associated with adverse effects such as general toxicity. Tea polyphenols a re powerful antioxidants that may play a role in
cardiovascular effects. effects on bone status and calcium bala nce. lowering the oxidation of LDL cholesterol. with a consequent
changes in adult behavior. i ncreased incidence of cancer or effects decreased risk of heart disease. and also diminish the formation
on male fertility. The data also show that reproductive-aged women of oxidized metabol ites of DNA. with an associated lower risk of
and child ren are 'at risk' subg roups who may req u i re specific advice specific types of cancer - for exam ple. involving the prostate.
on moderating their caffeine intake. Based on available evidence. it Tea and tea polyphenols selectively induce Phase I and Phase I I
is suggested that reproductive-aged women shou l d consume no metabolic enzymes that increase the formation and excretion of
more than ,,;; 3 00 mg caffeine (approximately 3 cups) per day while detoxified metabol ites of carcinogens. Tea a lso lowers the rate of
children shou l d consume no more than ";;2 .5 mg/kg 1 body
. weight per cell replication and thus the growth and development of neo
day (1 cup equiva lent) (Nawrot et a l 2003). plasms (Siddiqui et al 2006).
box continues
7 The i n ternal e nvironment 1 51
Tea helpfully mod ifies the intestinal microflora, red ucing Hegarty et al (2000) stud ied a g roup of 1 2 56 women aged 65-76
u ndesirable bacteria and increasing beneficial bacteria l iving near Cambridge, U K, of whom 1 1 34 were tea drin kers.
(Weisburger 1 999). Skeletal measurements were taken at the l u mbar spine, femoral
The health influences of g reen tea are claimed to include neck, greater trocha nter a nd Ward's triangle. Tea d rinking was
prevention of cancer, hypercholesterolemia, a rtherosclerosis, highly associated with greater BMD a t a l l sites, with the excep
Parkinson's disease, Alzhei mer's d isease and other aging tion of the femora l n eck. The beneficial effect of tea on BMD
related diso rders. There is, however, some q u estion as to the occu rred i ndependent of factors such as the addition of m i lk, cof
bioavailability of its active polyphenolic catech ins, suggesting fee d rinking, smoking or the use of hormone replacement therapy.
more research is requ i red to esta blish the true health benefits The tea drinkers overa l l had a 5% g reater mean BMD than non
(Zaveri 2006). tea d ri n kers. The a uthors eq uate this difference with a 1 0-20%
Tea polyphenols protect the nervous system agai nst lead toxicity, decl ine in fracture risk.
including antioxidant effects (Zhao 2006).
Anti-obesity i nfl uences: Green tea, green tea catech ins, and epi
Other polyphenol sources
gal locatechin gal late (EGCG) have been demonstrated in cell cul
Other beverages and foods conta i n ing polyphenols, such dark
ture and animal models of obesity to reduce adipocyte
chocolate and wi ne, have a lso been eva l uated for their possible
d ifferentiation and proliferation, l ipogenesis, fat mass, body
benefits on health and 'a nti-ag i ng' potential. Menat (2006) has
weight, fat absorption, plasma levels of triglycerides, free fatty
resea rched these substances and states:
acids, cholesterol, glucose, insu l i n and leptin, as well as to
i ncrease beta-oxidation and thermogenesis. Adipose tissue, l iver, Polyphenols are a family of molecules whose antioxidant properties
intestine, and skeletal muscle are target organs of g reen tea, are widely documented. Fruit and vegetables aside, three particular
mediating its a nti-obesity effects. Studies conducted with h u man types of food containing polyphenols in large quantities have demon
subjects report reduced body weight a nd body fat, as wel l as strated their protective role for human health. Tea is known for its
i ncreased fat oxidation a nd thermogenesis and thereby confirm preventative action, for both cardiovascular diseases and certain can
findings in cell culture systems and animal models of obesity cers. Many studies about wine and cocoa concern the diminution of
(Wolfram et a l 2006). the overall risk of cardiovascular problems. The antioxidant power of
It is suggested that the mechanisms whereby obesity is affected polyphenols lead us to believe that they play a role in age (especially
by tea i nclude: 'the modu lations of energy bala nce, endocrine cerebral) preven tion, and retrospective studies on tea and wine have
systems, food i ntake, lipid and carbohydrate metabolism, the already begun ta confirm this. A regular and moderate consumption
redox status, and activities of different types of cel ls (i.e. fat, liver, of these three food types help to gain synergy and efficiency without
muscle, and beta-pancreatic cel ls)' (Kao et al 2006). any side effects. Apart from the usual promotion of healthy nutrition
Reduced fracture risk: H i p fractures related to poor bone m ineral concerning proteins, 'good' fats and complex sugars, we can now
density (BMD) a re a significant cause of i l l ness in elderly women. advise moderated consumption of wine, chocolate and tea.
These statements may seem out of place in the face of (Bak & Grobbee 1989), or perhaps simply the fact that it was
seemingly contradictory reports (Papadopoulos 1993) not 'in moderation' (Tofler et al 2001) that creates ill effects.
about the ill effects of caffeine consumption. Caffeine's use
in cancer research and cell life has been discussed in a favor
able light (Bode & Dong 2007) and its use as a stimulant for W HEN S H OU L D PAIN AND DYS FUNCTION
the sleep deprived is common. Rosmarin (1989) notes that BE LEFT ALONE?
attention has been focused on caffeine and coffee's relation
ship to coronary heart disease and its potential to induce Splinting (spasm) can occur as a defensive, protective,
cardiac arrhythmias, yet concludes that: 'Until more con involuntary phenomenon associated with trauma (fracture,
v incing evidence against coffee is compiled, it appears that, for instance) or pathology (osteoporosis, secondary bone
at least in moderate amounts in otherwise healthy persons, tumors, neurogenic influences, etc.) (Simons et al 1999).
coffee is a safe beverage.' So where is the problem with this Splinting-type spasm commonly differs from more com
widely consumed beverage? mon forms of spasm because it releases when the tissues it
If we closely examine the ways by which caffeine is is protecting or immobilizing are placed at rest. When
ingested, we might readily see some of the potential for health splinting is long term, secondary problems may arise in
concerns. Perhaps it is the fats associated with chocolate, the associated joints as a result (e.g. contractures) and bone (e.g.
cream and sugar in coffee and tea, and the inordinate amount osteoporosis). Travell & Simons (1983) note that, 'Muscle
of sugar (or artificial sweeteners) in the colas that pose poten splinting pain is usually part of a complex process.
tially more health problems than the caffeine itself. If the Hemiplegic and brain-injured patients do identify pain tha t
freshly brewed coffee in moderation is not the problem, then depends on muscle spasm'. They also note 'a degree of mas
perhaps it is that which has sat in a pot on a low heat burner seteric spasm which may develop to relieve strain in trigger
for hours that may produce gastrointestinal irritation. points in its parallel muscle, the temporal is', which sug
Perhaps it is the Styrofoam cup in which it is served (Ohyama gests that spasm is sometimes a way of relieving overload
et al 2001), or whether it ran through a filter or was boiled elsewhere or repositioning a body part.
1 52 C LI N I CA L A P P L I CATI O N O F N E U RO M U SC U LA R T E C H N I Q U E S : T H E U P P E R B O DY
Travell & Simons (1983) also note a similar phenomenon he most aptly described, 'Pain is a more terrible lord of
in low back pain. mankind than even death itself.' The patient who has suf
fered for days in pain is desperate for relief. However, those
In patients with low back pain and with tenderness to pal
who have suffered for weeks, months or years have restruc
pation of the paraspinal muscles, the superficial layer tended
tured their lives, their habits and their ou tlook around that
to show less than a normal amount of EMC activity until
pain. If no psychological factors, no psychosocial impact
the test movement became painful. Then these muscles
and no need for psychological support exist for a chronic
showed increased motor unit activity or 'splinting' . . . This
pain pa tient, this would truly be the exception. Stress,
observation fits the concept of normal muscles ' taking over'
mood, coping skills, functional habits of use and beliefs
(protective spasm) to unload and protect a parallel muscle
about the future would likely have all been impacted by the
that is the site of significant trigger point activity.
debilitating effects of chronic pain. Depression may result
Recognition of this sort of spasm in soft tissues is a matter of due to, or may be a causal factor in, chronic pain. Either
training and intuition. Whether a ttempts should be made to way, biochemical changes in the CNS may be the result and
release, or relieve, what appears to be protective spasm should be considered in a comprehensive treatment plan.
depends on understanding the reasons for its existence. If
splinting is the resu lt of a cooperative a ttempt to unload a
HOW IS ONE TO KNOW ?
painful but not pathologically compromised structure, then
treatment is obviously appropriate to ease the cause of the Karel Lewi t (1992) suggests that, 'In doubtful cases the
original need to protect and support. If, on the other hand, physical and psychological components will be distin
spasm or splinting is indeed protecting the structure it sur guished during the treatment, when repeated comparison
rounds (or supports) from movement and further (possibly) of (changing) physical signs and the patient's own assess
serious damage, then it should clearly be left alone. ment of them will provide objective criteria'. In the main, he
Experience alone can assist in differen tiating between this suggests, if the pa tient is able to give a fairly preCise
sort of cooperative spasm and the board-like rigidity of description and localization of his pain, we should be reluc
spasm associated with, say, osteoporosis. It is safe to caution tant to regard it as 'merely psychological'.
that if any doubt exists, the spasm should be left intact, In masked depression, Lewit suggests, the reported symp
especially in the acute phase of recovery. toms may be of vertebral pain, p articularly involving the cer
Prolonged immobilization after tissue insult can, how vical region, with associated muscle tension and 'cramped'
ever, lead to scar tissue formation, formation of adhesions posture. The practitioner may be alerted by abnormal
and lowered fatigue tolerance (Liebenson 2006). During the responses during the course of treatment to the fact that there
remodeling phase, orientation of fibers can be influenced may be something other than biomechanical causes of the
along lines of imposed stress with appropriate movement. problem. The history should also provide clues, especially if
It is therefore necessary to plan intervention at the earliest this is a 'thick file' individual, someone who has consulted
acceptable stage or to refer for evaluation should joint, disc many people before yourself. In particular, Lewit notes that,
or pathological conditions be suspected. 'The most important symptom [associated with psychological
distress] is disturbed sleep. Characteristically, the patient falls
asleep normall y but wakes within a few hours and CaIU10t get
SOMATIZATION
back to sleep'.
It is entirely possible for musculoskeletal symptoms to If a masked depression is treated appropriately the verte
represent an unconscious attempt by the person to entomb brogenic pain will clear up rapid ly, he states. Pain and dys
their emotional distress. As noted in the segment on emo function can be masking major psychological distress.
tion and musculoskeletal distress (see Chapter 4) and most Awareness of if, how and when to crossrefer should be part
cogently expressed by Philip Latey (1996), pain and dys of the responsible practitioner 's skills base.
function may have psychological distress as the root cause. Becker (1 996) informs us that somatizers may go years
The person may be somatizing this distress and presenting without an adequate diagnosis, with misdiagnosis being:
with apparently somatic problems. The earlier discussion
the inevitable precursor to prolonged and ineffective treat
relating to neuropathic pain suggested that sometimes a
ment, and frequently to multiple and inappropriate chemi
misattribution occurs as to the cause of pain being 'psycho
cal, electrical and imaging studies; inappropriate
somatic'. This should not lead the practitioner to ignore the
medications, including narcotics (which frequently com
fact that some very real and intense somatic pain involves
pound the problem); or, worse yet, to invasive procedures,
roots in the psyche of the individual.
including surgical intervention.
It is also important to remember that psychological factors
may have played a role in the development of pain. However, He reports tha t, 'Depressed and otherwise psychologically
they may have developed and become a perpetuating factor unwell persons frequently do not recognize the psychologi
as a result of being in chronic pain. Dr Albert Schweitzer cal nature of their problem. In fact they usually deny vehe
(1931 ) understood the psychological implications of pain as mently any psychological or emotional d imension to their
7 The internal enviro nm e nt 1 53
clinical picture . . . [this] makes them particularly difficult to fail ure of reasonable treatments - patient may report
treat.' worsening symp toms to bewilderment of practitioner
Becker (1991) adds the important clue to recognizing practitioner may start feeling anger toward patient
somatizers, who need a special degree of help, not necessar (countertransference)
ily relating directly to their musculoskeletal symptoms: 'emotional hunger' may be masked by increased weight
'Certain individuals, emotionally shortchanged or scarred gain and use of pain-relieving medica tion.
during their forma tive years, evidence a proclivity to soma
Examination findings:
tize in the face of stressful untoward events and circum
stances of adult life, especially ones that awaken untoward theatrical presentation (excessive limp, unnecessary use
feelings buried in the unconscious and rooted in the past.' of walking stick, often in wrong hand, etc.)
How are you to recognize such a patient? An abbreviated non-anatomic sensory findings (accentuating the need
list of Becker 's suggested 'red flags' is as follows. for careful testing)
In the history look for: non-anatomic motor findings such as suboptimal grip
attempts (accentuating the need for careful testing)
vague and implausible history
inappropriate response to tests such as palpa tion and
symptoms which proliferate and link different body
percussion, especially if practitioner's hand is pushed
areas
away in an exaggerated manner.
highly emotionally charged descriptors (searing, blind
ing, cruel, etc.) But, despite the importance of the warnings suggested by
hyperbole ('I couldn't move') Becker and others, it is as well to remember that a great
discrepancies (pa tient reports 'cannot sit' but sits for many people with bodywide pain and virtual d isability do
duration of interview) indeed have musculoskeletal (or associated) conditions and
passivity (e.g. acceptance of disabled status) that their psychological distress derives directly from the
evidence of deconditioning, weight gain and/ or pain and disability they suffer. The truth is tha t we should
increased use of narcotic medication. not make a hard demarcation between 'mind' and 'body' as
origins of pain. This has been the folly of much medical
Psychosocial issues:
practice in the past, although ever more apparent is a recog
apportioning of blame for financial or employment or nition of the need to deal with the whole person. If, as we
personal problems to external sources know, psychological factors can influence the body (soma)
feelings kept internally then the reverse is patently true (see Box 7.8 - Placebo
tearfulness during interview power). It may well be tha t as part of the rehabilitation of
denial of link between symptoms and emotional status. someone with chronic pain and psychological distress,
appropriate bodywork can contribute toward recovery.
Mood disturbances:
What is needed, though, is recognition that the emotional
anger directed at employer or doctors may be displaced side needs skillful expert attention, just as much as do the
anger at parents somatic manifestations of dysfunction.
If someone believes a form of treatment w i l l relieve pain, it will do Placebos work best against headache-type pain (over 50% effec
so far more effectively than if the belief is that the treatment cannot tiveness).
help. I n trials involving over 1 000 people suffering from chronic pain, In about a third of a l l people, most pains a re rel i eved by
d ummy medication reduced the levels of the pain by at least 50% of placebo.
that achieved by any form of pain-killing d rug, including aspirin and A placebo works more effectively if injected, rather than if ta ken
morph ine (Melzack & Wall 1 989). by mouth.
Melzack & Wa l l ( 1 989) explain: Th is shows clea rly that the Placebos work more powerful ly if acco m pa nied by the suggestion
psychological context - particularly the physician's and patient's that they a re indeed powerful and that they will ra pidly produce
expectations - contains powerful therapeutic value in its own right results.
in addition to the effect of the d ru g itself Placebos that are in ca psu le or ta blet form work better if two are
taken rather than one.
Placebo facts Large ca psules work as placebos more effectively than do sma l l
Placebos a re far more effective against severe pain than m i l d ones.
pain. Red placebos a re most effective of a l l in helping pain problems.
Placebos a re more effective in people who a re severely anxious Green placebos help anxiety best.
and stressed than in people who are not, suggesting that the Blue placebos a re the most seda tive and ca lming.
'antianxiety' effect of placebos accounts for a t least part of the Yel low placebos a re best for depression and pink a re the most
reason for their usefu lness. sti m u la ting.
box continues
1 54 CLI N ICAL A P P LICAT I O N O F N EU R O M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY
Placebos have been shown to be effective in a wide variety of more influenced than others. It is essential that we should not think
con ditions including anorexia, depression, skin d iseases, diarrhea that because a placebo 'works' i n an individual that the person is not
and pa l pitation. genuinely suffering pain or that the reported relief is false (Mil lenson
Placebo effects do not only occur when taking something by 1 995).
mouth or injection; for exa m ple, any form of treatment from A person's attitudes and emotions can be seen to be
manipu lation to acupu ncture to su rgery carries with it a degree powerful aids (or h i ndrances) to recovery. The feeli ngs of hope
of placebo effect. and expectation of i m provement, coupled with a relationship with
caring helpers, professional or otherwise, assist in recovery a nd
Recognition of the placebo effect a l lows us to rea l ize the i mportance
coping.
of the power of suggestion on a l l of us, with some people being
mobilization/ articulation together with trigger point In the next c.h ap ter the focus turns to treatment methods
deactiva tion, soft tissue stretching and / or strengthen and how selection of the most appropriate therapeu tic
ing, using NMT, MET, PRT, MFR and massage) approaches demands the systematic use of sound observa
3. rehabilitation and self-care - breathing, posture, etc. tion and assessment protocols.
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N utrition 82(1):41-48 Atherosclerosis 148(2):209-214
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161
Chapter 8
assessment - to detect and construct a valid picture of the against which the person's current status can be measured.
past, relative to presenting symptoms. This might involve all or any of the following.
As will be noted later in this chapter, this calls not only
Assessing muscles for strength or weakness.
for attention to the structural and functional patterns asso
Evaluation of relative 'shortness' of muscles.
ciated with pain or dysfunction but also to how well or
Testing range of motion of soft tissues and joints.
poorly nourished the individual is; whether or not there
Evaluating for presence, absence or overactivity of neu
may be food intolerances associated with their symptoms;
rological reflexes.
how their beliefs and attitudes impact on their condition;
Evaluating for presence of localized, reflexogenically active
and their willingness and ability to undertake a rehabilita
structures, such as myofascial trigger points or spinal
tion program. It is not within the scope of practice, or skills
hyperreactivity (segmental facilitation).
base, of many practitioners and therapists to handle all such
Assessment of postural (a)symmetry.
health influences but this should not prevent them being
Gait function assessment.
aware of their potential to affect recovery. At the least, advice
Evaluating respiratory function.
can be offered regarding sources of information and appro
Consideration of nutritional and lifestyle influences.
priate professional care. In chronic pain conditions a team
Consideration of hormonal influences and other meta
approach is often ideaL as will be explained in the notes on
bolic disturbances.
cognitive behavior therapy later in this chapter.
Awareness of psychosocial influences and attributes.
patterns. When this is done a picture should emerge tha t I f the individual's presenting symptoms relate directly to a
suggests a line of action designed to minimize present single injury/traumatic inciden t, or to repetitive micro
symptoms, as well as to rehabilitate toward a more normal trauma, the individual characteristics of the trauma/micro
status. This should also prevent or reduce the likelihood of trauma should, of course, be considered against the
recurrence. background of the individual's unique characteristics, in
Unless the cause(s) of the person's problems relates to a much the same way as would be the case if the symptoms
specific tra uma, the present dysfunctional patterns are had emerged from a background of gradual compensation/
likely to represent the body's attempts to adapt to wha tever decompensation influences.
overuse, misuse, abuse and disuse stresses to which it has In evaluating for musculoskeletal imbalances, specific
been subjected. Treatment needs to deal with these adap tive tests and assessments are necessary (see Chapters 9 and 10).
changes, as far as is possible, as well as assisting in regain Broader views are also useful, such as that previously
ing an awareness of normal function, while also evalua ting described by Tom Myers (1997) which suggests 'chains' of
ways of preventing a return to the very patterns that pro soft tissue connections in which the fascial structures are
duced the symptoms. If all these elements are not incorpo key (see Chap ter 1).
rated into treatment, results will be short term at best.
In order to be truly successful, such a program would
include:
'LOO SENESS A N D TIG H T N ES S' AS PART OF
attention to soft tissue changes (abnormal tension, fibro T H E B I O M E C H A N I CA L M O DEL
sis, etc.) - possibly involving massage, NMT, MET, MFR,
PRJ, spray and stretch, and /or articulation/mobilization A different conceptual model is offered by Robert Ward DO
deactivation of myofascial trigger points - possibly involv (1997). Ward discusses the 'loose-tight' concept as an image
ing massage, NMT, MET, MFR, PRT, spray and stretch, required to appreciate three-dimensionality as the body, or
and/or articula tion/ mobiliza tion part of it, is palpated/assessed. This can involve large or
releasing and stretching the shortened soft tissues - uti small regions in which interactive asymmetry produces
lizing spray and stretch, MFR, MET or other stretching areas, or structures, which are 'tight and loose', relative to
procedures, including yoga each other. Ward illustrates this with the following examples:
strengthening weakened structures - involving exercise
a 'tight' sacroiliac/hip on one side and 'loose' on the other
and rehabilitation methods, such as Pila tes
a 'tight' SCM and 'loose' scalenes on the same side
proprioceptive reeducation - u tilizing physical therapy
one shoulder area 'tight' and the other 'loose'.
methods (e.g. wobble board) as well as methods such as
those devised by Feldenkrais (1 972), Hanna (1988), Fila tes In positional release methodology (strain/counterstrain,
(Knaster 1996), Trager (1987) and others functional technique, etc., see Chapters 9 and 10), the terms
postural and breathing reeducation - using physical ther 'ease' and 'bind' describe similar phenomena. Assessment
apy approaches as well as Alexander technique, yoga, tai of 'tethering' of tissues, and of the subtle qualities of 'end
chi and other similar systems feel' in soft tissues and joints, is a prerequisite for appropri
ergonomic, nutri tional and stress management strate ate treatment being applied, whether this is of a direct or
gies, as appropriate indirect nature, or whether it is active or passive. Indeed,
attention to any psychosocial elements that may be fac the awareness of these features (end-feel, tight/loose,
toring into the etiology or maintenance of symptoms ease/bind) may be the deciding factor as to which thera
occupational therapy specializing in activating healthy peutic approaches are introduced and in what sequence.
coping mechanisms, determining functional capacity, Ward (1997) states: 'Tightness suggests tethering, while
increasing activity that will produce greater 'concordance' looseness suggests join t and/or soft tissue laxity, with or
than rote exercise, while developing adaptive strategies without neural inhibition.' These barriers (tight and loose)
to return the individual to a greater level of self-reliance can also be seen to refer to the obstacles that are sought in
and quality of life (Lewthwaite 1990). preparation for direct (toward bind, tightness) and indirect
The essence of all of these approaches can be characterized (toward ease, looseness) techniques.
as having a dual focus: Clinically it is always worth considering whether restric
tion barriers ought to be released, in case they are offering
1. to reduce the adaptive load(s) (better ergonomics, exer some protective benefit. As an example, Van Wingerden
cise, postural and breathing habits - as examples), i.e. (1997) reports that both intrinsic and extrinsic support for
what is being adapted to, and the sacroiliac jOint derives in part from hamstring (biceps
2. to enhance the functionality of the tissues, area, person femoris) status. Intrinsically, the i nfluence is via the close
(improved mobility, stability, balance, etc.), so allowing anatomic and physiological relationship between biceps
the tissues/the person an improved ability to cope with femoris and the sacrotuberous ligament ( they frequently
the adaptive load, whatever it happens to comprise. attach via a strong tendinous link) .
1 64 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S C ULAR T E C H N I Q U ES: T H E U P P E R B O DY
He states: 'Force from the biceps femoris muscle can lead HVLT manipulation can offer any benefit to chronically
to increased tension of the sacrotuberous ligament in vari shortened, fibrosed, soft tissues, even if a reduction in
ous ways. Since increased tension of the sacrotuberous liga hypertonicity is more than short term. These comments
ment diminishes the range of sacroiliac joint motion, the are not meant to suggest that there is no value in such
biceps femoris can play a role in stabilization of the SIr (Van manipulation, only that it is unlikely to have any influ
Wingerden 1997; see also Vleeming et a I 1 989). ence on chronically modified soft tissue status.
He also notes that in low back patients forward flexion is In contrast, pOSitional release methods seek the indirect,
often painful as the load on the spine increases. This hap 'ease' or 'loose' barriers. This concept will be made
pens whether flexion occurs in the spine or via the hip joints explicit when posi tiona l release methods are described in
(tilting of the pelvis). If the hamstrings are tight and short Chapter 10.
they effectively prevent pelvic tilting. 'In this respect, an
increase in hamstring tension might well be part of a defen
PAIN AND THE TIGHT-LOOSE CONCEPT - AND
sive arthrokinematic reflex mechanism of the body to
THE TRIGGER POINT CONTROVERSY
diminish spinal load.' If such a state of affairs is long stand
ing the hamstrings (biceps femoris) will shorten (see discus Pain is more commonly associated with tight and
sion of the effects of stress on postural muscles in Chapters bound/ tethered structures, which may be due to local over
4 and 5), possibly influencing sacroiliac and lumbar spine use/misuse/ abuse factors, scar tissue, reflexively induced
dysfunction. The decision to treat a tight (, tethered') ham influences or centrally mediated neural control. When a tight
string should therefore take account of why it is tight, and tissue is then asked to either fully contract or fully lengthen,
should consider that in some circumstances it might be pain is often experienced. Paradoxically, as pointed out by
offering beneficial support to the SI}, or that it might be Lewit (1996), pain is also often noted in the 'loose' rather than
reducing low back stress. the 'tight' areas of the body, which may involve hypermobil
ity and ligamentous laxity at the 'loose' joint or site. These
(lax, loose) areas are vulnerable to injury and prone to recur
LEWIT (1996) AND 'LOOSE-TIGHT' THINKING rent dysfunctional episodes (SI joint, TM}, etc.).
Lewit observes that pain is often noted on the 'loose' side Myofascial trigger points may develop in either 'tight' or
when there is an imbalance in which a joint or muscle 'loose' structures but usually appear more frequen tly, and
(group) on one side of the body differs from the other. are more stressed, in those which are tethered, restric ted or
tight. Myofascial trigger pOints will continue to evolve if the
A 'tight and loose complex', i.e. one side is restricted and the etiological factors that created and / or sustained them are
other side is hypotonic, is frequently noted. Shifting [Lewit not corrected and, unless the trigger points are deactivated,
is referring to stretching offascial structures] is examined they will help to sustain the dysfunctional postural patterns
and treated in a craniocaudal or caudocranial direction on which subsequently emerge.
the back, but it should be assessed and treated in a circular Sterling et al (2001) highlight an ongoing debate as to the
manner around the axis of the neck and the extremities. validity of what may be termed the 'trigger point hypothe
sis'. They represent that group of clinicians and researchers
who question the model based on the work of Travell,
SOFT TISSUE TREATMENT AND BARRIERS
Simons and others (Simons et aI1 999).
MET methods can be utili zed to identify the tight bind
barrier and, using isometric contractions of agonist or
antagonist, attempt directly to push this barrier back or Box 8. 1 Tight-loose parpation exercise (Ward 1997)
to pass through it.
Myofascial release (in its direct usage) also addresses its Person is supine.
Practitioner grasps person's wrists.
directions of force directly toward the barrier of restriction.
A slow movement is made of both arms to full overhead
High-velocity, low-amplitude (HVLA) thrust manipula extension as particular focused attention is paid to symmetry
tion, or 'adj ustment', as employed in chiropractic, osteopa of freedom of movement and any sense of restriction com
thy and increasingly in physical therapy, also addresses mencing at the wrist contact but possibly i nvolving the body
the restriction barrier, forcing motion through that barrier. as a whole.
Attention needs to be paid to both quality and amplitude of
One objective of this procedure is the invoking of a neuro
the passive movement.
logical response that produces a reduction in local soft The same exercise sh ould be performed on each arm inde
tissue tone. In addition, such manipulation aims to pendently, as well as simultaneously, while attention is paid
mechanically modify previously 'blocked' movement to any sensations of restriction and the end-feel associated
(Gibbons & Teahy 2000). Whether such changes in soft with it.
Ward states, 'With practice, variable tension and loads are
tissue tone (as measured by surface EMG) actually occur
readily sensed from the h ands and wrists into the lumbodorsal
other than transiently has been questioned (Herzog et al fascia and pelvis' .
1 995). It is reasonable to also question whether use of
8 Assessment. trea t men t and re h a b i l itation 1 65
They (Sterling et al) note that workers such as Simons & low back area (which ends up involving the entire trunk
Mense (1998) maintain that palpable taut bands of trigger and cervical area) as 'tight' areas evolve to compensate for
points make muscles feel tense, even though these phenom loose, inhibited areas (or vice versa) (Fig. 8.1).
ena are not associated with propagated action potentials
that would be identified as EMG activity. 'Tightness' in the posterior left hip, SI joint, lumbar erec-
In relation to this concept Sterling et al (2001 ) state: tor spinae and lower rib cage.
'Although this proposal may sound enticing to both patients 'Looseness' on the right low back.
and clinicians, the validity and reliability of the existence of Tight lateral and anterior rib cage on the right.
trigger points have not been established.' They cite a study Tight left thoracic inlet, posteriorly.
by Stohler (1999) that holds to a neurological, rather than a Tight left craniocervical attachments (involving jaw
trigger point, explanation for myofascial pain and dysfunc mechanics).
tion, to support that statement. To be sure, other clinicians
also hold to a different model to explain myofascial pain, At any given treatment session, as tight areas are freed or
and these issues are discussed in Chapter 6. loosened, even if only to a degree, inhibiting influences on
Sterling et al maintain that increased muscle activity may 'loose' weak areas diminish and allow a return of tone. It is at
instead occur in the presence of pain, via the flexor with this time that rehabilitation, proprioceptive and educational
drawal reflex (i.e. involving central sensitization), a process p atterns of use need to be introduced and practiced by the
that offers a neurological interpreta tion for such changes person, so that what initially 'feels wrong' in terms of pos
(Matre et aI 1999). They also consider the possibility, basing ture and usage (proper position and movement) becomes
the assertion on the work of Simons & Mense ( 1998), that comfortable and starts to feel 'right'.
painful, taut muscles that are palpated at rest in patients
with musculoskeletal syndromes may be caused by changes
METHODS FOR RESTORATION OF
in the viscoelastic properties of the muscles themselves.
'THREE-DIMENSIONALLY PATTERNED
Note: The authors of this text, having examined the evi
FUNCTIONAL SYMMETRY'
dence (see Chapter 6), are not in complete agreement with
Sterling et aI's view, but feel that, in the interest of objectiv 1 . Identification of patterns of ease/bind-loose/ tight in a
ity, their point of view should be reported. There seems to given body area or the body as a whole. This can emerge
be every chance that various models are required to explain from sequential assessment of muscle shortness and
the pathophysiological changes noted in relation to muscu restriction or palpation methods, such as those described
loskeletal dysfunction and pain, involving variously, and by Ward (1997), or any other comprehensive evalua tion
possibly coincidentally, trigger point activity, neurological of the status of the soft tissues of the body as a whole.
sensitization and/ or viscoelastic modifications - and per 2. Appropriate methods for release of areas identified as
haps even factors that have not yet been considered. tight, restricted, tethered (possibly involving myofascial
release, spray and stretch, MET, NMT, PRT, singly or in
combination, plus other manual approaches) .
THREE-DIMENSIONAL PATTERNS 3 . I f j oints fail t o respond adequately t o soft tissue mobiliza
tion, the use of articulation/ mobilization or high-velocity
Areas of dysfunction will usually involve vertical, horizon thrust methods may be incorporated into this sequence as
tal and 'encircling' (also described as crossover, spiral or appropriate to the status (age, structural integrity, inflam
'wrap-around') patterns of involvement. Ward offers a matory status, pain levels, etc.) of the individual and the
' typical' wrap-around pattern associated with a tight left scope of practice and training of the practitioner.
c
1 66 C L I N I CA L APP LICAT I O N O F N E U R OM U S C U LA R TECH N I Q U E S: TH E UPP E R B O DY
4. Identification and appropriate deactivation (using NMT spray and stretch techniques, and
or other appropriate means) of myofascial trigger points variations on these basic themes.
contained within these structures. Whether step 2 pre
cedes step 4 or vice versa is a matter of clinical judgment
(and debate). They may happen simultaneously. MAN IPU LATING TISSUES
5. Trigger points always require the stretching of the affected
Lederman (1997) points out that, in effect, there are only a
tissues housing the trigger points after deactivation. In
limited number of ways of treating tissues ('modes of load
addition, restoration of normal resting length to the mus
ing') and most of the various direct 'techniques' employed by
cle housing the trigger point is seen to be an important
manual therapists are variations of these (Carlstedt & Nordin
objective of treatment.
1989). Indirect approaches that 'unload' tissues (i.e. they
6. Reeducation and rehabilitation (including homework) of
move away from any perceived restriction barrier), such as
posture, breathing and patterns of use (work, leisure activ
osteopathic functional technique and strain/ counterstrain,
ities, sitting, walking, lying down) in order to restore func
are not included in this summary of direct approaches.
tional integrity and prevent recurrence, as far as possible.
Lederman's perspective on variations of possible appli
7. Exercise (homework) has to be focused, time efficient and
cation of direct treatment forces (with additions from the
within the person's easy comprehension and capabilities,
authors) includes the following.
if cooperation is to be achieved.
1 . Tension loading in which factors such as traction, stretching,
extension and elongation are involved. The objective is to
lengthen tissue. The effect, if sustained, is to encourage
NEU RO M U S C U LA R M AN AGEMENT OF S OFT
an increase in collagen aggregation and therefore denser
TISSU E DYSF U N CT I O N
and stronger tissues. Lengthening forms a major part of
rehabilitation methodologies and, on a l ocal level, of trig
There are many ways of usefully applying manual methods
ger point deactivation.
to the musculoskeletal system. Treatment approaches can
2. Compression loading shortens and widens tissue, increasing
be categorized as direct and indirect, active and passive,
pressure and influencing fluid movement significantly.
gentle or mechanically invasive, and all have value in their
Over time, a degree of lengthening may also occur in the
appropriate settings.
direction of pressure if the underlying structures allow
A great many of the methods of manual treatment can
this (i.e. limited by any bony surface beneath the compres
cluster under a heading of 'neuromuscular ' inasmuch as
sion). As well as affecting circulation, compression also
they focus on the soft tissues, including musculature, and
influences neurological structures (mechanoreceptors,
they incorporate into their methodology influences on neu
etc.) and encourages endorphin release.
ral function. Methods that are seen to be natural allies of
3. Rotation loading produces a variety of tissue effects since
neuromuscular therapy (NMT), as applied in Europe and
it is effectively elongating (some fibers) and compressing
the USA, include:
simultaneously, with the circulatory and/ or neurological
muscle energy techniques (MET) (and other forms of influences outlined above. Techniques which produce a
induced stretching or release) 'wringing' effect on soft tissues, or in which joints are
positional release techniques (PRT) (including strain/ rotated as they are articulated, will cause this form ofload
counterstrain (SCS), functional technique, craniosacral ing on soft tissues. Manual methods such as 5 bends (in
' '
techniques, etc.) which tissues are stretched in two directions at the same
myofascial release (MFR) (varying from dynamic to time by, for example, the action of opposing thumbs; see
extremely gentle) Chapter 1 2) can be seen to be simultaneously compress
direct manual pressure (also called ischemic compres ing, elongating and, in those fibers close to the transition,
sion, trigger poin t pressure release, inhibition technique, applying rotation loading.
acupressure) 4. Bending loading is in effect a combination of compression
direct manual variations (such as crossfiber friction, spe (on the concave side) and tension (on the convex side). This
cific soft tissue mobilization, etc.) has both a lengthening and a circulatory influence. On a
rhythmically applied release methods (including percus local soft tissue level a 'e'-shaped bending of tissues that
sion and harmonic technique) can be held to encourage elongation is commonly applied.
mobilization of associated joints (including articulation, 5. Shearing loading, which translates or shifts tissue laterally
rhythmic pulsating approaches, e.g. Ruddy's technique in relation to other tissue. This is most used in joint
(Ruddy 1962), high-velocity thrust (HVT articulation but insofar as it involves soft tissues, has the
McKenzie methods to encourage centralization of periph effect of compression and elongation in the region of
eral pain (McKenzie & May 2003) transition. All techniques that attempt to slide a more
mobilization with movement methods deriving from the superficial layer of soft tissue across underlying tissues
work of Mulligan (1999) would be included here.
---- --------_._--
6. Combined loading involves the application of combined biochemical abnormalities which interfere with the ability of
variations of the modes of loading listed above, leading the muscle to recover or which continuously stress m uscle,
to complex patterns of adaptive demands on tissues. For reactivating the trigger point.
example, Lederman (1997) points out that a stretch that is
combined with a sidebend is more effective than either a Among the 'systemic biochemical abnormalities' identified
sidebend or a stretch alone, something which most man are 'hypothyroidism, folic acid insufficiency and iron insuf
ual therapists will recognize. ficiency'. These deficiency states are seen to be important
7. Apart from the varia tions in load ing that are chosen because of their influence on enzyme systems.
(push, pull, twist, bend, shift) additional permutations Gerwin continues:
include the following. Vitamins act as cofactors in different enzyme systems that
How hard? What is the degree of force being employed
may be functioning at different rates at any one time. The
(from grams to kilos)? optimum level of a vitamin is that which permits maximum
How large? What is the size of the area to which force
function for each enzyme for which it is an essential cofac
is being applied (lentil-sized nodule or whole limb or tor. The vitamin requirements therefore change with time
even whole body)? and circumstances. The daily vitamin intake should thus
How far? What is the intended amplitude of the ind uced
support optimum function . . . [and is] affected by host fac
movement? The degree of force largely determines the tors such as smoking or by competitive inhibition by drugs.
amplitude - how far the tissues are being taken (milli (Travell & Simons 1983, 1992)
meters or centimeters) .
How fast? What i s the speed with which force is Simons et al (1999, p. 212) are absolutely clear in their insis
applied (from extremely rapid to subtly slow)? tence that nutritional balance has to be restored if myofas
How long? What is the length of time force maintained cial pain is to be adequately addressed:
(from milliseconds to minutes)?
How rhythmic? What is the rhythmic quality of
Patients with chronic myofascial pain are a select group
applied force (from rapid to deliberate to synchronous which, in our experience, has a remarkably high prevalence
with, for example, breath or pulse rate)? of vitamin inadequacies and deficiencies. When the patient
How steady? Does the applied force involve movement
fails to respond to specific myofascial therapy 01' obtains
or is it static (sustained pressure or gEding action)? only temporary relief vitamin deficiencies must be ruled out
Active, passive or mixed? Is the patient active in any of
as a major contributing cause and, if present, corrected.
the processes (assisting in stretching, for example, or
resisting applied force)? SPECIFIC NUTRIENTS AND MYOFASCIAL PAIN
The reader might usefully reflect on which of the variations Folic acid (associated with the enzyme
of loading - and the permutations as to refining these as tetrahyd rofol ate)
listed above - is involved in any particular method or tech
nique currently employed. It will be rare indeed to find It is suggested that levels should be measu red in serum
direct methods that do not incorporate these elements. together with B1 2, as well as in red blood cells (Gerwin
1993). When in the low normal range, symptoms may
include:
N UTR ITION AN D PA I N: A BI O CHEM I CAL
feeling unnaturally cold (as in hypothyroidism but with
PERS PECTIVE
low cholesterol levels rather than high)
a tendency to diarrhea (rather than constipation, which is
A variety of nutritional influences can be noted in relation
associated with B12 deficiency)
to pain in general and myofascial trigger point evolution
a tendency to restless legs, headache and disturbed sleep
and behavior in particular. These include:
type II muscle fibers in the upper body are most likely to
nutritional deficiency develop trigger points.
allergy/intolerance
antiinflammatory tactics.
Iron (associated with various blood enzymes.
including cytochrome oxidase)
NUTRITIONAL TREATMENT STRATEGIES
Serum ferritin levels should be measured to evaluate cur
Gerwin (1993) states that while manual methods (pressure,
rent levels. Deficiency may be noted more frequently in per
needling, etc.) can deactivate myoascial trigger points:
imenopausal women whose diet is inadequate to replace
Management of recurrent myofascial pain syndrome (MPS) iron lost during menstruation. Blood loss may also be asso
requires addressing the perpetuating factors of mechanical ciated with taking NSAIDs. Gerwin (2005) notes that iron
imbalances (structural, postural, compressive) and systemic deficiency can be a factor in the development or perpetuation
1 68 CLINICAL APPLICATION OF NEUROM USCULAR TECHNIQ UES: THE UPPER BODY
of trigger points due to its impact on local muscle energy. misguided and has serious consequences, ie, the risk of vita
Symptoms include: min 0 deficiency and increased risk of many chronic diseases.
There is little evidence that adequate sun exposure will sub
unnatural fatigue (iron is needed to convert thyroid hor
stantially increase the risk of skin cancer; rather, long-term
mone T4 into its active T3 form, which may be an added
excessive exposure and repeated sunburns are associated
fatigue factor if either is deficient)
with nonmelanoma skin cancers.
exercise-induced muscular cramping
intolerance to cold
restless legs syndrome (Gerwin 2005).
Selenium and vitamin E
In a double-blind study 140 mg selenium and 100 mg alpha
Vitamin D tocopherol were supplemented daily and compared with
Vitamin 0 is an essential nutrient for utilization of dietary placebo. Glutathione peroxidase levels increased in 75% of
calcium. When vitamin 0 is deficient, absorption of calcium 81 patients with disabling muscular and osteoarthritic pain.
is inadequate to meet the demands of the body. To help cor Pain score reductions were more pronounced in the treated
rect this, the body increases its release of parathyroid hor patients (Jameson 1985).
mone, a hormone that acts to increase calcium levels by Additional nutritional deficiencies, including vitamins C
removing it from the bones and by enhancing absorption and B complex, have been identified by Simons et al (1999)
through the kidneys. Holick (2003a) notes that this result in as being implicated in myofascial trigger point evolution and
rickets, osteopenia and osteoporosis and 'may have serious activity. It is self-evident that the ideal source of nutrients is
adverse consequences, including increased risk of hyper well-selected and appropriately prepared food. Whether an
tension, multiple sclerosis, cancers of the colon, prostate, omnivorous or a vegetarian (or other variant) dietary pattern
breast, and ovary, and type 1 diabetes. There needs to be a is chosen, the key elements remain the need for adequate
better appreciation of the importance of vitamin 0 for over nutrient-rich protein, complex carbohydrate (fresh vegeta
all health and well being' (Holick 2003b). bles, pulses and grains), essential fatty acids, fruit and liq
In considering the prevalence of vitamin 0 deficiency: uid. Food choices may be limited by economic factors, food
intolerance issues (see below), ignorance or, more commonly,
Plotnikof & Quigley (2003) found vitamin 0 deficiency in
ignoring what is known to be appropriate, something most
89% of subjects with chronic musculoskeletal pain.
people are aware of as a personal issue at times. It is sug
Glerup et al (2000) reported that 88% of women investi
gested that, at the very least, a well-formulated multivita
gated who presented with muscle pains and weakness
min mineral supplement should be incorporated into any
were severely vitamin 0 deficient.
self-care advice offered to patients with musculoskeletal
Bischoff et al (2003) observed that adults with vitamin 0
dysfunction.
deficiency present with muscle weakness and are more
likely to fall.
ALLERGY AND INTOLERANCE: ADDITIONAL
Gerwin (2005), citing Glerup et al (2000) and Mascarenhas &
BIOCHEMICAL INFLUENCES ON PAIN
Mobarhen (2004), discusses vitamin 0 deficiency in its asso
ciation with musculoskeletal pain, loss of type II muscle In the 1920s and 1930s, Dr A H Rowe demonstrated that
fibers and proximal muscle atrophy. He notes: widespread chronic muscular pains - often associated with
fatigue, nausea, gastrointestinal symptoms, weakness,
The deficiency state is easily corrected, but it takes up to six
headaches, drowsiness, mental confusion and slowness of
months of replacement to reverse changes caused by defi
thought as well as irritability, despondency and widespread
ciency states. People not exposed to the sun are at great risk,
bodily aching - commonly had an allergic etiology. He
including those whose clothes leave little skin exposed to the
called the condition 'allergic toxemia' (Rowe 1930, 1972).
sun, and those who spend little time out of doors.
Theron Randolph (1976) described 'systemic allergic
Holick (2003a) agrees, specifying that 90% of required vita reaction' as being characterized by a great deal of pain, either
min 0 comes from exposure to sunlight: muscular and/ or joint related, as well as numerous associa
ted symptoms. He has studied the muscular pain phenome
Anything that in terferes with the penetration of solar ultra
non in allergy and his plea for this possibility to be considered
violet radiation into the skin, such as increased melanin pig
by clinicians was based on his long experience of it being
mentation and su nscreen use, will diminish the clltaneous
ignored.
production of vitamin 03, The most cost-effective and effi
cient method for preventing vitamin 0 deficiency is to have The most important point in making a tentative working
adequate exposure to sunlight. Some dermatologists advise diagnosis of allergic myalgia is to think of it. The fact remains
that people of all ages and ethnicities should avoid all direct that this possibility is rarely ever considered and is even more
exposure to sunlight and should always use sun protection rarely approached by means of diagnostico-therapeutic meas
when outdoors. This message is not only unfortunate, it is ures capable of identifying and avoiding the most common
8 Assessment. treatment a n d reh a b i l i tation 169
]
environmental incitants and perpetuants of this condition - the brain level, and not peripheral (immunological) sensitiza
namely, specific foods addictants, environmental chemical tion, is a major etiological mechanism by means of which
exposures and house dust. various abdominal and other health complaints are gener
ated and may be misinterpreted as 'food allergy' .
Randolph points out that when a food allergen is with
drawn from the diet it may take days for the 'withdrawal'
symptoms to manifest. TREATMENT FOR 'ALLERGIC MYALGIA'
During the course of comprehensive environmental control Rather than attempting to heal the intestinal changes (pro
[fasting or multiple avoidance] as applied in clinical ecol biotics, etc.) or deal with the stress-coping abilities of the
ogtj, myalgia and arthralgia are especially common with individual, Randolph (1976) sta tes his position - 'Avoidance
drawal effects, their incidence being exceeded only by of incriminated foods, chemical exposures and sometimes
fatigue, weakness, hunger and headache. lesser environmental excitants'. How this is achieved in a
setting other than a clinic or hospital poses a series of major
The myalgic symptoms may not appear until the second or
hurdles for the practitioner - and the person with the symp
third day of avoidance and may start to recede after the fourth
toms. If foods or other irritants can be identified, it makes
day. Randolph warned that in testing for (stimulatory) reac
perfect sense for these to be avoided, whether or not under
tions to food allergens (as opposed to the effects of with
lying causes (such as possible gut permeability issues) can
drawal), the precipitation of myalgia and related symptoms
be, or are being, addressed.
may not take place for between 6 and 12 hours after ingestion
According to the Fibromyalgia Network, the official p ub
(of a food which contains an allergen), which can confuse
lication of fibromyalgia patient support groups in the USA,
matters as other foods eaten closer to the time of the symp
the most commonly identified foods tha t cause muscular
tom exacerbation may then appear to be at fault. Other signs
pain for many people are wheat and dairy products, sugar,
which can suggest that myalgia is allied to food intolerance
caffeine, aspartame, alcohol and chocolate (Fibromyalgia
include the presence of a common associated symp tom,
Network Newsletter 1993).
restless legs (Ekbom 1 960).
Maintaining a whea t-free, dairy-free diet for any length
When someone has an obvious allergic reaction to a food,
of time is not an easy task, although many manage it. Issues
this may be seen as a causal event in the emergence of other
involving concordance (a term currently suggested as being
symptoms. If, however, the reactions occur many times every
more appropriate than commonly used words such as
day and responses become chronic, the cause-and-effect link
'compliance' or 'adherence', which denote passive obedi
may be more difficult to make. If a connection between par
ence) deserve special a ttention, since the way informa tion is
ticular foods and symptoms such as muscular pain can
presented and explained can make a major difference to the
indeed be made, the major question remains - what is the
determination displayed by already distressed people as
cause of the allergy? One possibility is that the gut mucosa
they embark on potentially stressful modifications to their
may have become excessively permeable ('leaky gut syn
lifestyles.
drome'), so allowing large molecules into the bloodstream
where a defensive 'intolerance' or allergic reaction is both
predictable and appropriate (Martinez-Gonzalez et a1 1994, Summary
Mielants et al 1991, Paganelli et aI 1 99 1 ) .
If muscle pain appears to relate to nutrition one or all of the
following may be helpful:
WHAT CAUSES THIS INCREASE IN Deal with underlying stress factors through better stress
PERMEABI LITY? management, or avoidance/ elimination of the stressors.
Identify whether increased intestinal permeability is a
Changes in the local intestinal environment due to factors
factor, and help to correct this by means of specific nutri
such as infection or stress encourage antigens (large mole
ents, herbal products and / or medication, as well as pro
cules from the gut) to penetrate the mucosa and induce
biotics.
allergic inflammation (Bhatia & Tandon 2005, Heyman
Identify and avoid (exclude/challenge) foods and food
2005). Evidence suggests that supplementation with probi
families that provoke symptoms.
otic microorganisms (beneficiaL or 'friendly' bacteria) can
improve the gut barrier function, and may, therefore, both Note: If any such approaches lie outside of the practitioner's
'undo and prevent unfavorable intestinal microecological scope of practice, suitable referral should be made.
alterations in a llergic individuals' (Bongaerts & Severijnen
2005).
ANTIINFLAMMATORY NUTRITIONAL
Alternatively, it has been suggested tha t prolonged or
( BIOCHEMICAL) STRATEGIES
repetitive stress might create a sensitization of the brain,
leading to what appear to be 'intolerance' symptoms. Berstad If an underlying inflammatory process is ongOing it may be
et al (2005) suggest that cognitivmotional sensitization at possible to modify or modulate this without recourse to
1 70 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S C U LA R T EC H N I Q U E S : T H E U P P E R B O DY
[
from being a pain avoider to a pain manager (Troup & improved health on their financial position and can demon
Videman 1989, Waddell et aI 1996). In a severely painful or strate that they are sufficiently motivated to change, despite
unstable acute injury it may be appropriate to equate hurt these considera tions and consequences (Watson 2000).
and harm. But, in less severe cases, or certainly in the suba Additionally, the litigation process itself, including depOSi
cute or recovery phase, hurt should not be automatically tions, medical improvement testing, court appearances and
associated with harm. In fact, the target of treatment may be other procedures, may impose stresses - and distresses -
the stiffness caused by the patients overprotecting them which create emotional challenges that stimulate and
selves during the acute phase. Muscles and joints that lose provoke the pain response. This situation often results in
their mobility while the patient restricts their activities dur setbacks in the recovery process.
ing acute pain should be expected to cause discomfort and
remobilizing them may hurt but certainly won 't harm. OTHER BARRIERS TO PROGRESS IN PAIN
MANAGEMENT (G i l et a 1 1 988, Keefe et a l 1 996)
Distorted perceptions of the person (and / or their partner
G UIDE LINES FOR PAIN M ANAGEMENT
or family) about the na ture of their pain and disabili ty.
(Brad l ey 1 996)
Beliefs based on previous (possibly incorrect) diagnosis
and treatment failure (,But the specialist said . . . ) .
Assist the person in altering beliefs that the problem is
'
Personality
, Cognition
' Affect
, Endocrine , Behavior
, Metabolism
, Neurochemistry
, Situational characteristics
, TIssue repair
Rehabilitation environment
, Nutrition
Intennedlate
blopaychologlcal
oufIlonIIe
Sport Injury rehabDltatIon
, Range of motion
outc:omea
, Strength
, Joint laxity Functional performance
, Pain Quality of life
, Endurance Treatment satisfaction
Rate of recovery Readiness to retum to sport
appraisal model that involves the individual's particular Lewit (1992) and Liebenson (1996, 2006) (see Further read
stress and coping responses (Horsley 1995). For a greater ing), highlight the need (in treatment and rehabilitation of
understanding of these issues the text by Kolt & Snyder dysfunction) to move as rapidly as possible from passive
Mackler (2003) is recommended. (opera tor-controlled) to active (pa tient-controlled) methods.
Rehabilitation demands a process of goal setting and The rate at which this happens depends largely on the degree
implementation as outlined by Liebenson above. This can of progress, pain reduction and functional improvement.
be visualized in the charted elements in Figure 8.3.
PATIENT ADVICE AND CONCORDANCE
CONCORDANCE (COMPLIANCE) ISSUES
It is of major concern that concordance (aka compliance, Individuals should be encouraged to l isten to their bodies
adherence, participation) is extremely poor regarding and to never do more than they feel is appropriate in order
1 74 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S CU LAR TECH N I Q U E S : T H E U P P E R B O DY
to avoid what can be severe setbacks in progress when they It is useful to explain that all trea tment makes a demand for
exceed their current capabilities. It is vital that rehabilitation a response (or several responses) on the part of the body
strategies are very carefully explained, as active participa and that a 'reaction' (something ' feels different') is normal and
tion is not high when novel routines or methods are sug expected and is not necessarily a cause for alarm but that i t
gested unless they are well understood. i s O K t o make contact for reassurance.
Routines and methods (homework) should be explained It may be useful to offer a reminder that symptoms are
in terms that make sense to the person and the practitioner(s). not always bad and that change in a condition toward nor
Written or printed notes, ideally illustrated, help greatly to mal may occur in a fluctuating manner, with minor setbacks
support and encourage compliance with agreed strategies, along the way.
especially if simply translated examples of successful trials It can be helpful to explain, in simple terms, that there are
can be included as examples of potential benefit. Information many stressors being coped with and that progress is more
offered, spoken or written, needs to answer in advance ques likely to come when some of the 'load' is lightened, espe
tions such as: cially if particular functions (digestion, respiratory, circula
tion, etc.) are working better.
Why is this being suggested? A basic understanding of homeostasis is also helpful
How often, how much? (,broken bones mend, cuts heal, colds get better - all exam
How can it help? ples of how your body always tries to heal itself') with par
Wha t evidence is there of benefit? ticular emphasis on explaining processes at work in the
What reactions might be expected? patient's condition.
What should I do if there is a reaction?
Can I call or contact you if I feel unwell after exercise (or
other self-applied treatment)?
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Further reading
For more detailed descriptions of the functional organiza Lederman E 2005 The science and practice of manual therapy, 2nd
tion of the motor system and of therapeutic considerations edn. Churchill Livingstone, Edinburgh
Lewit K 1 999 Manipulative therapy in rehabilitation of the locomo
the following are recommended for further reading. Note
tor system. Butterworths, London
that these texts do not always agree on which manual meth Liebenson C (ed) 2006 Rehabilitation of the spine, 2nd edn.
ods are most helpful! Lippincott Williams and Wilkins, Philadelphia
Morris C 2005 Low back pain syndromes: integrated clinical man
Kolt G, Snyder-Mackler L 2003 Physical therapies in sports and agement. McGraw-Hili, New York
exercise. Churchill Livingstone, Edinburgh Vleeming A, Mooney V, Stoeckart R (eds) 2007 Movement, stability
Lederman E 1997 Fundamentals of manua l therapy. Churchill and lumbopelvic pai.n: i.ntegration of research and therapy,
Livingstone, Edinburgh 2nd edn. ChurchilI Livingstone, Edinburgh
177
Chapter 9
Neuromuscular therapy tech niq ues have emerged in both Europe and medical, dental, massage and other therapeutic com m u n ities with
North America almost simulta neously over the last 50 years. Fi rst documen tation, research and references for a whole new field of
developed by Stanley Lief and Boris Chai tow, European-style NMT study - myofascial trigger poi nts.
was developed between the m id-1930s and ea rly 1940. Trained i n Several of N i m mo's students bega n teach ing their own NMT
chiropractic and naturopathy, these cousins developed i n teg rated protocols, based on Ni mmo's work. I n the USA the acronym NMT
concepts learned from teachers l ike Dewa nchand Varma and Bernarr sign i fied neurom uscular therapy rather than technique. NMT St John
Macfadden. Method and NMT American version became two prominent systems
Lief and Cha itow developed and refi ned what they called which today still retain a strong focus on Nim mo's original
'neuromuscular techniq ues' as a means of assessing and treating soft tech niques.
tissue dysfunction, i n Liefs world-famous health resort, Cham pneys, European and America n versions of NMT have subtle differences
at Tring in Hertfordshire, England. Many osteopaths and naturopaths in their hands-on applications wh ile reta i n i ng sim ilar fou ndations in
have taken part in the evolution and development of European their theoretical platform. North America n-style neuromuscular
neuromuscular therapy, i n clu d i ng Peter Lief, Brian Youngs, Terry therapy uses a med i u m-paced thumb or finger glide to uncover
Moule, Leon Chaitow and others. NMT is now taught widely i n contracted bands or m uscular nodules whereas European-style
osteopa thic and sports massage setti ngs i n Britain and forms part of n eu romuscu lar techn iques use a slow-paced, thumb drag method of
the tra i n ing lead ing to the Bachelor of Science (BSc(Hons)) degree in discovery. They also have slightly d ifferent emphasis on the method
Com plementary Health Sciences, Un iversity of Westmi nster, London. of application of ischemic compression in treating trigger poi nts.
A few years after neuromuscular techniq ues developed i n Eu rope, Both versions emphasize a home care program and the patient's
across the ocean in America, Raymond N i m mo and James Vannerson participation in the recovery process.
began writing of their experiences with what they termed 'noxious In this text. the American version of NMT is offered as the
nod ules', i n their newsletter, Receptor-Tonus Techniques. A step-by fou ndation for developing palpatory skills and treatment techniques
step system began to emerge, supported by the writings of Janet wh ile the European version accompa nies it to offer an alternative
Travell and David Simons. Travell and Simons' work i m pacted the approach.
A confusing element relating to the term NMT emerges from its use already in general manual medicine and osteopathic texts. In reality,
by some European a u thors when they describe what are, in effect, almost all man ual methods that add ress either soft tissue or joint
variations on the theme of isometric contractions (Dvorak et al dysfunction involve a degree of both muscula r and neural elements
1988). These methods, all of which form part of what is known as and could therefore receive a 'neuromuscular' designation. However,
m uscle energy technique (MET) in osteopathic medicine, will be there would seem to be little to be gained via such an exercise.
outlined in Box 9 .10. In this text, when the letters NMT a re used in relation to the
Dvorak et al (1988) have listed various MET methods as NMT, as American version, it should be understood to indicate neuromuscular
follows. therapies as described in this book in general and this chapter i n
particu lar (i.e. a broad a pproach t o addressing musculoskeletal
Methods that i nvolve active self-mobilization in o rder to encour
dysfu nction, i ncluding myofascial trigger poi nts).
age movement past a resistance barrier are called 'NMT l' by
When NMT is used in relation to the European approach it shou ld
Dvorak et al.
be understood to refer only to the technique of assessment and
Isometric contraction, i nvolving postisometric relaxation and sub
treatment of local m usculoskeletal dysfunction, mainly i nvolving
sequent passive stretching of agon ist m uscles is described as
myofascial trigger points u tilizing finger and/or thumb techniques,
'NMT 2'.
and not the eclectic selection of complementary approaches
Isometric contraction of antagonists, i nvolving reciprocal inhibi
i n corporated under the American NMT label.
tion followed by stretching is called 'NMT 3' by Dvorak et a l .
Naming these methods NMT 1 , 2 and 3 would seem t o a d d t o (rather
than reduce) semantic confusion since they a re adequately named
order to remove or modify as many etiological and perpet active), tenderness, motor disturbances and autonomic
uating stressors and influences as possible (Simons et al responses in other body tissues (see Chapter 6). Myofascial
1999), without creating further distress or reguirement for trigger points may form in muscle bellies (central trigger
excessive adaptation. Unless this is comprehensively and points) or tendons and periosteal attachments (attachment
effectively achieved, results of therapeutic intervention may trigger points). Trigger points can also occur in skin, fascia,
be unsatisfactory (DeLany 1999). ligaments, periosteum, joint surfaces and, perhaps, in vis
ceral organs. However, none of these would be considered
to be true myofascial TrPs since the mechanisms associated
BIOMECHANICAL FACTORS
with their formation are apparently different from those
Trigger points (TrPs) are located primarily in myofascial tis associated with motor endplate dysfunction in myofascial
sues. These points are hyperirritable ('sensitized') spots tissues (Simons et al 1999).
found in taut bands that are usually painful on compression Although it is not yet fully understood how trigger
and give rise to referred pain and other sensations (when points develop, their locations and referral patterns are
9 Modern neuromuscular techniques 179
fairly predictable. NMT identifies and deactivates trigger heading of 'postural influences', habits of use need to be
points primarily by means of trigger point pressure release considered, whether these involve overuse, disuse or abuse
(previously known as ischemic compression). Lengthening (repetitive strain, hyperventilation breathing tendencies,
the shortened fibers in which the points lie (stretching) is also inappropriate sitting, standing or sleeping habits).
part of the process of treating the trigger points as should also
be the removal of the underlying factors that helped create
BIOCHEMICAL FACTORS
them (Simons et aI1999).
Nerve entrapment/compression can result from pressure on Biochemical factors can be local or global, both of which are
neural structures by soft tissue including muscle, tendon, fully discussed in Chapter 7. Ischemia is an insufficiency of
disc, ligament, fascia or skin or via more direct osseous pres blood flow (therefore of oxygen and nutrients) commonly
sure (arthritic spur, for example). The structure(s) interfering caused by muscular spasm or contracture. While global
with normal neural function are known as the 'mechanical ischemia is associated with less common conditions, such as
interface'. The underlying cause of these entrapment/com cerebral palsy or regional spasms associated with spinal cord
pression situations may lie in traumatic incidents or they injuries, localized ischemia is so common that it is found (to
may be the result of repetitive microtrauma due to overuse or some degree) in virtually every person. If ischemia is pro
misuse patterns (work, sport, postural habits, etc.). longed, metabolic waste products accumulate and pool
In order to evaluate the possibility of such entrap within the ischemic tissues, increasing neuroexcitability
ment/compression, it is necessary to be aware of neural (Cailliet 1996). This may predispose toward a local energy
pathways as well as which hard tissues may crowd the crisis developing within the muscle tissue and a resultant
nerve and/or which soft tissues may entrap them (see notes decrease in ATP production just when the tissue's energy
on Butler's work in Chapter 13, Box 13.11, p. 475, as it relates needs increase (Simons et a11999), so encouraging the evolu
to shoulder and arm pain). For example, when considering tion of myofascial trigger points (see Chapter 6). Mense et al
pain in the arm, pressure may have been placed on nerve (2001) note that, 'Ischemia is one of the most potent factors
roots at the cord level by herniated discs, osteophytes or releasing bradykinin.' Bradykinin is capable of encouraging
subluxations; by the scalene muscles, as the nerves travel nociceptor sensitization (Koltzenburg et al 1992), which
between or through them; by the clavicle or first rib; by pec results in an enhanced response to peripheral stimuli. This
toralis minor; or by upper extremity tissues, such as the tri process leads to prolonged production of ischemia which
ceps or supinator muscles. Additionally, the position of the can be self-perpetuating.
upper extremity itself may create tension and drag on the NMT assesses and treats ischemia by using effleurage
brachial plexus and its fascial ensheathment (e.g. the inter (gliding techniques), pressure release methods and length
face between the head of the humerus and the glenoid fossa ening of the shortened myofascial fibers (stretching), which
alters if the shoulders are protracted). NMT attempts to all encourage blood flow and a return to a more normal
identify such entrapments and compressions and to use muscle length.
manual methods and rehabilitation exercises to modify or Nutrition is an area of consideration in musculoskeletal
correct them, when possible. pain and dysfunction that includes all the processes involved
Postural (and use) influences are innumerable. Debate con in the intake of nutrients necessary for cellular metabolism,
tinues as to the extent to which there is an anatomically 'cor repair and normal reproduction of cells in the body as a
rect' degree of alignment of the musculoskeletal system, a whole. It includes ingestion, digestion, absorption, assimila
so-called 'correct' or 'perfect' posture. Experts, including tion and a multitude of processes associated with these func
Feldenkrais (1972) and Hanna (1988), suggest that a degree tions. Sound nutrition also considers avoidance of exposure
of asymmetry is, in fact, the norm but that within that asym to substances that may be irritating and stimulating to the
metry there ought to be a relatively 'normal' functional nervous system or toxic to the body (smoke, heavy metals,
balance, range of motion, etc., taking account of genetic chemical exposures, excessive caffeine, etc.).
characteristics (hyperflexibility, for example), body type Nutritional imbalances may perpetuate the existence of
and age. The common compensatory pattern described by ischemia, trigger points, neuroexcitation and the resultant
Zink & Lawson (1979) helps to explain 'normal' (or at least postural distortions (Simons et al 1999). Vitamin and min
common) postural deviations (see Chapter 1). eral status should be considered, adequate fluid intake
Janda (1982) and Lewit (1992), among others, have iden ensured and breathing habits evaluated (since both oxygen
tified patterns of dysfunction that modify regions in rela and carbon dioxide are critical factors in the nourishment of
tion to each other (see crossed syndrome discussion in the body) . Additionally, obvious or hidden (,masked') food
Chapter 5). NMT seeks to correct dysfunctional postural intolerances and allergies should be identified in order to
patterns by releasing stressful tension in muscular and fas minimize the numerous negative effects such reactions can
cial tissues. An individualized home care program is usu have, including increased nociception and lymphatic con
ally developed, which includes awareness of undesirable as gestion (Randolph 1976).
well as improved postural and use habits, appropriate Additional biochemical influences that may require considera
stretching and strengthening procedures. Under the general tion include endocrine balance/imbalance (most particularly
180 CL INI CAL APP L I CAT I ON O F N E U R O M U SC ULA R T E C H N I Q U ES: T H E UPP E R B ODY
thyroid in the case of myofascial pain) (Ferraccioli 1990, Within these categories - biochemical, biomechanical and
Lowe & Honeyman-Lowe 1998) and inflammatory processes psychosocial - are to be fOillld most major influences on
(discussed in more detail in Chapter 7). A critical biochemical health, with 'subdivisions' (such as ischemia, postural imbal
influence on pain involves the balance between oxygen and ance, trigger point evolution, neural entrapments and com
carbon dioxide in the body, which is intimately connected pressions, nutritional and emotional factors) being of
with breathing patterns - a biomechanical function with huge particular interest in NMT.
psychosocial overlays. This 'three-way' interaction is dis NMT attempts to identify these altered states, insofar as
cussed in greater detail in Chapter 4. they impact on the person's condition, and either offers ther
apeutic intervention that reduces the 'load' and/or assists the
PSYCHOSOCIAL FACTORS self-regulatory filllctions of the body (homeostasis) or, if this
is inappropriate or outside the therapist/practitioner's scope
The influence of emotional stress on the musculoskeletal of practice, opens the opportunity for referral to appropriate
system is beyond doubt (see Chapter 4). It is sufficient at healthcare professionals.
this stage to restate that there exists a fundamental require A home care program should be designed for both physical
ment for stress factors, whether self-generated or externally relief of the tissues (stretching, self-help therapies, hydrother
derived, to be considered as a part of the 'load' to which the apies, postural awareness) and removal of perpetuating fac
individual is adapting. The degree to which anyone can be tors, including nutritional choices, postural habits, work and
helped in regard to emotional stress relates directly to how recreational practices, stress and lifestyle factors (rest, exer
much of the load can be removed, as well as to how effi cise, etc.) (see notes on concordance in Chapter 8, p. 173).
ciently adaptation is occurring. The same can, of course, be Lifestyle changes are encouraged to eliminate influences
said for biochemical and biomechanical stresses.
The role of the practitioner may include teaching and
encouraging the individual (and their self-regulating, Injury Tensile
homeostatic functions) to handle the load more efficiently, strength
: wound site. ,
,
,
,
: Very litlle
modifies calcium and magnesium status, alters neural
, ,
: collagen.
reporting (initially hyper and then hypo), creates feelings
of anxiety and apprehension, and directly impacts on the Response to : Increase in tensile : Improved mechanical behavior of
: No tensile
structural components (both muscles and joints) of the mechanical : strength. : strength. : scar.
stress : Poor response : Fibroblasts and
thoracic and cervical region (Gilbert 1998). : collagen align
: to mechanical
Altered chemistry (hypoglycemia, acidosis, alkalosis, etc.) : stress.
: along lines of stress.
: Improved formation
affects mood directly while altered mood (depression, anxi : of blood vessels
ety) changes blood chemistry as well as altered muscle tone : along lines of stress.
: Normal turnover of
and, by implication, trigger point evolution (Brostoff 1992). : collagen.
Altered structure (e.g. posture) modifies filllction (e.g.
breathing) and therefore impacts on chemistry (e.g.
02:C02 balance, circulatory efficiency and delivery of
nutrients, etc.) which impacts on mood (Gilbert 1998). F igure 9.1 Stages of the repair process.
9 Modern neuromuscular tech n i q u es 18 1
]
resulting from habits and potentially harmful choices made tissues offers insights - and raises questions - regarding
in the past. chronic postural patterning as well as repair processes follow
ing trauma (or surgery). SMCs have been located widely in
NMT TECHNIQUES CONTRAINDICATED IN INITIAL connective tissues including cartilage, ligaments, spinal discs
STAGES OF ACUTE INJURY and lumbodorsal fascia (Ahluwalia 2001, Hastreite et aI2001).
If an injury has occurred within 72 hours of therapy, great Yahia et al (1993) noted that, 'Histologic studies indicate
care must be taken to protect the tissues and modulate that the posterior layer of the (lumbodorsal) fascia is able
blood flow and swelling. The body wilL in most cases, nat to contract as if it were infiltrated with muscular tissue.'
urally splint the area and often produces swelling as part of Spector (2001) has reported that SMCs proliferate follow
the recovery process (Cailliet 1996). The acronym RICE ing trauma, and that their role might be largely 'architec
indicates appropriate care for the first 72 hours following a tural', contributing to wound closure and tissue repair.
soft tissue injury - Rest, Ice, Compression and Elevation.
The normal healing response after injury involves inflam While much of our understanding of myofibroblasts/SMCs
mation, vasodilation, swelling, relative ischemia (and the pain found within connective tissue remains vague, its intrigu
this induces), an influx of white blood cells which, together ing presence within fascia has gained attention and has
with macrophages, remove damaged cells and debris, the resulted in an explosion of research activity. For example, in
arrival of fibroblasts that prollierate to form connective tissue one study mechanical forces have been shown to be essen
and which subsequently turn into myofibroblasts that have tial for connective tissue homeostasis (Sarasa-Renedo &
the ability to contract to help consolidate the damaged area Chiquet 2005). This study showed that the extracellular
(MacIntosh et aI2006). As the remodeling phase of the healing matrix (ECM) plays a key role in the transmission of forces
process progresses, collagen fibers are laid down in line with generated by the organism (e.g. muscle contraction) and
tension forces. This is the stage where appropriate exercise, externally applied (e.g. gravity or via therapy). Cell-matrix
movement and careful manual therapy may usefully assist adhesion sites are thought to be good candidates for hosting
the intrinsic repair process (Watson 2005). a 'mechanosensory switch' as they transmit forces from the
NMT techniques should not be applied directly on the ECM to the cytoskeleton, and vice versa, by physically link
injured tissues within the first 72 hours following the injury, ing the cytoskeleton to the ECM. Integrins, transmembrane
as this would tend to encourage increased blood flow to the proteins located at these adhesion sites, have been shown to
already congested tissues and reduce the natural splinting trigger a set of internal signaling cascades after mechanical
that is needed in this phase of recovery. stimulation (Chen & Ingber 1999). For manual therapists
The patient should be referred for qualified medical, the implications of this information are profound. The
osteopathic or chiropractic care, when indicated, and tech expression of specific ECM proteins, such as collagens and
niques such as lymphatic drainage and certain movement tenascin-C, as well as of matrix metalloproteinases involved
therapies may be used to encourage the natural healing in their turnover, is influenced by mechanical stimuli. The
process. Additionally, NMT techniques may be used in precise mechanisms by which mechanical strains and pres
other parts of the body to reduce overall structural distress sures are translated into chemical signals that lead to differ
which often accompanies injuries. For instance, when an ential gene expression are not yet fully understood.
ankle is sprained, compensatory gait changes, crutch usage Some of the questions that research still needs to answer
and redistribution of weight may stress the lower back, hip relate to:
and even cervical or mandibular muscles. NMT applica
the presence of contractile cells (myofibroblasts) within
tions to these muscles may help reduce structural adapta
the fascial fabric. Clinicians are interested in their role in
tions that will not be needed beyond the acute phase and
creating contractile tonus in the fascial fabric, how they
help to decrease the overall effects of the injury.
form, what 'turns them on', and their influence on pas
After 72 hours, NMT may be carefully applied to the
sive muscle tonus
injured tissues (in most cases) and applications to the sup
mechanotransduction between the cytoskeletal structure
porting structures and muscles involved in compensating
within the cell and the extracellular matrix, and its impli
patterns should be continued. If range of motion work is
cations for health and disease (Ingber 2003)
questionable, such as when a moderate or severe whiplash
forms of communication within the fascial matrix, such
has occurred, consultation with the attending physician is
as the tugging in the mucopolysaccharides created by
suggested to avoid further compromise to the structures (in
twisting acupuncture needles (Langevin et a12005)
this case, cervical discs, ligaments or vertebrae) that may
how fascia is innervated, and how proprioception and
have been damaged in the injury.
pain are created, detected and modulated by the spinal
cord and the rest of the nervous system
Myofibroblasts and fascia
other new findings and significant hypotheses in the
Recent research into contractile smooth muscle cells realms of biochemistry and biomechanics of fascial
(SMCs)/myofibroblasts that are embedded in most connective deformation and reformation.
182 C LI N I CAL APPL I CAT I O N OF N EURO M U SCU LAR T E CH N I Q U E S : TH E UPP ER B O DY
Gliding techniques
Lightly lubricated gliding strokes (effleurage) are an impor
tant and powerful component of the manual applications of
NMT. Such strokes are ideal for exploring the tissue for
ischemic bands and / or trigger points and may also follow
compression or manipulation techniques. While increasing
blood flow, 'flushing' tissues and creating a mechanical
counterpressure to the tension within the tissues, they also
help the practitioner to become familiar with the individual
quality, internal (muscle) tension and degree of tenderness
in the tissues being assessed or treated.
To glide most effectively on the tissues, the practitioner 's
A
fingers are spread slightly and 'lead' the thumbs.
The fingers support the weight of the hands and arms,
which relieves the thumbs of that responsibility. As a
result, the pressure exerted by the thumb is more easily
controlled and can be changed as varying tensions are
matched in the tissues.
The fingers stabilize (steady) the hands while the thumbs
are the actual treatment tools in most cases.
The wrist needs to remain stable so that the hands move
as a unit, with little or no motion occurring in the wrist or
the thumb joints. Excessive movement in the wrist or
thumb may result in joint inflammation, irritation and
dysfunction.
When two-handed glides are employed, the lateral aspects
of the thumbs are placed side by side or one slightly ahead
of the other with the tips of both poin t
direction, that being the direction of the glide (Fig. 9.2A).
Pressure is applied through the wrist and longitudinally B
through the thumb joints (osteoarticular column), not Figure 9.2 A: The fingers offer support and enhance control as the
against the medial aspects of the thumbs, as would occur t h u mbs a pply pressure or gl ide. B: I ncorrect a p p l ication of
if the gliding stroke were performed with the thumb tips techniq ues which stresses the thumb join ts.
touching end to end (Fig. 9.28).
During assessment strokes, the practitioner is constantly only if appropriate. Some areas will feel doughy, although
aware of information that is being received as variable pres they may be extremely tender (as in the tender points of
sure is being applied. As palpation skills develop, this fibromyalgia), while others may feel 'sh'ingy' or 'ropy'.
awareness becomes second nature and does not require Indura tions may be felt as the thumb glides transversely
constant conscious thought, as it may during the early across taut bands. Once the bands are located, knowledge of
stages of manual development. the muscle's fiber arrangement and tendon architecture,
A varia tion in the degree of pressure to be used is deter combined with assessment longitudinally along the band,
mined by a constantly fluctuating stream of information will help determine mid-fiber range where most central
regarding the status of the tissues. As the thumb or fingers trigger points form. Palpa tion can then be al tered to include
move from normal tissue to tense, edematous, fibrotic or compression and pincer palpation, depending upon the tis
flaccid tissue, the amount of pressure required to 'meet and sue's availability to be grasped.
match' it will vary. Some areas will feel 'hard' or tense and Nodules are often embedded in (sometimes extensive)
pressure should actually be lightened rather than increased, areas of dense (thick) tissue congestion and may not be felt
so that the quality and extent of the dense tissue can be eval clearly when the hands first encoun ter the tissue. As the tis
uated . After assessment of the extent of tissue .involvement sue softens from repetitions of the gliding strokes, short
(i.e. the size of area involved, a sense of dep th of tissue applica tions of heat (when appropriate) or tissue elongation
involvement, degree of tenderness), pressure can be increased (all of which encourage a change of state of the colloidal
9 Modern n eu romuscular tech n iq u es 1 85
J
matrix), palpation of distinct bands and nodules becomes Box 9 . 5 Two i m portant ru les of hydrotherapy
clearer.
The practitioner moves from assessment to treatment There should a lmost a l ways be a short cold a p pl ication or
and back to assessment again as the palpa ting digits immersion after a hot one and preferably a lso before it (unless
uncover dysfunctional tissues. If trigger points are found, otherwise stated).
When heat is appl ied, it shou ld never be hot enough to sca ld
modalities can be applied, including trigger point pressure
the skin a nd shoul d a l ways be bearable.
release, various stretching techniques, heat or ice, vibra tion
or movements, which will encourage the release of the taut See also Chapter 10 for hydrotherapy protocols.
A
Figure 9.3 Fi ngers press through the skin a n d su perfici a l m u scles to
eva l uate deeper layers aga i nst underlying structures usi ng deep fla t
p a l pation.
The degree of pressure should be adj usted so that As the taut fibers present themselves, the tissues are
the person reports a mid-range number between 5 and held in that position as the fibers are treated as noted above.
7 on their discomfort scale, as the pressure is main As the tissue tension reduces, the tissue may be further
tained. stretched until more taut fibers are fel t.
Note : Alternative protocols for application of pressure The same procedure is used to release these until either
to trigger points are described in the d iscussion of full range of motion is restored or a barrier is met that
European NMT la ter in this chapter (see variable does not respond to this procedure.
ischemic compression and INIT, pp . 1 95 and 1 97) .
Since the tenderness of the tissue will vary from person
Other trigger point treatment considerations
to person, and even from tissue to tissue within the same
Trigger points frequently occur in 'nests' and 3-4 repeti
person, the pressure needed may range from less than an
tions of the protocol as described above may need to be
ounce to several pounds but should always provoke
applied to the same area.
between a 5 and 7 on the patient's discomfort scale when
Each time that digital pressure is released, blood flushes
the correct pressure is used .
into the tissue and brings with it nutrients and oxygen
The practitioner should feel the tissues 'melting and soft
while removing metabolic waste. If the colloidal state
ening' under the sustained pressure. The person fre
has changed sufficiently, the tissue will be more porous,
quently reports that they believe the practitioner is
a better medium for diffusion to take place (Oschman
reducing the pressure on the tissue even though it is
1997).
being sustained at the same level.
The treatment as described above is usually followed
Pressure can usually be mildly increased as tissue relaxes
with several passive elongations (stretches) of the tissue
and tension releases, provided the discomfort scale is
to that tissue's range of motion barrier, unless the attach
respected.
ments present with signs of inflammation.
The length of time pressure is maintained will vary but
The person is then asked to perform at least 3-4 active
tension should ease within 8-12 seconds and the discom
repetitions of the stretch, which they should be encour
fort level should drop.
aged to continue to do as 'homework'.
If it does not begin to respond within 8-12 seconds, the
It is important to avoid excessive trea tment at any one
amount of pressure should be adjusted accordingly (usu
session, as a degree of microtrauma is undoubtedly
ally lessened), the angle of pressure altered or a more pre
inherent in the processes described. This is particularly
cise location sought (move a little one way and then the
important at the first 2-3 sessions until the tissues, and
other to find heightened tenderness or a more distinct
the body as a whole, show a favorable response to the
nodule).
manual techniques.
Since the tissues are being deprived of normal blood flow
Residual discomfort, as well as the adaptive demands
while pressure is being applied to them (blanching), it is
that this form of therapy imposes on repair functions,
suggested that 20 seconds is the maximum length of time
calls for treatment to be tailored to the individual's abil
to hold the pressure.
ity to respond, which is a j udgment the practitioner
needs to make. If in doubt, it is better to do less at a time,
although this may slow progress, than to overwhelm the
Adding stretch to the palpation. Slightly stretching the
tissues or the person.
muscle tissue often makes the taut fibers much easier to pal
Treatment of the point directly, as described, should be
pate. However, cau tion should be exercised if movement
followed by range of motion work, as well as by one
produces pain or if palpa tion of the attachment sites reveals
or more forms of hydrotherapy - for example, heat
excessive tenderness that may represent an attachment trig
(unless inflamed), ice, contrast hydrotherapy or mild
ger point and inflammation. Placing more tension on these
a combination of heat to the belly and ice to the ten
already distressed tissues may provoke an inflammatory
dons (see hydrotherapy in Chapter 10 and Boxes 9.5 and
response. Additionally, care must be taken to avoid aggres
9.6).
sive applications (e.g. strumming or friction) while the tis
sue is being stretched, as injury is more likely to occur when
tissue is in a stretched position. Stretches should be performed before any prolonged appli
cations of cold as fascia elongates best when warm and
Manually commence a process of slowly elongating the more liquid. The elastic components of muscle and fascia
muscle fibers (stretching the muscle slowly by separating are less pliable when cold and less easily stretched (Lowe
the ends) while palpating at mid-fiber level for the first 1 995) . If the tissue is cold, it is helpful to rewarm the area
sign of tissue resistance (tension) . with a hot pack or mild movement therapy before stretches
As the muscle fibers are stretched, the first fibers to are applied. These precautions do not apply for brief expo
become taut may be shortened fibers and may house trig sures to cold, such as spray and stretch, or ice-stripping
ger points. techniques (see hydrotherapy in Chapter 10).
9 Modern neuro muscular techn iq ues 1 89
l4-inch vertical shaft. They have either a flat or a beveled There exist many variations of the basic technique as devel
rubber tip at the end of the vertical shaft (they somewhat oped by Stanley Lief, the choice of which will depend upon
resemble a T with a stopper on the bottom). The large flat particular presenting factors or personal preference.
tip is used to glide on flat muscle bellies, such as the ante NMT can be applied generally or locally and in a variety
of positions (seated, supine, prone, etc.). The sequence in
rior tibialis, or to press into large muscle bellies, such as the
which body areas are dealt with is not regarded as critical in
gluteals. The small beveled tip is used under the spine of
general treatment but is of some consequence in postural
the scapula, in the lamina groove and to assess tendons and
reintegration, much as it is in RolfingTM and HellerworkH".
small muscles that are difficult to reach with the thumb
(such as the intercostals). The beveled end of a flat 'pink The NMT methods described are in essence those of StanJey
Lief DC and Boris Chaitow DC (1983). The latter has written:
eraser ' can be used in a similar manner.
The pressure bars are never used at vulnerable nerve To apply NMT successfully it is necessary to develop the art of
areas, such as the lateral aspects of the neck, under the clav palpation and sensitivity offingers by constantly feeling the
icle, on extremely tender tissues or to 'dig' into tissues. appropriate areas and assessing any abnormality in tissue
Ischemic tissues, fibrosis and bony surfaces along with their structure for tensions, contractions, adhesions, spasms. It is
protuberances may be 'felt' through the bars just as a grain important to acquire with practice an appreciation of the feel'
of sand or a crack i n the table under writing paper may be ofnormal tissue so that one is better able to recognize abnormal
felt through a pencil when writing. The tools (pressure bars, tissue. Once some level ofdiagnostic sensitivity with fingers
erasers or other tools that touch the skin) should be scrubbed has been achieved, subsequent application ofthe technique will
with antibacterial soap after each use or cleaned with cold be much easier to develop. The whole secret is to be able to rec
sterilization or other procedures recommended by their ognize the 'abnormalities ' in the feel of tissue structures.
manufacturers. Having become accustomed to understanding the texture and
character of 'normal' tissue, the pressure applied by the thumb
The descriptions above relate to American neuromuscular in general, especially in the spinal structures, should always
therapy. In order to avoid confusion a separate description befirm but never hurtful or bruising. To this end the pressure
is offered below of European (Lief's) neuromuscular tech should be applied with a 'variable' pressure, i.e. with an appre
nique. The reader may reflect on similarities and differences ciation of the texture and character of the tissue structures
between them and experiment with aspects that are cur and according to the feel that sensitive fingers should have
rently unfamiliar. developed. The level of the pressure applied should not be
1 92 C L I N I C A L A P P L I CATI O N O F N E U RO M U S C U LA R T EC H N I Q U E S : T H E U P P E R B O DY
consistent because the character and texture of tissue is In order that pressure/force be transmitted directly to its
always variable. The pressure should therefore be so applied target, the weight being imparted should travel in as straight
that the thumb is moved along its path of direction in a way a line as possible, which is why the arm should not be flexed
which corresponds to the feel of the tissues. This variable by more than a few degrees at the elbow or the wrist.
factor in finger pressure constitutes probably the most The positioning of the practitioner 's body in relation to the
important quality a practitioner of NMT can learn, area being treated is of importance in order to achieve econ
enabling him to maintain more effective control of pressure, omy of effort and comfort. The optimum height vis-a-vis the
develop a greater sense of diagnostic feel, and be far less couch and the most effective angle of approach to the body
likely to bruise the tissue. areas being addressed should be considered (Fig. 9.10).
The degree of pressure imparted will depend upon the
nature of the tissue being treated, with changes in pressure
NMT THUMB TECHNIQUE
being possible, and indeed desirable, during strokes across
Thumb technique as employed in NMT, in either assess and through the tissues. When being treated, the pa tient
ment or treatment modes, enables a wide variety of thera should not feel pain al though a general degree of discom
peutic effects to be produced . fort is usually acceptable, as the seldom stationary thumb
The tip of the thumb can deliver varying degrees of pres varies its penetration of dysfunctional tissues.
sure via any of fom facets: A stroke or glide of 2-3 inches (5-8 cm) will usually take
4-5 seconds, seldom more unless a particularly obstructive
the very tip may be employed for extremely focused indurated area is being dealt with. If myofascial trigger
contacts points are being treated, a longer stay will usually be
the medial or lateral aspect of the tip can be used to make required at a single site (or intermittent pressure may be
contact with angled smfaces or for access to intercostal applied) but in normal diagnostic and therapeutic use the
structures thumb continues to move as it probes, decongests and gen
for more general (less localized and less specific) contact, erally treats the tissues.
of a diagnos tic or therapeutic type, the broad smface of It is impossible to state the exact pressures necessary in
the distal phalange of the thumb is often used. NMT applica tion because of the very na ture of the objec
tive, which in assessment mode attempts to meet and match
It is usual for a light, non-oily lubricant to be used to facili the tissue resistance precisely, and to vary the pressure con
tate easy, non-dragging passage of the palpating digit. stantly in response to what is being palpated.
In European NMT thumb technique application, the
hand should be spread for balance and control. The tips of
the fingers provide a fulcrum or 'bridge', with the palm
arched (Fig. 9.9). This a llows free passage of the thumb
toward one of the fingertips as it moves in a d irection that
takes it away from the practitioner's body.
During a single stroke, which covers between 2 and 3
inches (5-8 cm), the fingertips act as a point of balance while
the chief force is imparted to the thumb tip, via controlled
applica tion of body weight through the long axis of the
extended arm. The thumb and hand seldom impart their
own muscular force except in dealing with small, localized
con tractures or fibrotic ' nodules' .
The thumb, therefore, never leads the hand but always
trails behind the stable fingers, the tips of which rest just
beyond the end of the stroke.
Unlike many bodywork/ massage strokes, the hand and
arm remain still as the thumb, applying variable pressure,
moves through the tissues being assessed or treated.
Jr< "-'"
The extreme versa tility of the thumb enables it to modify
the direction of imparted force in accordance with the indica
tions of the tissue being tested / treated . As the thumb glides
across and through those tissues it should become an exten
sion of the practitioner 's brain. For the clearest assessment of
what is being palpated the practitioner should have the eyes (U----.
closed so that every change in the tissue texture or tone can Figure 9.9 NMT t h u m b technique. Reprod uced with permission
be noted. from Cha itow (2003b).
9 M o dern neuromusc u l a r tec h n i q u es 1 93
In subsequent or synchronous (with assessment) h'eat depending upon the direction of the stroke and density of
ment of whatever is uncovered d uring evalua tion, a greater the tissues, should be supported by one of its adjacent
degree of pressure is used and this will vary depending members.
upon the objective, whether this is to inhibit neural activity The angle of pressure to the skin surface should be
or circulation, to produce localized s tretching, to decongest between 40 and 50. As the treating finger strokes, with a
and so on (see Box 9.4). firm contact and a minimum of lubricant, a tensile sh'ain is
created between its tip and the tissue underlying it. The
LIEF'S NMT F I NGER TECHNIQUE tissues are stretched and lifted by the passage of the
finger, which, like the thumb, should continue moving
In certain areas the thumb's width prevents the degree of unless, or until, dense indurated tissue prevents its easy
tissue penetration suitable for successful assessment passage.
and / or treatment. Where this happens the middle or index These strokes can be repea ted once or twice as tissue
finger can usually be suitably employed. This is most likely changes dictate. The fingertip should never lead the
when access to the intercostal musculature is attempted or stroke but should always follow the wrist, the palmar sur
when trying to penetrate beneath the scapula borders, in face of which should lead as the hand is drawn toward
tense or fibrotic conditions. the practi tioner. It is possible to impart a great degree of
Working from the contralateral side, finger technique is traction on underlying tissues and the patient's reactions
also a useful approach to curved areas, such as the area must be taken into account in deciding on the degree of
above and below the pelvic crest or the la teral thigh. The force being used.
middle or index finger should be slightly flexed and, Transient pain or mild discomfort is to be expected, but
no more than that. Most sensitive areas are indicative of
some degree of associated dysfunction, local or reflex . It is
therefore important that their presence be recorded.
Unlike the thumb technique, in which force is largely
directed away from the practitioner's body, in finger treat
ment the s troke is usually toward the practitioner. The arm
position therefore alters, since elbow flexion is necessary to
ensure that the stroke of the finger, across the lightly lubri
cated tissues, is balanced. Unlike the thumb, which makes a
sweep toward the tips of the fingers while the rest of the
hand remains rela tively s tationary, the whole hand will
move when a finger stroke is applied . Some variation in the
degree of angle between fingertip and skin is in order dur
ing a stroke and some slight variation in the degree of
'hooking' of the finger may be necessary.
The treating finger should be supported by one of its In evaluating for myofascial trigger points, when a sense
neighbors if tissue resistance is marked. of something 'tight' is noted just ahead of the contact digit
as it strokes through the tissues, pressure lightens and the
thumb / finger slides over the 'tight' area and deeper pene
USE OF LUBRICANT tration is made to sense for the characteristic taut band and
The use of a lubricant during NMT application facilitates the trigger point, at which time the patient is asked whether
the smooth passage of the thumb or finger. A suitable bal it hurts and whether there is any radiating or referred pain.
ance between lubrication and adherence is found by mixing As the assessment stroke is made, any alteration in direc
two parts of almond oil to one part limewater. It is impor tion or in the degree of applied pressure should take place
tant to avoid excessive oiliness or the essential aspect of gradually, without any sudden change, which could irritate
slight traction, from the contact digit, will be lost. the tissues or produce a defensive contraction.
If a frictional effect is required - for example, in order to Should trigger points be located, as indicated by the
achieve a rapid vascular response - then no lubricant reproduction in a target area of an existing pain pattern,
should be used . then a number of choices are possible.
SOME LIM I TED NMT RESEARCH Second week, Group 1 was treated with NMT while
Group 2 was treated with MET.
NMT in Europe has been in use since the mid-1930s, and is
Quadriceps strength of the dominant leg was deter
taught at institu tions such as the University of Westminster
mined, before and after the procedure, by means of a
(as part of an undergraduate (BS) program on therapeutic
d igital myograph (Myo-tech, model OM 2000).
bodywork), as well as at the British College of Osteopathic
T-test analysis of the results demonstrated that MET
Medicine (BCOM), which was founded by the developer of
and NMT applied separately produced a high statisti
European NMT, Stanley Lief NO DO DC.
cal significant change on muscle strength (p < 0 .05).
In the age of 'evidence-based medicine' this length of
3. Tomlinson (2002) undertook a study to investigate whether
time in use of NMT (or any other modality) is not in i tself
or not two separate techniques (European NMT and MET)
proof of usefulness or efficacy; however, it is almost all that
used in clinical treatment at BCOM are effective in increas
is available since comprehensive research has not been con
ing ankle function in restricted dorsiflexion patients. The
ducted comparing NMT with other modalities, or evaluat
study included 21 subjects (12 females and 9 males) who
ing clinical outcomes.
were treated on three separate visits over 5 weeks.
A number of small undergraduate studies have been
After ascertaining the degree of ankle restriction in
undertaken as part of degree courses, and they offer a
dorsiflexion, and measuring passive ankle dorsillexion
glimpse of what might be possible ii more rigorous research
range of motion using a universal goniometer, this fea
is ever carried out. For example:
ture was measured again both before and after treat
ment to the affected ankle.
1. Patel (2002), as part of her undergraduate training at The unaffected ankle was used as a control.
BCOM, compared the effects of European neuromuscular MET and NMT were applied to the plantar flexors, at
technique and a muscle energy technique on cervical range two separate treatments, on two separate occasions,
of motion. Forty asymptomatic female subjects between 20 with a week of no treatmen t d ividing the two.
and 25 years of age were randomly selected. The subjects The final treatment included both techniques.
were randomly placed into one of two possible groups. T-test analysis demonstrated a significant increase in
Group 1 received neuromuscular technique on week passive ankle dorsiflexion range of motion (p < 0.05)
one, followed by a 'rest' period on week two, followed for both MET and NMT used alone, as well as for MET
by neuromuscular technique on week three. and NMT combined.
Group 2 received muscle energy technique on week There was no significant difference between the effec
one, followed by a 'rest' period on week two, followed tiveness of the two techniques used alone.
by neuromuscular technique on week three. One-way Anova analysis demonstrated a significant
All treatments were a single application given to both increase in passive ankle dorsiflexion range of motion
scalene muscle groups (bilaterally) for 3 minutes. (p < 0.05) using MET and NMT in combination com
Measurements were taken of the cervical spine ranges pared to MET used in isolation.
of motion before and after treatment. It was concluded that MET and NMT are effective
The cervical range-of-motion goniometer T-test analysis methods for increasing passive ankle dorsiflexion
demonstrated tha t both neuromuscular technique and range of motion when applied to the triceps surae
muscle energy technique signiiicantly increased cervical m uscle group, and that when both modalities are used
range of motion in all planes of movement (p <0.05). together a greater ankle joint flexibility in dorsiflexion
MET was shown to be more effective in increasing is attainable.
range of motion than European NMT. 4. Rice (2002) investigated the effect of European NMT to
2. Palmer (2002) noted tha t MET and NMT are used fre the diaphragm on cervical range of motion. In this study
quently in osteopathic practice to resolve muscle and 24 s tudents at the BCOM were selected, 13 females and
joint dysfunction, but that there remains li ttle scientific 11 males.
evidence to establish the efficiency of these techniques on A wi thin-subject or repeated measures design was
muscle strength effect. She conducted a study to compare used where each subject was exposed first to the con
the effectiveness of MET and European NMT on quadri trol procedure and then received the intervention.
ceps muscle strength. Cervical range of motion was measured.
The study population comprised 30 asymptomatic Statistical analysis showed an increased range of
subjects (20 females and 10 males) from the BCOM. motion following the application of NMT to the
All subjects were free of inj ury and pathology to the diaphragm (p 0 .05).
=
knee, hip and lumbar spine. There was no statistically significant difference in
The participants were randomly allocated to two response to treatment between the male and female
groups of 15 subjects. population (p 0.06).
=
Group 1 was treated with MET while Group 2 was There was no correlation between response to treat
treated with NMT during the same week. ment and age of subjects (p 0. 12).
=
9 M od e r n n e u r o m uscu lar tec h n i q u es 1 97
This study provides quantita tive evidence that appli The positi9n of ease will effectively have 'folded' the tis
cation of NMT to the diaphragm can increase cervical sues surrounding the trigger point, so that an isometric
range of motion, highlighting the importance of treat contraction introduced into these tissues will target the
ing all factors involved in maintaining cervical spine very fibers that subsequently require lengthening.
dysfunction, both local and distant. After maintaining the ease position for 20 seconds an iso
metric contraction, focused into the musculature around
While the sort of evidence summarized above shows that the trigger point, is initiated (see muscle energy tech
NMT 'works', it says little about people with problems niques, Box 9.10). Following this, the tissues are stretched
(apart from those with limited range ankle dorsiflexion both locally and, where possible, in a manner that
described in study 3). In studies 1 and 2 the focus was to involves the whole muscle (usually after a second iso
compare NMT and MET effectiveness in increasing range of metric contraction involving the entire muscle).
motion in people who had no symptoms, whereas in study It is then useful to add a reeducational activation of antag
4 an interesting remote effect was noted when NMT was onists to the muscle housing the trigger point, possibly
applied to the diaphragm. using Ruddy's rhythmic pulsing methods (see Box 9.12) to
Until rigorous research evaluates NMT in the real world complete the treatment.
of pain and dysfunction, we are left with its long history, This is the integrated neuromuscular inhibition tech
many anecdotal case histories, and encouraging undergrad nique (INIT) protocol.
uate studies such as these.
INIT rationale
INTEGRATED NEUROMUSCULAR INHIBITION
TECHNIQUE ( B a i l ey 8: D i c k 1 99 2 , J a c o b s o n 1 9 8 9 , When a trigger point is being palpa ted by direct finger
K o r r 1 9 7 4, R a t h b u n 8: M a c n a b 1 9 70) or thumb pressure and when, during positional release
application, the very tissues in which the trigger point lies
In an attempt to develop a treatment protocol for the deac
are positioned in such a way as to take away (most of) the
tivation of myofascial trigger points a sequence has been
pain, the most stressed fibers in which the trigger point is
suggested (Chaitow 1994) .
housed will be in a position of relative ease.
The trigger point is identified by palpation methods, At this time the trigger point would have already received,
after which ischemic compression is applied, sufficient and would again be under, direct inhibitory ischemic pres
for the patient to be able to report that the referred pat sure, and would have been positioned so that the tissues
tern of pain is being activa ted. housing it are relaxed (relatively or completely).
The preferred sequence after this is for that same degree Following a period of not less than 20 seconds of
of pressure to be maintained for 5-6 seconds, followed by this posi tion of ease, the patient introduces an isometric
2-3 seconds of release of pressure. contraction into the tissues, and holds this for 7-1 0 sec
This pattern is repeated for up to 2 minutes, or until the onds, involving the precise fibers that had been reposi
patient reports that the local or referred symptoms (pain) tioned to obtain the positional release.
have reduced, or that the pain has increased, a rare but The effect of this would be to produce (following the
significant event sufficient to warrant ceasing application contraction) a reduction in tone in these tissues. These tis
of pressure. sues could then be stretched locally or in a maImer
If, therefore, on reapplication of pressure, during this to involve the whole muscle, depending on their location,
make-and-break sequence, reported pain decreases or so that the specifically targeted fibers would be stretched.
increases (or if 2 minutes elapse with neither of these Subsequently the pa tient would be taught how to peri
changes being reported), the ischemic compression odically activate the antagonists to the muscle housing
aspect of the INIT treatment ceases. the trigger point, to use as homework, to inhibit the
A moderate degree of pressure is then rein troduced stressed muscle.
and whatever level of pain is noted is ascribed a value of Appropriate guidance would also be given regarding
10, at which time the patient is asked to offer feedback enhancement of posture, pa tterns of use, etc., that might
information in the form of 'scores' as to the pain value, as be creating stresses that either created or aggravated the
the area is repositioned according to the guidelines of trigger point activity.
positional release methodology (Box 9 .9). A posi tion is
sought that reduces reported pain to a score of 3 or In this chapter we have looked at some of the major tools
less. and modalities that cluster together as 'neuromuscular
This 'position of ease' is held for not less than 20 seconds techniques'. In the next chapter an overview wiiJ be given of
to allow (it is thought) neurological resetting, reduction associated modalities and techni ques, including a deeper
in nociceptor activity and enhanced local circula tory coverage of muscle energy techni ques and posi tional
interchange. release techniques.
1 98 C L I N I CA L A P P L I CAT I O N O F N E U R O M U S C U LA R T E C H N I Q U E S : T H E U P P E R B O DY
Note: PRT is described more fu lly in Cha pter 1 0, with additional SCS rules of treatment
variations. The fo l l owing 'ru les' are based on c l i n ical experience and should be
borne in m i nd w h e n using positional release (SCS, etc.) methods i n
Strai n/counterstra i n (Chaitow 2002, Jones 1 98 1 , treating pain a n d dysfu nction, especia l ly w here the patient is
Walther 1 988) fati g ued, sensi tive and/or d i stressed.
There are m a ny differen t methods i n volving the positioning of an
Never treat more than five 'tender' points at any one session and
area, or the whole body, i n such a way as to evoke a physiological
treat fewer than this in sensitive i n d ividuals.
response that h el ps to resolve m usculoskeletal dysfu nction. The
Forewarn patients that, just as in a ny other form of bodywork
m e a ns whereby the beneficial changes occur seem to i nvolve a
that prod uces a l tered function, a period of physiolog ical adapta
combination of n e u ro l og ica l a n d circu la tory changes which a rise
tion is inevita b l e and that there w i l l the refore be a 'reaction' on
when a distressed a rea is pl aced in its most comforta ble, most 'easy',
the day(s) fol l owing even this extremely l i g h t form of treatment.
most pain-free position.
Soreness and stiffness are therefore to be anticipated.
Walther ( 1 988) describes h ow Laurence Jones DO first observed
If there are m u l t i p l e tender points, as is inevitable in fibromyal
the phenomenon.
g i a , select those most proximal and most media l for primary
Jones ' initial observation of the efficacy of coun terstrain was with a attention; that is, those closest to the head a n d the center of the
patient who was unresponsive to treatment. The patient had been body rather than dista l and lateral pain points.
unable to sleep because of pain. Jones a ttempted to find a comfort Of these tender poi nts, select th ose that are most painful for
able position for the patient to aid him in sleeping. After 20 minutes i n itial attention/treatment.
of trial and error, a position was finally achieved in which the If self-treatment of painfu l and restricted areas is advised - and
patien t's pain was relieved. Leaving the patien t in this position for a it s h o u l d be, if at all possible - a pprise the patient of these rules
short time, Jones was astonished when the patient came out of the (Le. o n ly a few pain poi nts to be given attention on a ny one day,
position and was able to stand comfortably erect. The relief of pain to expect a 'reaction', to select the most painful points a n d those
was lasting and the patient made an uneven tful recovery. cl osest to the head and the center of the body) (Jones 1 98 1 ).
The position of 'ease' that Jones found for this patient was a n The g e neral g u id e l i n es that Jones g ives for relief of the dysfu nction
exaggeration o f t h e posi tion i n w h i ch spasm w a s h o l d i n g h i m , which with which such tender points are related involve d i recti ng the
provided Jones w i th a n insight i nto the mecha n isms i nvolved. movement of these tissues toward ease that commonly involves the
All areas that palpate as inappropriately painful are responding to or fo l lowing elements.
are associated with some degree of i m bala nce, dysfu nction or reflexive
For tender points on the a n terior su rfa ce of the body, flexion,
activity that may well involve acute or chronic strain. Jones identified
sideben d i n g and rotation should be toward the pal pated point,
positions of tender points relating to particu lar strain positions but it
followed by fine-tu n i ng to reduce sensitivity by at least 70%.
makes just as m uch sense to work the other way round. Any painful
For tender points on the posterior su rface of the body, extension,
point fou n d d u ring soft tissue eva luation could be treated by positional
sidebe n d i n g and rotation should b e away from the palpated
release, whether the stra in pattern (acute or chronically ada ptive) that
point, followed by fine-t u n i n g to reduce sensitivity by 70010 .
produced or mainta i ns it can be identified or not.
The closer the tender point is to the m i d l i ne, the less sidebe nding
a n d rotation should be req u i red a n d the further from the m i d l i ne,
Com mon basis
the more sidebending a n d rotation should be req u i red, i n order to
All PRT m ethods m ove the pa tient or the affected tissues away from
effect ease and comfort in the tender point (without a ny addi
any resistance barriers and toward positions of comfort. The
tional p a i n or d iscomfort being produced a nywhere else).
shorthand terms used for these two extremes a re 'bind' a n d 'ease'.
The d i rection toward wh ich sidebe n d i n g is i n troduced when try
One can i m a g i n e a situation in w h i c h the use of Jones' 'tender
ing to fi nd a position of ease often needs to be away from the
points as a m o n i tor' method would be i na ppropriate (lost a b i l i ty to
side of the pal pated p a i n point, especially in relation to tender
com m u n icate verba lly or someone too you ng to verbal ize). In such a
points found o n the posterior aspect of the body.
case there is a need for a method that a l l ows ach ievement of the
sa m e ends without verbal com m u n i cation. This is possi b l e using These brief n otes on SCS should be seen in context as this represents
'fu nctional' a pproaches that i nvolve fi n d i n g a position of maxi m u m only o n e version of positional release methodo logy. Other
ease b y m e a ns of p a l pation a lo n e, assessi n g for a state of 'ease' i n a pproaches emerg i n g from osteopa thic medicine include fu nctional
t h e tissues. tech n i q u e (Johnston 2005) and fac i l i tated positional release
(Sch iowitz 1 990), and aspects of these w i l l be found in the main
Method body of the text.
Stra i n/coun terstra i n (SCS) i nvolves m a i nt a i n i n g pressure o n the Add i tional positional release a pproaches deriv i n g from other
m o n i tored tender point or periodica l ly probi n g it, as a posit ion is professions - some of w h ich will be addressed in Chapter 10 -
ach ieved i n w h i c h : include:
there is no add itional pain i n whatever a rea is symptomatic, a n d m o b i l iza tion with movement - physiotherapy (Horton 2002)
t h e m o nitor p a i n point has reduced b y a t least 75010 . McKenz ie method - physioth erapy (McKenzie Et May 2003)
u n loading taping - physiotherapy (Landorf et al 2005)
This is then h e l d for a n a ppropriate l ength of t i m e (90 seconds
sacrooccipital tec h n i q u e (SOT) - ch i ropractic (Cooperstein 2000).
accord i n g to Jones).
9 M o dern n e u ro m u scu l a r tec h n i q ues 1 99
Note: MET is described more fu l ly i n Chapter 1 0, with a d d itional Duration of con traction - 7 - 1 0 seconds i n itial ly, i ncreasing up to 20
variations. seconds in subseq uent contractions if g reater effect req u i red.
Action following con traction - Area (muscle) is ta ken to l i g h t stretch
Assessments and use of M ET after ensuring complete relaxation, with patient partici pation if
1 . When the term 'restriction barrier' is used in rel ation to soft tis possible. Perform movement to new barrier on a n exhalation. Stretch
sue structures, it i n d i cates the first signs of resista nce (as pal is held for not less t h a n 20 seconds.
pated by sense of 'bind' or sense of effort req u i red to move the
Repetitions Little g a i n is l i kely after t h i rd repetition.
area or by visu a l o r other palpable evidence), not the g reatest
-
Isometric contraction using reciprocal inh ibition Action following con traction - Area (muscle) is taken to l i g h t stretch
Indications after ensuring compl ete relaxation, with patient participation if
possible. Perform movement to new barrier on an exhalation. Stretch
Relaxing muscu lar spasm or contraction is held for not less t h a n 20 seco nds.
Stretching muscle housing trigger point
Repetitions - Little g a i n is l i kely after t h i rd repetition.
Contraction starting poin t - Com m e nce contraction just short of
first sign of resistance as tissues a re taken thro u g h their ra nge of Example:
movement. The head/neck is rotated fu l ly to the left to its end of range.
Method - Antagon ists to affected muscl e(s) are used in A l i g h t attempt to rotate the head/neck back tow a rd its starting
isometric contraction, thus obliging shortened m uscles to relax via position is resisted for 5-7 seconds.
reciprocal i n h i bition. Patient is attempting to push t h rough the This ind uces postisometric relaxation (PI R) of the muscles that
barrier of restriction agai nst practitioner's precisely matched have been contract i n g .
coun terforce. After a few seconds of complete relaxation the head/neck
shou l d be able to turn further to the left than previously, without
Forces - Practitioner's a nd patient's forces are matched. I n itial effort force.
involves approximately 200/0 or less of patient's strength ; i ncrease to Evidence sugg ests that a feature of g reater i m portance than
no more than 500/0 on subsequent contractions if ap propriate. P I R is a n increased tolerance to stretch fol l owing the
I ncreasing the d u ration of the contraction - u p to 20 seconds - may contraction, a l lowing a pa i n l ess i ncreased ra nge (Ba l l a n tyne
be more effective than a ny increase i n force. et a l 2003).
box continues
200 C L I N I C A L A P P L I CATI O N OF N E U R O M U S C U LA R T E C H N I Q U E S : T H E U P P E R B O DY
Rapid isotonic eccentric contraction/stretch (isolytic) Slow isotonic eccentric contraction/stretch (SEIS)
Indications Indications
Stretch i n g tight fibrotic muscu lature housing trigger points To n i n g i n h ib ited a n tagon ists of shortened m uscle i n need of
stretC h i ng , w h i l e s i m u l ta n eously prepa ring the agon ist for subse
Contraction s tarting point - A l ittle short of restriction ba rrier.
quent lengthening
Method - The muscle to be stretched isotonically is contracted Contraction starting point - A l ittle short of restriction barrier.
and is prevented from d o i n g so by the practitioner's g reater
effort. The contraction is then overcome a nd reversed, so that Method - The muscle to be stretched isotonica l ly is contracted
the contracti ng muscle is stretched. Ori g i n a n d i n sertion do not and is prevented from doing so by the practitioner, via superior
a pproximate. The m usc le is stretched to, or as close a s possible practitioner effort, and the contraction is slowly overcome and
to, fu l l physiological resti n g length. The proced u re should be reversed, so that a contracting muscle i s stretched. Origin and
acco m p l i shed i n a few seco nds o n ly, to achieve the isolytic insertion do not a pproximate. Muscle is stretched to, or as close as
effect. possible to, fu l l physiological resting length. Fol l owing this the
agon ist is stretched as in MET procedures described a bove em ploying
Forces - Practitioner's force is greater t h a n patient's. Less t h a n PIR or R I .
maxi m a l patient's force is e m p l oyed a t first. Subseq uent contractions
b u i l d toward th is, if discomfort is not excessive. Forces - Practition er's force is g reater than patient's. Less t h a n
m a x i m a l patient's force is employed at first. Subsequent contractions
Dura tion of contraction - 2-4 seconds. b u i ld toward th is, if discomfort is not excessive. Fol l owing the slow
eccentric stretch of the a ntagon ist the agon ist is stretched to
Repetitions Once is adeq uate as m icrotra u m a is being i n d uced.
encourage lengthening.
-
A B
F i g u re 9. 1 3 A & B : Ecce ntric resist a n c e of w rist a n d fi n g e r exten sion a n d t h u m b a bd uctio n . Reproduced with perm i ssion from C h a i tow
(200 1 ) .
9 M od e r n n e u ro m u sc u l a r tech n iq u e s 201
A subcategory of i n hibition and faci l itation involves a Sh ifting the eyes toward the d i rection of m uscle activity (e.g. look
neurophysiological phenomenon known as syn k i nesis (Greek for 'with left a n d turn l eft) is usually fac i l i tatory ('i psiversive'). w h ereas
motion'). Synkinesis methods reflexively affect the target m uscle sh ifting the eyes away from the d i rection of m u sc l e activity (e.g. look
function by either i ncreasing i n hibition or by facil itati n g the m uscle. down as you extend the spine) is usua l ly i n h ibitory ('con traversive')
There are two forms of synkinesis: respiratory and visu a l ; (Lisberger et al 1 994).
however, because o f t h e lack o f agreement a s t o its app l ications, Use of syn ki nesis can be particul arly h e lpfu l where pain is a major
respiratory syn ki nesis will not be described i n these notes apart from fea ture, a l l o w i n g pa i n l ess contractions. Morris (2006) reports that, i n
the observa tion that, in general, resp i ratory synkinesis is util ized i n h i s c l i nical experience, visual synkinesis methods have a greater
NMT/MET b y having the patient relax a n d e x h a l e a s a passive effect on the upper body than on the lower body.
movement is introduced (as in stretch ing after a n isometric
contraction) (Lewit 1 999).
A promising addition t o t h i s sequence takes acco u n t o f t h e potential being treated. Furthermore, he believed that the method i n fl uences
offered by the methods developed some years ago by osteopathic both static and k i n etic posture because of the effects on
physician T J Ruddy ( 1 962). I n the 1 940s and 1 950s Ruddy developed proprioceptive a n d i n teroceptive afferent pathways, so helping to
a method of rapid pu lsating contractions agai nst resistance that he mai ntain 'dy n a m i c equ i l ibrium', which i nvolves 'a bala nce i n
termed 'rapid rhythmic resistive d u ction '. For obvious reasons, the chemica l , physical, therma l , electrical and tissue fl u i d hom eostasi s'.
shorthand term ' p u l sed m uscle energy tech n i q ue' is now a p p l ied to I n a setting i n which tense hypertonic, possibly shortened
Ru ddy's method. m usculature has been treated by stretching, it is i m porta n t to begin
I ts simplest use involves the dysfu nctio nal tissue or j o i n t being facilitating and strengthening the i n h ibited, weakened antagon ists.
held at its restriction barrier, at which time the patient ideally (or This is true whether the hypertonic m uscles have been treated for
the practitioner if the pa tient can not adequ ately cooperate with the reasons of shortness/hyperton icity a lone or because they
i nstructions) i ntroduces a series of rapid (two per second), minute accommodate active trigger points within their fibers.
effo rts toward the barrier, agai nst the resistance of the practitioner. The intro d u ction of a p u lsating m u scle energy procedure, such as
The barest i n itiation of effort is ca l l ed for, with (to use Ruddy's Ruddy's, involving these weak a n tagon ists offers the opport u n ity for:
words) 'no wobble and no boun ce'.
proprioceptive reeducation
The appl ication of this 'condition i n g ' a pproach i nvolves, i n
strengthening facil itation of the wea k a n ta g o n ists
Ruddy's words, contractions t h a t a r e 'short, rapid a n d rhythmic,
further i n h ibition of tense a g o n ists
g ra d ua l ly i n creasi ng the a m p l itude and degree of resista nce, t h u s
e n h a n ced l ocal circulation and d ra i n a g e
condition i ng the proprioceptive system b y ra pid movements'.
and, i n Liebenson's ( 1 996) words, 'reed ucation of movem e n t pat
Ru ddy sugg ests that the effects are l i kely to i n c l u d e i m p roved
terns on a reflex, subcortical basis'.
oxygenation, venous a n d lymphatic circulation thro u g h the area
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205
Chapter 10
The techniques described in this chapter represent those heat, the tissues will tend to become congested. For this rea
methods that the authors see as most usefully combining son a cold application almost always follows a hot one in
with NMT (either Lief's or American version as described hydrotherapy methodology.
in Chap ter 9). This is not meant to suggest that other meth When a short cold application is applied to tissues it
ods that address soft tissue dysfunction are necessarily less causes vasoconstriction of the local blood vessels. This has
effective or inappropriate. It does, however, mean that the the effect of decongesting tissues and is rapidly followed by
methods described and incorporated throughout the clini a reaction in which blood vessels dilate and tissues are
cal applications text, such as variations on the theme of flushed with fresh, oxygen-rich blood.
muscle energy technique (MET), positional release tech Alternate hot and cold applica tions produce circulatory
nique (PRT) and myofascial release technique (MFR), are interchange and improved drainage and oxygen supply to
known to be helpful as a result of the clinical experience of the tissues, whether these be muscles, skin or organs.
the authors. Traditional massage methods are also fre Two important rules of hydrotherapy are that:
quently mentioned, as are applications of lympha tic
1. there should almost always be a short cold application,
drainage techniques. All these methods require appropriate
or immersion, after a hot one and preferably also before it
training and the descriptions and explanations offered in
(unless otherwise stated), and
this chapter are not meant to replace that requirement.
2. when heat is applied, it should never be hot enough to
The material in this chapter describes both the methods
scald the skin and should always be bearable.
employed in the different techniques as well as some of the
underlying principles that may help to explain their mecha The general principles of hot and cold applications are as
nisms. Those methods that are described are (in alphabeti follows.
cal order):
Short cold applications (less than 1 minu te) stimulate cir
acupuncture/acupressure (see Box 10.1) culation.
hydrotherapy/ cryotherapy Long cold applications (more than 1 minute) depress cir
integrated neuromuscular inhibition technique (INTI) cula tion and metabolism.
including Ruddy's reciprocal antagonist facilitation (RRAF) Long hot applications (more than 5 minutes) vasodilate
lymphatic drainage and can leave the area congested and static and require a
McKenzie Method cold application or massage to help restore normality.
massage Short hot applications (less than 5 minutes) stimulate cir
mobilization and articulation techniques (including culation but long hot applications (more than 5 minutes)
mobilization with movement - MWM) depress both circulation and metabolism.
muscle energy technique (MET) Short hot followed by short cold applications cause alter
myofascial release techniques (MFR) - including skin nation of circulation followed by a return to normal.
and scar tissue Hot is defined as 9S-104 Falu'enhei t or 36.7-40
neural mobilization Centigrade. Anything hotter than that is undesirable and
positional release techniques (PRJ, including strain/ dangerous.
counterstrain (SCS)) Neutral applications or baths at body heat are very
rehabilitation soothing and relaxing.
relaxation Cold is defined as 55-65F or 12.7-1S.3C
rhythmic (or vibrational or harmonic) methods Anything colder is very cold, and anything warmer is:
spray and stretch techniques 1. cool (66-S0F or lS.5-26.5C)
stretching techniques. 2. tepid (Sl-92F or 26.5-33.3C)
3. neutral/warm (93-97F or 33.S-36.1 0c).
Acupuncture points are sited at fairly precise anatomic locations, Clearly stimulation of an area which contains both an acupuncture
which can be corroborated by electrical detection, each point being and a trigger point will influence both types of neural transmission
evidenced by a small area of lowered electrical resistance (Mann and both 'points: Which route of reflex stimulation is producing a
1963). When 'active', due presumably to reflex stimulation, these therapeutic effect or whether other mechanisms altogether are at
points become even more easily detectable, as the electrical work - endorphin release, for example - is therefore open to
resistance lowers further. The skin overlying them also alters and debate. This debate can be widened if we include the vast array of
becomes hyperalgesic and easy to palpate as differing from other reflex influences identified by other systems and workers
surrounding skin. In this way they mimic the characteristics of including neurolymphatic and neurovascular reflexes (Chaitow
trigger points (see Chapter 6 for discussion of skin characteristics in 1 996b).
relation to trigger points). Whereas traditional Oriental concepts focus on energy (01)
Active acupuncture points also become sensitive to pressure and imbalances in reaction to acupuncture points, there also exist a
this is of value in assessment since the finding of sensitive areas number of Western interpretations. Melzack ( 1 977) assumed that
during palpation or treatment is of diagnostic importance. Sensitive acupuncture points represent areas of abnormal physiological
and painful areas may well be 'active' acupuncture points (or tsubo, activity, producing a continuous, low-level input into the CNS. He
in Japanese) (Serizawa 1 980). Not only are these points detectable suggests that this might eventually lead to a combining with
and sensitive, they are also amenable to treatment by direct pressure noxious stimuli deriving from other structures, innervated by the
techniques (see beloW). same segments, to produce an increased awareness of pain and
Serizawa ( 1 980) discusses a 'nerve reflex' theory for the existence distress. He found it reasonable to assume that trigger points and
of these points. acupuncture points represented the same phenomenon, having
found that the location of trigger points on Western maps and
The nerve reflex theory holds that, when an abnormal condition
acupuncture points used commonly in painful conditions showed a
occurs in an internal organ, alterations take place in the skin and
remarkable 70% correlation in position.
muscles related to that organ by means of the nervous system. These
Lewith Et Kenyon ( 1 984) point to a variety of suggestions as to
alterations occur as reflex actions. The nervous system, extending
the mechanisms via which acupuncture (or acupressure) achieves its
throughout the internal organs, like the skin, the subcutaneous tis
pain-relieving results. These include neurological explanations such
sues, and the muscles, constantly transmits information about the
as the gate control theory. This in itself is seen to be an incomplete
physical condition to the spinal cord and the brain. These information
explanation and humoral (endorphin release, etc.) and psychological
impulses, which are centripetal in nature, set up a reflex action that
factors are also shown to be involved in modifying the patient's
causes symptoms of the internal organic disorder to manifest them
perception of pain. A combination of reflex and direct neurological
selves in the surface areas of the body.... the intimate relation
elements, as well as the involvement of a variety of secretions
between internal organs and external ones has a reverse effect as
such as enkephalins and endorphins, is thought to be the modus
well; that is, stimulation to the skin and muscles affects the condition
operandi of acupressure. Some of these influences are also
of the internal organs and tissues.
considered to be operating during manual treatment of trigger
A conceptual link between the forces underlying tsubo/acupuncture points (see Chapter 6).
points and the explanations of facilitation (Chapter 6) is clearly
evident. Ah Shi points
Acupuncture methodology also includes the treatment of points that
Are acupuncture points and trigger points the same are not listed on the meridian maps, known as Ah Shi points. These
phenomenon? include all painful points that arise spontaneously, usually in relation
Pain researchers Wall Et Melzack ( 1 989), as well as Travell Et to particular joint problems or disease. For the duration of their
Simons ( 1 992), maintain that there is little, if any, difference sensitivity they are regarded as being suitable for needle or pressure
between acupuncture points and most trigger points. Since they treatment. These points may therefore be thought of as identical to
spatially occupy the same positions in at least 70Dlo of cases (Wall Et the ' tender' points described by Laurence Jones (1995) in his strain
Melzack 1 989) there is often a coincidence of treatment in that a and counterstrain method, which also frequently coincide with
trigger point could be 'mistaken' for an active acupuncture point and established trigger point sites (see p. 228).
vice versa. Wall Et Melzack have concluded that 'trigger points and It is not the intention of this book to provide instruction in
acupuncture points, when used for pain control, though discovered acupuncture methodology, nor to necessarily endorse the views
independently and labeled differently, represent the same expressed by traditional acupuncture in relation to meridians and
phenomenon'. their purported connection with organs and systems. However, it
Baldry ( 1 993) claims differences in their structural make-up, would be shortsighted to ignore the accumulated wisdom that has
however. He states: led many thousands of skilled practitioners to ascribe particular
roles to these points. As far as a manual therapy is concerned, there
It would seem likely that they are of two different types, and their
seems to be value in having awareness of the reported roles of
close spatial correlation is because there are A-delta afferent-inner
particular acupuncture points and of incorporating this into
vated [fast transmitting receptors with a high threshold and sensitive
diagnostic and therapeutic settings. As we palpate and search
to sharply pointed stimuli or heat-produced stimulation] acupuncture
through the soft tissues, in basic neuromuscular technique, we
points in the skin and subcutaneous tissues immediately above the
are bound to come across areas of sensitivity that relate to
intramuscularly placed predominantly C afferent-innervated [slow
these points.
transmitting, low threshold, widely distributed and sensitive to
chemical - such as those released by damaged cells - mechanical or
thermal stimulus] trigger points.
208 CLI N I CAL A P PLI CATIO N OF N E U R O M U S C U LA R T E C H N IQ U ES: TH E U P P E R B O DY
is an ideal method for self-trea tment or first aid for any of one thickness of woolen or flannel material, almost the
the following: same dimension as the cotton but a little wider and a little
longer so that none of the cotton material has access to air
painful joints
safety pins and cold water
mastitis
a warm room.
sore throat (compress on the throa t from ear to ear and
supported over the top of the head) The cotton material is wrung out using cold water so that the
backache (see trunk pack below) material is just damp, not dripping, and is wrapped around
sore tight chest from bronchitis. the trunk so that it covers the area from the underarm to the
pelvis. It is immediately covered with the dry wool/flannel
Materia ls material and pinned firmly so that it completely covers the
damp cotton with no edges protruding. The patient is asked
A single o r double piece of cotton sheeting large enough
to lie down and is covered with a blanket. This method can
to cover the area to be treated (double for people with
be used for a few hours during the day or overnight.
good circulation and vitality, single for people with only
moderate circula tion and vitality) Within about 5 minutes any sense of cold should vanish
One thickness of woolen or flannel material (toweling and the material should feel comfortable. If it still feels
will do b u t is not as effective) larger than the cotton mate cold after 5 minu tes, the compress is removed.
rial so that it can cover it completely with no edges After about 20 minutes the compress should start to feel
protruding hot and this should be maintained for several hours until
Plastic material of the same size as the woolen material it 'bakes' itself dry.
Safety pins The initial cold has a decongesting effect, followed by a
Cold wa ter period of neutral temperature (at around body tempera
ture) that relaxes the muscles, followed by the period of
Method damp warmth that further enhances this relaxation.
If the pa tient has a strong constitu tion and good vitality
The cotton material is well wrung out in cold water so
and is not adversely influenced by cold, two thicknesses
that it is damp but not dripping wet.
of damp cotton are used, following all the same guide
This is placed over the painful area and immediately cov
lines, to get a more powerful effect.
ered with the woolen or flannel material, and also the
This method is used three or four times weekly (alternate
plastic material if used, and pinned in place.
days) during either acute or chronic stages of back pain.
The compress should be firm enough to ensure tha t there
The cotton ma terial should be thoroughly washed before
is no access for air to cool it but not so tight as to impede
reuse as it will absorb acid wastes from the body that can
circula tion.
irritate the skin.
The cold material should rapidly warm and feel comfort
able, and after several hours should be virtually dry.
The cotton material should be thoroughly washed before A LT E R N ATE HEAT A N D C O L D: CO N STITUTIO N A L
reuse as i t will absorb acid wastes from the body that can HY D R OTHE RA PY (HO M E A P P L I CATI O N )
irritate the skin. Effects
A local (single joint) warming compress is used up to
four times daily with at least an hour between applica Constitutional hydrotherapy has a non-specific 'balancing'
tions. Ideally it is left on overnight. effect, reducing chronic pain, enhancing immune function
and promoting healing. There are no contraindications
Caution since the degree of temperature contrast in its applica tion
can be modified to take account of any degree of sensitivity,
If for any reason the compress is still cold after 20 minutes frailty, etc.
( the compress may be too wet or too loose or the vitality
may not be adequate to the task of warming i t), then remove Materials
it and give the area a brisk rub with a towel.
Somewhere for the patient to lie down
A full-sized sheet folded in two or two single sheets
Trunk pack - an exa m p l e of a wa rm ing com press
Two blankets (wool if possible)
A trunk pack has no contraindications and is useful in either Two bath towels (when folded in two, each should be
acute or chronic stages of back pain. Materials include: able to reach from side to side and from shoulders to hips)
Two small towels (each should as a single layer be the
one or two thicknesses of cotton ( tear up an old sheet)
same size as the large towel folded in two)
wide enough to measure from the underarm to the pelvis
Hot and cold water (see temperature in notes below)
and long enough to pass just once around the body with
out overlapping This method cannot be self-applied, assistance is needed .
10 Associated therapeutic mod a l ities and techniques 209
J
Method Materials
1. Patient undresses and lies supine between sheets and A bathtub
under blanket. Water
2. Two hot folded bath towels (four layers) are placed Ba th thermometer
directly onto the skin of the patient's trunk - shoulders to
hips, side to side. Method
3. The patient is covered with sheet and blanket and left for
5 minutes. The bath is filled with water as close to 97F (36.1C) as
4. Helper returns with a small hot towel and a small cold possible.
towel. The bath has its effect by being as close to body tempera
5. The 'new' hot towel is placed on top of the four 'old' hot ture as can be achieved.
towels and the stack of towels is 'flipped' so that the hot Immersion in water at this neutral temperature has a
towel is on the skin. The old towels are discarded. profoundly relaxing, sedating effect on nervous system
6. Immediately the cold towel is placed onto the new hot activity.
towel and these are flipped so that the cold towel is on The patient submerges in the bath so that the water cov
the skin. The small hot towel is discarded. ers the shoulders. The back of the head should rest on a
7. The patient is covered with a sheet and left for 10 minutes towel or sponge.
or until the cold towel is warmed. The thermometer should be in the bath to ensure that the
8. The previously cold (now warm) towel is removed and temperature does not drop below 92F (33.3C).
the patient turns to lie prone. The water can be ' topped up' periodically but must not
9. Steps 2-7 are repeated to the back of the patient. exceed the 97F/36.1C limit.
The duration of the bath should be anything from 30
N otes minutes to 2 hours.
After the bath the patient should rest in bed for at least an
If using a bed, precautions should be taken to avoid it hour.
getting wet.
'Hot' water in this context is a temperature high enough
to prevent a hand remaining in it for more than 5 seconds.
A LT E R NAT E BATH I N G
The coldest water from a running tap is adequate for the B y alternating hot and cold w a ter in different ways i t is pos
'cold' towel. In hot summers adding ice to the water in sible to have profound effects on circulation.
which this towel is wrung out is acceptable if the temper
Alternate bathing is useful for all conditions that involve
ature contrast is acceptable to the patient.
congestion and inflamma tion, locally or generally, and
If the patient feels cold after the cold towel is placed,
for an overall tonic effect.
back, foot or hand massage should be applied (through
Alternating sitz baths are ideal for varicose veins and
the blanket and towel) to warm them.
hemorrhoids.
By varying the differential between hot and cold, so that
the contrast is small for someone whose immune func
tion and overall degree of vulnerability is poor, for exam Contra ind ications
ple, and using a large contrast, very hot and very cold, Alternate bathing should not be used if there is hemorrhage,
for someone whose constitution is robust, the application colic and spasm, acute or serious chronic heart disease or
of the method can be tailored to meet individual cases. acute bladder and kidney infections.
The method is used once or twice daily, if needed.
Materials
N E UTRAL BATH
Conta iners suitable for holding hot and cold water
A neutral bath, in which body temperature is the same as that If the whole pelvic area is to be immersed, then a large
of the water, has a profoundly relaxing influence on the nerv plastic or other tub (an old-fashioned hip bath is best) is
ous system. This was the main method of calming violent required, along with a smaller container for simultane
and disturbed patients in mental asylums in the 19th century. ous immersion of the feet
A neutral bath is useful in all cases of anxiety, for feelings of A bath thermometer
'stress' and for relieving chronic pain and insomnia. Hot and cold water
in hot and then cold water following the timings given Method
below for alternating sitz baths.
Crushed ice is placed on a toweL to form a thickness of
For local immersion treatment ice cubes can be placed in
1 inch (2.5cm).
the cold water for greater contrast.
The towel is then folded and pinned to contain the ice.
If the area is unsuitable for treatment by immersion
A layer of wool or flannel material is placed onto the site
(a shoulder or a knee could prove awkward), then appli
cation of hot and cold temperatures is possible by using of the pain and the ice pack is placed onto this.
The pack is then covered with plastic and the bandage is
towels, soaked in water of the appropriate temperature
used to hold it all in place.
and lightly wnmg out, again following the same timescales
Clothing and bedding should be protected with addi
as for sitz baths, given below.
tional plastic and towels.
The ice pack is left in place for up to half an hour and
ALTERNATING SITl BATHS repeated after an hour, if helpful.
These baths involve the immersion of the pelvic area (buttocks
and hips up to the navel) in water of one temperature, while
the feet are in water of the same or a contrasting temperature. INTEGRATED NEUROMUSCULAR INHIBITION
The sequence to follow in alternating pelvic sitz baths is: TECHNIQUE (lNIT) (Chaitow 1994)
1-3 minutes seated in hot water (106-110F or 41-43 C)
15-30 seconds in cold (around 60F/15C) INIT involves using the position of ease as part of a sequence
1-3 minutes hot that commences with the location of a tender/trigger point,
15 seconds cold. followed by application of ischemic compression (optional
avoided if pain is too intense or the patient too sensitive), fol
During hip immersions the feet should, if possible, be in lowed by the introduction of positional release. After an
water of a contrasting temperature, so that when the hips appropriate length of time during which the tissues are held
are in hot water, the feet are in cold, and vice versa. If this is in 'ease' (20-30 seconds), the patient is guided to introduce
difficult to organize, the alternating hip immersions alone an isometric contraction into the tissues housing the trigger
should be used. point. The contraction is held for 7 -10 seconds, after which
these tissues are stretched (or they may be stretched at the
ICE PACK same time as the contraction, if fibrotic tissue calls for such
attention).
Ice causes vasoconstriction in tissues it is in contact with An additional sequence can often be usefully introduced,
because of the large amount of heat it absorbs as it turns involving rhythmic contractions of the antagonist to the
from solid into liquid. muscle housing the trigger point, which will introduce an
Ice treatment is helpful for: inhibitory effect on excessive fiber tone as well as strength
all sprains and injuries ening inhibited antagonists. This sequence is described
bursitis and other joint swellings or inflammations (unless below in detail.
cold aggravates the pain)
toothache
headache INIT METHOD 1
hemorrhoids
bites. In an attempt to develop a treatment protocol for the deac
tivation of myofascial trigger points, a sequence has been
Contraindications suggested.
Box 1 0.2 A summary of soft tissue approaches to FMS and CFS (Chaitow 2000)
When people are very ill (as in fibromyalgia syndrome - FMS and Subsequent treatment of short muscles by means of MET or self
chronic fatigue syndrome - CFS), where adaptive functions have stretching will allow for regaining of strength in antagonist mus
been stretched to their limits, any treatment (however gentle) cles that have become inhibited. At the same time, gentle toning
represents an additional demand for adaptation (i.e. it is yet another exercise may be appropriate.
stressor to which the person has to adapt).
It is therefore essential that treatments and therapeutic Treatment of local (Le. trigger points) and whole muscle
interventions are carefully selected and modulated to the patient's problems (Fernandez-de-Ias-Penas et al 2006, Nijs et al
current ability to respond, as well as this can be judged. 2006)
When symptoms are at their worst only single changes, simple Tissues held at elastic barrier to await physiological release (skin
interventions, may be appropriate, with time allowed for the stretch, C bend, S bend, gentle NMT, etc.).
body/mind to process and handle these. Use of positional release methods - holding tissues in 'dynamic
It may also be worth considering general, whole-body, neutral' (strain/counterstrain, functional technique, induration
constitutional approaches (dietary changes, hydrotherapy, non-specific technique, fascial release methods, etc.) (Jones 1981 ).
'wellness' massage, relaxation methods, etc.), rather than specific Myofascial release methods - gently applied.
interventions, in the initial stages and during periods when symptoms MET methods for local and whole muscle dysfunction (involving
have flared. Recovery from FMS is slow at best and it is easy to make acute, chronic and pulsed [Ruddy's] MET variations as described
matters worse by overenthusiastic and inappropriate interventions. in this chapter).
Patience is required by both the healthcare provider and the patient, Vibrational techniques (rhythmic/rocking/oscillating articulation
avoiding raising false hopes while realistic therapeutic and educational methods; mechanical or hand vibration).
methods are used which do not make matters worse and which offer Deactivation of myofascial trigger points (if sensitivity allows)
ease and the best chance of improvement. utilizing INIT or other methods (acupuncture, ultrasound, etc.)
(Baldry 1 993).
Identification of local d ysfunction
Off-body scan for temperature variations (cold may suggest Whole-body approaches
ischemia, hot may indicate irritation/inflammation). Wellness massage and/or aromatherapy
Evaluation of fascial adherence to underlying tissues, indicating Hydrotherapy
deeper dysfunction. Cranial techniques
Assessment of variations in local skin elasticity, where loss of Therapeutic touch
elastic quality indicates hyperalgesic zone and probable deeper Lymphatic drainage
dysfunction (e.g. trigger point) or pathology.
Evaluation of reflexively active areas (triggers, etc.) by means of Reeducation/rehabilitation/self-help approaches
very light single-digit palpation seeking phenomenon of 'drag' (Prins et al 2001)
(Lewit 1992). Postural (Alexander, etc.)
NMT palpation utilizing variable pressure, which 'meets and Breathing retraining (Garland 1 994)
matches' tissue tonus. Cognitive behavioral modification and neurophysiological
Functional evaluation to assess local tissue response to normal education (Moseley et al 2004)
physiological demand, e.g. as in functional shoulder evaluation as Aerobic fitness training (McCain et al 1 988)
described in Chapter 5. Yoga-type stretching, tai chi
Deep relaxation methods (autogenics, etc.)
Short postural muscles Pain self-treatment (e.g. self-applied SCS)
Sequential assessment and identification of specific shortened
postural muscles, by means of observed and palpated changes, Sound nutrition and endocrine balancing
functional evaluation methods, etc. (Greenman 1 989).
the node group responsible for evacuation of a particular area method, McKenzie Method is in reality a system of assess
(lymphotome). Chikly emphasizes that hand pressure used in ment and trea tment that relies on predictable responses to a
lymph drainage should be very light indeed, less than 10z series of mechanical examinations or tests. The assessment
(28 g) per cm2 (under 8 0z per inch2), in order to encourage aspect of the McKenzie Method is often overlooked by those
lymph flow without increasing blood filtration. who are unfamiliar with the system (Razmjou et al 2000).
Stimulation of lymphangions leads to reflexively induced The McKenzie Method allocates the central role to the
contraction of the lymphangions (internally stimulated), way the patient responds to a variety of challenges. As the
thereby producing peristaltic waves along the lymphatic individual goes through a series of positions and repetitive
vessel. There are also external stretch receptors that may be movements, the response to each is evaluated:
activated by manual methods of lymph drainage that create
a similar peristalsis. However, shearing forces (such as those Does the range of motion increase or decrease?
created by deep-pressure gliding techniques) can lead to Does pain intensity increase or decrease?
temporary inhibition of lymph flow by inducing spasms of Does the location of perceived pain change? (i.e. does the
lymphatic musculature. Lymph movement is also aug pain spread peripherally and/or reduce centrally7)
mented by respiration as movements of the diaphragm
'pump' the lymphatic flu ids through the thoracic duct. To the practitioner using the McKenzie Method such find
Specific protocols have been devised for the most effi ings may be seen as being more important than findings
cient treatment of lymphatic stasis. For example, movemen ts based on palpation (Doneslon et aI 1 997).
are usually applied proximally first and gradually moved to
The examination assesses the pa tient's response to end
distal (retrograde) in order to drain and prepare (empty) the
range loading (the application of forces such as in flexion
lymphatic pathway before congested regions are 'evacu
or extension to end of range).
ated' of lymph through that same path. After the distal por
The load can be applied singularly and sustained, or
tion is treated, the practitioner proceeds back through the
repetiti vely.
pathway proximally to encourage further (and more com
This is different from many other forms of musculoskele
plete) drainage of the lymph.
tal assessment because the patient performs much of the
A variety of extremely important cautions and con
examination by means of active ranges of motion, with
traindications are attached to Iympha tic d rainage usage (see
the patient's response to these efforts being considered as
p. 31). For this reason no attempt is made in this text to
more important than what the practi tioner might sense
describe the methodology. The lymphatic pathways have
through palpation.
been illustrated in each regional overview of this text.
During the examination, the patient discovers which
Practitioners who are trained in lymphatic drainage are positions and movements are beneficial (range and/or
reminded by these illustrations to apply lymphatic pain improves, or pain centralizes) and which are harm
drainage techniques before NMT procedures to prepare ful (range and/or pain worsens, or pain peripheralizes).
the tissues for treatment and after NMT to remove exces In this way the assessment combines education with self
McKenzie has classified mechanical low back pain into Summary: Pain increases with end-range loading but is
three syndromes - postural, dysfunction and derangement eliminated when load is removed (Liebenson 2005).
(Lisi 2007). Treatment suggestions: These include repetitive motions that
increase pain being indicated to break adhesions and increase
Postural (in which normal tissues may be being strained
elasticity; incorporating exercises, posture/ergonomics and
as a result of prolonged inappropriate posture). manual treatment.
During examination, postural syndrome patients will
Derangement (which might involve discogenic pain with
have full range of motion.
or without competent annulus).
Repetitive end-range motions do not typically bring on
or worsen their pain. During mechanical examination, derangement syndrome
This pain is intermittent and only initiated by prolonged patients will display restriction in active range of motion
(inappropriate) postural overload, thus the patient may in one or more directions.
be asymptomatic during the examination. Pain will be produced at the premature end-range and
The examination procedure likely to be positive is the perhaps during the range of motion prior to that point
sustained static posture. ( this is in contrast to the pain of the dysfunction syn
Some patients may experience the onset of pain when in drome which is only elicited at the restricted end-range).
a given position for under 1 minute, whereas others may Repetitive motion examination will reveal centralization
take several minutes or more. and/or peripheralization. When centralization occurs, it
is typically in response to one given direction of motion
Summary: History of static mechanical sensitivity (Liebenson
only; the opposing direction very commonly, but not
2005).
always, will cause peripheralization.
Treatment suggestions: These include avoiding painful posi The motion that results in centralization is called that
tions; maintaining correct posture. patient's directional preference. In the lumbar spine, exten
sion has been shown to be the most common directional
Dysfunction (involving chronic soft-tissue contracture or preference (Donelson et al 1 991 ).
fibrosis, such as facet capsular fibrosis or nerve root adhe When annulus is not competent, active range of motion is
sions). restricted in one or more directions, is painful at end
range and repetitive motion reveals peripheralization
On examination these patients will demonstrate a restric
only, with no centralization (with competent annulus
tion in range of motion in one or more directions.
centralization of pain occurs).
Pain will be elicited at the inappropriately premature
end-range; however, this pain will diminish virtually Summary: Pain increases with mid- to end-range loading
instantly when the patient returns to neutral. that persists when load is removed (Liebenson 2005).
During the course of a repetitive motion examination
Treatment suggestions:
there may be a gradual increase in the restricted range of
motion as the shortened soft tissue is repeatedly brought When annulus is competent: exercises, posture/
to tension. ergonomics and manual treatment, with movements that
1 0 Associated therapeutic modal ities and tech n iq u es 21 5
centralize pain being indicated, while those that periph The contast is the flat hand or the thenar or hypothenar
eralize are contraindicated. eminence .
When annulus is incompetent: a poor prognosis exists for This series of overlapping, circular, clockwise/anticlock
conservative treatment for this patient. Patient should be wise hand movements rhythmically stretches and relaxes
advised that anything which creates peripheralization of the soft tissues of the area.
pain should be avoided.
One-handed petrissage may involve treatment of an arm,
Summary points (Lisi 2006): for example. In this, the trea tment hand lifts and squeezes
the tissues, making a small circular motion. Many other
There is good to excellent interexaminer reliability regard variations exist in this technique, which is mainly aimed at
ing assessment of centralization. achieving general relaxa tion of the muscles and improved
A single preferred direction of motion typically results in circulation and drainage.
centralization.
Centralization and/or peripheralization indicate painful
intervertebral disc pathology.
KNEADING
Pain that centralizes most likely arises from a disc with a This is used to improve fluid exchange and to achieve relax
competent annulus; pain that peripheralizes, but does ation of tissues. The hands shape themselves to the contours
not centralize, most likely arises from a disc with an of the area being treated. The tissues between the hands, as
incompetent annulus. they approximate each other, are lifted and pressed down
For patients with intervertebral disc pathology, those wards and together. This squeezes and kneads the tissues.
whose symptoms can be made to centralize have a better Each position receives three or four cycles of this sort before
prognosis for response to conservative care than those the adjacent tissues are given the same attention. Little lubri
whose symptoms cannot. cant is required, as the hands should cling to the part being
manipulated, lifting it and pressing and sliding only when
changing position. A few deep strokes are then used to
MASSAGE
encourage venous drainage.
Soft tissue techniques, apart from those specifically associ
ated with NMT, might usefully include the following. INHIBITION
Also known as ischemic compression or trigger point pres
PETRISSAGE sure release, this involves application of pressure directly to
This involves wringing and stretching movements that the belly or origins or insertions of contracted muscles or to
attempt to 'milk' the tissues of waste products and assist in local soft tissue dysfunction for a variable amount of time or
circulatory interchange. The manipulations press and roll in a 'make-and-break' (pressure applied and then released)
the muscles under the hands. Petrissage may be performed manner to reduce hypertonic contraction or for reflexive
with one hand, where the area requiring treatment is small effects.
or, more usually, with two hands. In extremely small areas
(base of the thumb, for example) it can be performed by
using two fingers or a finger and thumb. It is applicable to EFFLEURAGE (STRO KING)
skin, fascia and muscle. In a relaxing mode, the rhythm Effleurage is used to induce relaxation and reduce fluid
should be around 1 0 -15 cycles per minute; to induce stimu congestion and is applied superficially or at depth. This is a
lation, this can rise to around 35 cycles per minute. It is usu
relaxing drainage technique that should be used, as appro
ally a crossfiber activity rather than following fiber direction.
priate, to initiate or terminate other manipulative methods.
Unhurried, deep pressure is the usual mode of applica
Pressure is usually even throughout the strokes, which are
tion in large muscle masses, which require stretching and
applied with the whole hand in contact. Any combination
relaxing. The thenar eminence and the hypothenar emi
of areas may be treated in this way. Superficial tissues are
nence are the main strong contacts, but fingers or the whole
usually rhythmically treated by this method. Since drainage
of the hand may be involved. An example of this move
is one of its main aims, peripheral areas are often treated
ment, as applied to the low back, would be as follows.
with effleurage to encourage venous or lymphatic fluid
Both hands are placed on one side of the prone patient, movement toward the center. Lubricants are usually used.
one at the level of the upper gluteals, the other several Fluid may be directed along the lines of lymph channels
inches higher. (shown in the techniques portion of this book) with superfi
One hand describes clockwise circles and the other anti cial effleurage to enhance general drainage (see lymphatic
clockwise circles. drainage precautions on p. 31). These strokes may also be
As one hand starts to move away from the spine, the applied with fingers or thumbs.
other hand begins to move toward it, from a point a little A variation for the lower back is to stroke horizontally
higher on the back. across the tissues. The practitioner stands facing the side of
216 C L I N I C A L A P P L I CAT I O N O F N E U RO M U SC U LA R T EC H N I Q U E S : T H E U P P E R B O DY
the prone patient at waist level. The caudad hand rests on The methods listed above do not represent a comprehensive
the upper gluteals and the cephalad hand on the area just description of massage-based soft tissue techniques but are
above the iliac crest. One hand strokes from the side closest meant to indicate some of the basic movements available.
to the practitioner away to the other side as the other hand Some or all of these can be usefully employed in treatment
applies a pulling stroke from the far side toward the practi of most soft tissue problems. Other methods that we would
tioner. The two hands pass and then, without changing associate with the above techniques of traditional massage
position, reverse direction and pass each other again. The might include the various applications of NMT, MET and
degree of pressure used is variable and the technique can be MFR, as described in this text.
continued in one position for several strokes, before moving
the hands cephalad on the back.
EFFECTS EXPLAINED
This is but one of many variations on the theme of
stroking, a technique which is relaxing to the patient and How are the various effects of massage and soft tissue
useful in achieving fluid movement. manipulation explained? A combination of physical effects
occurs, apart from the undoubted anxiety-reducing influ
ences (Sandler 1983) which involve a number of biochemical
VI BRATION AND FRICTION
changes. For example, plasma cortisol and catecholamine
Used near origins and insertions and near bony attach concentrations alter markedly as anxiety levels drop and
ments for relaxing effects on the muscle as a whole and to depression is also reduced (Field 1992). Serotonin levels rise
reach layers deep to the superficial tissues. It is performed as sleep is enhanced, even in severely ill patients - preterm
with the tips of fingers or thumb, which apply small circu infants, cancer patients and people with irritable bowel
lar or vibratory movements. The heel of the hand may also problems as well as HIV-positive individuals (Acolet 1993,
be used. The aim is to move the tissues under the skin and Ferel-Torey 1993, Ironson 1993, Weinrich & Weinrich 1990).
not the skin itself. It is applied, for example, to joint spaces, On a physical level, pressure (as applied in deep knead
around bony prominences and near well-healed scar tissue ing or stroking along the length of a muscle) tends to dis
to reduce adhesions. Pressure is applied gradually, until the place fluid content. Venous, lymphatic and tissue drainage is
tolerance of the patient is reached. The minute circular or thereby encouraged. The replacement of this with fresh oxy
vibratory movement is introduced and maintained for sev genated blood aids in normalization via increased capillary
eral seconds, before gradual release and movement to another filtration and venous capillary pressure. This reduces edema
position. Stroking techniques are llsed subsequently to and the effects of pain-inducing substances that may be
drain tissues and to relax the patient. Vibration can also be present (Hovind 1974, Xujian 1990). Massage also produces
achieved with mechanical devices which may have varying a decrease in the sensitivity of the gamma efferent control of
oscillation rates that may affect the tissue differently (see the muscle spindles and thereby reduces any shortening ten
thixotropy, pp. 3-4). dency of the muscles (Puustjarvi 1990).
Fascial influences include provoking a transition from
gel to sol as discussed in Chapter 1 . Colloids respond to
TRANSVERSE FRICTION
appropriately applied pressure, shearing force and vibra
This is performed along or across the belly of muscles using tion by changing state from a gel-type consistency to a
the heel of the hand, thumb or fingers applied slowly and solute, which increases internal hydration and assists in the
rhythmically. Crossfiber friction is one such approach that removal of toxins from the tissue (Oschman 1997).
involves pressure across the muscle fibers. In this form, the Pressure techniques, such as are used in NMT and MET,
stroke moves across the skin, in a series of short deep strokes. have a direct effect on the Golgi tendon organs, which detect
One thumb following the other in a series of such strokes, lat the load applied to the tendon or muscle. These effects have
erally from the spinous processes, aids in reduction of local an inhibitory capability, which can cause the entire muscle
contraction and fibrous changes. Short strokes along the to relax.
fibers of muscle may also be used, in which the skin contact The Golgi tendon organs are set in series in the muscle
is maintained and the tissues under the skin are moved. This and are affected by both active and passive contraction of
requires deep short strokes and is useful in areas of fibrous the tissues. The effect of any system that applies longitudinal
change. Thumbs are the main contact in this variation. pressure or stretch to the muscle will be to evoke this reflex
Another variation on the treatment of fibrotic change is relaxation. The degree of slow stretch, however, has to be
the use of deep friction, which may be applied to muscle, great as there is little response from a small degree of stretch.
ligament or j oint capsule, across the long axis of the fibers, The effect of MET, articulation techniques and various func
using the thwnb or any variation of the finger contacts. The tional balance techniques depends to a large extent on these
index finger (supported by the middle finger) or the middle tendon reflexes (Sandler 1983).
finger (with its two adjacent fingers supporting it) makes Lewit (1986) discusses aspects of what he describes as the
for a strong treatment unit. Precise localization of target tis 'no man's land' which lies between neurology, orthopedics
sues is possible with this sort of contact. and rheumatology which, he says, is the home of the vast
10 Associated therapeutic modal ities a n d techniq ues 217
In some instances, as well as actively moving the head Following an isometric contraction (see below) of the
and neck toward the direction of restriction while the agonist or antagonist, in acute conditions the tissue is pas
practitioner maintains the translation, the patient may sively moved to the new barrier (first sign of resistance)
usefully apply 'overpressure' in which a hand is used to without any attempt to stretch. Additional contraction
reinforce the movement toward the restriction barrier. followed by movement to a new barrier is repeated until
The patient is told that at no time should pain be experi no further gain is achieved.
enced and that if it is, all active efforts should cease. When MET is applied to joints the acute model is always
The reason for pain being experienced could be because: used, i .e. no stretching, simply movement to the new bar
1. the facet p lane may not have been correctly followed rier and repetition of isometric contraction of agonist or
2. the incorrect segment may have been selected for antagonist.
translation In chronic conditions (non-acute) the same barrier is iden
3. the patient may be attempting movement toward the tified but the isometric contraction (see below) is com
barrier with excessive strength. menced from short of it (for patient comfort and safety,
If a painless movement through a previously restricted avoidance of cramp, etc.).
barrier is achieved while the translation is held, the same Following the contraction, in chronic conditions, the tis
procedure is performed several times more. sues are moved beyond (a short way only) the new bar
There should be an instant, and lasting, functional rier and are held in tha t stretched state for 10-20 seconds
improvement. (or longer), before being returned to a pOSition short of
The use of these mobilization methods is enhanced by the new barrier for a further isometric contraction.
normalization of soft tissue restrictions and shortened Wherever possible, the patient assists in the stretching
musculature, using NMT, MFR, MET, etc. movement in order to activate the antagonists and facili
tate the stretch.
(See Chapter l l , Fig. l l .43, and Chapter 14, Fig. 14.32, for There are times when 'co-contraction' is useful, involving
descriptions of applica tion of SNAGs.) contraction of both the agonist and the antagonist.
Studies have shown that this approach is particularly
useful in treatment of the hamstrings, when both these
MUSCLE E N E RG Y TECH N I Q U E S (MET) A N D and the quadriceps are isometrically contracted prior to
VA R IATI O N S (DiG iovan na 1 991 , Greenman 1 989, stretch (Moore 1980) .
Janda 1 989, Lewit 1 986, Liebenson 1 989/ 1 990,
M itchel l 1 967, Travel l & Si mons 1 992) N E U R O LO G I CA L EX PLANAT I O N FOR M ET EF FE CTS
1. When a muscle is contracted isometrically, a load is
Muscle energy techniques (MET) are soft tissue manipula placed on the Golgi tendon organ that, on cessation of
tive methods in which the p atient, on request, actively uses effort, results in a phenomenon known as postisometric
muscles from a controlled pOSition, in a specific direction, relaxation (PIR). This is a period of relative hypotonicity,
with mild effort against a precise counterforce. The counter lasting in excess of 15 seconds, during which a stretch of
force can match the patient's effort (isometrically) or fail to the tissues involved will be more easily achieved than
match it (isotonically) or overcome it (isolytically), depend before the contraction (Lewit 1986, Mitchell et aI 1979).
ing upon the therapeutic effect required. Depending upon 2. During and following an isometric contraction of a mus
the relative acuteness of the situation, the contraction will cle, its antagonist(s) will be reciprocally inhibited (RI),
be commenced from or short of a previously ascertained allowing tissues involved to be more easily stretched
barrier of resistance. (Levine 1954, Liebenson 1996a) .
In order to apply the MET methods effectively there are 3 . Contractions are kept light in MET methodology (15-20%
several basic 'rules' that need to be well understood and of available strength) as clinical experience indicates this is
applied. as effective as a strong contraction in achieving the desired
effects (PIR or RI). Light contractions are also easier to con
The 'barrier ' described refers to the very first sign of pal
trol and far less likely to provoke pain or cramping. There
pated or sensed resistance to free movement as soft
is evidence that greater strength use recruits phasic muscle
tissues are taken toward the direction of their restriction (as
fibers (type II) rather than postural (type I) fibers, with the
palpated by sense of 'bind' or sense of effort required to
latter being the ones which will have shortened and
move the area or by visual or other palpable evidence).
require stretching (see Chapter 4) (Lewit 1992).
This will be well short of the physiological or pathophysio
logical barrier and literally means that the very first sign of
USE OF B R EAT H I N G C O O P E RAT I O N (Gaymans 8
perceived restriction needs to be identified and respected.
Lewit 1 975)
It is from this barrier that MET is applied in acute condi
tions, acute being defined as anything that is acutely Breathing cooperation can and should be used as part of the
painful or which relates to trauma that occurred within methodology of MET if appropriate (i.e. if the patient is
the last 3 weeks or so. cooperative and capable of following instructions).
10 Associated therapeutic mod a l ities and tech n iques 219
)---- Dorsal root ganglion Contraction starting point - For acute muscle or any joint
problem, commence at 'easy' restriction barrier (first sign of
---m...:;==-...L.--:7'="'-
Response from
Golgi tendon organ
Dorsal root
resistance).
r---- Dorsal root ganglion Action following contraction - Area (muscle/joint) is pas
sively taken to its new restriction barrier without stretch after
ensuring complete relaxation. Perform movement to new
barrier on an exhalation.
Interneuron releasing
inhibitory mediator Repetitions - 3-5 times or until no further gain in range of
motion is possible.
9+-- Motor neuron of
Muscle
agonist muscle
spindle
Motor neuron of
Isometric contraction using postisometric
antagonist muscle relaxation - PI R (acute setting. without
stretch i ng)
Agonist muscle Antagonist muscle
Indications
F i g u re 1 0.4 Schematic representation of mech a n i s m s i nvolved i n
rec i p roca l i n h i b i t i o n relaxation resp o n se to a M ET i sometric Relaxing acute muscular spasm or contraction
contract i o n i nvo lvi ng t h e a n tago n i st. Reproduced with p e r m i s s i o n Mobilizing restricted joints
from Chaitow ( 1 996c). Preparing joint for manipulation
ensuring patient has completely relaxed. Perform move Contraction starting point - Short of resistance barrier, in
ment to new barrier on an exhalation. mid-range.
Repetitions - 3-5 times or until no further gain in range of Method Antagonist(s) to affected muscles are used in the
-
Indications
Rapid eccentric isotonic stretch (iso lytic, for
Stretching chronic or subacute restricted, fibrotic, con red u ction of fi b rotic change, to introd u ce
tracted, soft tissues (fascia, muscle) or tissues housing control led m icrotra uma)
active myofascial trigger points
Indications
This approach is chosen if contraction of the agonist is
contraindicated because of pain Stretching tight fibrotic musculature
10 Associated therapeutic moda l ities and tech n iq u es 22 1
Contraction starting point - A little short of restriction barrier. Contraction s arting point - Easy mid-range pOSition.
vented from doing so by the practitioner, via superior prac first, progressing to maximal effort subsequently, as practi
titioner effort, and the contraction is overcome and reversed, tioner puts joint rapidly through as full a range of movements
so that a contracting muscle is stretched. Origin and inser as possible. This approach differs from a simple isotonic
tion do not approximate. The contracting muscle is rapidly exercise by virtue of whole ranges of motion, rather than
stretched to, or as close as possible to, full physiological single motions being involved, and because resistance varies,
resting length. progressively increasing as the procedure progresses.
Forces - Practitioner's force is greater than pa tient's. Less Forces - Practitioner's force overcomes patient's effort to
than maximal patient's force should be used. prevent movement. First movements (for instance, taking
an ankle into all its directions of motion) involve moderate
Duration of contraction - 2-4 seconds.
force, progressing to full force subsequently.
Repetitions - 3-5 times if discomfort is not excessive.
An alternative is to have the practitioner (or machine) resist
Caution - Avoid using isolytic contractions on head /neck the patient's effort to make all the movements.
muscles or at all if patient is frail, very pain sensitive or
Duration of contraction - Up to 4 seconds.
osteoporotic.
Repetitions - 2-4 times.
Morris (2006) notes: 'Restricted neural mobility can occur it indicates only that there exists AMT somewhere in the
anywhere along the neuraxis, nervous tissue and support nervous system, and not that this is necessarily at the site of
ing structures housed within the axial skeleton, and also reported pain.
continuing into the periphery.'
A positive tension test is one in which the patient's symp
Maitland et al (2001) suggest that we consider this form
toms are reproduced by the test procedure and where
of assessment and treatment as involving 'mobilization' of
these symptoms can be altered by varia tions in what are
the neural structures, rather than stretching them, and that
termed 'sensitizing maneuvers' used to 'add weight to',
these methods be reserved for conditions that fail to respond
and confirm, the initial diagnosis of AMT. For example,
adequately to normal mobilization of soft and osseous
adding dorsiflexion during straight leg raising (SLR) test
structures (muscles, joints).
is an example of a sensitizing maneuver.
Among the negative influences on nerves are: 'deforma
Precise symptom reproduction may not be possible, but
tions such as compression, stretching, angula tion and tor
the test is still possibly relevant if other abnormal symp
sion' in their passage over highly mobile joints, through
toms are produced during the test and its accompanying
bony canals, intervertebral foramina, fascial layers and ton
sensitizing procedures. Comparison with the test find
ically contracted m uscles (for example, posterior rami of
ings on an opposite limb, for example, may indicate an
spinal nerves and spinal extensor muscles) (Korr 1981 ).
abnormality worth exploring.
Stewart (2000) notes that neural damage can result from
Altered range of movement is another indicator of abnor
all or any of the following: laceration, crush, stretch, rup
mality, whether this is noted du ring the initial test posi
ture, compression and angula tion, and that nerves can also
tion or during sensitizing additions.
be affected negatively by ischemia, hemorrhage, tumors,
infection, autoimmune conditions, vasculitis, irradiation Note: Various tests that also become part of the subsequent
and marked temperature change such as intense cold. treatment are described in this text. For example, the upper
Maitland ( 1986), as well as Bu tler & Gifford ( 1989, 1991), limb tension test (ULTT) is fully described and discussed in
has described the mechanical restrictions that impinge on Chapter 13 of this volume and the 'slump' and straight leg
neural structures in the vertebral canals and elsewhere as raising tests are fully described and illustra ted in Chapter 14,
the mechanical interface (MI) - the tissues surrounding neural Volume 2 of this text.
structures. Any structural changes or pathology in the MI
can produce abnormalities in, or interference with, free TYPES OF SYM PTO M S
nerve movement with in its Ml, resulting in tension on neu
The two types of tissue associated with nerves give rise to
ral structures with unpredictable effects.
different types of symptoms, and require different treat
Good examples of MI pa thology are nerve impingement
ment approaches.
by disc protrusion, osteophyte contact or carpal tunnel con
striction. Any symptoms resulting from mechanical Connective tissue elements, either external or internal to
impingement on neura l structures will be more readily pro the nerve, give rise to local! general aching, pressure and
voked in tests that involve movement, rather than passive pulling symptoms.
tension. When conductive tissues (neural) are affected, these give
Chemical or inflammatory causes of neural tension also rise to sensations of tingling and numbness, sometimes
occur, resulting in ' interneural fibrosis', leading to reduced accompanied by motor and / or autonomic effects.
elasticity and increased 'tension', which would be revealed
during tension testing. N E U RAL T E N S I O N T EST I N G
Butler & Gifford (1989) report on research indica ting that
70% of 115 pa tients with either carpal tunnel syndrome or The neural tension tests selectively tension, compress and
lesions of the ulnar nerve at the elbow showed clear electro attempt to glide tissue along a chosen nerve tract from the
physiological and clinical evidence of neural lesions in the central neural axis out to the distal end of the extremity.
neck. This is, they maintain, beca use of a 'double crush' By adding and subtracting various differentia ting (sensi
phenomenon, in which a primary and often long-standing tizing) movements it may be possible to infer the relationship
disorder, perhaps in the spine, results in secondary or the nervous system has with various interfacing structures.
' remote' dysfunction at the periphery. When the neural tension tests are combined with the con
This is probably a function of the nerve's physiology being cepts of irritability and non-irritability it may be possible to
altered as well as its biomechanics (Upton & McComas 1973). frame the treatment approach.
Questions to ask when slack is being taken out of the sys
tem include:
A DVE R S E M E C H A N I CAL T E N S I O N (AMT) A N D
Wha t do you feel?
PAI N S ITE S A R E N OT N E C ESSA R I LY T H E SAM E
Where do you feel it?
When a tension test is positive (i.e. pain is produced by one How long does the sensation last after I release the ten
or another element of a test that puts a nen'e under tension) sion (pressure, etc.)?
10 Associated therapeutic modal ities a n d techn iques 225
It [strain dysfunction] often relates to the inappropriate R E S O LVI N G R EST R I CTI O N S U S I N G PRT
signaling from muscle proprioceptors that have been ( D i G iova n na 1 99 1 , Jones 1 964, 1 966)
strained from rapid change that does not allow proper
If someone has been in a flexed position and they find it
adaptation.'
painful to straighten, as in the example discussed above
This situation would be unlikely to resolve i tself sponta
under the heading 'Proprioceptive hypothesis', they
neously and is the 'strain' posi tion in Jones' strain/ co un
would be locked in flexion with an acute low back pain.
terstrain method.
The resulting spasm in tissues 'fixed' by this or other sim
This is a time of intense neurological and proprioceptive
ilar neurologically induced 'strains' causes the fixation of
confusion. This is the moment of 'strain'.
associa ted joint(s) and prevents any attempt to return to
Using positional release methodology, the affected tis
neutral.
sues are placed into an 'ease' position and maintained
Any a ttempt to force this toward its anatomically correct
there for a minute or more, offering an opportunity for
position would be strongly resisted by the shortened fibers.
neurological resetting to occur, with partial or total reso
It is, however, usually not difficult or painful to take the
lution of the dysfunctional state.
joint(s) further toward the position in which the strain
occurred (flexion in this case), thus shortening the fibers,
TH E N O C I C E PTIV E HYPOT H E S I S (Bai ley & Dick 1 992, now in spasm, even further.
Va n Buski rk 1 990) Joints affected in this way behave in an apparently irra
tional manner, in that they do the converse of what a
If someone were involved in a simple whiplash-like neck
relaxed, normal joint would do. When a strained joint is
stress as their car came to an unexpected hait, the neck
placed in a position that exaggerates i ts deformity, it feels
would be thrown backwards into hyperextension, provok
more comfortable.
ing all the factors described above involving the flexor
group of muscles in the bending forward strain.
The extensor group would be rapidly shortened and the
Toward 'ease'
various proprioceptive changes leading to strain and reflex
ive shortening would operate. At the time of the sudden Jones (1964, 1981) found that by taking the distressed
braking of the car, hyperextension would occur and the flex joint (area) close to the position in which the original
ors of the neck, scalenes, etc. would be violently stretched, strain took place, proprioceptive functions were given an
inducing actual tissue damage. opportunity to reset themselves, to become coherent
Nociceptive responses would occur (which are more again, during which time pain in the area lessened.
powerful than proprioceptive influences) and these multi This is the 'counterstrain' element of Jones' approach. If
segmental reflexes would produce a flexor withdrawal, the position of ease is held for a period (Jones suggests
increasing tone in the flexor muscles. 90 seconds), the spasm in hypertonic, shortened tissues
The neck would now have hypertonicity of both the exten commonly resolves, following which it is usually possi
sors and the flexors, pain, guarding and stiffness would be ble to return the joint/ area to a more normal resting posi
apparent and the role of the clinician would be to remove tion, if this action is performed extremely slowly.
these restricting influences layer by layer. The muscles that had been overstretched might remain
Where pain is a factor in strain, this has to be considered sensitive for some days, but for all practical considera
as producing an overriding influence over whatever other tions the joint would be normal again.
more 'normal' reflexes are operating. In reality, matters are Since the position achieved during Jones' therapeutic
likely to be even more complicated, since a true whiplash methods is the same as that of the original strain, the
would introduce both rapid hyperextension and hyperflex shortened muscles are repositioned so as to allow the
ion and a multitude of layers of dysfunction. dysfunctiorung proprioceptors to cease their inappropri
As Bailey & Dick (1992) explain: ate activity.
Probably few dysfunctional states result from a purely pro Korr's (1975) explanation for the physiological normalization
prioceptive or nociceptive response. Additional factors such of tissues brought about through positional release is that:
as autonomic responses, other reflexive activities, joint recep
The shortened spindle nevertheless continues to fire, despite
tor responses or emotional states must also be accounted for.
the slackening of the main muscle, and the CNS is gradually
Fortunately, the methodology of positional release does not able to turn down the gamma discharge and, in turn,
demand a complete understanding of what is going on neu enables the muscles to return to 'easy neutral', at its resting
rologically, since what Jones and his followers, and those length. In effect, the physician has led the patient through a
clinicians who have evolved the art of strain and counter repetition of the lesioning process with, however, two essen
strain to newer levels of simplicity, have shown is that by a tial differences. First it is done in slow motion, with gentle
slow, painless return to the position of strain, aberrant neu muscularforces, and second there have been no surprisesfor
rological activity can often resolve itself. the CNS; the spindle has continued to report throughout.
10 Associated therapeutic modal ities a n d tech n iq u es 227
Jones' approach to positioning requires verbal feedback from Moving the area away from the restriction barrier is,
the patient as to tenderness in a 'tender' point the practi however, riot usually a problem.
tioner is palpating (which is being used as a monitor) while The position required to find ease for someone in this
attempting to find a position of ease. There is also a need for state normally involves painlessly increasing the degree
a method that allows achievement of the same ends without of distortion displayed, placing them (in the case of the
verbal communication. It is also possible to use 'functional' example given) into some variation based on forward
approaches that involve finding a position of maximum bending, until pain is found to reduce or resolve.
ease by means of palpa tion alone. After 60-90 seconds in this position of ease, a slow return
to neutral would be carried out and commonly in prac
tice the patient will be partially or completely relieved of
C I RCU LATO RY HYPOT H E S I S
pain and spasm.
We know from the research o f Travell & Simons (1 992) that
in stressed soft tissues there are likely to be localized areas of
Replication of position of stra in (an element of
relative ischemia, lack of oxygen, and that this can be a key
SCS methodology)
factor in the production of pain and altered tissue status,
which leads to the evolution of myofascial trigger points. Take as an example someone who is bending to lift a load
Studies on cadavers have shown that a radiopaque dye when an emergency stabilization is required and strain
injected into a muscle is more likely to spread into the ves results (the person slips or the load shifts). The patient
sels of the muscle when a 'counterstrain' position of ease is could be locked into the same position of 'lumbago-like'
adopted as opposed to when it is in a neutral position. distortion as in the above.
Rathbun & Macnab (1970) demonstrated this by injecting a
If, as SCS suggests, the position of ease equals the posi
suspension into the arm of a cadaver while the arm was
tion of strain then the patient needs to go back into flex
maintained at the side. No filling of blood vessels occurred.
ion in slow motion until tenderness vanishes from the
When, following injection of a radiopaque suspension, the
monitor / tender point and/ or a sense of ease is perceived
other arm was placed in a position of flexion, abd uction and
in the previously hypertonic shortened tissues.
external rotation (position of ease for the supraspinatus
Adding small, fine-tuning positioning to the initial posi
muscle), there was almost complete filling of the blood ves
tion of ease achieved by flexion usually produces a max
sels as a result.
imum reduction in pain.
Jacobson (1989) suggests that, 'Unopposed arterial filling
may be the same mechanism that occurs in living tissue
during the 90 second counterstrain treatment'. It is likely,
therefore, that in taking a distressed, strained (chronic or
acu te) muscle or joint into a position which is not painful for
it and which allows for a reduction in tone in the tissues
involved, some modification of neural reporting takes place
as well as local circulation being improved.
The end result of such positioning, if slowly performed
and held for an appropriate length of time, is a reduction in
hyperreactivity of the neural structures, which resets these
to painlessly allow a more normal resting length of muscle
to be achieved and circulation to be enhanced.
VAR I AT I O N S OF PRT
Exaggeration of distortion (an elem ent of
SCS methodology)
Consider the example of an individual bent forward in
psoas spasm /'lumbago'.
This position is held for 60-90 seconds before slowly relies solely on these 'menus' or formulae could find diffi
returning the patient to neutral, at which time a partial or culty in handling a situation in which Jones' prescription
total resolution of hypertonicity, spasm and pain should failed to produce the desired results. Reliance on Jones'
be noted. menu of points and positions can therefore lead the practi
The position of strain, as described, is probably going to tioner to become dependent on them and it is suggested
be similar to the position of exaggeration of the apparent that a reliance on palpation skills and other variations on
distortion. Jones' original observa tions offers a more rounded
approach to dealing with strain and pain.
Patients can rarely describe precisely in which way their
Fortunately, Goodheart (and others) have offered less
symp toms developed. Nor is obvious spasm such as torti
rigid frameworks for using positional release.
collis or acu te anteflexion spasm (,lumbago') the norm and
so ways other than 'exaggerated distortion' and ' replica tion
of position of strain' are needed in order to easily be able to Good heart's a pproach (Good he art 1 984,
identify probable positions of ease. Wa lther 1 988)
George Goodheart DC (the developer of applied kinesiol
Stra i n/cou nterstrai n : using tender poi nts as ogy) has described an almost universally applicable guide
mon itors that relies more on the individual features displayed by the
pa tient and less on rigid formulae as used in Jones' SCS
Over many years of clinical experience, Jones (1981) and his approach.
colleagues compiled lists of specific tender point areas relat
ing to every imaginable strain of most of the joints and mus Goodheart suggests that a suitable tender point be
cles of the body. These are his 'proven' (by clinical experience) sought (palpated for) in the tissues opposite those 'work
points. ing' when pain or restriction is noted.
The tender points are usually found in tissues that were If pain / restriction is reported/apparent on any given
in a shortened state at the time of strain, rather than those movement, muscles antagonistic to those operating at
tha t were stretched. the time pain is noted will be those housing the tender
New points are periodically reported in the osteopathic point(s).
literature - for example, the identification of sacral foramen Thus, for example, pain (wherever it is felt) which occurs
points relating to sacroiliac strains (Ramirez 1989). when the neck is being turned to the left will suggest that
Jones and his followers have also provided strict guide a tender point be located in the muscles which turn the
lines for achieving ease in any tender points that are being head to the right.
palpated (the position of ease usually involving a 'folding' In the case of a person locked in forward bending with
or crowding of the tissues in which the tender point lies). acute pain and spasm, using Goodheart's approach, pain
This method involves maintaining pressure on the monitor and restriction would be experienced as the person moved
tender point, or periodically probing it, as a position is toward extension, from their pOSition of enforced flexion.
achieved in which: This action (straightening up) would usually cause pain
in the back but, irrespective of where the pain is noted, a
there is no additional pain in whatever area is symp to- tender point would be sought (and subsequently treated
matic, and by being taken to a state of ease) in the muscles opposite
the monitor poin t pain has reduced by at least 75%. those working when pain was experienced, i.e. it would
This is then held for an appropriate length of time (90 sec lie in the flexor muscles (probably psoas) in this example.
onds according to Jones; however, variations are suggested It is important to emphasize this factor, that tender points which
for the length of time required in the position of ease, as will are going to be used as 'monitors' during the positioning phase of
be explained). this approach are not sought in the muscles opposite those where
In the example of a person with acu te low back pain who pain is noted but in the muscles opposite those which are actively
is locked in flexion, tender points will be located on the moving the patient, or area, when pain or restriction is noted.
anterior su rface of the abdomen, in the muscle structures
which were short at the time of strain (when the patient was
in flexion). The posi tion that removes tenderness from this Functional tech n i q ue ( Bowles 1 981 , Hoove r 1 969)
point will usually require flexion and probably some fine
Osteopathic functional technique relies on a reduction in
tuning involving rotation and / or sidebending.
palpated tone in stressed (hypertonic/spasm) tissues as the
If there is a problem with Jones' form ulaic approach, it is
body (or part) is being posi tioned or fine-tuned in relation
that while he is frequently correct as to the position of ease
to all available directions of movement in a given region.
recommended for particular points, the mechanics of the
particular strain with which the practitioner is confronted One hand palpates the affected tissues (molded to them,
may not coincide with Jones' guidelines. A practi tioner who without invasive pressure).
--------
tion then being stacked onto the first one and so on m a x i m u m ease is fo u n d and h e l d to a l l o w phys i o l o g i c a l cha nges to
com m e nce. Re produced w i t h perm ission from Cha i tow ( 1 996a).
through all variables (rotation, translation, etc.).
A full sequence would involve flexion/ extension, side
bending and rotation in each direction, translation right
and left, and translation anterior and posterior, as well as
occurred in relation to any pain point which has been
compression/ distraction, so involving all available direc
identified.
tions of movement of the area.
It could therefore be considered that any painful point
Finally, a posi tion of maximum ease would be arrived at
found during soft tissue evaluation could be treated by
and the position held for 90 seconds.
positional release, whether it is known what strain pro
A release of hypertonicity and reduction in pain should
duced it or not and whether the problem is acute or
result.
chronic.
The precise sequence in which the various directions of
Experience and simple logic tell us that the response to
motion are evaluated is irrelevant, as long as all possibilities
positional release of a chronically fibrosed area will be less
are included.
dramatic than from tissues held in simple spasm or hyper
Theoretically (and often in practice) the position of pal
tonicity. Nevertheless, even in chronic settings, a degree of
pated maximum ease (reduced tone) in the distressed tissues
release can be produced, allowing for easier access to the
should correspond with the position that would have been
deeper fibrosis.
found were pain being used as a guide, as in either Jones' or
This approach, of being able to treat any painful tissue
Goodheart's approach, or using the more basic 'exaggera
using positional release, is valid whether the pain is being
tion of distortion' or 'replication of position of strain'.
monitored via feedback from the patient (using reducing
levels of pain in the palpated point as a guide) or whether
the concept of assessing a reduction in tone in the tissues is
Any pa i nfu l point as a starting pl ace for SCS
being used (as in functional technique).
All areas that palpate as painful are responding to, or are A 60-90 second hold is recommended as the time for
associated with, some degree of imbalance, dysfunction maintaining the position of maximum ease.
or reflexive activity that may well involve acu te or
chronic strain.
Faci litated positional release (FPR)
Jones identified positions of tender points relating to par
(Sc h iow itz 1 990)
ticular strain positions.
It makes just as much sense to work the other way This varia tion on the theme of functional and SCS methods
around and to identify where the 'strain' is likely to have involves the posi tioning of the distressed area into the
230 C L I N I CAL A P PL I C AT I O N OF N E U R O M U S C U LA R T E C H N I Q U E S : THE U P P E R B O DY
direction of its greatest freedom of movement starting from use minimal force
a position of 'neutral' in terms of the overall body position. use minimal monitoring pressure
achieve maximum ease/comfort/relaxation of tissues
The seated pa tient's sagittal posture might be modified
produce no additional pain anywhere else.
to take the body or the part (neck, for example) into a
more neu tral position - a balance between flexion and These elements need to be kept in mind as pOSitional
extension - following which an application of a facilitat release/SCS methods are learned and are major points of
ing force (usually a crowding, compression of the tissues) emphasis in programs that teach it (Jones 1981).
is introduced. The general guidelines that Jones gives for relief of the
No pain monitor is used but rather a palpating/ listening dysfunction with which such tender points are related
hand is applied (as in functional technique) which senses involves directing the movement of these tissues toward
for changes in 'ease' and 'bind' in distressed tissues as ease, which commonly involves the following elements.
the body / part is carefully positioned and repositioned. For tender points on the anterior surface of the body, flex
The final crowding of the tissues, to encourage a slacken ion, sidebending and rota tion should be toward the pal
ing of local tension, is the facilitating aspect of the pated pOint, followed by fine-tuning to reduce sensitivity
process (according to its theorists) . by at least 70%.
This crowding might involve compression applied For tender points on the posterior surface of the body,
through the long axis of a limb, or directly downwards extension, sidebending and rotation should be away
through the spine via cranially applied pressure or some from the palpated point, followed by fine-tuning to reduce
such variation. sensitivity by 70%.
The length of time the position of ease is held is usually The closer the tender point is to the midline, the less
suggested at just 5 seconds. It is claimed that altered tis sidebending and rotation should be required and the fur
sue texture, either surface or deep, can be successfully ther from the midline, the more sidebending and rotation
treated in this way. should be required, in order to effect ease and comfort in
the tender point (without any add itional pain or discom
SCS rules of treatment fort being produced anywhere else).
The direction toward which sidebending is introduced
The following 'rules' are based on clinical experience and when trying to find a position of ease often needs to be
should be borne in mind when using positional release (SCS, away from the side of the palpa ted pain point, especially
etc.) methods in treating pain and dysfunction, especially in relation to tender points found on the posterior aspect
where the patient is fa tigued, sensitive and / or distressed. of the body.
Never treat more than five 'tender ' points at any one ses
sion and treat fewer than this in sensitive individuals.
Forewarn patients tha t, j ust as in any other form of body
R E HA B I LITATI O N
work that produces altered function, a period of physio
Rehabilitation implies returning the individual toward a
logical adapta tion is inevitable and that there may be a
state of normality that has been lost through trauma or ill
'reaction' on the day(s) following even this extremely
health. Issues of patient compliance and home care are key
light form of treatment. Soreness and stiffness are there
features in recovery and these have been discussed else
fore to be anticipated.
where in this text (see Chapter 8).
If there are multiple tender points, as is inevitable in
Among the many interlocking rehabilitation fea tures
fibromyalgia, select those most proximal and most medial
involved in any particular case are the following.
for primary attention, i.e. those closest to the head and the
center of the body rather than distal and lateral pain points. Normalization of soft tissue dysfunction, including
Of these tender points, select those that are most painful abnormal tension and fibrosis. Treatment methods might
for initial a ttention/ treatment. include massage, NMT, MET, MFR, PRT and /or articula
If self-treatment of painful and restricted areas is advised tion /mobiliza tion and / or other stretching procedures,
and it should be if at all possible - apprise the patient of including yoga.
these rules (i.e. only a few pain points to be given atten Deactiva tion of myofascial trigger points, possibly involv
tion on any one day, to expect a 'reaction', to select the ing massage, NMT, MET, MFR, PRT, spray and stretch
most painful points and those closest to the head and the and / or articula tion/ mobilization. Appropriately trained
center of the body). and licensed practitioners might also use injection or
acupuncture in order to deactivate trigger points.
The guidelines that should therefore be remembered and
Strengthening weakened structures, involving exercise
applied are:
and rehabilitation methods, such as Pilates.
locate and palpate the appropriate tender point or area of Proprioceptive reeducation utilizing physical therapy
hypertonicity methods (e.g. wobble board) and spinal stabilization
10 Associated therapeutic mod a l ities a n d tech n i q u es 231
exercises, as well as methods such as those devised by 30-minute treatments, twice weekly, for 10 weeks and
Feldenkrais (1972), Hanna ( 1988), Pilates (Knaster 1996), subsequently showed improvement in both function and
Trager ( 1987) and others wellbeing.
Postural and breathing reeducation, using physical ther A recent systematic review of all RCTs on relaxation for
apy approaches as well as Alexander technique, yoga, tai chronic pain of any type arrived at cautiously positive
chi and other similar systems. conclusions (Carroll & Seers 1 998).
Ergonomic, n utri tional and stress management strate
gies, as appropriate.
Psychotherapy, counseling or pain management tech R H YT H M I C ( O S C i l lATO RY, V I B RATI O NA L,
niques such as cognitive behavior therapy. H A R M O N I C) M ETH O D S
Occupational therapy that specializes in activating heal thy
coping mechanisms, determining functional capacity, (See also details of Ruddy's rhythmic 'p ulsed MET' above.)
increasing activity that will produce greater concordance A variety of therapeutic methods employ rhythmic oscil
than rote exercise and developing adaptive strategies to latory, vibrational (harmonic) approaches, similar to those
return the individual to a greater level of self-reliance employed in the Trager technique (Ramsey 1997, Trager
and quality of life (Lewthwaite 1 990). 1987) :
Appropriate exercise strategies to overcome decondition Duval et al (2002) describe measurable changes with the
L.'1g (Liebenson 1 996b) . Trager technique on muscle rigidity. A Trager-style
exercise applied to the shoulder is described later in these
A team approach to rehabilita tion is called for where refer
notes.
ral and cooperation allow the best outcome to be achieved.
Harmonic therapy, developed by Lederman (2000), as
well as the methods described by Comeaux (2002), are
also well thought out approaches to the clinical use of
R E LAXAT I O N M ET H O D S
oscilla tion.
Ernst (2004) has reviewed and evaluated the evidence to Morris (2006) has noted three models of oscillatory
support a range of relaxa tion (and other) complementary methodology:
approaches in treatment of musculoskeletal problems. His
Proactive oscillatory methods are where the patient per
findings regarding relaxation benefits are summ arized below.
forms the movements while the practitioner/ therapist
Autogenic training: 'This au to-hypnotic technique was offers resistance - either partially (isotonic) or totally
compared to Erickson's relaxation training in a random (isometric). Variables include the arc of motion, as well as
ized controlled trial, with 53 fibromyalgia patients (Rucco the speed, ranging from several oscillations per second to
et al 1995) . The authors found that the la tter approach one oscillation every 3-4 seconds.
was more suited to FM patients and led to a faster relief Reactive oscilla tory methods involve the practitioner /
of symptoms.' therapist performing the movement, with the patient
Fifty-five women with fibromyalgia were randomized to offering resistance. Very clear instructions need to be
receive guided imagery plus relaxation training, or relax offered to the patient to ensure tha t the degree of force
ation training alone, or no such treatments for 4 weeks and the rhythm are wha t is called for.
(Fors et aI 2002). The results suggested that guided imagery Passive oscillatory methods involve the practitioner /
was associated with a more rapid pain relief than that therapist creating all the movements with the patient
observed in the other two groups. totally passive. The amplitude and rate of movements are
According to data from the USA (Eisenberg et al 1998), therefore entirely under the control of the practitioner. It is
57% of people with neck pain used CAM in the previous this format that is described in the examples offered below.
12 mon ths, two-thirds visiting a practitioner. Chiropractic,
massage and relaxation techniques were used most com W H AT'S H A P P E N I N G ?
monly and perceived as 'very helpful' by patients (Wolsko
Comeaux (2004) describes the effects of facilitated oscilla
et aI 2003).
tory release (FOR) methods as follows.
Therapeutic touch (healIDg) showed a trend to greater
effectiveness for reducing osteoarthritic pain in 82 elderly A functionally appropriate rhythmic force may miLk edema
subjects than did progressive m uscle relaxation, and it fluid from the area, may directly stretch tissue, may gently
was more effective at reducing distress (Eckes Peck 1997). rearrange joint surfaces, or more to the point may induce,
Several relaxation techniques have been advocated for through entrainment, a functionally appropriate LeveL of osciL
rheumatoid arthritis (RA) . Muscle relaxation training latory neuraL coordination. In an articuLar or myofasciaL con
was demonstrated to be superior to no such interven text, it may be an occasion to add energy to the system lost
tion, in a randomized controlled trial (RCT) with 68 through trauma to reverse the deformation offibrin through
RA patients (Eisenberg et al 1 998). Patients received hysteresis.
232 C L I N I C A L A P PL I C AT I O N O F N E U R O M U S C U LA R T E C H N I Q U E S : THE U P P E R B O DY
profound as with the vapocoolant spray. For many practi If aching or 'cold pain' develops or if the application of
tioners, the practicality and ease of application of spray and the spray or ice activates a reference of pain, the interval
stretch technique were set aside in favor of protection of the between applications is lengthened. Care is taken not to
environment and, for many, the use of the techniques all but frost or blanch the skin.
disappeared during the last decade. During the application of cold or directly after it, the taut
Recently, Gebauer's Spray and Stretch (prescription) and fibers should be passively stretched. The fibers should
Instant Ice (non-prescription), both non-flammable, non not be stretched in advance of the cold.
ozone-depleting vapocoolants, emerged into a market that Steady, gentle stretching is usually essential if a satisfac
has been devoid of environmentally friendly sprays. Spray tory result is to be achieved.
and stretch techniques can now not only be applied in the As relaxation of the muscle occurs, continued stretch
treatment room, but also in home care with the pa tient's use should be maintained for 20-30 seconds and, after each
of the non-prescription version. Ethyl chloride is still avail series of cold applications with stretch, active motion is
able (prescription only) in both can and bottle; however, the tested.
previously preferred product, Fluori-Methane (aka fluo The tissue is then passively taken out of stretched posi
romethane), has been replaced by Spray and Stretch spray, a tion by the practitioner while avoiding active loading of
less environmentally damaging product. the tissue immediately following the application of the
A few guidelines are suggested for the application of spray technique.
and stretch techniques. The following is a s umm ation of the The patient is then asked to move in the directions which
major points in application. Appropriate training is suggested were restricted before spraying or which were painful to
in order to avoid the potential hazards associated with use of activate.
these products. Alternative choices, such as ice in a plastic An attempt should be made to restore the full range
bag, are discussed below and are applied in a similar manner. of motion, but always within the limits of pain, since
sudden overstretching can increase existing muscle
A container of an environmentally friendly vapocoolant spasm.
spray with a calibrated nozzle that delivers a moderately The treatment is continued in this manner until the trigger
fine jet stream is needed. points (often several are present or a 'nest' of them) and
The fine jet stream should have sufficient force to carry in their respective pain reference zones have been treated.
the air for at least 3 feet (1 meter), although a shorter The entire procedure may occupy 15-20 minutes and
range will be used in application (a mist-like spray is not should not be rushed.
effective for this purpose). Simple exercises that utilize the principle of passive or
The container is held 12-18 inches (30-45 cm) away from active stretch should be outlined to the patient, to be car
the surface, in such a manner that the fine stream meets ried out several times daily, after the application of gentle
the body surface at an acute angle, not perpendicularly. heat (hot packs, etc.) at home. Usual precautions should
The stream is sometimes started in air or on the practi be mentioned, such as avoiding use of heat if symptoms
tioner's hand and gradually brought into contact with the worsen or if there is evidence of inflammation.
skin overlying the trigger point to lessen the shock
of impact. It is suggested to offer an experience of the cold Many variations on spray and stretch technique have
by demonstrating on the patient's hand prior to treatment. emerged through the years, and can be usefully employed
The fine stream is applied only in unidirectional parallel when the vapocoolants cannot be used, such as when they
sweeps, not back and forth, from the trigger point through are not available or when their use is beyond the scope of a
the reference zone. practitioner's license. The following highlights alternative
Each sweep is started slightly proximal to the trigger and adjunct techniques that may be easily incorporated.
point and is moved slowly and evenly through the refer
ence zone to cover it and extend slightly beyond it. A cylinder of ice may be used instead of the spray, formed
It is advantageous to spray both trigger point and refer by freezing water in a paper cup and then peeling the cup
ence areas, since satellite trigger points are likely to down to expose the ice edge. A wooden handle can be
develop within reference zones. This type of sweep also frozen into the ice to allow for ease of application, as the
addresses both central and attachment trigger points thin, cold edge of the ice is applied in unidirectional par
(Simons et aI 1 999). allel strokes from the trigger point toward the referred
The direction of movement is usually in line with the area in a series of sweeps.
muscle fibers, toward their insertion. Simons et al (1999) have, however, pointed out that
The optimum speed of movement of the sweep /roll over the skin should remain dry for this method to be success
the skin seems to be about 4 inches (10 cm) per second. ful as dampness retards the rate of cooling of the skin
The sweeps are repeated in a rhythm of a few seconds on and may delay rewarming. Wrapping the ice in thin plas
and a few seconds off, until all the skin over trigger and tic (bag or wrap) will prevent moisture from touching
reference areas has been covered once or twice. the skin (a factor which Dr Janet Travell insisted, in a
10 Associated therapeutic mod a l ities and tech n i q u es 235
personal communication to JD, was of particular impor methods available (see below) and we do u tilize other
tance), but reduces the efficacy somewhat over that of forms of stretching in practice. However, in the clinical
vapocoolants. applications sections of the book where particular areas and
One author (LC) has found that a cold drink can that has muscles are being addressed, with NMT protocols being
been partially filled with water and then frozen is a good described, sometimes with both a European and an American
substitute. The ice-cold metal container can be rolled over version being offered, as well as MET, MFR and PRT addi
the skin and will adequately retain its chilling potential tions and alternatives, it was impractical to include the
without excessive moisture touching the skin. Should many variations available.
dampness be transferred to the skin, this can be blotted The stretching method chosen for this text (MET) is one
as needed with a small cloth. that carries the endorsement of David Simons (Simons et al
Cryostimulators (smooth-ended metal 'hot dog' shaped 1999) as well as some of the leading world experts in reha
instruments that are frozen prior to use) are effective and bilitation medicine (Lewit 1 992, Liebenson 1 996b).
do not produce much moisture. The authors use, and recommend, other stretching
Contrast of cold spray (or alternative method) and hot approaches (if appropriately studied and applied), including
pack can be applied, switching between the two thermal facilitated stretching, active isolated stretching and yoga.
units several times. To use this method, apply the spray These and several other approaches are summarized below.
as described above, and then apply a hot pack (or hot
towel) for 30-60 seconds. Then reapply the cold spray,
followed by hot application. Repeat this 6-8 times to pro FACI LITAT E D STR ETCH I N G
foundly release the soft tissues. This can be followed
This active stretching approach represents a refinemen t of
with a variety of stretches, addressing multiple tissues
PNF and is largely the work of Robert McAtee LMT (McAtee
rather than single muscles, and manual manipulation of
& Charland 1999). This approach uses strong isometric con
any tissues, as needed.
tractions of the muscle to be treated, followed by active
Another substitute for the vapocoolant spray is a neurol
stretching by the pa tient. The main difference between this
ogist's pinwheel, run in a similar manner in parallel
and MET lies in the strength of the contraction and the use
sweeps, which creates a prickling sensation rather than
of spiral, diagonal patterns (see MET notes on pp. 218-219).
the cold sensation (Simons et aI 1 999).
The debate as to how much strength should be used is unre
Whichever method is chosen, the patient should be com
solved. MET prefers lighter contractions than facilitated
fortably supported to promote muscular relaxation and
stretching and PNF because:
should be warm. If the person is cold elsewhere on the
body, a blanket or heating pads may be used to assist in
it is considered that once a greater degree of strength
providing comfort and to discourage muscular tighten
than 25% of available force is used, recruitment is occur
ing. Basmajian (1978) demonstrated that relaxation is an
ring of phasic muscle fibers, rather than the postural
active process, requiring learning as to how to actively
fibers which will have shortened and require stretching
turn off motor unit activity (Simons et aI 1 999).
(Liebenson 1 996a)
it is far easier for the practitioner to control light contrac
These examples of the wide variety of hydrotherapy methods
tions than strong ones
available for both clinical and home application should pro
there is far less likelihood of provoking cramp, tissue
vide a basis for recommendations to patients. A key caution
damage or pain when light contractions rather than
is that wherever heat is applied, cold should follow as the
strong ones are used
final application. The referenced texts are all recommended
researchers, such as Karel Lewit (1992), have demon
for further reading on the subject, particularly Naturopathic
strated that very light isometric contractions, u tilizing
Hydrotherapy by Wayne Boyle and Andre Saine (1988) .
breathing and eye movements alone, are often sufficient
to produce postisometric relaxation and in this way to
facilitate subsequent stretching .
A D DITI O N A L STRETC H I N G TECH N I Q U E S
For these reasons, the modified facilitated stretches that
The methods o f stretching described in this text are largely
have been described in this text are far lighter than the rec
based on osteopathic MET methodology that is itself, in
ommendations in McAtee's excellent text.
part, a refinement of proprioceptive neuromuscular facilita
tion (PNF) methodology. Aspects of PNF are described in
some of the stretching exercises, notably spiral upper limb
PRO P R I O C E PTIVE N E U RO M U SC U LAR
movements, modified into an MET format (see p. 3, and Box
FACI LITAT I O N ( P N F) VA RIAT I O N S
13. 12, p. 478).
Why are we, as authors, not embracing and describing These include hold-relax and contract-relax (Surburg 1 981,
other forms of stretching? There are excellent alternative Voss et aI 1 985).
236 C L I N I CA L A P PL I CAT I O N O F N E U R O M U S C U L AR T E C H N I Q U E S : T H E U P P E R B O DY
Most PNF variations involve stretching that is either 'creep' in Chapter 1, p. 3) seems to be taking place as tissues
passive or passive assisted, following a strong contraction. are held, unforced, at their resistance barrier. Yoga stretching,
The same reservations listed above in the facilitated stretch applied carefully after appropriate instruction, represents an
ing discussion apply to these methods. There are excellent excellent means of home care. There are superficial similari
aspects to their use but the authors consider MET, as detailed ties between yoga stretching and static stretching as described
in this text, to have distinct advantages and no drawbacks. by Anderson (1984). Anderson, however, maintains stretch
ing at the barrier for short periods (usually no more than 30
seconds) before moving to a new barrier. In some settings the
ACTIVE I S O LATE D STRETC H I N G (A I S ) stretching aspect of this method is assisted by the practitioner.
(Mattes 1 995)
Flexibility is encouraged in AIS by using active stretching
B A L L I ST I C STR ETCH I N G (Bea u l ieu 1 98 1 )
(by the patient) to incorporate RI mechanisms. The stretch,
which is performed with the muscle to be stretched in a A series o f rapid, 'bouncing', stretching movements are the
non-loadbearing state, can be assisted by the practitioner or key feature of ballistic stretching. Despite claims that it is an
performed independently. It i ncorporates an active full effective means of lengthening short musculature rapidly,
range of fluid movement of the joint at a medium speed that the risk of irritation or frank inj ury makes this method
eludes the stretch reflex mechanism by being held just past undesirable in our view.
its barrier for only 2 seconds or slightly less.
MET (as detailed in this text) offers the use of either RI or
PIR as well as active patient participation. While AIS does
U S I N G M U LTI PLE TH ERAPI E S
not u tilize the benefits of PIR as MET does, its inhibitory
effect is rapidly achieved by its use of active full range of
Hou e t a l (2002) investigated immediate effects o f several
movement. The deliberately induced irritation in the
therapeutic modalities applied to the upper trapezius mus
stretched tissues is mild and soreness commensurate with
cle of patients with cervical myofascial pain syndrome. The
the degree of irritation produced . However, when the tissue
modalities used included hot pack, active range of motion
is overstretched (beyond light irritation) or held for too long
(ROM), ischemic compression, TENS, stretch with spray,
(beyond 2 seconds), some degree of microtrauma can result,
interferential current and myofascial release techniques, in
which Mattes ( 1995) suggests is not an acceptable exchange
a variety of combinations. Pre- and posttreatment compar
and should be avoided. Additionally, the stretch (myotatic)
isons were made using pain threshold, pain tolerance, visual
reflex can be inappropriately stimulated which will result in
analog scale (VAS) for pain and cervical ROM. 'Results sug
reflexive spasming due to stimulation of muscle proprio
gest that therapeutic combinations such as hot pack plus
ceptors. This is particularly the case in hard, bouncy, high
active ROM and stretch with spray, hot pack plus active
veloci ty movements, which are to be avoided.
ROM and stretch with spray as well as TENS, and hot pack
AIS employs the following factors to (at least in part)
plus active ROM and interferential current as well as
achieve i ts results.
myofascial release technique, are most effective for easing
MTrP pain and increasing cervical ROM.'
Repetitive isotonic contractions (as utilized in AIS) increase
blood flow, oxygenation and nutritional supply to tissues.
In this chapter we have covered a variety of treatment
When tissues are loaded and unloaded heat will be pro
options that allow, as discussed with INIT earlier in the
duced as energy is lost due to friction. Heat is one of the
chapter, a practitioner to move seamlessly from one to
factors that can induce a colloid (the matrix of the myofas
another, incorporating several modalities in a short period
cial tissue) to change state from a gel to a sol (see hystere
of time. Although each of the modalities discussed in this
sis discussion in relation to connective tissue, p. 222).
chapter will have its own effect on the soft tissues, combi
Movement encourages the collagen fibers to align them
nations used together might have a synergistic outcome. It
selves along the lines of structural stress as well as improv
is the opinion of the authors of this text that it is best to
ing the balance of glycosaminoglycans and water and
acquire varied skills so that there are choices that can be
therefore lubricating and hydrating the connective tissue.
made with each patient, customizing the treatment plan as
to what works best, including the possibility of combina
tions of modalities.
YO GA STRETC H I N G (A N D STAT I C STR ETC H I N G)
The remaining chapters of this book discuss protocols for
Adopting specific postures, based on traditional yoga, and regional treatment, incorporating much of what has been
maintaining these for some minutes at a time (combined with discussed here. Even when a particular modality is not
deep relaxation breathing as a rule) allows a slow release of included in the outlined protocol, the reader is reminded
contracted and tense tissues to take place. A form of self that most of them can be woven into the steps in a seamless
induced, viscoelastic, myofascial release (see discussion of fashion to achieve the greatest outcome for the patient.
1 0 Associated therapeutic modal ities a n d techniques 237
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syndrome: Rivista Europea Per Ie Scienze Mediche E Twomey L, Taylor J 1982 Flexion, creep, dysfunction and hysteresis
Farmacologiche 17:41-50 in the lumbar vertebral column. Spine 7(2):11 6-122
Ruddy T J 1962 Osteopathic rapid rhythm..i c resistive technic. Upton A, McComas A 1973 The double crush in nerve entrapment
Academy of Applied Osteopathy Yearbook, Carmel, CA, syndromes. Lancet 2:359-362
p 23-31 Van Buskirk R 1990 Nociceptive reflexes and the somatic dysfunc
Sandler S 1983 The physiology of soft tissue massage. British tion. Journal of the American Osteopathic Association
Osteopathic Journal 15: 1-6 90: 792-809
Schiowitz S 1990 Facilitated positional release. Journal of the Voss D, Ionta M, Myers B 1985 Proprioceptive neuromuscular facili
American Osteopathic Association 90(2): 145-156 tation, 3rd edn. Harper and Row, Philadelphia
Serizawa K 1980 Tsubo: vital points for Oriental therapy. Japan Wall P, Melzack R 1989 Tex tbook of pain. Churchill Livings tone,
Publications, Tokyo London
Shea M 1993 Myofascial release - a manual for the spine and Walther D 1988 Applied k inesiology. Systems DC, Pueblo, CO
extremities. Shea Educational Group, Juno Beach, FL Weinrich S, Weinrich M 1990 Effect of massage on pain in cancer
Simons D, Travell J, Simons L 1999 Myofascial pain and dysfunc pa tients. Applied N u rsing Research 3 : 140--- 1 45
tion: the trigger point manual, vol 1: upper half of body, 2nd Wolsko P, Eisenberg D, Davis R 2003 Patterns and perceptions of
edn. Williams and Wilkins, Baltimore care for trea tment of back and neck pain. Spine 28:292-298
Stewart J 2000 Focal peripheral neuropathies, 3rd edn. Lippincott Xujian S 1990 Effects of massage and temperature on permeability
Williams and Wilkins, Philadelphia of initial lymphatics. Lymphology 23:48-50
f
241
In each region, descriptions are presented of the region's student editions), Clinical Biomechanics by Schafer, Ward's
structure and function, as well as detailed assessment and Foundations of Osteopathic Medicine, Lewit's Manipulative
treahuent protocols. It is assumed that all previous Therapy in Rehabilitation of the Motor System, Liebenson's
'overview' chapters have been read since what is detailed in Rehabilitation of the Spine, 2nd edn, Simons et aI's Myofascial
the clinical applications chapters builds organically from Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd
the information and ideas previously outlined. Although edn, The Physiology of the Joints, Vols 1 & III by Kapandji,
numerous specific citations are included in the following Color AtlasIText of Human Anatomy: Locomotor System, Vol1,
chapters, the authors wish to acknowledge, in particular, 5th edn by Platzer and Cailliet's 'Pain Series' textbooks.
the following primary sources: Gray's Anatomy (39th and
243
Chapter 11
TH E V E RTEBRAL CO LUM N:
A STRUCTU RA L WO NDE R
The first three are flexjble curves while the fourth, the sacral
curve, is inflexible, being composed of fused joints. Each
curve is not only interdependent on the position of the others,
but is also subservient to the center of gravity (CaiUiet 1991).
Centered atop this flexjble (indeed, bendable) mast is 8-12
pounds of additional compressional force - the crallium.
Kapandji (1974), who often presents the body from an
'architectural' point of view, tells us:
In relation to the spine, the tensegrity principle suggests Normal posture implies:
that when the soft tissues around the spine are under appro 1 . there is essentially minimal or no muscular activity needed
priate tension, they can 'lift' each vertebra off the one below to support the head
it. This viewpoint sees the spine as a tensegrity mast, rather 2. the intervertebral discs maintained in proper alignment
than a stack of blocks (Robbie 1977). The suggestion which experience no excessive anterior or posterior vertebral disc
emerges from this theoretical model is that, if the strength annular compression
and tone of ligaments and the soft tissues generally can 3. the nucleus remains in its proper physiologic center
be enhanced, the spine can become more 'tensegrous' and 4. the zygapophyseal joints are properly aligned and do not
functional. bear excessive weight upon the body assuming the erect
When viewed from an anterior or posterior position, the posture
normal spine is seen to be straight. But when viewed from 5. the intervertebral foramina remain appropriately open and
the side (coronal), four superincumbent curves are immedi the nerve roots emerge with adequate space.
ately obvious (Fig. 11.3).
Two lordotic curves (concave posteriorly) are found, one There are four regions of relative instability in the spine,
each in the cervical and lumbar regions, while the thorax and which require particular attention. These are areas where
sacrum display ky photic curvature (convex posteriorly). relatively rigid structures are in direct opposition to more
CLI N I CAL A P P L I CATI O N O F N E U R O M U SC U LA R TEC H N I Q U E S : T H E U P P E R B O DY
Ka pandji (1974) reports: curve), suggesting a dehydration process proportional to the volume of
the n ucleus. When the load is removed, the disc regains its initial
The nucleus rests on the centre of the vertebral plateau, an area l i ned thickness, once more exponentially, and the restoration to normal
by cartilage which is transversed by numerous m icroscopic pores requires a fin ite time. If forces are applied and removed at too short
l inking the casing of the n ucleus and the spongy bone underlying the intervals, the disc does not have the time to regain its initial thickness.
vertebral plateau. When a sign ificant axial force is a pplied to the Similarly, if these forces are appl ied or moved over periods that are too
column, as during sta nding, the water contained within the prolonged (even if one gives time for restoration), the disc does not
gelatinous matrix of the nucleus escapes into the vertebra l body recover its initial thickness. This results in a state a nalogous to ageing.
through these pores. As this static pressure is maintai ned throughout
the day, by night the n ucleus contains less water than i n the morning Rene Cailliet ( 1 99 1 ) explai ns:
so that the disc is perceptibly thinner. I n a healthy individual this
cumulative thinning of the discs ca n amount to 2 cm. Disk n utrition has been wel l-studied (Maroudas et al 1975), and it is
Conversely, during the nig ht, when one lies flat, the vertebral accepted that the vascu lar su pply to the intervertebral d isk is
bodies are subject, not to the axia l force of gravity, but only to that obliterated by calcification of the vertebra l endplates at puberty.
generated by muscu lar tone, which is m uch reduced during sleep. At Disk nutrition is the response considered to occur by diffusion from
this time the water-absorbing capacity of the nucleus draws water variable sol u te concentrations which a re transported i n to the d isk
back into the n ucleus from the vertebral bodies and the disc regains via ( 1 ) blood vessels surrounding the d isk and (2) blood vessels in the
its original thickness. Therefore, one is taller in the morning than at subchondral layers of the endplates.
night. As the preloaded state is more marked in the morn ing the By variations of alternating compressive forces, imbibition has
flexibility of the vertebral col u m n is greater at this ti me. The been postulated to be as im portan t in nutrition of the d isk as it is i n
imbibition pressure of the nucleus is considerable si nce it can reach cartilage, b u t some questions regarding this mechanism in d isk
250 mmHg. With age the water-absorbing abil ity of the disc nutrition are a risi ng. Studies (Maroudas et a11975) have indica ted
decreases, reducing its state of preload ing. This explains the loss of that hydraulic permeability of the d isk m atrix is very low, whereas
height and flexibility in the aged. solute d iffusivity is very high. This wou ld ind icate greater i n fusion of
Hirsch has shown that when a constant load is applied to a disc nutritive sol utes via diffusion than by imbibition. The method by
the loss of thickness is not linear, but exponential (first part of the which the disk receives its nutrition is not yet confirmed.
i f stretched beyond physiological length, the amino acid postural distortions brought on by overuse, strain and trauma
chains may be damaged and will no longer recoil can lead to degenerative changes in the disc, usually accom
the annular fibers course on a diagonal to connect adja panied by muscular dysfunction and often resulting in
cent vertebral endplates chronic pain. Postural dysfunction, once initiated, tends to
each layer of fibers lies in the opposite direction to the lead to further postural compensation and a self-perpetuating
previous layer so that when one layer is stretched by pattern in which dysfunction begets ever greater dys
rotation or shearing forces the adjacent layer is relaxed function.
the cartilaginous end plates of adjacent vertebrae serve as The pathology of the forward head posture is well
the top and bottom of the disc with the annular fibers explained by Cailliet (1991).
firmly attached to both endplates
In this pose the zygapophyseal (facet) joints become
though the discs have a vascular supply in early stages of
maximally weight bearing and their cartilage is exposed
life, by the third decade the disc is avascular
to persistent recurrent trauma.
nutrition to the disc is thereafter in part supplied through
In this increased cervical lordotic posture the interverte
imbibition, where al ternating compression and relax
bral foramina are closed and the nerve roots are poten
ation create a sponge-like induction of fluids (Box 11.1)
tially compressed.
the nucleus, a proteoglycan gel, is approximately 80% water
With prolonged unremitting compression from the pos
the nucleus is completely contained within the com
ture, the zygapophyseal joint capsules can become con
pressed center of the annulus
stricted and even adherent, thus leading to gradual
as long as the container remains elastic, the gel cannot be
structural limitation.
compressed but can merely reform in response to any
With cartilaginous structural changes, a degenera tive
external pressure applied to it
arthritic condition of the facet joints occurs.
the nucleus conforms to the laws of fluids under pressure
If there is also superimposed muscular tension, the com
when the disc is at rest, external pressure applied to the disc
pression is increased and structural tissue changes are
will be transmitted in all directions, according to Pascal's law
precipitated.
when external forces compress the disc, the nucleus
deforms and the annular fibers, while remaining taut, Juhan (19 87) offers further inSights.
bulge.
Because of this posture, the normaL supporting structures
While the design offers optimal conditions of hydraulic (the internaL disc pressure, the intervertebral ligaments, the
support as well as numerous combinations of movements, Ligamentum nuchae, and soforth) now must be suppLemented
248 CLI N ICAL A P P L I CATI O N OF N E U R O M U SCU LAR TECH N I Q U E S : TH E U P PER B O DY
A
,___-- Mastoid
process
---- Posterior
atianlooccipital
Normal disc, Normal disc, Diseased disc, ligament
at rest under loa d under load
Figu re 1 1 .7 The liga mentu m n uchae. Rep rod uced with perm ission
from Gray's Anatomy (2005).
Transverse
process
Foramen
transversarium
Posterior arch
"'--- Posterior tubercle
Figure 1 1 .8 The atlas (C 1 ) appears as a sim ple r ing with the odontoid process of C2 fi l ling the space where the verteb ra l body is missing.
Flexion and extension of the h ead occur between the occipital condyles a n d the su perior a rticu l a r facets of C1. Reproduced with permission
from Gray's Anatomy for Students (2005).
Dens Axis (C2 vertebra) Transverse ligament of atlas ,...---,--- Alar ligaments
Dens
Fig u re 1 1 .9 Rotation of the head occurs primarily between C1 a n d C2 as the atlas encircles the u nique odontoid process of the axis. Flexion
a n d extension occur between the atlas (Cl) a n d the occiput. Reproduced with permission from Gray's Anatomy for Students (2005).
Uncinate process
Vertebral canal
transversarium Spinous process
Figure 1 1 . 1 0 The lower fu nctional u nit is com posed of typica l cerv ical vertebrae and 0, where the cervical spine t ransitions to the thoracic
spine. Reprod uced w i th permission from Gray's Anatomy for Students (2005).
The superior articular facets between Cl and C2 are Except the atlas, all vertebrae have a spinous process that is
designed to allow considerable rotation with very lim palpable most of the time. The portion of the vertebra that
ited flexion and extension of the head or lateral flexion. lies between the spinous process and the transverse process
Excessive movements in these directions might cause is the lamina. When the vertebrae are addressed as a col
odontoidal encroachment upon the spinal cord . umn, each lamina is contiguous with the next, forming a
Minimal sidebending occurs above the C2-3 articulation. trough-like structure next to the spinous processes. This
'trench' is the attachment site of numerous muscles and is
The typical cervical vertebrae (Fig. 11.10) referred to in this text as the lamina groove.
Temporal bone,
petrous part ------- r-------.- Internal acoustic meatus
Foramen magnum,
- --- Anterior atlantooccipital
membrane
posterior border ----t<-;f
'111--- Apical ligament of dens
Posterior atlantooccipital Superior longitudinal band
membrane of cruciform ligament
-____,...:
_ :.: I__---- Posterior longitudinal ligament
jllll"---
Ligamentum flavum -------1
Superior
longitudinal band of
cruciform ligament -----!
Jugular foramen
Anterior edge of
foramen magnum
Alar ligament --------'III...:..;;=iIIII.
B
Figure 1 1 . 12 A: Median sagittal section t h rough the occipita l bone and 1 st to 3rd cervical vertebrae. B: Posterior aspect of atlantooccipital
a n d atla ntoaxial joints. The posterior p a rt of the occipita l bone and the la minae of the cervica l vertebrae have been removed and the
atl antooccipita l joint cavities o pened. Reprod uced with permission from Gray's Anatomy (2005).
of cervical paraspinal tissues. Prevalence estimates range knowledge of the role of these muscles in tension-type
from 0.4 to 2.5% of the general population up to 15-20% of headache awaits further research'.
patients with chronic headaches. CGH affects patients with Understanding the possible etiology, and the structures
a mean age of 42.9 years, has a 4:1 female disposition and involved - as suggested above - should allow treatment
tends to be chronic (Langemark 1987). choices to be more effective.
Almost any pathology affecting the cervical spine has
been implicated in the genesis of CGH as a result of conver LOWER CERV I CA L L I GA M E N TS
gence of sensory input from the cervical structures within
There are four anterior and four posterior intervertebral lig
the spinal nucleus of the trigeminal nerve. The main differ
aments associated with the lower five cervical vertebrae.
ential diagnoses are tension-type headache and migraine
Anteriorly:
eadache, with considerable overlap in symptoms and 1. The relatively thin anterior longitudinal ligament con
fmdmgs between these conditions. No specific pathology
nects the anterior vertebral bodies, merging with the
has been noted on imaging or diagnostic studies which cor
annulus fibrosus anterior to the discs. Its role is to limit
relates with CGH (Haldeman & Dagenais 2001).
extension.
In 1999 a review was conducted to examine the likelihood
2. The annulusfibrosus is the peripheral aspect of the inter
of there being an anatomic relationship between the dura
vertebral disc, made up of laminated, concentric fibers,
mater and the rectus capitis posterior minor (RCPMin) mus
running in oblique directions near the core but tending
cle in the etiology of cervicogenic headaches (Alix & Bates
toward a vertical orientation at the periphery where
1999). These authors note that cervicogenic headaches are
they bind the vertebral bodies together. The attachment
described as 'referred pain perceived in any region of the
to the bodies is very powerful at the periphery of the
head caused by a primary nociceptive source in the muscu
disc (Sharpey's fibers) where they merge with the poste
loskeletal tissues innervated by cervical nerves'. In such
nor and anterior longitudinal ligaments.
headaches the actual source of pain originates not in the head
3. The posterior longitudinal ligament forms an anterior
but in the cervical spine joint complex. Structures innervated
wall for the spinal cord, attaching strongly to the inter
by cervical nerves Cl-3 have been shown to be capable of
vertebral discs (annulus fibrosus) but not to the verte
producing cervicogenic headache pain. Possible sources of
bral bodies (apart from the lips). It is possible for
pain include the C2-3 intervertebral disc annular fibers, mus
ossification or thickening of this ligament to trespass
cles, joints, ygaments and related dura mater of the upper
on the vertebral canal. The role of the ligament is to
cervICal spme. Structural or functional abnormalities can
restrict flexion.
occur in any of these components and manifest during rest or
4. Running between adjacent vertebrae, connecting the
active or passive ranges of motion (Olesen 1990).
inferior aspect of the transverse process above to the
Alix & Bates (1999) hypothesize that: 'Understanding the
superior aspect of the transverse process below and
suggested neurophysiologic mechanism for the cervico
just anterior to the vertebral artery, is the intertrans
genic headache allows for a potential correlation to be
verse ligament. Its role is to check lateral bending and
drawn with the dura-muscular connection obsen1ed by
rotational movement.
!iack et al (l995). ' They note that joint complex dysfunction Posteriorly:
m the upper cervical spine, affecting the dura-muscular
1 . Connecting the lamina of adjacent vertebrae is the
integrity, may activate nociceptors in the trigeminocervical
powerful ligamentum flavum. The stabilizing potential
nucleus receptive field, promoting cervicogenic headache
of this ligament prevents any tendency to folding or
pain, and that nociceptors in the dura mater (Seaman &
buckling of the structures it supports.
interstein 1998) could serve as the primary origin of pain 2. Connecting the spinous processes are the interspinous
m the presence of cervical joint dysfunction.
and the supraspinous ligaments. The latter is continuous
Naturally enough, Alix & Bates see the solution for such
with the ligamentum nuchae posteriorly. The role of
dysfunction hrough chiropractic eyes and advocate high
1 these ligaments is to prevent undue displacement of
veAoCIty mampulatlOn as the treatment of choice in such sit
the vertebrae during flexion and rotation.
uations. The evidence presented throughout this text
3. The ligamentum nuchae represents an inelastic support
should offer a alternative perspective - that appropriately
. mg structure preventing undue cervical flexion and, by
applied soft tissue manipulation, incorporating NMT, can
means of its bridge-like attachment to the dura, protects
commonly achieve similar benefits. Fernandez-de-las Penas
it from folding on translation of the head (see above).
et al (2006) support this alternative approach when they
note tat headache which appear to benefit most from trig
ger pomt deactivatIOn are those where there is tenderness of ASS E S SM E N T O F TH E C E RVI CAL R E G I O N
the muscles attaching to the head. However, Fernandez-de
las Pe as et al caution that although 'myofascial trigger I t can be cogently argued that the success of any treatment
.
pomts m the suboccipital muscles might contribute to the method depends on how appropriate that treatment is
origin and/ or maintenance of headache, a comprehensive (McPartland & Goodridge 1997). Understandably, where
2 54 C LI N I CA L A P P LICAT I O N O F N E U R O M USCULAR TEC H N I QU E S : T H E U PP E R B O DY
movements and/or positioning. Perhaps the greatest limita C2 spinous process is easily palpated on the mid-line
tion of these examinations and tests is the supposition that below the occiput, having the most bifid (double
each test movement need be performed only once [in order] headed) tip of all vertebrae.
to fathom how the patient's complaint responds. The effects C3-5 spinous processes are not as easily palpated as C2
of repetitive movements or positions maintained for pro but careful introduction of slight flexion and extension
longed periods of time are not explored, even though such allows palpation access, unless the cervical musculature
loading strategies might better approximate what occurs in is extremely heavy.
the 'real world'. C4 has the shortest spinous process and is usually level
with the angle of the j aw. However, its transverse
Patterns and co u p ling processes are readily palpable.
C4 (Schafer 1987) or C3 (Hoppenfeld 1976) is at the same
Other 'real-world' factors also need to be kept in mind when level as the hyoid bone anteriorly.
assessing function and one of the most important of these is C4-5 are at the same level as the thyroid cartilage.
that movements should reproduce those actually performed C6 transverse and spinous processes are both easily pal
in daily life. It is, of course, appropriate to evaluate single pated, with a likelihood of a markedly bifid spinous
directions of motion - abduction of the arm, for example - in process in half the population. C6 is at the same level as
order to gain information about specific muscles. In daily the cricoid cartilage anteriorly and presents the carotid
hfe, however, abduction of the arm is a movement seldom tubercle on the anterior surface of its transverse process.
performed on its own; it is usually accompanied by flexion C7 is often mistaken for n, especially if the spinous
or extension and some degree of internal or external rota process is being used for assessment, as neither C7 nor T1
tion, depending on the reason for the movement. is bifid. To ensure that contact is on C7, the practitioner
This highlights the fact that many (most) body move contacts the transverse processes of wha t is thought to be
ments are compound and a great many have a spiral nature C7 and asks the patient to extend the neck. If the contact
(to bring a cup to the mouth requires adduction, flexion and is on C7, the contacts will move anteriorly; if on n, only
internal rotation of the arm). a minimal movement will be noted.
McAtee & Charland (1999) quote from Hendrickson (1995)
who discusses the way in which tissues, such as actin and
F U N CT I O N A L FEATU RES O F THE CERVI CAL
myosin, are organized in spirals microscopically and that 'the
S P I N E (Ca la is-Germ a i n 1993, Jacob &
gross structure of the tendon and ligament is also spiral.
M c Kenzie 1996, Ka ppler 1997, Lewit 1992,
Tendons, ligaments and bones are composed mostly of type I
Schafer 1987)
collagen, which is a triple helix. On the macroscopic level the
long bones, such as the humerus, spiral along their axes'. Anteroposterior movement of vertebrae occurs mainly at
Note also Myers' discussion in Chapter 1 of the spiral nature the fibrocartilaginous intervertebral discs and at the
of fascial interaction throughout the body. zygapophyseal joints, between the inferior facets of the
These observations reinforce the need, when performing superior vertebra and the superior facet of the one posi
assessments, to take accOlmt of movement patterns that tioned below it.
approximate real-life activities, most of which are multidirec The flexibility of the disc and the angle of the facet, to a
tional. In the spine, for example, many movements are 'cou great extent, structurally govern the degree of movement
pled'. It is virtually impossible for a spinal segment to move possible.
on its own without its neighbors being involved to some The superior aspect of the atlas is shaped to articulate
degree, and it is quite impossible for a sideflexion movement with the occipital condyles.
to occur spinally without rotation also occurring (coupling) The body of C2 (axis) is modified superiorly to form a
due to spinal biomechanics. This is discussed further in the peg (odontoid or dens) onto which the atlas slots.
section on cervical motion palpation (pp. 266-270) and in the The remaining five cervical vertebrae have a more typical
section covering thoracic motion (p. 548) (Ward 1997) . structure with facets lying on a plane that angles toward
the eyes. Rotation of the lower five cervical vertebrae there
LAN D M ARKS fore follows the facet planes rather than being horizontal.
Full flexion of the cervical spine prevents any rotation
In order to palpate the cervical spine, its basic landmarks below C2, allowing rotation to take place only at C1 and C2.
need to be identified (Mitchell et a1 1979, Schafer 1987). Full extension of the cervical spine locks C1 and C2 and
The cervical vertebrae (as in the lumbar spine) lie in the allows rotation to occur only below these .
same horizontal plane as their spinous processes (not Cervical biomechanics are unusual. Whereas in the spine
true in the thoracic spine) . below the cervical region it is common for sidebending of a
C1 is not palpable apart from between the mastoid vertebral segment to be accompanied by rotation to the
process and lobe of the ear, where its transverse process opposite side (type 1), this is not the case throughout the
can usually be located. cervical spine (Van Mameren 1992).
256 C L I N ICAL A P P L I CA T I O N O F N E U R O M U S C U LA R TEC H N I Q U E S : THE U P PER B O DY
Adson's test for subclavian artery compression Some practitioners prefer DeKleijn's test, which is performed in the
(Fig. 1 1 . 1 3) same way but with the patient supine and the head free of the
The patient is seated and the practitioner supports the arm at the end of the table, so that it can be held in extension and rotation.
elbow and with the other hand records the radial pulse rate. The patient is asked to keep the eyes open so that the pupils can
While continuing to monitor the pulse, the arm is abducted, be monitored.
extended and externally rotated. This position is held for approximately 30 seconds to eva l uate the
When these movements have been fully realized the patient is onset of d izziness, nausea or syncope (loss of consciousness or
asked to inhale and hold the breath, while turning the head away postural tone) resu lting from decreased cerebral blood flow. Other
from the side being assessed. signs might include tinnitus, vertigo, light headaches, slurring of
If the radial pu lse drops or vanishes or if paresthesia is reported speech or nystagmus.
within a' few seconds, compression of the subclavian artery is The indication of vertebrobasilar ischemia i m plicates comprom ise
implicated, probably as a result of shortening of anterior a nd/or of the vertebral arteries on the side opposite that to which the
middle scalene or possibly 1 st rib restriction. head was turned.
A variation is to move the a rm into fu ll elevation and extension
of the shoulder (arm above head and back of tru nk) after in itial ly
taking the pu lse. If the pulse rate drops or symptoms appear, pec
toralis minor is implicated.
Both variations should be performed since pectoralis m inor and
the sca lenii might both be implicated.
rotation.
Figure 1 1 . 1 3 Adson's test for subclavia n a rtery com p ression. Figu re 1 1 . 1 4 Maig ne's test for vertebral a rtery fu nction.
Compression test (Fig. 1 1 . 1 5) An alternative procedure has all the same elements described
The patient is seated; the practitioner sta nds beh ind. One side is above but in this i nstance the patient extends the head slightly
tested at a ti me. before compression is a pplied.
I nitially, the patient will laterally flex and rotate the head slightly In this variation bi lateral foraminal crowding will be ind uced with
toward the first side to be tested. possible sym ptom reprod uction, or exacerbation, confirm i ng the
The practitioner's fingers are interlocked and the hands placed at etiological features of the problem (disc degeneration, etc.).
the vertex of the patient's head. Firm caudal pressure (5 pounds,
2-3 kilos) is applied Decompression test (Fig. 1 1 . 1 6)
If there is a narrowing of an intervertebral foramen this compres The patient is seated, with the practitioner to one side.
sion test will aggravate the situation, producing pain that may The practitioner cu ps the chin with one hand and the occiput
m irror the patient's symptoms. with the other and introduces a slow, deliberate deg ree of
box continues
2 58 C L I N ICAL A P P L I CATI O N O F N E U RO M USCULAR TEC H N I QU E S : T H E U PP E R B O DY
Figure 1 1.1 5 Cervical com pression test. Figure 1 1 . 1 6 Decom p ression test.
traction, easing the head toward the ceil ing, while sensing for any
protective, defensive barrier which may be produced if tissues are
being irritated by the maneuver.
Extreme care is needed to avoid irritating tissues that may have
been tra umatized, therefore the emphasis is on the key words
'slow a n d deliberate'.
If pain a nd/or other radicu lar symptoms are rel ieved by this test
the i n dication is that na rrowing at one or more i ntervertebral
fora men, bulging of the disc(s) into the spinal ca nal or cervical
facet syndrome exists.
'Relief positions can a lso be demonstrated in which deviations forwa rd-stretched arms, at rotation of the head, in the opposite
occur in the starting position (say, neutral) and are normal ized in d i rection to that of deviation [of the arm during Hauta nt's test],
one or other of the head positions. and at retroflexion [extension] of the head: He found that
Lewit ( 1 985, p. 327) reports: The reaction to changed head deviation seldom occurred in the direction towa rd which the
position in cases of imbala nce is so cha racteristic that we can head was turning or on flexion. In a sign ificant number of cases,
speak of a "cervical pattern': He continues: 'A cervical factor Lewit reports: 'Deviation [of the a rms] d isappears after treatment
[confirmed by Hautant's test] may be present in a l l forms of of [associated cervical] movement restriction, or at least becomes
vertigo and d izzi ness ... In 72 examinations of 69 patients I fou nd m uch less marked, the effect being visible a few minutes after
the most constant phenomenon was i ncreased deviation of the treatment:
arteries. Extreme caution should b e exercised i n palp at Steiner (1994) has discussed the influence of muscles in
ing the regions where these arteries l i e . disc and facet syndromes. He describes a possible sequence
A foramen exists in the lateral aspects of the first six cer as follows.
vical vertebrae through which the vertebral artery and A strain involving body torsion, rapid stretch or loss of
three veins pass. The hard encasement of the transverse balance produces a myotatic stretch reflex response (for
process offers some protection to the vessels but also example, in a part of the erector spinae).
exposes them to danger from ill-advised cervical move The muscles contract to protect excessive joint movement
ments, from chronically dysfunctional vertebral seg and spasm may result if there is an exaggerated response
ments, or from cervical trauma. Cailliet (1991) notes: 'The and they fail to assume normal tone following the strain.
space difference between body and foramen (3-6 mm) The reason for 'an exaggerated response' might be due to
and facet foramen (2-3 mm) indicates that vascular factors such as segmental facilitation (see notes on facili
impingement is most commonly due to encroachment by tation in Chapter 6).
the superior articular process and rarely due to changes This limits free movement of the attached vertebrae,
of the uncovertebral joints.' approximates them and causes compression and bulging
Kappler (1997) reports that in normal individuals, exten of the intervertebral discs and/or a forcing together of
sion and rotation of the occiput produce a functional the articular facets.
occlusion of the opposite vertebral artery. Therefore, Bulging discs might encroach on nerve roots producing
excessive or prolonged rotation of the cervical spine is to disc syndrome symptoms.
be avoided, particularly in the elderly, where even tem Articular facets, when forced together, produce pressure
porary occlusion of this vessel might significantly reduce on the intra articular fluid, pushing it against the confin
cranial arterial flow or venous drainage (see Box 11 .5 for ing facet capsule, which becomes stretched and irritated.
tests for circulatory dysfunction) . The sinuvertebral capsular nerves may therefore become
Circulatory return from the head and neck area can be irritated, provoking muscular guarding and initiating a
compromised by various compression possibilities relat self-perpetuating process.
ing to thoracic outlet syndrome. These include crowding
of neural and vascular structures by: Steiner continues, 'From a physiological standpoint, correc
1. anterior and middle scalenes tion or cure of the disc or facet syndromes should be the rever
2. clavicular and 1st rib dysfunction sal of the process that produced them, eliminating muscle
3. pectoralis minor and upper ribs. spasm and restoring normal motion'. He argues that before
Lymphatic drainage from the cervical region that has to discectomy or facet rhizotomy is attempted, with the all-too
pass through the thoracic inlet/ outlet is easily restricted frequent 'failed disc syndrome surgery' outcome, attention to
by these same biomechanical features. the soft tissues and articular separation to reduce the spasm
should be tried, to allow the bulging disc to recede and/ or the
facets to resume normal motion. Clearly, osseous manipula
tion often has a place in achieving this objective but the evi
CERV I CA L S P I N A L DYS F U N CTI O N
dence of clinical experience indicates that soft tissue
While Janda (1988) acknowledges that it is not known approaches also produce excellent results in many instances.
whether dysfunction of muscles causes joint dysfunction or
vice versa, he points to the undoubted fact that they greatly ASSESS MENTS
influence each other and that it is possible that a major ele
Strength tests (Da n i e l s 8 Worth i ng h a m 1980)
ment in the benefits noted following joint manipulation
derives from the effects such methods have on associated A standard scale of, say, 5 (normal) to 0 (no contraction
soft tissues. occurs) should be used to record findings of strength (see
260 C L I N ICAL A PP L I CATI O N O F N E U RO M U S C U LA R TECH N I QU E S : TH E U PP E R B O DY
Juguloomohyoid node
;r>,--- External jugular vein
Figure 1 1 . 1 8 Lym phatic system of the neck. Reprod uced with perm ission from Gray's Anatomy for Students (2005).
discussion below). These strength tests involve, by their palpable trigger points in affected (weak) muscles,
nature, isometric contractions as the patient attempts to notably those close to the attachments
move against the resistance offered by the practitioner. trigger points in remote muscles for which the tested
Lewit (1985) points out that such tests may induce pain muscle lies in the target referral zone
that is likely to be of muscular origin. Although these tests trigger points in synergists or antagonists to the tested
are designed to evaluate muscular strength, if pain is muscle.
induced, implicating particular muscles, this too should Muscle strength is most usually graded as follows.
have diagnostic value. If muscles test as weak, the reason
Grade 5 is normal, demonstrating a complete (100%)
for this is often excessive tone in their antagonists that recip
rocally inhibit them Qanda 1988). See upper and lower range of movement against gravity, with firm resistance
crossed syndromes in Chapter 5 for a full discussion of the offered by the practitioner.
implications of the chain reaction of influences as some Grade 4 is 75% efficiency in achieving range of motion
muscles become excessively hypertonic and their antago against gravity with slight resistance.
nists are almost constantly inhibited. Grade 3 is 50% efficiency in achieving range of motion
In the absence of atrophy, weakness of a muscle may be against gravity without resistance.
Grade 2 is 25% efficiency in achieving range of motion
due to:
with gravity eliminated.
compensatory hypotonicity relative to increased tone in Grade 1 shows slight contractility without joint motion .
antagonistic muscles Grade 0 shows no evidence of contractility.
1 1 The cervical reg i o n 261
Box 1 1 .7 Whiplash
The term 'whiplash' was first coined by Dr Harold Crowe ( 1 928). preva lence rate in the neck inj u ry group was 1 3 times greater than
Thirty-six years later, he commented in a fol low-up article (1 964) the leg fracture group'. Pa in threshold levels were significantly lower,
that: This expression was intended to be a description of motion, tender point cou n ts were higher and qual ity of life was worse in the
but it has been accepted by physicians, patients and attorneys as the neck injury patients as compared with leg inj u ry subjects. Over 2 1 %
name of a disease; and the misunderstanding has led to its o f the patients with neck inj u ry (none o f whom had chronic pain
misappl ication by many physicians and others over the years: problems prior to the inju ry) developed fibromyalgia within 3.2
'Whip' impl ies two forces in different directions, opposing each months of tra u ma as agai nst only 1 .7% of the leg fracture patients
other in a differential motion. When applied to the experience of (not sign ifica ntly different from the genera l population). The
trauma, there may a l so be a jerk, jolt, stress or stra in and those may researchers make a particu lar point of noting that, 'In spite of the
include a shear or torque force that affects the load deformation. injury or the presence of fibromya lgia, all patients were employed at
The soft tissues, including the l igaments and joint capsules of a l l the time of examination a n d that i nsurance claims were not
affected joints, may exceed their elastic limits, resulting in plastic associated with increased fibromyalgia symptoms or i m paired
deformation that incl udes tissue tears, ruptures and loss of functioning'.
mechan ical properties. Why should whiplash-type injury provoke fibromya lgia more
Although discussions of 'whiplash synd rome' (acceleration effectively than other forms of tra u ma? One answer may l ie in
deceleration injury) usually revolve around motor veh icle the role of rectus capitis posterior mi nor, part of the suboccipital
accidents (MVAsl. a whiplash effect on the spine (particu la rly the g roup, details of which are found on pp. 52 and 294 (Hallgren
cervical region) ca n also occu r as a result of 'sl i p and fall', bicycle et a l 1 993, 1 994).
accidents, horse riding injuries, sport inju ries and recreational Dommerholt (2005) notes:
occurrences. The fol lowing discussions pri marily involve MVAs since
There is no question that people with persistent pain following
these a re com mon and a lso because of the substantial forces that
whiplash suffer from widespread cen tral hyperexcitability, which can
resu lt from them.
cause seemingly exaggerated pain responses, even with low-intensity
True whiplash injuries are norma lly thought of as relating to
nociceptive input (Banic et 01 2004, Curatola et a1 2001, 2004,
'non-impact' trauma. However, Taylor & Taylor (1 996) state that:
Munglani 2000). Persistent pain following whiplash may start with
A large proportion of cervical spinal injuries are secondary to head the so-called 'wind-up' of dorsal ham neurans and activation of
impact. A comparison of the nature and distribution of cervical spine N-methyl-O-aspartate receptors. These phenamena can lead to central
injuries in those subjects with primary head impact, and those with sensitization and its hallmark characteristics of allodynia and hyper
out head injury but with primary acceleration of the torso (i.e. sensitivity, which, in animal models, can persist even after peripheral
whiplash), fails to reveal significant differences in the nature and dis noxious input has been elimina ted. Persisten t pain following whiplash
tribution of injuries. thus can be considered a dysfunctional pain disorder (Lindbeck 2002).
Whiplash-associated disorders (WAD) account for upwards of 20%
of compensated traffic injury claims in some regions (Cassidy 1 996). Treatment choices for whiplash?
Cassidy states that when over 3000 whiplash claims were analyzed With common whiplash symptoms ranging from radiating neck and
by the Quebec Task Force they found that 'The vast majority of WAD arm pain to chronic headache and virtually incapacitating d izziness
victims recovered q uickly, but that 1 2.5% of claimants still [being] and imbalance, WAD has attracted a wide range of (apparently
compensated 6 months after the collision accounted for 460/0 of the mostly useless) treatment strategi es.
total cost to the insurance system'. Collars are probably con traindicated for whiplash ... they irritate jaws,
The Quebec Task Force has classified whiplash-related d isorders fosterjoint adhesions, and lead to tissue atrophy. Physicians can be
as fol lows (Spitzer et al 1 995). blamed for prescribing too many drugs . . . most of which are probably
Category I: neck complaint without musculoskeletal signs such as an ugly approach to whiplash. Physiotherapists are chided for exces
loss of mobility sive passive modalities which not only do no good, but by their
Category I I : neck complaint with m uscu loskeletal signs such as repeated failure can help convince the poor suffering patien ts that all
loss of mobility is lost. Among the chiroproctors repeated manipulations can also fos
Category I I I : neck com plaint with neurological signs ter illness behavior. but short-term manipulation and mobilization
Category IV: cervical fracture or d islocation may be helpful. (Allen 1996)
Research suggests that 75% of persons with sign ificant whiplash Dr Allen, whose opinion is quoted above, is a world authority on
injury recover in approximately 6 months and over 90% by the end whiplash and his views are based on both experience and research
of the first year following the accident, irrespective of age or gender, and a re therefore deserving of respect. Contrary viewpoi n ts (Schafer
as demonstrated in Ca nadian, Swiss and Japa nese studies (Cassidy 1 987) and clinical experience suggest that short-term use of cervical
1 996, Radanov 1 994). collars and NSAID medication d u ring the acute phase, postwhiplash,
may be helpful. However, it is our opinion that illness behavior and
Variations in response to WAD retardation of healing can certainly be promoted by a nything other
Why do some of these traumatic soft tissue sprains not heal when than a brief use of such approaches.
most do? The answer for some researchers suggests tearing of the
end plates of discs and damage to facet joints (Taylor 1 994). What happens in a collision?
A study involving over 1 00 patients with traumatic neck injury as Ea rly studies suggested that in rear-end a utomobile accidents the
well as approximately 60 patients with leg trauma eva luated the trauma occu rring in the cervical spine related to hyperextension
presence of severe pa in (fibromya lgia syndrome) an average of 1 2 a nd/or hyperflexion of the neck. Cu rrent seat and head su pport
months posttrauma (Buskila & Neumann 1 997). The fi ndings were design tend to prevent hyperextension and yet whiplash injuries do
that 'Almost all symptoms were significa ntly more prevalent or not appea r to have lessened and research has tried to assess the
severe in the patients with neck inj u ry ... The fibromya lgia reasons for this apparent anomaly.
box continues
262 CLI N I CA L A P PLI CAT I O N O F N E U R O M U SC U LA R TECH N I Q U E S : THE UPPER B O DY
;
T ,
" .
Cervical damage resulting from rear-end accidents seems to could be classified as 'excel lent' in 37, 'fai r' i n 1 8, with 1 0
relate d irectly to the position i n itially adopted by the injured fai l u res. 'Fa i l ure was most freq uently d u e t o ligament pain and
individual d u ring the incident, with those leaning forward anteflexion [Le. flexion) headache; the most frequent site of
experiencing compressive stresses as well as hyperflexion inju ries blockage was between atlas and axis: lewit's methods in these
and those seated u pright or reclining experiencing initial extension, cases involved 'manipulation', which incorporates, in his
with no compressive cervical damage. The speed of im pact, the defin ition, soft tissue approaches such as MET and trigger point
weight of the target car in relation to that of the bullet ca r, road deactivation.
viscosity and skid marks, as well as different directions of impact and Dommerholt (2005) em phasizes a central viewpoint:
car design features, all add obvious va riations to these basic fi ndings
There are importan t consequences when central pain mechanisms
(Delany 2006, Gough 1 996). Of substa ntial im portance is the change
and MTrPs are included in the differential diagnosis and in the man
in velocity measured as d istance over time (feet per second, m iles
agement ofpatients with persistent pain following whiplash. Once
per hour) ; sim ply put, this is the amount of time it takes for the
structural lesians have been ruled out with magnetic resonance imag
accident to occur from beginning to end. If the overall time of the
ing, computed tomography scans, and radiography. clinicians should
col l ision is increased, the acceleration factors are reduced, resu lting
consider that MTrPs can contribute to and maintain central sensitiza
in less force tra nsference to the occupant cage.
tion phenomena. Eliminating the painful peripheral input is likely to
break the pain cycle, discontinue dysfunctional pain patterns, and
All in the m i nd?
facilitate the return to a productive and pain-free life. Adding the
lewit ( 1 999) places whiplash i n context w h e n he says:
iden tificotion and treatment of MTrPs to the clinical toolbox can pro
The high incidence of traumatic neurosis [following whiplash-type vide patients with hope and optimism.
injuries] must be put down to mismanogement; in the vast mojority of
We bel ieve that the methods outlined in this text, in which a
cases without gross neurological findings doctors not troined in the
comprehensive soft tissue approach is recommended, involving NMT,
manual diagnosis of movement restriction and segmental reflex
MET, PRT, MFR and massage, as well as rehabilitation methods, offer
change come to the disastrous conclusion that there ore no 'organic
the best opportunity for successfu l ly treating the majority of
findings', and hence dismiss the trouble as 'functional', i.e. 0 psycho
patients suffering the seq uels of whiplash, as long as fu l l and
logical disturbance.
accurate assessments are undertaken before and during treatment.
In treating patients with whiplash and concussion (the sym ptoms In some cases active manipu lation (mobil ization or high-velocity
of wh ich differ only in minor ways, accord ing to lew itl. he found thrust) may a lso be required but it is strongly suggested that soft
that out of a series of 65 patients, he achieved results that tissue approaches be a ttempted initially.
For efficient muscle strength testing, it is necessary to places a stabilizing hand on the upper posterior thoracic
ensure that: region and the palm of the other hand on the occiput as
the prone patient slowly extends the neck against this
the patient builds force slowly after engaging the barrier
resistance. The suboccipital muscles are tested if this
of resistance offered by the practitioner
extension movement concludes with a 'tipping' back
the patient uses maximum controlled effort to move in
wards and caudad of the occiput.
the prescribed direction
Assessment of rotational strength (Fig. 11.19C) evaluates
the practitioner ensures that the point of muscle origin is
sternocleidomastoid, upper trapeZius, obliquus capitis
efficiently stabilized
inferior, levator scapula, splenius capitis and cervicis (and
care is taken to avoid use of 'tricks' by the patient, in
to a secondary degree the scalenii and transversospinalis
which synergists are recruited.
group). The practitioner stands in front of the seated
patient and places a stabilizing hand on the posterior
Strength tests for the cervical region
aspect of the shoulder with the other hand on the patient's
Assessment of flexion strength (Fig. 1l. 19A) evaluates
cheek on the same side, as the patient slowly turns the head
sternocleidomastoid, longus colli and capitis, rectus capi
ipsilaterally to meet the resistance offered by the hand.
tis anterior and lateralis (and to a secondary degree the
Assessment of sidebending (lateral flexion) strength (Fig.
scalenii and hyoid muscles). If a group of muscles tests as
1l. 19D) involves the scalenii and levator scapula (and to a
weak this could involve inhibitory influences from their
secondary degree rectus capitis lateralis and the transver
antagonists.
sospinalis group). The practitioner places a stabilizing hand
The practitioner places a hand on the forehead of the
on the top of the shoulder to prevent movement and the
supine patient and the other hand on the sternum (to pre
other hand on the head above the ear as the seated patient
vent thoracic flexion) as the patient slowly attempts to
attempts to flex the head laterally against this resistance.
flex the neck against this resistance.
Assessment of extension strength (Fig. 1l.19B) evaluates
upper trapezius, splenius capitis and cervicis, semi
Palpation of sym m etry of m ovem ent - general
spinalis capitis and cervicis, erector spinae (longissimus
capitis and cervicis) and, to a secondary degree, levator As is so often the case when comparing anatomy texts, there
scapulae and the transversospinalis group. The practitioner exists disagreement as to the normal ranges of motion of the
1 1 The cervical region 263
A B
c o
Figu re 1 1 . 1 9 Va rious strength tests for the cervica I region. A : Flexion. B : Extension. C: Rotation. D : Sid ebending (latera l flexion).
structures of the cervical region. The authors have offered The normal range of flexion is approximatel y 500 (Mayer
approximate ranges below which are intended to guide the et al 1994). If pain is noted when full, unforced flexion
practitioner in assessing joint motion (Fig. 11 .20). has been achieved (and if meningitis and radicular pain
Lewit (1985) suggests the patient be seated with the have been ruled out), Lewit maintains that this probably
shoulder girdle stabilized with one hand as the other hand indicates restriction of the occiput on the atlas. If, how
guides the head into flexion. ever, there is pain after the head has been in flexion for
15-20 seconds (see McKenzie notes, p. 213), it is probably
The chin (mouth closed) should easily touch the sternum ligamentous pain. This is especially corrunon in individu
and any shortness in the posterior cervical musculature als who display hypermobility tendencies. Headaches will
will prevent this. be a likely presenting symptom with extreme sensitivity
2 64 C L I N I CA L A P P L I CATI O N O F N E U RO M U SC U LA R TECH N I Q U E S : T H E U P PER B O DY
Figure 1 1 .2 0 Though there is d isagreement as to exact 'normal' deg rees of cervical movement, these offer approximate ra nges. Reprod uced
with perm ission from Kapandji ( 1 998).
noted on palpation of the lateral tip of the transverse important in this assessment to avoid chin poking
process of the axis. (which would induce anterior translation of the mid
Normal range of extension is approximately 70 (Mayer et cervicals), but to maintain the chin relatively fixed.
al 1994). Extension should be assessed but with caution
relating to possible interference with cranial blood sup
ply. During extension, an increased degree of 'bulging' of Functional evaluation of fascia l postural patterns
distressed intervertebral discs may occur, along with a Zink & Lawson ( 1979) have described methods for testing
folding of the dura and anteriorly directed pressure on tissue preference.
the ligamentum flavum, any of which could produce a
degree of increased symptomatology, including pain. There are four crossover sites where fascial tensions can
The normal range of lateral flexion is 45 (Mayer et al most easily be noted: occipitoatlantal (OA), cervicotho
1994). When testing sidebending (lateral flexion) of the racic (CT), thoracolumbar (TL) and lumbosacral (LS).
cervical spine, the side toward which lateral flexion is tak These sites are tested for rotation and side flexion prefer
ing place is stabilized. If the shoulder on the side from ence.
which lateral flexion is taking place is stabilized, upper Zink's research showed that (assessing the occipitoat
trapezius is being evaluated. lantal pattern first) most people display alternating pat
The normal range of rotation is approximately 85 (Mayer terns of rotatory preference, with about 80% of people
et aI 1994). showing a common pattern of left-right-left-right (L-R-L-R,
1. With the patient seated, gentle rotation around a verti termed the 'common compensatory pattern' or CCP).
cal axis is carefully performed as symmetry and qual Zink observed that the 20% of people whose compensa
ity of movement are evaluated. tory pattern did not alternate had poor health histories
2. Full flexion rotation is then performed to assess sym and low levels of 'wellness' and coped poorly with stress.
metry of rotational movement of the occiput and C2. Treatment of either CCP or uncompensated fascial pat
3. The practitioner is standing behind the seated patient. terns has the objective of trying as far as possible to cre
With the neck upright, the patient's chin is actively ate a symmetrical degree of rotatory motion at the key
drawn toward the neck (without flexion of the remain crossover sites.
der of the cervical spine) while the practitioner's other The methods used to achieve this range from direct mus
hand cradles the occiput in order to direct subsequent cle energy approaches to indirect positional release tech
rotational movement of the head. Rotational restric niques and high-velocity thrusts.
tion with the head in this position indicates dysfunc
tion localized to C2 and C3. Assessment of tissue preference. This basic Zink &
4. With the head and neck in extension, rotation increas Lawson assessment (as described in Box 1.7, Chapter 1) has
ingly focuses on the lower cervicals (the greater the been elaborated on by clinicians who suggest that the
extension, the lower the segment involved). It is assessment described above (and in Box 1.7, Chapter 1)
11 The cervical region 265
j
1. Was there an 'alternating' pattern to the tissue preferences, Once a barrier of resistance is identified, several treatment
and was this the same when supine and when standing? options are open to the practitioner.
11 The cervical region 267
j
1. If a shortened soft tissue structure is identified during uses a series of movements involving all the variables
assessment, holding tissues at their barrier of resistance available (flexion, ex tension, sideflex ion both ways,
and then waiting allows a slow passive myofascial release rota tion both ways, translation, compression, traction),
to occur (as in holding a yoga posture for several minutes seeking in each the most easy, relaxed, comfortable
and then being able to move further in that direction). response from the tense, distressed tissues under palpa
2. If a shortened soft tissue structure is identified during tion. Each tested direction of movement commences
assessment, holding tissues at their barrier of resistance from the combined positions of ease previously identi
and having the patient attempt to push further in that fied, so that the final position represents a 'stack' of
direction, using no more thiw 20% of strength for 7 sec positions of ease. This is held for 90 seconds before a
onds, against the practitioner's resistance, produces an slow release and retesting occurs.
isometric conh'action of the antagonists to the tissues 7. Changes of a dysfunctional nature (fibrotic, contracted,
restricting movement (the agorusts) which would produce etc.) might be palpated in the shortened soft tissues and
a reciprocal inhibition effect (MET) and allow movement to after the tissues had been placed in a shortened state, the
a new barrier - or through it if stretching was being used. area of restriction could be localized by a flat compression
3. If a shortened soft tissue structure is identified during (thumb, finger, heel of hand). The patient then initiates a
assessment, holding the tissues at their barrier of resist slow stretching movement that would take the muscle to
ance and having the patient attempt to push away from its full length while compression is maintained, before
that barrier, using no more than 20% of strength for 7 returning it to a shortened state and then repeating the
seconds, against the practitioner's resistance, produces exercise. This is a form of active myofascial release (MFR).
an isometric contraction of the agonists which would 8. The soft tissues of the area could be mobilized by means
produce a postisometric relaxation effect (MET) and allow of massage techniques, including neuromuscular nor
movement to a new barrier - or through it if stretching maliza tion of areas of dysfunction and reflexogenic
was being used. activity discovered during palpation (NMT).
4. In examples 2 and 3, an alternative is to introduce a 9. The joints and soft tissues of the area can be mobilized
series of very small rhythmic contractions (20 contrac by careful articulation movements, which take the tissues
tions in 10 seconds, rather than a 7-second sustained through their normal ranges of motion in a rhythmic
one) toward or away from the resistance barrier pulsed
- painless sequence, so encouraging greater range of
MET (Ruddy's approach) - in order to achieve an motion. This approach actively releases and stretches
increase in range of movement. If the pulsa ting contrac the soft tissues associated with the joint, often effectively
tions are toward the restriction barrier, this wiH effec mobilizing the joint without recourse to manipulation.
tively be activating the antagonists to the shortened soft 1 0. A suitably trained and licensed individual could engage
tissues that are restricting movement. This action the restriction barrier identified during motion palpa
would therefore induce a series of minute reciprocal tion and u tilize a high-velocity thrust (HVT) to overcome
inhibition influences into the shortened tissues. Note: the barrier.
Ruddy's method should not be confused with ballistic
All these examples indicate different ways in which assess
stretching. Ruddy specifically warns against 'bounce'
ment becomes treatment, as a seamless process of discovery
occurring during the pulsations, which because they
leads to therapeutic action.
involve the merest initiation and cessation of an action
are extremely small in their amplitude, designed to both
produce a series of small isometric contractions as well Caution
as reeducate proprioceptive function. When MET is used in relation to joint restriction, no stretch
5. If a barrier of resistance was noted when (as an example) ing should be introduced after an isometric contraction,
flexion of the neck was being tested, the cause might lie only a movement to the new barrier. This is also true of
in a restriction (shortening of the muscles) which would MET trea tment of acute soft tissue dysfunction. Therefore,
move the area in the opposite direction, in this example for acute m uscular problems and all joint restrictions:
the extensors. If the principles of strain--cou nterstrain
identify the barrier
(SCS) are being used as part of positional release
introduce MET
methodology (PRT), an area of localized tenderness or
move to the new barrier after release of the contraction.
pain should be sought in the shortened m usculature
(extensors) and this point should be used as a monitor Any sense that force is needed to move a joint, or that tis
(press and score '10') as the area is positioned to take the sues are 'binding' as movement is performed, should
pain down to a score of '3' or less. This position of ease inform the hands of the practitioner that the barrier has
is then held for 90 seconds (see guidelines for SCS, been passed or reached.
including Goodheart's approach, in Chap ter 10). Only in chronic soft tissue conditions is stretching
6. An alternative positional release method (PRT) might beyond the restriction barrier introduced, never in joint
involve functional technique, in which the practitioner restrictions.
268 CLI N I CA L A P P L I CATI O N O F N E U R O M U SC U LA R TECH N I Q U E S : THE U P PER B O DY
[
The following examples offer a means of exploring the The patient is supine while the practitioner sits or stands
therapeutic possibilities that emerge from assessment meth at the head of the table.
ods that uncover restrictions. The clinical language used The patient's head is supported in both the practitioner 's
derives from osteopathic medicine. hands with middle and/or index fingers immediately
inferior to the occiput, b ilaterally.
The fingers assess tissue change as the hands take the
U p per cervical dysfunction assessm ent ( F i g . 1 1.23)
head into lateral translation one way and then the other
To test for dysfunction i n the upper cervical region, the (a 'shunt' movement along an axis; simple translation
patient lies supine. side to side, without rotation or deliberate sideflexion).
The practi tioner passively flexes the head on the neck Translation assessment is performed with the head in a
fully, with one hand, while the other cradles the neck. neutral position, as well as in flexion and also in extension.
Since flexion locks the cervical area below C2, evaluation As translation occurs in a given direction (say, toward the
is isolated to a tlantoaxial rotation where half the gross right), a sideflexion is taking place to the left and there
rota tion of the neck occurs. fore, in the case of the occiput/atlas, rotation is occurring
With the neck flexed (effectively 'locking' everything to the right (refer to notes on spinal coupling earlier in
below C2), the head is then passively rotated to both left this section, p. 255).
and right. It is far safer (and much simpler) to use translation in
If the range is greater on one side, this is indicative of a order to evaluate sideflexion and rota tion than it would
probable restriction which may be amenable to soft tissue be to perform these movements at each articulation.
manipulation trea tment or HVT. Two sets of information are being received from the
If rotation toward the right is restricted compared with hands as the translation movement takes place.
rotation toward the left, the indication is of a 'left rotated 1. The relative ease of movement left and right as trans
atlas' or, in osteopa thic terminology, an atlas which is lation is performed.
'posterior left' (as the transverse process on the left has 2. The changes in the tissue tone and texture as transla
moved posteriorly). tion takes place. There may also be reported discom
Treatment options discussed above can then be utilized fort, either in response to the movement or to the
by means of engaging the barrier and introducing MET palpation of suboccipital tissues.
1 1 The cervical region 269
Because spinal biomechanics decree that sidebending and is used as the start point for the next sequence of assess
rotation take place in opposite directions at the occipitoat ment. In no particular order, the following ranges and
lantal j unction, the following findings would relate to any directions of motion are tested, seeking always the easi
sense of restriction (' bind') noted (using the same example) est position to 'stack' onto the previously identified posi
during flexion and translation toward the right. tions of ease as evaluated by the 'listening hand'.
1. Flexion/extension
1. The occiput is extended and rotated left and sideflexed
2. Sidebending left and right
right (this describes the positional situation of the struc
3. Rotation left and right
ture involved - the occiput in relation to the a tlas).
4. Anteroposterior translation
2. This same restriction pattern can be described differently,
5. Side-to-side translation
by saying that there is a flexion, right rotation, left side
6. Compression / traction
flexion restriction (this describes the dysfunctional pattern,
Once ' three-dimensional equilibrium' has been ascer
i .e. the directions toward which movement is restricted).
tained (known as dynamic neutral), the patient is asked to
Treatment choices might include the following. inhale and exhale fully, to identify which stage of the
cycle increases 'ease', and then asked to hold the breath
NMT. Application of soft tissue manipulation methods,
in tha t phase for 10 seconds or so.
deep massage and neuromuscular techniques to the soft
The combined position of ease is held for 90 seconds
tissues of the area which display altered tone or tissue
before slowly returning to neutral.
texture, followed by reassessment of range of motion.
MET. Takes the occiput/atlas to its restriction barrier, Note that the sequence of movements is not relevant, pro
either using simple translation (as in the assessment) or vided that as many variables as possible are employed in
into full flexion, right rotation, left sideflexion, in order to seeking a combined position of ease. The effect of this held
engage the restriction barrier before introducing a light position of ease is to allow neural resetting to occur, reduc
isometric contraction toward or away from the barrier for ing muscular tension, and also to encourage dramatically
7 seconds, and then reassesses the range of motion. better circulation through previously tense and possibly
PRT. Takes the occiput/atlas away from its restriction ischemic tissues. Following this sequence, a direct inhibitory
barrier, either into translation to the left, in the direction method (such as cranial base release - see Box 11.11) is used
opposite that in which restriction was noted, or into to further release the suboccipital musculature.
extension, left rotation, right sideflexion to disengage
from the restriction barrier, and waits for 30-90 seconds
, TRA N S LAT I O N ASS E SS M E NT F O R C E RV I CA L
for a positional release change to occur. Range of motion
" S P I N E (C2-7)
is then reassessed .
HVT. A high-velocity thrust could be performed (by a The following assessment sequence is based on the work of
suitably l icensed individual) by taking the structures to Philip Greenman DO ( 1989). In performing this exercise, it
their restriction barrier and then rapidly forcing them is important to recall that normal physiology dictates that
through the restriction barrier. sidebending and rotation in the cervical area below the axis
are type 2, i.e. segments that are sidebending will automati
All these methods would be successful in certain circum
cal ly rotate toward the same side. Most cervical restrictions
stances. The MET and PRT choices, as well as the applica
are compensations and will involve several segments, all of
tion of NMT, would be the least invasive. HVT may be the
which will adopt this type 2 pattern. Exceptions occur if a
only choice if the less invasive measures fail.
restriction is traumatically induced by a direct blow to the
joint, in which case there might be sidebending to one side
F U N CT I O N A L R E LEASE OF ATLANTO O CC I PITA L and rotation to the o ther - type 1 - which is the physiologi
J O I NT cal pattern for the rest of the spine.
The patient is supine. To easily palpate for sidebending and rotation, a side-to
The practitioner sits at the comer of the head of the table, side translation movement is used, with the neck in
facing the patient's head from that corner. slight flexion or slight extension.
The caudal hand cradles the occip ut with opposed index When the neck is absolutely neutral (no flexion or exten
finger and thumb controlling the atlas. sion, an unusual state in the neck) true translation side to
The other hand is placed on the patient's forehead. side is pOSSible.
The caudal hand (,listening hand') searches for feelings As a segment is translated to one side, it is au tomatically
of 'ease', 'comfort' or 'release' in the tissues surrounding sidebending to the opposite side and because of the bio
the atlas as the hand on the forehead directs the head into mechanical rules which govern i t, it will be rotating to
a compound series of motions. the same side.
As each motion is ' tested', a point is found where the tis The practitioner is seated or standing at the head of the
sues being palpated feel at their most relaxed or easy. This supine patient.
270 C LI N I CA L A P P L I CATI O N O F N E U R O M U SC U LA R T E C H N I Q U E S : T H E UPPER B O DY
A C E RVI CA L T R EATM E N T : S E Q U E N C I N G
Infrahyoid muscles
T hyroid
2"iif;
-----------
F i g u re 1 1 .2 9 Fascia of the neck, transverse view, Reprod uced with permission from Gray's Anatomy for Students (2005),
(i,e, cervical spine is treated when the upper extremity is second plane - splenius capitis, splenius cervicis, levator
addressed) , scapula (levator scapula anatomy given with prone posi
Beginning in a supine position (especially the first ses tion, p. 436)
sion or two) allows the pa tient to communicate more eas third plane - semispinalis capitis, semispinalis cervicis,
ily when tenderness is found since the face is not transversus thoracis, longissimus thoracis, most superior
obscured by the table (European (Lief's) NMT applied to portion of iliocostalis (thoracic muscles with thorax, p. 558)
the posterior aspect of the body is a lmost always per fourth (deep) plane - the suboccipital muscles, rotatores,
formed with the pa tient prone, from the outset.), multifidus, interspinalis muscles.
A reclining position for the patient reduces the muscle's
The muscles listed in the various planes, when contracting
weight-bearing responsibilities and is usually preferred
unilaterally, usually provide movements similar to others
over upright postures (sitting or standing), although
on the same plane (superficial plane - contralateral head
upright postures can be used in some areas,
rotation; second plane - ipsilateral head rotation; third
Alternative body positions such as sidelying postures
plane - lateral flexion; fourth (deep) plane - fine contralat
may be substituted where appropriate, although they are
eral rotation or sideflexion). All of these muscles, when con
not always described in this text.
tracting bila terally, extend the spine or head, with the
Note: The instructions in this text are given for the right
exception of rectus capitis posterior minor, which attaches
side of the neck but both sides of the spine should always
to the dura via an anteriorly oriented bridge and pulls pos
be treated to avoid instability and reflexive splinting,
teriorly on the d ura ma ter to prevent it from folding on
which may occur if only one side is addressed.
itself or on to the spinal cord during anterior transla tion of
the head (Hallgren et al 1994).
C E RVI CAL PLA N ES AN D LAY E R S Confusion may occur when considering the information
offered above if the reader is thinking in terms of layers of
When addressing multiple muscles simultaneously, a s occurs
muscles, rather than muscular planes. For exa mple, when lay
during the cervical larnina groove treatment, it is very useful
ers are considered, we see that the second layer at the supe
to envision them in layers. Ii the direction of fibers is known
rior aspect of the cervical lamina is semispinalis capitis
for each muscle and the muscles residing in each layer are
(deep to trapezius), whereas in the lower cervical region the
considered, it is much easier to ascertain which tissues are
splenii comprise the second layer (also deep to trapezius)
being palpa ted and which are involved when tenderness,
and semispinalis capitis there forms the third layer.
contracture or fibrosis is revealed. These palpation skills are
Developing palpation skills to provide quick reference to
enhanced by a comprehensive knowledge of anatomy, partic
involved muscula ture is very useful in NMT. Understanding
ularly in regard to fiber arrangement and the muscle layers.
movement and relationships of synergists and antagonists is
However, when considering movement (or movement
also helpful. Orientation to muscular planes (for movement
dysfunctions) of the cervical region, it is also helpful to
dysfunctions) as well as muscular layers (for palpation) are
think in terms of muscular planes. In the posterior neck
both discussed and illustrated by Kapandji (1974). Knowing
(Kapandji 1974), these would be:
the direction and approximate length of fibers and tendons
superficial plane - trapezius and sternocleidomastoid will assist in quickly locating trigger point si tes.
(posterosuperior part) (SCM anatomy with an terior cer Upper portions of the trapezius are included here with
vical muscles, p. 300) the posterior cervical muscles since it is the most superficial
1 1 The cervical region 275
Upper fibers
Lower fibers Headache over or into the eye or into the temporal a rea
Pain in the angle of the jaw
Neck pain and/ or stiff neck
Pain with pressure of clothing, purse or luggage
strapped across upper shoulder area
S pecial notes
further down the body (in the spine, pelvis or feet). Therefore,
fibers of the upper trapezius may be active when the patient is
sitting or standing in order to make adaptive compensations
for structural distortions or strained postures.
If the muscle is in a shortened state the occiput will be
pulled inferolaterally via very powerful fibers. Due to its
attachments, trapezius has the potential to directly influ
ence occipital, parietal and temporal function, which
should be noted in cranial therapy.
The motor innervation of trapezius is from the spinal por
tion of the XI cranial (spinal accessory) nerve. Originating
within the spinal canal from ventral roots of the first five cer Fig u re 1 1 .3 1 The outermost fibers of u pper trapeziu s may be ro i led
vical segments (usually), it rises through the foramen mag between the t h u m b a n d fingers to identify ta u t bands. Eleva tion of
the elbow of the trea ting hand may red uce stra i n on the wrist.
num, exiting via the jugular foramen, where it supplies and
wh ich may be ind icated in this i l l ustration. Referred pattern d rawn
sometimes penetrates sternocleidomastoid before reaching a
after Simons et a l ( 1 999).
plexus below trapezius (Gray 's Anatomy 2005). Dpledger
points out that hypertonus of trapezius can produce dys
function at the jugular foramen with implications for acces
sory nerve function, so increasing and perpetuating tested and stabilizing it. The other hand is placed on the
trapezius hypertonicity (Dpledger & Vredevoogd 1983). ipsilateral side of the head and the head /neck is taken
Research by Lundberg et al (1994) showed that psychological into contralateral sidebending without force while the
stress increased muscular activity in trapezius and that this shoulder is stabilized. The same procedure is performed
was accentuated, in addition to any existing physical load. on the other side with the opposite shoulder stabilized. A
Fibers of upper trapezius initiate rotation of the clavicle comparison is made as to which sidebending maneuver
to prepare for elevation of the shoulder girdle. Any position produced the greater range and whether the neck can
that strains or places the trapezius in a shortened state for easily reach 45 of sideflexion in each direction, which it
periods of time without rest may shorten the fibers and lead should. If neither side can achieve this degree of
to dysfunction. Long telephone conversations, particularly sidebend then both upper trapezius muscles may be
those which elevate the shoulder to hold the phone itself, short. The relative shortness of one, compared with the
working from a chair set too low for the desk or computer other, is evaluated.
terminal and elevation of the arm for painting, drawing, 3. The patient is seated and the practitioner stands behind
playing a musical instrument and computer processing, with a hand resting over the muscle on the side to be
particularly for extended periods of time, can all shorten assessed. The patient is asked to extend the arm at the
trapezius fibers. Overloading of fibers may activate or per shoulder joint, bringing the flexed arm/ elbow backwards.
petuate trigger point activity or may make tissue more vul If the upper trapezius is stressed on that side it will inap
nerable to activation when a minor trauma occurs, such as a propriately activate during this movement. Since it is a
simple fall, minor motor vehicle accident or when reaching postural muscle, shortness in it can then be assumed (see
(especially quickly) to catch something out of reach. discussion of postural muscle characteristics, Chapter 2).
Trigger points in the upper trapezius (Fig. 11 .31) are some 4. The patient is supine with the neck fully (but not force
of the most prevalent and potent trigger points found in the fully) sidebent contralaterally (away from the side being
body and are relatively easy to locate (Simons et al 1999). assessed). The practitioner stands at the head of the table
They are easily activated by day-to-day habits and abuses and uses a cupped hand contact on the ipsilateral shoul
(such as repetitive use, sudden trauma, falls) and also by der (i.e. on the side being tested) to assess the ease with
acceleration/ deceleration injuries ('whiplash'). They are which it can be depressed (moved caudally). There
often predisposed to activation by postural asymmetries, should be an easy 'springing' sensation as the practi
including pelvic tilt and torsion that require postural com tioner pushes the shoulder toward the feet, with a soft
pensations by these and other muscles (Simons et aI 1999). end-feel to the movement. If depression of the shoulder
is d ifficult or if there is a harsh, sudden end-feel, upper
trapezius shortness is confirmed.
Assessm ent of u pper trapezi u s fo r sho rtness
5. This same assessment (always with full lateral flexion)
1. See scapulohumeral rhythm test (pp. 91-92) which helps should be performed with the head fully rotated con
identify excessive activity or inappropriate tone in leva tralaterally, half turned contralaterally and slightly
tor scapula and upper trapezius that, because they are turned ipsila terally, in order to assess the relative short
postural muscles, indicates shortness. ness and functional efficiency of posterior, middle and
2. The patient is seated and the practitioner stands behind anterior subdivisions of the upper portion of the trapez
with one hand resting on the shoulder of the side to be ius (see also p. 279) .
1 1 The cervical region 277
The patient's head should then be rotated away from the The prachhoner applies light pressure with the palm
treated side and sideflexed toward the tender point until through the skin and slides the skin on the neck toward
the pain score drops to 3 or less. the cranium lU1.til skin restriction is felt. This pressure will
In some cases light extension of the cervical spine assists Simultaneously stabilize the neck in its sidebent, rotated
in achieving this degree of sensitivity reduction. position.
The final position is held for not less than 30 and up to 90 The practitioner laterally tractions the skin lU1.der the
seconds before a slow return to a neutral position. palm placed on the shoulder to its restriction barrier and
simultaneously presses the shoulder caudally and later
M YO FAS C I A L R E LEASE O F U PP E R TRAPEZ I U S ally lU1.til a firm barrier of the skin and muscles lying
between the hands is felt.
The patient is seated erect. Feet are separated to shoulder The practitioner maintains the traction of the skin and
width and placed flat on the floor below the knees; arms myofascia of the region for 90-120 seconds. As the pres
hang freely. sure is maintained, a softening of the tissues between the
The practitioner stands to the side and behind the patient hands may be felt. As this occurs, the hands may traction
with the proximal aspect of the forearm closest to the the tissue further until the next barrier is encountered.
patient resting on the lateral aspect of the muscle to be Caution should be exercised with the cervical hand so as
treated (Fig. 11 .36A). The forearm is allowed to glide not to strain the neck. The shoulder-side hand is used to
slowly medially toward the scapula/ base of the neck, aU apply the most traction while the cervicaUy placed hand
the while maintaining a firm but acceptable pressure stabilizes the neck and skin with only enough pressure to
toward the floor. engage the skin to avoid lU1.due stress on the cervical region.
By the time the contact arm is close to the medial aspect Varying the placement of the shoulder-side hand as well
of the superior border of the scapula, the practitioner's as the angle of lateral flexion will vary the fibers being
treatment contact will be with the elbow itself. addressed.
As this slow glide is taking place, the patient should The finger pads may be used and more precisely placed
equally deliberately be sidebending and turning the head to address specific portions or bands found in the upper
away from the side being treated, having been made trapezius. The center of the muscle fibers may be
aware of the need to maintain an erect Sitting posture all stretched more precisely with this method.
the while (Fig. 1 1 .36B) .
The pressure being applied by the practitioner's fore Making sense of the tissue layers
arm/ elbow contact should be transferred through the
upright spine toward the ischial tuberosities and ulti As we look at the posterior cervical region, the trapezius,
mately the feet. No slump should be allowed to occur in which lies superficial and extensively covers the upper back,
the patient's posture. is immediately obvious. With its remova l, a complex, often
If areas of extreme tension are encolU1.tered by the practi confusing array of short and long extensors and rotators are
tioner 's moving arm, it is useful to maintain firm pres revealed. While the names of these muscles are similar, their
sure into the restricted area while the patient can be distinctions become apparent when the systems by which
asked to slowly return the head to the neutral position they are associated and differentiated are lU1.derstood.
and to make several slow rotations and lateral flexions of There are many useful ways to interpret these muscles
the neck away from the treated side, altering the degree and to group them by performance.
of neck flexion as appropriate to ensure maximal tolera One could group those muscles that erect and laterally
ble stretching of the compressed tissues. flex the spinal column (erector spinae group) and lie for
Separately or concurrently, the patient can be asked to the most part on a vertical line.
stretch the fingers of the open hand on the side being Those muscles that traverse the spine on a diagonal line
treated toward the floor, so adding to the fascial 'drag' (transversospinal group) rotate the column.
which ultimately achieves a degree of lengthening and All of these muscles bilaterally extend the spine.
release.
PIa tzer (1992) further breaks these two groups into lateral
SEM I S P I N A L I S CERVI C I S
Attachments: Transverse processes o f Tl-5(6) t o the spin-
ous processes of C2-5
Innerva tion: Dorsa l ra mi of the cervical nerves
-tl--+--f+--- Ligamentum nuchae
Muscle type: Postural (type I), shortens when stressed -fi----- Splenius capitis
Function: Unila tera lly, flexes the neck to the same side and
contralaterally rota tes the cervical spine; bilaterally
"jt----- Levator scapulae
ex tends the spine
S yne rg i sts : For rotation of the neck: contralateral splenius cer
vicis and levator scapula, and ipsilateral multifidi and
rotatores
For extension of the neck: splenius cervicis, longissimus t-.,--\::----- Splenius cervicis
cervicis, semispinalis capitis, levator scapula, multifidi
Antagonists: For extension of the neck: anterior neck muscles,
including infrahyoids and prevertebral muscles
Mlr'I--'T1'r::::t,;::".",-*---- Deep back
Ind ications for treatment
Headache (especially cervicogenic)
Reduced flexion of head and neck Figure 1 1 .40 The diagonal bands of splenii are rea d i ly identified
Possibly other painfully restricted motion when g l i d i n g in the l a m i n a g roove, as no other muscles have a
s i m i l a r d i rection of fiber. Reprod uced with permission from Gray's
Anatomy for Students (2005J.
Special notes
The semispinalis muscles are powerful ex tensors of the
head and neck. They comprise the second and third muscu Elongation of the tissues after the gliding techniques as well
lar layer in the upper medial half of the posterior neck and as home care stretching is suggested for this region.
the third and fourth layers in the lower medial half where
the splenii overlie them.
S P LE N I I ( F I G S 1 1 . 4 0 , 1 1 . 4 1 )
The large, thick occipital a ttachment of semispinalis capitis
is often mistaken as the trapezius tendon, which is thinner Attachments: Splenius capitis: lower half of ligamen tum
and overlies it. Trapezius and semispinalis capitis both have nuchae, spinous processes and supraspinous ligaments
the ability to entrap the greater OCCipital nerve, which usually of lower four cervical and upper 3-4 thoracic vertebrae,
passes through them on its way to supply the scalp with sen coursing diagonally to the mastoid process and occipital
sory branches (Simons et al 1999, p. 455). This nerve also sup bone (just deep to the SCM)
plies motor branches to the semispinalis capitis itself. Due to Splenius cervicis: spinous processes of T3-6 coursing diag
this entrapment possibility, chemodenervation of the semi onally to the transverse processes of the upper two or
spinal is capitis muscle has been suggested in an a ttempt to three cervical vertebrae
provide migraine symptom relief (Mosser et aI 2004). Innervati on: Dorsal rami of the middle and lower cervical
The semispinalis capitis may be divided by one or more nerves (varying from C1 to C6)
tendinous inscriptions, which allow the fibers split by them Muscle type: Postural ( type I), shortens when stressed
to have separate endplate zones. Because of the varying Function: Extension of the head and neck and ipsilateral
lengths of fibers, trigger point occurrences will be widely rotation and flexion (questionable on capitis) of the head
distributed throughout the posterior cervical region. The and neck
gliding techniques described above will assess the upper Synergists: For extension: posterior cervical group, espe
half of both semispinalis capitis and cervicis, although in cially semispinalis muscles
some areas they lie in the third and fourth layers, which For rotation: contralateral SCM, trapezius, semispinalis cer
makes them more difficult to distinguish. vici5, rotatores, multifidus and ipsilateral leva tor scapula
In addition to the gliding techniques, unidirectional Antagonists: To extension: SCM, prevertebral muscles and
transverse friction (snapping across the fibers in one direc hyoid muscles
tion - see spinalis muscles, p. 286) may be used as long To rotation: ipsila teral SCM, trapezius, semispinalis cervicis,
as care is taken not to impact the spinous processes. rota tores, multifidus and con h'alateral levator scapula
284 CLI N I CAL A P P L I CATI O N O F N EU R O M U S C U LAR TEC H N I Q U E S : TH E U PP E R B O DY
Splenius capitis
Splenius cervicis
Lower TrP
F i gu re 1 1 .41 The combined pa tterns of splen i i trigger poi nt target zones of referra l . D rawn after Simons et a l (1 999).
Ind ications for treatment Headache ( to vertex of head) and neck pain as well as
blurred vision can result from trigger point activity in sple
'Stiff neck' nius capitis (Simons et al 1999). Headache with explosive
Pain p roduced by rotation
pressure 'in the eye' is a frequent complaint, therefore glau
Pain in head, especially the eyes coma and other eye pathologies should be ruled out in
Blurred vision
addition to addressing trigger points within these and other
cervical and cranial muscles. Cold wind or drafts across the
Specia l notes neck tend to activate trigger points in these two muscles.
Cervical articulation d ysfunctions are often associated with
The splenii are often distinguished in the second layer of the splenii, particularly C1 and C2.
posterior cervical muscles as a diagonal band lying in the lam The splenii are implicated in spasmodic torticollis (TS),
ina groove which runs from the lower mid-line of the cervical along with the contralateral SCM (Hasegawa et al 2001).
region to the upper cervical transverse processes and to the Deuschl et al ( 1992) reported:
mastoid process j ust under the posterior aspect of the stern
ocleidomastoid attachment. They (capitis more easily than Rotating TS (72% of the patients) was due to dystonic
cervicis) can often be palpated during the gliding tech activity of the splenius muscle ipsilateral to and/or the ster
niques described above, as the thumb glides caudally on the nocleidomastoid muscle contralateral to the side of chin
second (sometimes third) row of the lamina since the two deviation. One-third of these patients had also dystonic acti
muscles lie directly under the skin in this area and are not vation of the contralateral splenius muscle and, rarely, the
obscured by other muscle fibers. contralateral trapezius muscle. Ten patients had laterocollis
The cranial attachment of splenius capitis crosses the due to dystonic activation of all recorded muscles on one
suture between the temporal and the occipital bones just side of the neck. Nine patients had retrocollis due to activity
posterior to the mastoid. As Upledger & Vredevoogd ( 1983) of both splenius muscles and rarely additional activity in
point out, contraction of splenius capitis causes the squa both trapezius muscles.
mous portion of the temporal bone to rotate posteriorly
while producing internal rotation of the petrous portion.
Crowding of the occipitomastoid suture, they state, can
f N M T TE C H N I Q U ES F O R S P LE N I I T E N D O N S
contribute to a wide range of symptoms including head The mid-bellies of the splenii are addressed in the gliding tech
pain, dyslexia, gastrointestinal symptoms and personality niques previously discussed. Their cranial attachments are
problems. The cranial attachments are addressed with the treated with the suboccipital assessment. However, the spinal
suboccipital region on pp. 292-297. attachments may be assessed here with a special procedure
1 1 The cervical region 285
As the left hand rotates the head, the right hand should
rotate with the neck as if glued to the back of the neck.
This rotating movement will 'open the pocket' by pas
sively shortening the upper trapezius fibers while
angling the thumb toward the nipple of the contralateral
breast and against the lateral surface of the spinous
processes.
The thumb pad should press toward the ceiling as the
right thumb slides into the 'pocket' formed anterior to
the trapezius.
If the area does not allow penetration, or if pressure of
A the thumb produces more than moderate discomfort,
light sustained pressure is applied to the 'mouth' of the
pocket until the tissues relax enough to slide in further
(Fig. ll .42B,C).
Pressure is directed toward the ceiling, as the thumb is
positioned j ust lateral to the spinous processes.
Appropriate pressure is applied continuously for 8-12
seconds, which will often provoke a referral pattern if
active trigger points are encountered. Pressure can be
maintained for up to 20 seconds. If the tissue is involved,
it will likely be intolerant to friction.
The thumb will be pressing into the tendons of the sple
nius capitis and splenius cervicis superficially.
The thumb should then sink more deeply into the pocket
B (caudally) as the pressure release technique is repeated.
When taut fibers stop the thumb's caudal movements,
mild to moderate static pressure may produce more
relaxation of the surrounding tissue and may allow the
thumb to slide further down the spinal column. This step
may also address a small portion of the rhomboid minor,
serratus posterior superior, semispinalis capitis, cervicis
and thoracis, spinalis cervicis, multifidi and rotatores,
since these muscles attach within the lamina of this area.
If tender, repeat the entire process 3-4 times during a sin
gle session.
c This step will help restore cervical rotation as well as
reduce tilting pull on the transverse processes of Cl-3.
Figure 1 1 .42 A-C: The thumb slides i nto a 'pocket' formed anterior
Surrounding tissue may also be treated by adj usting the
to the trapezi us while rem a i n i n g posterior to the tra nsverse process
to d i rectly p a l pate a portion of l ower splenii. thumb position and its direction of pressure.
S P I N A L I S CAPITIS A N D C E RVI C I S
that allows the thumb to be placed deep to the trapezius and
Attachments: Spinous processes of C7-T2 and lower portion
directly onto a portion of the spinal attachments. Dr Raymond
of ligamentum nuchae to the (cervicis) spinous process of
Nimmo referred to this procedure as the 'corkscrew tech
C2-4 or (capitis) b lending with semispinalis capitis
nique' (Chaitow 1996a, Nimmo 2001).
Innervation: Dorsal rami of spinal nerves (C2-TlO)
No pressure should be applied until the hand is correctly Muscle type: Postural (type I), shortens when stressed
positioned and the head is rotated. Function: Flexes the spine laterally to the same . side and
The fingers of the right hand cup across the back of the (bilaterally) extends the spine
base of the neck, like a shirt collar (C6-7 area). Synergists: For lateral flexion: longissimus, semispinalis cer
The right thumb is placed anterior to the trapezius and vicis, splenius cervicis, iliocostalis cervicis
posterior to the lower cervical transverse processes, For extension: posterior cervical group
pointing caudally. Antagonists: For lateral flexion: contralateral fibers of the
The left hand is used to rotate the head ipsilaterally, i.e. same muscle and contralateral fibers of its synergists
toward the side being treated (Fig. 1l .42A). For extension: prevertebral group
286 C L I N I CA L A P P L I CATI O N OF N E U R O M USCU LAR TEC H N I Q U E S : THE U P P E R B O DY
The spinalis muscles represent the most centrally located head to the same side and ex tends the head when bila ter
fibers of the three muscular columns commonly referred to ally active
as the erector spinae group. Longissimus components lie Synergists: Semispinalis capitis, spinalis capitis, longis
intermediately while iliocostalis has the most la teral influ simus cervicis
ence on the positioning of the torso and spinal column. Antagonists: Fibers of its contralateral synergists
Repeat the gliding steps for the lamina groove while cervicis, longissimus capitis and cervicis, spinalis cervicis
Antagonists: Fibers of i ts contralateral synergists
increasing the pressure (if appropriate) to penetrate to
the spinalis muscles, which lie deep to the semispinalis
muscles. Ind ications for treatment of long issi mus m uscles
When trigger point tenderness or contractures are
revealed, individual examination and appropriate releases Loss of range of motion in flexion and rotation
may be applied, such as static compression, muscle energy Pain behind, below or into the ear region, into the eye
techniques and pOSitional release. region and down the neck (trigger point referral pa ttern)
Transverse, snapping friction may be applied to tissues
that have a more fibrotic quality as long as evidence of Specia l notes
inflamma tion is not present.
The fingertips of the contralateral hand (nails cut short) The longissimus muscles represent the intermediate verti
are used to apply the techniques. cal column of muscular tension tha t erects the torso and
The hand lies across the back of the neck with the finger head . The cranial attachment of longissimus capitis lies
tips curled so that they lie in the lamina of the opposite deep to both splenius capitis and sternocleidomastoid. It
side. usually has a tendinous inscription transversing it so that i ts
While avoiding contact with the spinous processes, the upper and lower fibers would have separate endplate zones
fingertips are transversely snapped across the fibers as if and, therefore, two locations for potential central trigger
plucking a guitar string. point formation.
The snapping transverse friction is applied repea tedly to The fibers of the longissimus muscles are addressed with
the most fibrotic fibers, which are then lengthened the gliding strokes and transverse friction techniques previ
through stretching. ously mentioned within this section. The occipital attach
Microtrauma of the tissues is an almost certain outcome ment is a ddressed with the suboccipital techniques on
of such attention, requiring appropriate attention to avoid p. 292. Hydrotherapy applications appropriate to the condi
excessive posttreatment discomfort and the patient's tion of the tissues as well as stretching techniques may be
commitment to stretch the tissues daily throughout the used both in the treatment session and at home.
repair phase.
Ice applica tions can be used both immediately following
I LI O C O STA L I S C E RV I C I S
treatment and a lso as home care, coupled with carefully
employed active elongation of the involved m uscles. Attachments: The superior aspect o f the angles o f the
Active movement methods may follow immediately in 3rd-6th ribs to the posterior tubercles of the transverse
the treatment session and should also be added to the processes of C4-6
home care program to encourage parallel connective tis Innervation: Dorsal rami of lower cervical nenres (C6-8)
sue repair (see Chapter 1). Muscle type : Postural (type I), shortens when stressed
1 1 The cervical region 287
Function: Laterally flexes the spine and extends the spine M uscle type:.Postural (type I), shortens when stressed
when bilaterally active Function: When these contract unilaterally they produce
Synergists: For extension: splenius cervicis, semispinalis cer contralateral rotation; bilaterally, they ex tend the spine
vicis, longissimus cervicis Synergists: Multifidi, semispinalis cervicis
For lateral flexion: scalenii, longus capitis, longus colli Antagonists: Matching contralateral fibers of rotatores as
Antagonists: Contralateral fibers of scalenii, longus capitis, well as contralateral multifidi and semispina lis cervicis
longus colli and fibers of contralateral iliocostalis cervicis
Ind ications for treatment
Speci al notes
Pain and tenderness at associated vertebral segments
The iliocostalis muscles represent the most lateral vertical Tenderness to pressure or tapping applied to the spinous
column of muscles of the back. They extend segmentally processes of associa ted vertebrae
from the most caudal attachments of the erector spinae
group at the sacrum, iliac crest and thoracolumbar fascia to
Speci a l notes
the cervical vertebrae. While no ind ividual fibers span the
entire length, these segments work dynamically to erect the Multifidi and rotatores muscles comprise the deepest layer
spine. A l though iliocostalis does not a ttach to the cranium, of posterior cervical muscles and are responsible for fine
it influences cranial posi tioning through its attachment to control of the rotation of vertebrae. They exist through the
the cervical spine. entire length of the spinal column and the multifidi a lso
Fibers of iliocostalis cervicis are influenced in the most broadly attach to the sacrum after becoming appreciably
lateral gliding strokes of the posterior cervical lamina as the thicker in the lumbar region.
thumb glides along the posterior aspect of the transverse These muscles are often associated with vertebral segments
processes. Further applica tions of gliding as well as trans that are difficult to stabilize and should be addressed
verse friction are used in a prone position, which is dis throughout the spine when scoliosis is presented. Discomfort
cussed later in this section (p. 320). or pain provoked by pressure or tapping applied to the spin
ous processes of associated vertebrae, a test used to identify
dysfunctional spinal articulations, also often indicates multi
M U LT I F I D I
fidi and rotatores involvement.
Attachments: From the articular processes o f C4-7 these Trigger points in rotatores tend to produce rather localized
muscles cross 2-4 vertebrae and attach to the spinous referrals whereas the multifidi trigger points refer locally and
processes of higher vertebrae to the suboccipital region, medial scapular border and top of
Innervation: Dorsal rami of spinal nerves shoulder. These local (for both) and d istant (for multifidi) pat
Muscle type: Postural (type I), shortens when stressed terns of referral continue to be expressed through the length
Function: When these contract unilaterally they produce of the spinal column. In fact, the lower spinal levels of multi
ipsilateral flexion and contralateral rotation; bila terally, fidi may also refer to the anterior thorax or abdomen.
they extend the spine In addition to the deepest level of gliding techniques sug
Synergists: For rotation: rota tores, semispinalis cervicis, gested above for the cervical lamina groove (when appro
scalenii, longus capitis, longus colli priate), the fibers may be treated with sustained digital
Antagonists: Ma tching contralateral fibers of multifid i as pressure, such as tha t used in trigger point pressure release.
well as contralateral rota tores, semispinalis cervicis, Unless contraind icated, contrast hydrotherapy (alternating
scalenii, longus capitis, longus colli heat and cold applications) may be applied several times for
short intervals (10-15 seconds), which often profoundly
releases the overlying muscles so that these deeper tissues
Indications for treatment
may be more easily palpated.
Chronic instability of associated vertebral segments
Reduced flexion of neck
I N T E R S P I N ALES
Restricted rotation (sometimes painfully)
Suboccipital pain (referral zone) Attachments: Connects the spinous processes o f contigu
Vertebral scapular border pain (referral zone) ous vertebrae, one on each side of the interspinous liga
ment, in the cervical and lumbar regions
Innervati o n : Dorsal rami of spinal nerves
ROTATO RES LO N G U S AN D B R EV I S
Muscle type: Postural ( type I), shortens when stressed
Attachments: From the transverse processes o f each verte Function: Extends the spine
bra to the spinous processes of the second (longus) and Synergists: All posterior muscles and especially multifidi,
first (brevis) vertebra above (ending at C2) rota tores and intertransversarii
Innervation: Dorsal rami of spinal nerves Antagonists: Flexors of the spine
288 C L I N I C A L A P P L I CAT I O N O F N E U RO M U S C U LA R TE C H N I Q U E S : T H E U P P E R B O DY
L
New Zea land physiotherapist Brian Mul ligan ( 1 992) has described a
series of extremely effective mobi lization with movement techniques
for the spinal joints. In this summary only those relating to the
cervical spine a re detailed, a lthough precisely the same principles
a pply wherever they are used. M u l l igan high ly recommends that the
work of Kaltenborn ( 1 989) relating to joint a rticulation be studied,
especially that relating to end-feel (see Cha pter 1 3).
These mobilization methods carry the acronym SNAGs, which
stands for 'sustained natural a pophyseal glides'. They are used to
im prove function if any restriction or pain is experienced on flexion,
extension, sideflexion or rotation of the cervical spine, usu a l ly from
C3 and lower. (There are other more special ized variations of these
techniques for the u pper cervicals, not described in this text.)
In order to apply these methods to the spine, it is essential for the
practitioner to be aware of the facet ang les of those seg ments being
treated. These are discussed in the structure portion of this chapter.
It should be reca l led that the facet ang les of C3-7 lie on a plane
which angles toward the eyes. Rotation of the lower five cervical
vertebrae therefore follows the facet planes, rather than being
horizontal (Kappler 1 997, Lewit 1 985).
Notes on SNAGs
Most appl ications of SNAGs com mence with the patient weight
bearing, usually seated.
They are movements which are actively performed by the patient,
in the direction of restriction, while the practitioner passively
holds a n area (in the cervical spine it is the segment i m m ediately
cephalad to the restriction) in a translated direction.
In the cervical spine the direction of tra nslation is a l most always
anterior, a long the plane of the facet articulation, i.e. toward the
eyes. Fi g u re 1 1 .43 Mobi lization for cervical rotation restriction using
In none of the SNAGs appl ications should any pain be experi the SNAG method.
enced, although some residual stiffn ess/soreness is to be a ntici
pated on the fol lowing day, as with most mobilization
approaches.
In some instances, as well as actively movin g the head and neck This contact, against the tip of the spinous process, acts as a
toward the direction of restriction while the practitioner main 'cushion', as the other thumb is placed agai nst the lateral aspect
tains the translation, the patient may usefu lly a pply 'overpressure' of the 'cush ion' th umb, reinforci ng the contact.
in which a hand is used to reinforce the movement toward the The practitioner's hands rest over the lateral aspect of the
restriction barrier. neck.
The patient is told that at no time should pain be experienced The practitioner gl ides the spinous process a long its a rticulation
and that if it is, a l l active efforts should cease. plane (toward the eyes) until slack has been removed (a very
Reasons for pain being experienced could be: small a mount of translation, gl ide, will be noted). The 'force' used
1 . the facet plane may not have been correctly followed is a pplied by the superimposed thumb, not the one in contact
2. the incorrect segment may have been selected for translation with the spinous process, which acts as a cushion to avoid dis
3. the patient may be attempting movement toward the barrier comfort on the spinous process tip.
excessively strongly. The sustained glide/translation is maintained as the patient turns
If a painless movement through a previously restricted barrier i s the head and neck in the direction of restriction or pain. Th is
achieved w h i l e t h e translation is held, t h e same procedure is per should be pain free and have a greater range, if the correct spin
formed several times more. ous process is receiving the a ppropriate translation. Mul ligan
There shou ld be an i nstant, and lasting, fu nctional im provement. says: 'Remember to try more than one [seg mental] level if your
The use of these mobi lization methods is enha nced by normaliza first choice is painfu l . There is a tendency to locate on the spin
tion of soft tissue restrictions and shortened m uscu lature, using ous process below the appropriate one, or rather, this has often
NMT, MFR, MET, etc. been so in my case:
If pain is sti l l noted or the range is not painlessly increased, the
Treatment of l i mited cervical rotation or pain practitioner should recheck and identify the correct segment and
on rotation repeat the process.
The patient is seated with the practitioner standing behind. As rotation is carried out by the patient, the practitioner's
The restricted segments will have been identified using normal ha nds follow the movement so that the angle of translation is
pal pation methods. constant.
The practitioner places the medial aspect of the distal phalanx of If a new range is achieved this should be held for several seconds
one thumb agai nst the spinous process of the vertebra,
. cephalad before return ing to the start position and repeating the process
to the dysfu nctional vertebra. several times.
box continues
1 1 The cervical region 289
Identical mechanisms are used for treatment of sideflexion, flexion Self-treatment using SNAGs
and extension restrictions. The anterior gl ide/translation is Mulligan suggests using a small hand-towel to engage the spinous
mainta ined as the restricted movement is actively introduced by the process, with the patient holding the ends of the towel to introduce an
patient, with a l l the cautions and recommendations as above. anterior pu l l and therefore a gl ide/translation of the engaged segment.
It is i m portant to remember that as fu l l flexion is ach ieved, the At the same time, the restricted movement is slowly performed.
direction of glide will be more or less horizontal (always toward the We have found that this is even more effectively achieved if the
eyes) and during extension it will be more vertical. pa tien t places the hands behind the neck, with one middle (or index)
Mulligan reminds the reader to ensure that the end of ra nge is finger on the appropriate spinous process (previously identified by
maintained for severa l seconds before a return to neutra l and that the practitioner and shown to the patient). The other m iddle (or
the g lide/tra nslation should be ma intai ned until neutral is resumed. index) finger is superi mposed on the initial contact and the patient
An additional caution relating to extension dysfunction a rises g l ides the segment anteriorly, toward the eyes. This process w i l l have
because as extension is introduced, the approximation of the spinous been explained by, and practiced with, the practitioner.
processes makes localization of contact more difficult. Mul ligan The restricted movement is then carried out (sideflexion, rotation,
states: 'This is especially true if the neck being treated is smal l and etc.), while the translation is maintained. After the end of range has
your thumbs a re of a generous size. This is where "self SNAGs" are been achieved, the translation is susta ined until a neutra l neck
marvelous: position is resumed.
Ind icati ons for treatment Innervation: Dorsal and ventral rami of spinal nerves
Muscle type: Not established
Tenderness between the spinous processes
Function: Lateral flexion of the spine
Loss of cervical flexion
Synergists: Interspinales, rotatores, multifidi
Antagonists: Spinal flexors of the contralateral side
Specia l notes
The interspinalis muscles are present in the cervical and Ind ications for treatment
lumbar regions and sometimes the extreme ends of the tho
Cervical segments restricted in lateral flexion
racic segment. In the cervical region, they sometimes span
two vertebrae (Gray's Anatomy 2005).
Specia l notes
N M T F O R I N T E R S P I N A L ES These short, laterally placed muscles most likely act as pos
tural muscles that stabilize the adjoining vertebrae during
The tip of an index finger is placed between the spinous
movement of the spinal column as a whole. The pattern of
processes of C2 and C3. Mild pressure is applied or gentle
movement of intertransversarii is unknown, but thought to
transverse friction used to examine the tissues that cormect
be lateral flexion. Fibers may also extend the spine.
the spinous processes of contiguous vertebrae. This process
These muscles are difficult to reach and attempts to pal
is gently applied to each interspinous muscle in the cervical
pate them may endanger cervical nerves which exit the
region. The neck may be placed in passive flexion in order
spine near the muscles. Additionally, the vertebral artery
to slightly separate the spinous processes and allow a little
courses between each unilateral pair; pressure on this is to
more room for palpation.
be avoided. The cervical portion of the intertransversarii
The tissues being examined include the supraspinous lig
may be elongated by active contralateral flexion, especially
ament, interspinous ligament and interspinalis muscles. In
when combined w ith rotation, as when one attempts to
the cervical region, the supraspinous ligament is altered to
touch the chin to the contralateral shoulder.
form the ligamentum nuchae.
We suggest that the small beveled pressure bar is not
appropriate as a treahnent tool in the cervical region due to L EVATO R SCAPU LA ( F I G . 1 1 .44)
the vulnerability of the vertebral artery in the suboccipital
region and the highly mobile nature of cervical vertebrae in Attachments: From the transverse processes of Cl and C2
general. While the tool can readily be used in the thoracic and the dorsal tubercles of C3 and C4 to the medial
and lumbar region, the fingertips are safer and sufficient for scapular border between the superior angle and the
addressing the cervical region. medial end (root) of the spine of the scapula
Innervation: C3-4 spinal nerves and the dorsal scapular
nerve (C5)
I N T E RTRAI\l S V E R S A R I I
Muscle type: Postural (type I), shortens when stressed
Attachments: Anterior and posterior pairs of bilateral muscles Function: Elevation of the scapula, resists downward
that join the transverse processes of contiguous vertebrae movement of the scapula when the arm or shoulder is
290 C L I N ICAL A P P L I CATI O N OF N E U R O M USCULAR T EC H N I Q U E S : THE U P PER B O DY
For positional release on the left, the practitioner's right scapula muscle on Cl, C2, C3, and C4 transverse
hand supports the head and neck while the middle or processes, until the reported pain score drops to 7 or less.
index finger compresses the tender point sufficiently for Fine-tuning is achieved by gently rotating the neck and
the patient to be able to use it as a monitor during reposi head toward the left, and possibly adding in sideHexion
tioning. to the left, until the palpated tenderness is reported as 3
A value of '10' is ascribed to the tenderness which should or less.
be moderate but not severe. This should be held for not less than 30, and up to 90, sec
The practitioner's left hand slides beneath the left onds, before a slow return to neutral.
scapula to contact the inferior angle and the scapula is
d rawn cephalad toward the attachment of the levator S U B O C C I PITAL R E G I O N ( F I G . 1 1 .48)
Rectus capitis posterior minor (RCPMin) and major
(RCPMa), obliquus capitis superior (OCS) and obliquus
capitis inferior (OCI) (collectively called the suboccipital
group) perform fine-tuning movements which are vital to
the positioning of the head and counteractive to the com
posite triple movements of the lower functional unit of the
cervical region. The suboccipital group, because of their
attachments, are often directly involved in cranial suture
crowding and / or temporal bone dysfunction, with the
potential to negatively influence cranial function.
Unilateral contraction of the four muscles produces
slight la teral Hexion of the head with associa ted ipsilateral
head rotation accompanied by extension - the three com
posite movements of the upper cervical unit (type II).
Bilateral contraction of all four muscles produces extension
of the cranium and translation of the cranium anteriorly on
Figure 1 1 .47 Leva tor sca pula positional rel ease. Reprod uced with the atlas. However, when acting alone, each of these mus
perm ission from Deig (2001 ) cles individually produces a fine control of stabilization or
Splenius capitis
Figure 1 1 .48 The subocci pita l s, which a re often d iscussed as a g roup, each has i ts own u n ique fu nction in movements of the head.
Reproduced with perm ission from Gray's Anatomy for Students (2005).
1 1 The cervical region 293
movement of the cranium on the atlas, the atlas on the axis eyes and ears in an approximately level position. When the
or retraction of the d ural tube wi thin the spinal canal (see cranium is posteriorly rotated, the suboccipital group's role
discussion of rectus capitis posterior minor on pp. 52, 252). in sustaining this position is substantial. A forward head
Their functions can be more fully appreciated when they position involves a posteriorly rotated cranium that has
are viewed from above as well as from the side since the then been brought to a position where the eyes and ears are
normal posterior view does not fully expose their oblique level with the horizon. The suboccipital space is crowded
angles and, therefore, their full influence as head position and the muscles significantly shortened, which often leads
ers. Their roles are discussed individually below. to trigger point formation. The contractu res associa ted with
Three of the four suboccipital muscles (all except RCPMin) trigger pOints may then assist in mainta ining the shortened
form the suboccipital triangle. The vertebral artery lies rela position wi thout excessive energy consumption.
tively exposed in the lower aspect of this triangle and is to Pain patterns and dysfunctional biomechanical patterns
be avoided when pressure or friction is applied to this area, associated with trigger points may lead to compensatory
especially when the tissues are placed on stretch. The changes in the lower functional unit and more distant struc
greater occipital nerve courses through the top of the trian tures. Until these m uscles are considered and treated,
gle before penetrating the semispinalis capitis and trapezius a ttempts to restore the head to a balanced posture are
muscles, then continues on to supply the posterior ex ternal unlikely to fully succeed. Similarly, addressing only these
cranium. The nerve may also penetrate obliquus capitis suboccipital muscles for forward head posture, while ignor
inferior. ing the role of other cervical tissues, pectoralis minor, the
Ideally, flexion (1 0) and extension (25) of the head occur diaphragm, upper rectus abdominis and pelvic positioning,
between the occiput and atlas, as well as translation of the as well as more wide-ranging causes of postural imbalance,
head upon the atlas. The degree of rotation or lateral flexion will produce short-term results at best.
is only slight since more would be undesirable at this par Pollard & Ward (1 997) explored this concept from a dif
ticular joint due to the risk of unwanted spinal encroach ferent perspective. Their study, conducted on 50 university
ment of the odontoid process (the dens) on the spinal cord. students (18-35 years of age), was comprised of three groups:
The vertebral artery, which l ies on the superior aspect of the one group stretched the hamstring m uscles, another stretched
lateral masses of the a tlas, might also be crowded by exces the suboccipital muscles and a third was placebo. Straight
sive movements of the a tlas. The transverse ligament leg raise for testing ROM of the hip j oint showed that
retains the dens in position while allowing the atlas to rotate stretching the hamstrings increased hip ROM by 9% while
around it. The ligament articula tes with the posterior aspect stretching the suboccipital muscles resulted in a 13% increase
of the dens while the atlas articulates with its anterior of hamstring length. These findings clarify tha t cervical
surface. treatment should be included with the treatment of
Faulty head/neck mechanics, such as forward head pos extraspinal, lower limb musculoskeletal conditions as well
ture, place high demand on the suboccipital m uscles to as in inj ury prevention for a thletes.
maintain the head's position, while simultaneously crowd The proprioceptive role of the muscles of the suboccipital
ing the space in which they operate, often physiologically region is directly related to the number of spindles per gram
shortening them in the process. People who wear bifocal or of muscle. There are an average of 36 spindles per gram in
trifocal glasses while working a t the computer are prone to RCPMin and 30.5 spindles/gram in RCPMa, as compared,
chronic shortening of these muscles by placing the head in for example, with 7.6 spindles/ gram in splenius capitis and
posterior rota tion so as to see out of the appropriate portion just 0.8 in gluteus maximus (Peck et aI 1984). McPartland &
of the lens for the chosen depth of field. Brodeur (1999) suggest that 'The high density of muscle
When suboccipital muscles house trigger points, these spindles found in the RCPM m uscles suggests a value . . .
are usually accompanied by articular dysfunctions of the [which] . . . lies not in their motor function, but in their role as
upper three cervical levels (Simons et a I 1 999) . All the sub "proprioceptive monitors" of the cervical spine and head'.
occipital muscles apart from obliquus capitis inferior con Liu et al (2003) showed that, not only do the suboccipital
nect the atlas or axis to the cranium, while the inferior muscles have distinct morphological features, but also that
a ttaches the atlas to the axis. each m uscle is unique in both fiber type composition and
While the motor function of these four muscles is prima sensorimotor organization. This suggests functional spe
rily to extend the head and to translate and rotate the head, cialization.
their dysfunctions include involvement in the all-too Hallgren et al (1994) suggest that damage to RCPMin,
common forward head position. A number of researchers such as occurs in whiplash, would reduce i ts proprioceptive
have shown that dysfunction of these small muscles in gen input, while facilitating transmission of impulses from a
eral, and RCPMin in particular (often resulting from wide range of nociceptors which could develop into a
whiplash), leads to marked increase in pain perception as chronic pain syndrome (such as fibromyalgia) .
well as reflex irritation of other cervical as well as j aw m us Forward head posture i s discussed further i n Volume 2 of
cles (Hack et a1 1 995, Hallgren et al 1994, Hu et aI 1995). An this text, where the influences of the lower half of the body
ultimate aim of postural compensation is to maintain the on total body mechanics are more fully explored.
294 C L I N ICAL A P P L I CATI O N OF N E U R O M USCU LA R TECH N I QU E S : TH E U P P E R B O DY
Ind ications for treatment A disease cycle involving RCPMinor, initiated by injury or
chronic somatic dysfunction . . . leads to RCPMinor atrophy
Loss of suboccipital space . . . [which] . . . may directly irritate the meninges via the
Deep-seated posterior neck pain posterior atlantooccipital membrane, and result in reduced
Headache wrapping around the side of the head to the proprioceptive output to higher centers. The lack of proprio
eyes ceptive output causes a loss of standing balance and cervical
Trigger points in overlying muscles vertigo . . . chronic pain . . . reflexive cervical and jaw muscle
activity, directly affecting the biomechanics of the region.
Special notes
Hack & Hallgren (2004) implicate postsurgical myodural
Recent research (Hack et al 1995) has demonstrated that a adhesions as a possible source of postoperative headache fol
connective tissue extension links this muscle to the dura lowing excision of acoustic tumors. They integrate two types
mater which provides it with potential for influencing the of myodural union (anatomic and pathologic) into a unified
reciprocal tension membranes directly, with particular theory of headache production, and report on a single patient
implications to cerebrospinal fluid fluctua tion because of its who experienced relief from chronic headache after surgical
site close to the posterior cranial fossa and the cisterna separation of the myodural bridge from the suboccipital
magna. It could also influence normal functioning of the musculature. We can gain insight from their results, and
11 The cervical region 295
Box 1 1 . 1 1 Cranial base release contralaterally, i .e. the superior oblique on one side and the
inferior on the opposite side will be shortened by a tilted,
This technique releases the soft tissues where they attach to the rotated a tlas. Since compensation by the upper functional
cranial base and may be used either before or fol lowing cervical unit can be associated with any distortions occur
suboccipital NMT assessment. ring in the remainder of the spinal column, we recommend
The patient is supine and the practitioner is seated at the head examina tion of the suboccipital region (and the cervical
of the table with the arms resting on and supported by the table. spine) when any spinal distortions are found further down
The dorsum of the practitioner's hand rests on the table with the column. Likewise, when the upper unit is found to be
fingertips pointing toward the ceil ing, acting as a fu lcrum on
dysfunctional, a full spinal examination may reveal associ
which the patient rests the occi put so that the back of the
sku l l is resting on the practitioner's pa lm. The distal fingertips a ted distortions.
touch the suboccipital m uscles while the pa lmar su rfaces of When tissues of the suboccipital region are too tender
the tips (finger pads) touch the occiput itself. to be frictioned or when cranial techniques are to be
The patient allows the head to lie heavily so that the pressure applied, the static release techniques offered in Box 1 1 . 11
induces tissue release against the fingertips.
may be preferred over those appearing here. The cranial
As relaxation proceeds and the fingertips sink deeper into the
tissues, the a rch of the atlas may be palpated and it may be base release may also be used prior to the following steps or
encouraged to disengage from the occiput by application of following them and is recommended to accompany cran
mild traction appl ied to the occiput, 'sepa rating' it from the iomandibular therapy, especially when fonvard head pos
atlas ( ou nces of effort at most, applied cra n ia l ly by the middle ture is noted.
fingers) . This would probably not be for some minutes after
com mencement of the exercise.
The effect is to relax the attach ments in the area being
treated with benefit to the whole m uscle. This 'release' of deep , N MT F O R S U B O C C I PITAL G R O U P - S U PI N E
structures of the u pper neck enhances d rainage from the head " (FI G . 1 1 . 5 1 )
and circulation to it, while reducing intercranial congestion.
The practitioner is seated at the head of the table with the
pa tient lying supine. The palms of the practitioner 's hands
cradle the posterior cranium and the fingers cup the occipi
tal bone with the finger pads resting on the inferior surface
of the bone. The first two fingers of the treating hand
address one side at a time, as the person may be intolerant
of two sides being treated at once. A small space is usually
palpable between the occipital ridge and the first vertebra
(atlas). This area infl uences rocking and tilting of the head
( and, therefore, posterior rotation of the cranium.
The treating fingers are placed just lateral to the mid-line at
the inferior aspect of the occipital bone and press into the
\ trapezius muscle and its tendon. Static pressure for 8-12 sec
onds may be followed by medial to lateral friction directly on
the trapezius a ttachment. Deeper pressure, if appropriate,
F i g u re 1 1 .50 Hand positions for cra n i a l base release. will treat semispinalis capitis and RCPMin. Since the minor's
a ttachment to the dura may be fragile, static pressure is
B
Fig u re 1 1 .51 ARB: Friction may be a pp l i ed to the subocci pitals a n d overlyi ng m uscles from the m i d - l i n e to the m astoid process. However,
CAUTIO N m ust be exerci sed to avoid deep friction to the rectus ca pitis posterior m i nor a n d to the vertebral a rtery, w h ich is located in the
subocci pita l tri a n g l e (see Fig. 1 1 .48) .
11 The cervical region 297
]
preferred over the more aggressive frictional techniques styloid process is avoided anterior to the SCM tendon
when the pressure intrudes this deeply. Longer durations of where the styloid is located j ust inierior and slightly ante
static pressure can also be used. rior to the earlobe.
The fingers are moved latera lly I inch (2.5 cm) and static Cranial to caudal friction may also be used on the occipi
pressure and frictional movements repeated to influence tal tendon attachments which will have m inor influence on
the remainder of the trapezius, semispinalis capitis and suboccipital muscles but significant influence on the tissues
RCPMa . The head may be rotated slightly away from the overlying them.
side being treated to make these muscles more palpable. The fingers are now placed caudally approxima tely a fin
CAUTION: Moderate to extreme head rotation is not ger width and the steps repeated between CI (a tlas) and C2
recommended for prolonged periods of time as the verte (axis) to treat the inferior half of RCPMa and to include
bral artery may be occluded within the transverse process, obliquus capitis inferior. If the spinous process of C2 is
thereby reducing blood flow to the cranium (see Box 11.5 located, the fingers examine the space cephalad and slightly
for tests for circulatory dysfunction). lateral to the process. This area influences rotation of the
Static pressure and iriction are continued at I-inch (2.5 -cm) head. The center of the s ubOCCipital triangle is avoided dur
intervals along the remainder of the suboccipital ridge to ing the frictional techniques due to the location of the verte
treat SCM, splenius capitis, longissimus capitis and obliquus bral artery.
capitis superior. Contralateral rotation of the head may be To influence and examine tissues caudal to the suboccip
used with the caution above kept in mind. Pressure on the ital muscles, this process may be continued throughout the
298 CLI N I C A L A PP L I C AT I O N O F N EU R O M U S C U LA R TEC H N I Q U E S : THE U P P E R B O DY
.:
, . - ...
PLATYS M A ( F I G . 1 1 . 54)
Attachments: A broad sheet of muscular fibers arising from
fascia of the upper chest which interlace medially with
the contralateral muscle, below and behind the symph
ysis menti; intermediate fibers attach to the lower border
of the mandibular body while posterior fibers cross the
mandible and the anterolateral part of the masseter and
attach to subcutaneous tissue and skin of the lower face
Innervation: Facial nerve (cranial nerve Vll)
Muscle type: Not established
Function: May assist in depressing the mandible or d raw
the lower lip and corners of the mouth inferiorly, espe
cially when the jaw is already open wide; produces skin
ridges in the neck which may release pressure on under
lying veins (Moore 1980)
Synergists: To mandibular depression: lateral p terygoid, Figure 1 1 .54 The prick l i n g pain pattern of platysm a is d istinct from
mylohyoid, digastric, geniohyoid, gravity the pattern of the u nd erlying SCM ( see Fig . 1 1 .57). Dra w n after
A n tagonists: Masseter, medial pterygoid, temporalis Simons et al ( 1 999).
11 The cervical reg ion 299
Speci a l notes
While the platysma does not seem to have an important
function, its referra l pattern and potential influence on mus
cles located in its target zone may lead to indirect influences
and perpetuation of trigger points in those tissues. The
muscles of mastication (masseter especially) might be thus
influenced. Since somatovisceral referrals are known to F i g u re 1 1 .55 General cervica l stretch, supine, fo l lowing isometric
occur in other body areas (see p. 47), it would be logical that contraction.
tissues overlying the thyroid gland might have influence on
glandular function. Pla tysma (as well as sternocleidomas
toid, infrahyoids and scalenii) should be examined when
glandular dysfunctions are noted. . G E I\J E RAL ANTE R I O R N E C K M U SC L E STRETCH
Studies indicate activity during sudden deep inspiration, " UTI LI Z I N G M ET
=
vigorous contraction during sudden, violent effort and in For involvement of rectus capitis anterior, suprahyoids,
expressions of horror and surprise (Gray's Anatomy 2005). infrahyoids, platysma, supra thyroids and infra thyroids
CAUTION: While spray and stretch techniques for treat the hvo procedures described immediately below are
ment of trigger points are excellent applications for the performed with the mouth closed.
anterior neck muscles, sustained hot or cold app lications For involvement of longus colli and longus capi tis, the
over the carotid artery and thyroid gland are not recom mouth is held slightly opened.
mended. Clear warnings should be given to avoid standing
under a hot shower with the neck stretched in extension
Note: Sternocleidomastoid and scalenii stretches described
i n order to allow a hot spray on the anterior neck, as the
elsewhere in this chapter will a utomatically produce
patient may experience a rapid fluctuation in blood pres
stretching of many of these anterior neck m uscles.
CAUTION: Avoid traction or sidebend, especially with
sure accompanied by dizz i ness, which could result i n loss
rotation of the neck i f d i sc damage is suspected, or i mme
of balance and injury. A loosely wrapped hydrocolator
d iately after a n accident until extent of inj uries is known.
pack that focuses its heat primarily onto the posterior cer
vical and filters somewh a t onto the anterior neck can be
applied with the patient recl ined or seated. Adequate
Va riations
, time should be given after appl ication before the patient 1. Supine
is asked to stand. This is a general non-specific stretching proced ure
(Fig. 11 .55). It would not be used if anterior displacement
It N M T F O R P LATYSMA of the articular disc (TM j oint) is suspected as even m i ld
mandibular condyle pressure into the articular fossa may
The skin o f the anterior neck i s fairly elastic and therefore create intense discomfort.
usually lifts eaSily to be rolled. To address the fibers of The use of an open or closed mouth to involve different
platysma, the skin of the anterior neck is gently and slowly structures as explained above should be noted .
rolled betvveen the thumb and fingers in an attempt to d is The p ractitioner places the forearm (left in this example)
tinguish tender points or trigger points. When tender tissue in a position which allows the mid-cervical spine to rest
is encountered, gentle static pressure can be applied to on it and with the right hand cups the pa tient's jaw
assess for referral pa tterns and taut fibers that feel as (which should be relaxed throughout the p rocedure,
though they a re 'glued' to the internal surface of the skin. whether open for longus colli and longus capitis, or
CAUTION: Aggressive techniques of tractioning the skin, closed for other anterior hyoid-rela ted muscles).
tuggi ng i t or stretching i t away from the neck or continu The practi tioner grasps his own right distal forearm with
ously rolling the tissues over and over should not be used, the left hand, so forming a stable contact.
to avoid damaging its attachments to the underlying tis When the practitioner gently leans backwa rd a degree of
sues. The skin over the anterior neck tends to l oosen with mild traction is introduced into the patient's cervical
aging. The elastic and collagen fibers are fragile and spine, to remove slack.
should be treated with special care to avoid inducing a The patient is asked to lightly move the head into flexion
'saggy neck'. against the resistance of the contact hand on the (relaxed)
300 CLI N I CA L A P P L I CATI O N OF N E U R O M U SC U LA R TEC H N I Q U E S : T H E U P PER B O DY
jaw. This isometric contraction position is held for 7-1 0 lowered, one segment at a time, for subsequent isometric
seconds. contractions and stretches.
Following release of the effort, a mild amount of exten A slight movement (50) toward the neutral position
sion (100) is introduced to effectively stretch the anterior should be produced before each contraction and subse
muscles of the neck. quent stretch.
The practitioner gently leans backward so that a degree Immediately discontinue stretching if any dizziness is
of mild traction is introduced into the patient's cervical reported.
spine. This traction is released extremely slowly. To produce greater emphasis on stretching of one side or
The procedure is stopped if p ain or dizziness is reported. the other, a moderate degree of sidebend (about 20)
away from that side should be introduced prior to the
2. Seated. A general MET stretch involving most of the deep extension.
and shallow muscles attaching to the anterior cervical spine,
skull and hyoid bone is perfonned as follows (Fig. 11.56).
STE R N O C L E I D O M ASTO I D ( F I G . 1 1 . 5 7 )
The patient is seated and the practitioner stands at the
side facing (in this example) the left side of the head. Attachments: Sternal head: Anterior surface o f the sternwn
The practitioner's left hand wraps around the right side to the mastoid process and occipital bone (lateral half of
of the patient's head, palm of hand cupping the ear and superior nuchal line)
mastoid, stabilizing the head finnly against the practi Clavicular head: from the superior surface of the medial third
tioner's chest or upper abdominal region. of the clavicle to blend with the tendon of the sternal head
Female practitioners should introduce a shallow cusmon and attach with it to the mastoid process and occipital bone
between the patient's head and their own torso, in order Innervation: Accessory nerve (cranial nerve XI) and
to avoid inappropriate contact. branches of ventral rami of e2-4 cervical spinal nerves.
The use of an open or closed mouth to involve different May also include motor fibers from vagus nerve which
structures as explained above should be noted. join at the jugular foramen (Simons et a1 1999)
The small finger of the practitioner's left hand is at the Muscle type: Postural (type I), shortens when stressed
level of the p a tient's axis (e2) . Function: Unilaterally: rotates the head contralaterally (and
The practitioner's right hand stabilizes the posterior aspect tilts it upward) and sidebends the head and neck ipsilat
of the neck in order to support it below the level of e3. erally
Traction is gently initiated as a slow movement is made Bilaterally: flexes or extends the head, depending on the
into p ure extension of the head and neck of about 10 at position of the cervical vertebrae (see below), lifts the
most. head from the pillow when the patient is supine, may
The patient is asked to gently (20% of strength) take the assist in forced inspiration (especially when the inter
head and neck forward into flexion, as the practitioner costals are paralyzed)
resists this effort, mainly with the left-hand contact. Synergists: For rotation: trapezius of the same side, con
The contraction is held for 7-10 seconds after which, with tralateral splenius capitis and cervicis, obliquus capitis
traction still being maintained, a further 50 of extension is inferior and levator scapula
initiated and held for not less than 10 seconds. For lateral flexion: scalenii, trapezius
To introduce stretch into m uscles attaching more distal For flexion of cervical column (see below): longus colli
than e3, the contact hand on the posterior neck can be
Sternocleidomastoid
muscle
Fig u re 1 1 .56 Genera l cervica l stretch, seated, following isometric Figure 1 1 .57 Composite referral patterns of SCM muscle. Drawn
contraction. after Simons et a l ( 1 999).
1 1 The cervical reg ion 301
Antagonists: For rotation: contralateral SCM and trapezius, (two vapocoolant dispensers, one of which may have been
ipsilateral splenius capitis, splenius cervicis, levator used) the patient will [give] evidence [oJ] dysmetria by
scapula and obliquus capitis inferior underestimating the weight of the object held in the hand on
For lateral flexion: contralateral SCM, scalenii, trapezius the same side as the affected sternocleidomastoid muscle.
Inactivation of the responsible sternocleidomastoid TrPs
promptly restores weight appreciation by this test.
Ind ications for treatment Apparently, the afferent discharges from these TrPs disturb
A diagnosis of atypical facial neuralgia, tension central processing of proprioceptive information from the
headaches or cervicocephalangia upper limb muscles as well as vestibular function related to
Persistent dry cough or sore throa t neck muscles.
Mimics trigeminal neuralgia and produces facial pain or
Lymph nodes lie superficially a long the medial aspect of the
sca lp tenderness
SCM and may be palpated, especially when enlarged. These
Blurred vision, perception of dimmed intensity of light
nodes may be indicative of chronic cranial infections stem
Visual disturbances, eye pain, excessive lacrima tion,
ming from a throat infection, dental abscess, sinusitis or
ptosis and difficulty raising the eyelid
tumor. Likewise, trigger points in SCM may be perpetuated
Inflamed or congested sinuses
by some of these conditions (Simons et aI 1999) . See Figure
Hearing loss and ear pain
11.18 for lymphatic system of the neck and Figure 12.39 for
Disturbances in orientation including postural dizziness,
lymphatic drainage pathways of head and neck.
vertigo, disequilibrium, ataxia, sudden falls and nausea
Lewit (1999) points out that tenderness noted at the
medial end of the clavicle is often an indication of SCM
Special notes hypertonicity. This will commonly accompany a forward
head position and /or tendency to upper chest breathing
Sternocleidomastoid (SCM) is a prominent muscle of the and will almost inevitably be associated with hypertonici ty,
anterior neck and is closely associated with the trapezius. shortening and trigger point evolu tion in associated muscu
SCM often acts as postural compensator for head tilt associ lature, inclu ding scalenii, upper trapezius and levator
ated with postural distortions found elsewhere (spinal, scapula (see crossed syndrome notes on p. 82). SCM, along
pelvic or lower extremity functional or structural inadequa with the splenii, have also been implica ted in spasmodic
cies, for instance) although it seldom causes restriction of torticollis (TS) (Hasegawa et al 2001, Deuschl et aI 1992).
neck movement.
f N MT F O R S C M
SCM is synergistic with anterior neck muscles for flexion
of the head and flexion of the cervical column on the tho
racic column, when the cervical column is already flattened
The patient i s supine and the practitioner is seated cephalad
by the prevertebral muscles. However, when the head is
to the head and positioned slightly away from mid-line on
placed in extension and SCM contracts, it accentuates lor
the side to be trea ted . The pa tient's head is rotated approxi
dosis of the cervical column, flexes the cervical column on
mately 45 ipsilaterally and passively sidebent to shorten
the thoracic column and a dds to extension of the head. In
the SCM so it may be lifted while also moved somewhat
this way, SCM is both synergist and antagonist to the pre
away from the carotid artery. There still remains an area
vertebral muscles (Kapandji 1974).
where the a rtery lies vertically deep to the now diagonally
SCM trigger points are activated by forward head posi
overlying SCM. Orienting the head and neck in this manner
tioning, 'whiplash' injury; positioning of the head to look
avoids positioning the SCM to overlie the entire length of
upward for extended periods of time and structural compen
the artery and decreases the chance of disturbance of the
sations. The two heads of SCM each have their own patterns
artery. However, cau tion is exercised to avoid compression
of trigger point referral which include (among others) into
of the artery in all circumstances (Fig. 11.59).
the ear, top of the head, into the temporomandibular joint,
The SCM is compressed in a broad general release
over the brow, into the throat and those which cause propri
between the flattened fingers and opposing thumb of the
oceptive disturbances, disequilibrium, nausea and dizziness.
same treating hand. The finger pads provide more effective
Tenderness in SCM may be associated with trigger points in
compression against the opposing thumb pad than the fin
the digastric muscle and digastric trigger points may be satel
ger joints do. As thickened bands or nodules are located in
lites of SCM trigger points (Simons et al 1999).
the sternal head of SCM, the cranium may be placed in va ry
Simons et al (1999) report:
ing positions that stretch the fibers slightly while still allow
When objects of equal weight are held in the hands, the ing the muscle to be lifted and held in flat compression. The
patient with unilateral TrP involvement of the clavicular m uscle fibers may be rolled between the fingers and thumb
division [of SCM] may exhibit an abnormal weight test. gently to reveal more localized contractures. The bands are
When asked to judge which is heavier of two objects of the examined through their entire length for thickenings associ
same weight that look alike but may not be the same weight ated with trigger point formation or for exquisitely tender
302 C L I N ICAL A P P L I CAT I O N OF N E U R O M USCU LAR TE C H N I Q U E S : T H E U P PER B O DY
Superior belly of
omohyoid muscle
Sternocleidomastoid
muscle -----t-+-+__
The head is in eq uil ibrium when the eyes look horizontal ly. In this
position the plane of the bite, shown here by a piece of cardboard
held tightly between the teeth, is a lso horizonta l, as is the
auriculo-nasal plane (AN ) , which passes through the nasa l spine
and the superior border of the external aud itory meatus.
The head taken as a whole constitutes a lever system :
....1--
.. ---- Thyrohyoid muscle
Figure 1 1 .64 Su pra- and infra hyoid m uscles control posi tioning of the hyoid bone, w h ich, a mong other functions, assists in mainta i n i n g a n
adeq uate a i r passageway. Reprod u ced w i th permission from Gray's Anatomy for Students (2005).
group stabilizes and depresses the hyoid bone and, acting of the hyoid bone, its fibers merging with the contralat
with the suprahyoid muscles, contributes to flexion of the eral sternohyoid near the mid-belly
cervical column when the mouth is closed. Innervation: Ansa cervalis (Cl-3)
Since somatovisceral referrals are known to occur in Muscle type: Phasic ( type II), weakens when stressed
other body areas (see p . 47), it would be logical that tissues Function: Depresses the hyoid bone (especially from an ele-
overlying the thyroid gland might have influence on glan vated position during swallowing); functions with the
dular function. Infrahyoid muscles, sternocleidomastoid infrahyoid group to flex the cervical column with the
and scalenii should be examined when glandular dysfunc mouth closed
tions are noted due to their proximity to the thyroid and Synergists: For hyoid movement: sternothyroid / thyrohyoid
parathyroid glands. unit, omohyoid
For hyoid stabilization: suprahyoids and remaining
infrahyoids
For flexion of cervical column: longus colli, longus capitis,
STE R N O HYO I D
sternocleidomastoid, scalenii, rectus capitis anterior and
Attachments: Posterior surface of the manubrium sternum, latera lis, suprahyoids and remaining infrahyoids
the medial clavicle and the sternoclavicular ligament to Antagonists: To hyoid movement: suprahyoid muscles
attach to the inferior border and inner surface of the body To flexion of cervical column: posterior cervical muscles
306 C L I N ICAL A P P L I CAT I O N OF N E U R O M USCU LA R TECH N I Q U E S : THE U P P E R B O DY
Ind ications fo r treatment Function: Depresses the hyoid bone; eleva tes the larynx;
functions with the infrahyoid group to flex the cervical
Dysfunction in hyoid bone movement during swallowing
column with the mouth closed
Prepa ration for prevertebral treatment (longus colli,
Synergists: For hyoid movell1ent: sternohyoid, sternothyroid,
longus capitis)
omohyoid
Difficulties in swallowing
For hyoid stabilization: suprahyoids and remain.ing
infrahyoids
ST E R N OT H YR O I D For flexion of cervical column: longus colli, longus capitis,
sternocleidomastoid, scalenii, suprahyoids and rema in
Attachments: Posterior surface o f the manubri um sternum
ing infrahyoids
and from the 1st rib cartilage to the thyroid cartilage
Antagonists: To hyoid movement: suprahyoid muscles
Innervation: Ansa cervalis (Cl-3) To flexion of cervical column: posterior cervical muscles
Muscle type: Phasic (type II), weakens when stressed To elevation of the larynx: sternothyroid
Function: Depression of larynx, depression of hyoid bone
when acting as a unit with thyrohyoid; functions with the
infrahyoid group to flex the cervical column with the I nd i cations for treatment
mouth closed Dysfunction in hyoid bone movement during swallowing
Synergists: For hyoid move men t : sternohyoid, thyrohyoid, Preparation for prevertebral trea tment (longus colli,
omohyoid longus capitis)
For hyoid stabilization: suprahyoids and remaining Changes in voice or voice range (la rynx positioning)
infrahyoids
For flexion of cervical column: longus colli, longus capitis,
O M O H YO I D
sternocleidomastoid, scalenii, suprahyoids and remain
ing infrahyoids Attachments: The inferior belly of this t\ivo-bellied muscle
Antagonists: To depression of larynx: thyrohyoid arises from the upper margin of the scapula near the
To hyoid movement: suprahyoid muscles scapular notch and its superior belly from the lower bor
To flexion of cervical column: posterior cervical muscles der of the hyoid bone lateral to the insertion of sternohy
oid. The two bellies are joined by a central tendon which is
Ind i cations fo r treatment ensheathed by a fibrous loop which may extend to the
deep cervical fascia and attaches to the clavicle and 1st rib
Dysfunction in hyoid bone movement d uring swallowing Innervation: Ansa cervicalis profunda (Cl-3)
Preparation for prevertebral treatment (longus colli, Muscle type: Phasic (type II), weakens when stressed
longus capitis) Function: Depresses the hyoid bone; tenses deep cervical
Changes in voice range (larynx positioning) fascia which reduces the possibility of soft tissue being
Difficulties in swallowing sucked inwardly d uring respiration; dilates the internal
j ugular vein; functions with the infra hyoid group to flex
Speci a l notes the cervical column with the mouth closed
Synergists: For hyoid movement: sternohyoid, sternothyroid,
Sternothyroid draws the larynx downwards during swal
thyrohyoid
lowing and speech and during the singing of low notes, for
For hyoid s ta bilization : suprahyoids and remaining
example. The linkage between the sternum and the hyoid
infrahyoids
allows this muscle to influence crania l mechanics.
For flex io n of cervical column: longus colli, longus capitis,
The fibers of sternothyroid lie in direct contact with the
sternocleidomastoid, scalenii, suprahyoids and remain
anterolateral surface of the thyroid gland and should be
ing infrahyoids
exam ined and treated with all glandular dysfunctions.
Antagonists: To hyoid movement: suprahyoid muscles
However, ca u tion should be exercised to avoid frictioning
To flexion of cervical column: posterior cervical muscles
d irectly over where the gland lies. Further studies are
needed to assess the trigger point referral patterns of the
infra hyoid m uscles and their possible role in neck, throat, I nd ications for treatment
thyroid, voice and TM] dysfunctions.
Dysfunction in hyoid bone movement during swallowing
Preparation for prevertebral treatment (longus colli,
T H Y R O H YO I D longus capitis)
Attachments: Anterior surface of thyroid cartilage to the The extraordinary connections of this muscle, linking as it
lower portion of the greater horn and body of hyoid bone does the scapula, clavicle and hyoid bone (which via other
Innervation: Hypoglossal nerve attachments links it indirectly to the mandible), give some idea
Muscle type: Phasic (type II), weakens when stressed of the potential for cranial problems arising from numerous
1 1 The cervical region 307
It N M T F O R I N FRAHYO I D M US C L E S
CAUTION: The treatment protocols o f the superficial and
deep anterior cervical muscles are some of the most deli
cate and precise used in NMT. They are to be approached
with extreme caution due to the proximity of the carotid
artery and the thyroid gland. Training (with hands-on
supervision) is strongly recommended prior to practice of
any anterior neck techniques.
The practitioner stands at shoulder or chest level of the
supine patient and faces the throat. The hyoid bone is stabi
lized with the index finger of the practitioner's most caudal
hand by reaching across the patient to the opposite greater
horn of the hyoid bone and carefully placing the index fin
ger on its outer surface. Cau tion must be exercised to stay in
contact with the hyoid bone and not allow the stabilizing
finger or i ts posteriorly oriented fingertip to venture off the
lateral edge of the hyoid bone where the carotid artery
resides. Additionally, the hyoid bone must not be pressed
\
posteriorly but only stabilized enough to discourage its
movement when frictional techniques are used.
With the index finger of the practitioner's cephalad hand,
gentle friction may be applied to the supra- and infrahyoid
muscles on the superior, anterior and inferior aspect of the
hyoid bone. Caution must be exercised to keep the trea ting
finger in contact with the hyoid bone and not allow it to
slide or be accidentally placed lateral to the edge of the
hyoid bone or thyroid cartilage due to the location of the
carotid artery (Fig. 11 .65A).
The stabilizing finger is reloca ted to the thyroid cartilage on
the contralateral side. The treating finger is placed on the
uppermost medial aspect of the anterior surface of the thyroid
cartilage and is used to press the overlying infrahyoid muscles
onto the thyroid cartilage where sta tic pressure or gentle trans Carotid
artery
verse friction is used to assess their fibers. When the p roper
pressure is used, the vertical fibers may be distinctly felt as
they are caph.lred against the underlying cartilaginous surface B
or as the trea ting finger is slid across them in gentle frictional
movements. If too little pressure is used, the skin will merely Fig u re 1 1 .65 The infra hyoid gro u p is exam ined a t fingertip i n terva ls
slide over the muscles and benefit of treatment will be sig from the hyoid bone (A) to the cricoid carti lage (8). Extreme
nificantly reduced. Too much p ressure might press the entire CAUTION is exercised to avoid the carotid a rtery (immediately
stnlcture posteriorly into the esophagus, longus colli, longus latera l to the edge of the hyoid bone and thyroid carti lage) and the
capitis and the anterior surface of the cervical vertebrae. thyroid gland (ca udal to the cricoid cartilage). See text for
CAUTIONS.
The right amount of pressure will meet and match the ten
sion found in the tissues and elicit a mid-range response on
the patient's discomfort scale if tension exists in the tissues. The anterior surface of the stabilized thyroid cartilage is
The treating finger is moved laterally one fingertip width treated in this compressional or frictional manner until the
and the frictional work repeated. It may be moved laterally cricoid cartilage (first cartilaginous ring of the trachea) is
once more in most cases, depending upon the size of the reached at approxima tely mid-way between the hyoid bone
practitioner's hands and the width of the patient's cartilage and the sternal notch. Extreme care is used at the most lat
(Fig. 11 .658). eral aspects of the hyoid bone and the thyroid cartilage
308 CLI N I CA L A P P LI CATI O N OF N E U R O M U S C U LA R TEC H N I QU E S : THE U P P E R B O DY
Figure 1 1 .66 With the h ead passively e l evated and the patient Pitch control is primarily controlled by the thyrohyoid mus
holding a deep breath, attachment of the sternohyoid and
cles. To treat these muscles, the patient lies supine and the
sternothyroid may be reached ( on some patients) o n the posterior
[practitioner] fixes on the thyroid cartilage with the forefin
aspect of the stern u m .
ger and thumb of one hand whilst the other handfixes on the
inferior border of the hyoid with a finger and thumb. The
cartilages are then held apartfor 20 seconds byfixing on one
along their full length t o avoid allowing the treating finger
and moving the other. This stretch should be given in an
to go laterally beyond the edge of the cartilage (even mildly
inferior, superior direction and a lateral direction.
during friction) as the carotid artery runs vertically the
It is essential to treat the cricothyroid visor, if it is locked
entire length of these structures. Friction applied near the
in position due to a restricted cricothyroid muscle for func
lateral edge should be unidirectional toward the mid-line
tion of the vocal cords. These muscles are of particular
which adequately transverses the muscular fibers while
importance as thetj affect the vocal folds directly. If the
avoiding contact with the artery.
cricothyroid muscles are short and the visor mechanism
Caudal to the cricoid cartilage, the thyroid gland lies rel
locked they create an unhealthy stretching and elongation of
atively exposed, covered only by the skin, cervical fascia
the vocal folds. To open the visor, the thumb tip of one hand
and the thin infrahyoid muscles. Frictional or compres
is placed on the anterior surface of the cricoid, whilst the
sional techniques (either flat or pincer) are not used caudal
other thumb tip is placed on the inferior aspect of the thyroid
to (below) the cricoid cartilage since the thyroid gland
cartilage, gentle pressure is applied to both cartiLages to
would most likely be intruded upon. These lower portions
open the visor.
of the fibers are easily stretched (in most cases) by extension
of the head and neck with the mouth closed. Among the posttreatment effects, the patient might note a
The patient's head is supported with a wedge or pillow in drop in pitch and increased resonance of voice, decrease in
passive flexion at approximately 45 (chin toward chest). The pain and discomfort, decreased tenderness in musculature
practitioner's treating fingertip is placed on the posterior sur and decreased hoarseness when these associated symptoms
face of the sternal notch. As the patient takes in and holds a have been present. Spray and stretch applications for the
deep breath, the sternum will lift away from the thorax and anterior neck, as discussed by Simons et al (1999), could
(sometimes dramatically) allow the finger to penetrate fur also be isolated to these tissues and the myofascial release
ther (Fig. 11 .66). The finger is swept first to one side and then described above used .
the other while maintaining a firm contact onto the posterior
surface of the sternum where the sternohyoid and sternothy
roid muscles attach. Static pressure may be used if the attach
LO N G U S C O L L I ( F I G . 1 1 . 68)
ments are too tender for frictional techniques. Attachments: Superior oblique portion: anterior tubercles of
transverse processes of C3-6 to the anterior tubercle of
the atlas
'S O FT T I SS U E T E C H N I QU E D E R I V E D F R O M
" OSTE O PAT H I C M ET H O D O LO G Y Inferior oblique portion: from the first three thoracic verte
bral bodies to the anterior tubercles of transverse
Simone Ross (1999), i n discussing osteopathic approaches processes of C4-7 (varies)
to dysphonia, describes the following safe soft tissue treat Vertical portion: from the vertebral bodies of C5-T3 to the
ment technique (Fig. 11 .67). vertebral bodies of C2-4
" The cervical region 309
AnteriOr
'rI'I.--- Middle
} Scalene muscles
Posterior
Figure 1 1 .68 Prevertebral a n d lateral vertebral muscles. Reproduce d w i t h permission from Gray's Anatomy for Students (2005).
Innervation: Ventral rami (C2-6) Synergists: For lateral flexion and contralateral rotation:
Muscle type: Not established scalenii, SCM, longus colii, levator scapula (Warfel 1985)
Function: Unilaterally, sidebends and contralaterally For cervical flexion: longus colli, suprahyoids, infrahyoids,
rotates the neck; bilaterally, flexes the cervical spine rectus capitis anterior, SCM (when the neck is a lready
Synergists: For lateral flexion and rotation: ipsilateral scalenii, flexed)
SCM, longus capitis, levator scapula (Warfel 1985) Antagonists: To lateral flexion and rotation: contralateral
Forflexion: longus capitis, suprahyoids, infrahyoids, rectus scalenii, SCM, longus capitis, longus colli, contralateral
capitis anterior, SCM (when the neck is already flexed) levator scapula
Antagonists: To lateral flexion and rotation: contralateral To cervical flexion: posterior suboccipitals, posterior cervi
scalenii, contralateral levator scapula, SCM, longus capi cal muscles, SCM (when the neck is already extended)
tis, longus colli
To cervical flexion: posterior cervical muscles, SCM (when
Ind ication for treatment of prevertebra l
the neck is already extended)
muscles
Difficulty swallowing
L O N G U S CAP I T I S
Diagnosis of loss of cervical lordosis or 'mil itary neck'
Attachments: Anterior tubercles o f the transverse processes Unstable cervical column
of C3-6 to the basilar part of the occipital bone Unstable atlas
Innervation: Ven tral rami of Cl-3 Chronic posterior cervical myofascial dysfunction
Muscle type: Phasic (type II), weakens when stressed Chronic dysfunctions elsewhere in the spinal colunm
Function: Unilaterally, rotates the neck contralaterally and (compensatory)
flexes the head to the same side; bilaterally, flexes the Loss of vertical dimension of cervical discs
head and neck Posterior protrusion of cervical discs
CLI N I CAL A PPLI CAT I O N O F N E U RO M U S C U LA R TEC H N I QU E S : T H E U P P E R B O DY
-- Trachea
____
Figure 1 1 .69 Sca lenus a n terior, longus col l i a n d longus capitis are removed from the l eft side of this d ra w i ng to revea l attachment of
sca lenus m edius deep to it Also visible is the cou rse of the vertebra l a rtery t h rough the transverse process of the cervical reg ion. Reproduced
with perm ission from Gray's Anatomy for Students (2005).
Specia l notes
The deep anterior cervical muscles produce flexion of the
Longus colli and longus capitis lie on the anterior surface of head and neck and therefore reduce the cervical curva ture.
the vertebral bodies of the cervical spine. Superficial to them When shortened, they can increase anterior pressure on the
lie the hyoid bone, thyroid cartilage, larynx, pharynx, esopha discs and can contribute to posterior protrusion of the disc
gus and trachea. Irrunediately lateral to these structures, the into the spinal cord. Unilaterally, they also sidebend and
carotid arteries run vertically as they pass through the cervical rotate the column and therefore may be involved in scoliotic
region to serve the cranium. All of these surrounding struc and other compensatory postural dysfunctions originating
tures require that extreme caution be exercised in the assess in other aspects of the spinal column or elsewhere in the
ment and treatment of the prevertebral muscles. Fingernails body. The number of muscle slips for each varies grea tly as
of the treating fingers should be cut short and filed smooth. do their individual attachmen ts.
Hoppenfeld (1976) notes: 'Difficulty or pain upon swal The superficial muscles of the anterior neck should
lowing may be caused by cervical spine pathology such as always be treated before the longus colli and capitis to help
bony protuberances, bony osteophytes, or by soft tissue release tension of the muscles covering the thyroid carti
swelling due to hematomas, infection, or tumor in the ante lage. The superficial structures must all be displaced in
rior portion of the cervical spine.' If the patient reports diffi order to reach the prevertebral muscles. Tension in the over
culty swallowing or if the practitioner encounters suspicious lying 'strapping' muscles may prevent the structures from
tissue, it is important to rule out these (as well as esophageal) being moved sufficiently to allow room for manual treat
pathologies prior to treatment of the deep cervica l muscles. ment to be applied.
11 The cervical region 31 1
It M ET STR ETCH O F L O N G U S C A P I T I S
This m uscle is sometimes called the rectus capitis anterior
minor when the longus capitis is referred to as the rectus
capitis anterior major. However, more current texts refer to
CAUTIO N : Stretching with the head in extension can b e
them as rectus capitis anterior and longus capitis. Trigger
dangerous if circulation to t h e cra nium is i n a n y w a y com
point referral patterns from or to these deep anterior cervi
promised (see p . 257).
cal tissues have yet to be established.
To treat the right longus capitis, the patient is supine and According to Up ledger & Vredevoogd (1983), bilateral
positioned so that the head extends beyond the edge of hypertonicity of either longus capitis or rectus capitis anterior
------ - ------
While rectus capitis latera lis attaches to the upper surface of Chest, back and arm pain (any or all of these)
the transverse process and very likely will not be touched Tingling and numbness in hand associated with entrap
directly, connective tissue continuations may be influenced ment syndrome
on the transverse process i tself. If not too tender and if neu Whiplash syndrome, particularly if lateral flexion action
rovascular struc tures are clear of the treatment finger, gen was involved
tle medial/ lateral friction may be applied as well. This area Cervical dysfunctions which are not responding to other
is often extremely tender and may require several applica modalities
tions of ligh t pressure. The authors caution against the use Sedentary lifestyle, leading to quiet breathing patterns as
of heavy, or even moderate, pressure on C1 when treating the norm
myofascial tissues. This upper cervical area is involved in Evidence of dysfunctional breathing patterns in genera l
major proprioceptive input as well as conta ining important Loss of vertical dimension of cervical d iscs
and vulnerable neural structures and blood vessels and all
manual approaches to it should be gentle.
Specia l notes
The attachment sites of the scalenii muscles vary, as does
S CA L E N I I ( F I G . 1 1 . 7 3 )
their presence. The scalenus posterior is sometimes absent
Attachments: Anterior: C3-6 anterior tubercles o f the trans and sometimes blends with the fibers of medius. Scalenus
verse processes to the superior aspect of the 1st rib ante medius is noted to frequently attach to the atlas (Gray's
rior to the subclavian artery Anatomy 2005) and sometimes extends to the 2nd rib (Simons
Medius: C2-7 posterior tubercles of the transverse et aI 1999). The scalenus minimus (pleuralis), which attaches
processes to the superior su rface of the 1st ri b posterior to to the pleural dome, is present one-third (Pla tzer 1992) to
the subclavian artery three-quarters (Simons et a1 1999) of the time on at least one
Posterior: C4-6 posterior tubercles of the transverse side. When absent, is replaced by a transverse cupular liga
processes to the 2nd rib ment (Platzer 1992).
Minimus: C7 (C6) anterior tubercle to the suprapleura l The brachial plexus exits the cervical column between the
membrane and 1st rib scalenus anterior and medius. These two muscles, together
Innervation: Ventral rami - anterior: C4-6; medius: C3-8; with the 1st rib, form the scalene hia tus (also called the sca
posterior: C6-8; minim us: C8 lene opening or scalene posticus aperture) (Platzer 1992). It is
M u s c l e type: Phasic ( type II), weakens when stressed, but through this opening that the brachial plexus and vascular
modifies to type J (postural) if pattern of use demands structures for the upper extremity pass. When these muscle
this, as in asthma tic or habitual hyperventi lation breath fibers are taut, they may directly entrap the nerves (scalene
ing (Lin et a1 1994) anticus syndrome) or may elevate the 1st rib against the over
Function: Unilaterally, the scalenii group flexes the cervical lying clavicle and indirectly entrap the vascular or neurolog
spine laterally and rotates the spine contralateral ly. ical structures (simul taneous compromise of both neural and
Bilaterally, they flex the neck and assist in elevation of the vascular structures is rare) (Stedman's Medical Dictionan)
1st and 2nd ribs (which assists inspiration) 2004). Any of these conditions may be diagnosed as thoracic
Synergists: For lateral flexion: ipsilateral sternocleidomas outlet syndrome, which is 'a collective title for a number of
toid, prevertebral muscles, posterior cervical muscles conditions attributed to compromise of blood vessels or
For contralateral rotation: ipsila teral sternocleidomastoid, nerve fibers (brachial plexus) at any point between the base
contralateral splenius cervicis, levator scapula, rotatores, of the neck and the axilla ' (Stedman's Medical Dictionary 2004).
multifidi During respiration, the scalenii assist by tractioning the
For flexion of the cervical spine: longus colli, longus capi tis, upper two ribs and pleura cranial ly. This action increases
suprahyoids, infrahyoids, pla tysma the diameter of the thoracic cavi ty, thereby supporting
A n tagonists: For lateral flexion: contralateral scalenii, SCM, inspiration. When diaphragmatic function is reduced,
longus colli, posterior cervical muscles scalenii may become overloaded, especially in quiet breath
For contralateral rotation: contralateral SCM, scalenii and ing (see Chapter 14 for more detail of the important role
ipsilateral splenius cervicis, levator scapula these muscles play in respiration).
For flexion of the cervical spine: posterior cervical muscles, When longus colli holds the neck rigid and cervical lor
SCM (when the neck is already extended) dosis is reduced, the bilateral scalenii flex the cervical col
umn on the thoracic column (as in looking down at one's
own chest). However, when the cervical column is not held
I nd ications for treatment
rigid, bilateral contraction of the scalenii flexes the cervical
A rterial obstruction to a rm column on the thoracic column and accen tuates cervical lordo
Compression of brachial plexus sis (as if looking up) which, when dysfunctional, may con
Diagnosis of thoracic outlet syndrome or carpal tunnel tribu te considerably to forward head posture as the eyes
syndrome and ears are brought to horizontal level.
1 1 The cervical region 315
. I
\
A
Scalene mlnlmus
Figure 1 1 .73 ACtB : Sca l e n i i trigger points produce patterns of com m o n com p l a i n t that may come from any of the scal e n e m uscl es. Drawn
after Simons et a l ( 1 999).
316 C LI N I CA L A P P L I CATI O N O F N EU R O M U SC U LA R TECH N I Q U E S : T H E U PP E R B O DY
.
Body Su pport Systems I n c . PO Box 337, Ash land OR 97520 (800) 448-2400 or (54 1 ) 488- 1 1 72.
'" N M T F O R SCALE N I I under the edge of the clavicular head of SCM (Fig. 1l .75A).
It will feel similar to the clavicular SCM and will attach to
The treatment of the scalenes can be performed in ei ther the first rib. The subclavian artery, which courses between
supine or sidelying posture (Box 1 1 . 1 5) . Both positions are scalenus anterior and medius, is avoided by palpa ting its
discussed here. pulse and locating the fingers in a position that does not
The patient is supine with the head rotated contralaterally compress it.
approximately 45. The practitioner is seated cephalad to the The fingers apply unidirectional (laterally oriented) trans
patient's head and locates the sternal and clavicular attach verse friction in a gentle snapping manner, beginning near the
ments of the sternocleidomastoid muscle. The pa tient may 1st rib and working up toward the tubercle attachments.
need to lift the head slightly to make the SCM more obvious to Uncontrolled aggressive snapping techniques are avoided
palpation. Contralateral head rotation will move the SCM and considerable caution must be exercised to avoid the
medially and allow a slightly better access to the scalenus ante artery and also the brachial plexus, which exit the vertebrae
rior, which often lies under SCM's lateral edge. Additionally, between the first two scalene muscles. Entrapment of the
lateral flexion against resistance will assist the practitioner in nerves or irritation of them by the treati.ng fingers should be
locating the muscle bellies. One side is treated at a time. avoided and the fingers reposi tioned if electric shock-like
The practitioner uses the first two fingers of the trea ting referrals are provoked. Additionally, extreme caution is used
hand to locate the scalenus anterior j ust lateral to or slightly to avoid pressing the nerves into the foraminal gutters, which
11 The cervical region 317
lie between the anterior and posterior tubercles. These gutters almost directly under the ear when the head is in neutral
are sharp and could damage the nerves or myofascial tissues position and in proper coronal alignment (Fig. 11 .75C). This
that attach nearby. muscle is often difficult to palpate. Transverse friction and
The treating fingers are moved posterolaterally and onto static pressure techniques are again used to assess this short
the scalenus medius (Fig. 11 .75B). This muscle is the longest scalene muscle. Unidirectional finger movements oriented
and usually the largest of the scalenii. The treating fingers anteriorly will usually identify this muscle when it is pres
repeat the transverse frictional steps while avoiding the ent, if it can be palpated.
brachial plexus, which exits the spinal column between the The tubercle attachments may be treated by flexing the
first two scalene muscles. When taut bands are located in fingers so that they arch around to the anterior aspect of the
any of the scalene muscles, flat palpation against the under transverse processes and are placed directly onto the ante
lying tubercles can be applied provided the nerves are not rior tubercles while taking care to avoid the nerves coursing
compressed or irritated by the treating fingers. immediately posterior to the tubercles (Fig. 11 .76A). The
The fingers are moved again posterolaterally and onto posterior tubercles are found by sliding onto them from a
the scalenus posterior, which attaches to the 2nd rib and lies posterior direction. The transverse processes are located and
318 C L I N ICAL A P P L I CATI O N O F N E U R O M U SC U LA R TECH N I Q U E S : TH E U P P E R B O DY
the SCM and will feel similar to the SCM clavicular head.
The entire length of the anterior, middle and posterior
scalenes are each separately assessed and treated in a man
ner similar to the supine description above. General gliding
techniques on the la teral neck are not recommended due to
the location of the brachial plexus and its close proximity to
the sharp foraminal gu tters.
f T R EATM E NT O F S H O RT SCAL E N I ! BY M ET
The patient lies supine with a cushion or folded towel
under the upper thoracic area so that, unless supported
by the practitioner's contra lateral hand, the head would
fall into extension.
The head is rota ted contralaterally (away from the side to
be trea ted).
B
There are three positions of rotation required:
Figure 1 1 .76 The a n terior a n d pos terior tubercles may be ca refully
pal pated. CAUTIO N is exercised to avoid the sharp edges of the 1. full contralateral rota tion of the head / neck produces
fora m inal g u tters and the b rachial plexus. A: Anterior tubercles. B : involvement of the more posterior fibers of the scalenii
Posterior tubercles. 2. a contralateral 45 rotation of the head /neck involves
the middle fibers
3. a position of only slight contrala teral rotation involves
the more anterior fibers.
the fingers slide around their lateral tips and onto the poste The practitioner 's free hand is placed on the side of the
rior tubercles (Fig. 11 .76B). Mild, minute frictional move patient's head to restrain the isometric contraction which
ments or light static pressure are used, while ensuring that will be used to release the scalenii.
the sharp foraminal gutters and cervical nerves are avoided. With appropriate breathing cooperation (,Breathe in and
hold your breath as you commence the effort, and exhale
Variation in side/ying position. The scalenii may a lso be completely when ceasing the effort'), the patient is
treated with the patient in sidelying position and with the instructed to try to l ift the forehead a fraction and to
head rotated toward the table approximately 45 (Fig. 11.77). a ttempt to turn the head toward the affected side while
The practitioner stands posterior to the head. The patient resistance is applied by the practitioner 's hand to pre
can simply begin to lift the head off the table with no resist vent both movements ('lift and turn').
ance needed to activate the scalenii for verification of their Both the effort and the counterpressure should be mod
location. The scalenus anterior will be located j ust lateral to est and painless at all times.
1 1 The cervical region 319
J
Figu re 1 1 .78 M ET treatment of sca lenus anterior. Fig u re 1 l . 7 9 Scalene positional release. Reproduced with
permission from Deig (2001).
During the gliding strokes, osseous structures may be contraindicated d ue to inflammation. Detailed protocols for
encountered in the lamina groove. These dense calcific pro assessing and treating the trapezius (pp . 429-435) and the
tuberances may be bifid (split) spinous processes, a spinous levator scapula (p. 436) are also offered in the prone position.
process of a dysfunctional (rotated) vertebra or the effects of
enthesitis on the m ultitude of myofascial tissues attaching
in the lamina groove. When osseous tissue is found, the
I N MT F O R POST E R I O R CRAN I A L ATTAC H M ENTS
contralateral side is examined for similar structures. The The prone pa tient's chin is tucked slightly, in order to gen
soft tissues of the area should be examined and treated and tly open the suboccipital space between the occiput and C1
osseous manipulations applied, if needed. However, the (atlas) . The practitioner remains at the level of the shoulder
practitioner is strongly advised to practice within the scope or chest, facing the head to trea t the ipsila teral side.
of their professional license. Referral to the appropriate Excessive s tretching into flexion is not recommended for
healthcare practi tioner for osseous assessment and manipu these procedures that treat the soft tissues of the posterior
lation may be necessary if the segments do not respond to suboccipital region, due to the position of the vertebral
soft tissue applica tions. artery in the lateral aspect of the suboccipital space between
C 1 and the occiput. Caution is exercised to avoid the verte
bral artery, which lies relatively exposed in the suboccipital
16 N MT F O R POSTE R I O R C E RV I C A L LA M I N A - triangle.
, PRO N E P O S I T I O N
The fingers provide stability and support for the move
The prone patient's chin is tucked toward the chest. The ments of the thumbs. The thumbs are touching end to end
practitioner stands at the level of the shoulder or chest, fac and are placed just caudal to the inferior nuchal line where
ing the head, and treats one side at a time. One or both of the rectus capi tis posterior major and minor attach and
the practitioner 's thumbs begin at the level of C7 and glide between the inferior and superior nuchal lines where the
superiorly from C7 to the occiput, while maintaining con obliguus capitis superior attaches (Fig. 11.81). Transverse
tact against the lateral surface of the spinous processes and (medial/lateral) friction is applied to the cranial attach
the lamina . The fingers provide stability for the thumbs as ments of the posterior cervical muscles and mid-belly
they repeat the gliding stroke 6-8 times (Fig. 11 .80). region of the suboccipital muscles. Static pressure may also
The thumbs are moved laterally about 1 inch (2.5 cm) and be applied when trigger points are loca ted in the suboccipi
the gliding strokes repeated 6-8 times. The gliding strokes tal muscles or posterior cervical muscles lying superficial to
are continued in strips in the lamina through the posterolat them, or when tissues are too tender to be frictioned. The
eral aspect of the transverse processes. The strokes are not attachments of trapezius, semispinalis capitis, splenius
continued further anteriorly due to the position of the capitis, longissimus capitis and sternocleidomastoid may
brachial plexus and the sharp edges of the foraminal gutters be included in this examination of posterior cranial attach
on the anterolateral surface of the transverse processes. ments. Cranial-to-caudal friction may also be used as long
Unidirectional or bidirectional transverse friction may as the vertebral artery is avoided (see Fig. 11 .48, p. 292).
be applied to the attachments of the levator scapula, sple The frictional technigues are repeated between C1 (atlas)
nius cervicis and other posterior cervical muscles unless and C2 (axis) to address the inferior half of rectus capitis
posterior major and obliguus capitis inferior through the
Figure 1 1 .80 The fingers h e l p to sta b i l ize the th u m bs w h e n gliding Figure 1 1 .81 M u ltiple attachments on the posterior cra n i u m may
cra n i a l ly i n the l a m i n a g roove. be assessed as the t h u m bs contact the occipital bone.
1 1 The cervical reg ion 321
]
Figure 1 1 .83 The thin, flat occi pita lis m uscl e i s part o f t h e
epicranius and refers strongly i n to the eye region.
Figure 1 1 .82 The tra nsverse process of the a tlas is the a ttach ment
site of several m uscles that may be treated with ca refu l ly appl ied
u n i d i rectional (latera l) friction.
which attaches to the skin over the craniwn and slides it over
the bony surface of the craniwn as the brows are lifted.
overlying tissues. Lighter pressure may be needed and may Occipitalis' fibers are often not distinct and the practitioner
only penetrate into the superficial tissues if they are too ten must rely on anatomic knowledge rather than palpation
der to be pressed through. skills when locating it. When occipitalis' fibers are taut, they
The attachments on the transverse process of C1 of may be vaguely palpable but their tenderness and trigger
obliquus capitis superior and inferior, levator scapula and point referrals will be apparent to the patient when they are
splenius cervicis muscles are carefully examined. The SCM involved. Movement of this muscle may be palpable on some
may need to be displaced anterolaterally in order to palpate individuals when the eyebrows are raised repeatedly, since it
the muscles attaching to the transverse process of Cl. merges with the cranial aponeurosis and connects with the
Caution is exercised to maintain contact with the posterolat frontalis muscle. However, with the patient prone, the face
eral tip of the transverse process (Fig. 11 .82) and not allow the cradle may inhibit the movement of the cranial fascia and
thumbs to intrude into the suboccipital triangle due to the prevent palpation of distinct movement of the occipitals.
vertebral artery's location within the triangle (Fig. 1 1 .48). Trigger point referrals from occipitalis often produce
The thumbs are placed on the occipitalis muscle, which lies strong patterns of pain, pressure and headache into and
approximately 1-2 inches (2.5-S cm) lateral to the occipital around the orbit of the ipsilateral eye. The weight of the
protuberance (Fig. 11 .83). Transverse friction or static pressure head on a solid foam pillow may irritate occipitalis trigger
can be used to examine the occipitalis muscle. This thin, flat points and cause the patient to awaken in the night with the
muscle attaches to the superior nuchal line of the occipital headache (eyeache) pattern. See further discussion with the
bone and to the galea aponeurotica (epicranial aponeurosis), cranium in the following chapter.
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325
Chapter 12
The cranium
-;:-
Holding tissues, sutures or joints in a position of relative comfort The breathing pattern may alter and may become slow and deep
or ease or applying specific techniques may result in a 'release' of or, in contrast, may become q u icker and be accompanied by rapid
the dysfunctional pattern, either completely or partial ly. How is eye movement and restlessness.
the practitioner to recognize when this occurs? Observation of the diaphragm region may provide useful informa
There are certain guidelines based on the clinical experience tion of such a change being i m m i nent or current.
of many experts that can ind icate a loca l tissue release. Fasciculation may be observed, with trembling and twitching
intermittently or constantly.
A sense of steady and strong pulsation, or of greater warmth, The patient may express a wish to vomit or cry or may sim ply
enters the area. begi n crying or laughing.
A very definite change (reduction) in palpated tone is noted.
A sense of the tissues 'lengthening' or 'freeing up' is perceived. How should such changes be handled? If a local release is noted this
can be held a nd gently released with nothing more being done to the
On a wider, whole-body level, such release phenomena may also particular area at that session apart from some soothing massage
involve deeper emotional release, sometimes ca l led 'emotional strokes. Alternatively, the holding pattern can continue at the new
discharge'. This may be accompanied by a l l , or any, of the 'barrier' as the tissues are offered the opportunity to continue to
fol lowing. release, perhaps in the form of an u nwinding process. The skills
appropriate for such techn ique a pplication need to be learned i n
The patient becomes flushed and a change in skin color is suitably detailed instructional forums.
observed, from pale to ruddy perhaps. The 'emotional release' phenomenon is discussed in detai l in
A light perspiration appears on the patient's u pper lip or brow. Chapter 4.
Pterygoid process
Styloid process --------'
Inferior turbinate
Pterygoid process --------'
Maxilla
Zygomatic bone --------.../
Vomer
Lacrimal bone --------"
'------ Coronoid process
Maxilla --------'
+------ Mandible
Ramus of mandible --------'
Fig u re 12.1 Disarticu lated sku ll show i n g major bony components. Reprod uced w ith permission from Chaitow (2005).
328 C L I N I C A L A P P L I CAT I O N O F N E U R O M U S C U LA R TECH N I QU E S: T H E U P P E R B O DY
See Box 12.3 for anatomical groupings of these bones. The condyles, which form the lateral borders of the fora
men magnum
OCCIPUT
Articu lations
The squama, the main body of the bone which forms the
posterior border of the foramen magnum With the atlas at the condyles .
The basiocciput, which forms the anterior border of the With the sphenoid at the synchondrosis - this is potentially
foramen magnum and which possesses a rostrum joining mobile up to about age 25 (Gray's Anatomy 2005, p. 464).
it to the sphenoid at the synchondrosis With the parietal bones at the lambdoidal suture.
.----- Clivus
.____--- Jugular lubercle
With the temporal bones. The jugular notch of the Muscu l a r attachments (Fig. 12.3)
occiput and the jugular fossa of the temporal bone meet
Occipitofrontalis, which is rea lly two muscles that cross
to form an articulation.
Posterior to this notch there is a beveled articulation which many sutures:
1. occipitalis, which attaches to the occiput and temporal
is partially internally (anterior aspect of articulation) and
partially externally (posterior aspect of articulation) bones (via tendinous fibers to the mastoid), crossing
beveled, with a point of transition, known as the condy the suture on the lateral aspects of the superior nuchal
losquamomastoid pivot, which allows an easily achieved line
rocking potential in clinical evaluation and treatment. 2. frontalis, which has no bony attachments but merges
Anterior to the notch the basiocciput has a tongue-and with the superficial fascia of the eyebrow area with
some fibers continuous with fibers of corrugator
groove articulation with the petrous portion of the tem
supercilii and orbicularis oculi, attaching to the zygo
pora! bone.
matic process of the frontal bone and further linkage
to the epicranial aponeurosis anterior to the coronal
Rec i procal tension m e m brane rel ationshi ps with
suture.
the occi put
Trapezius (upper) attaches to the superior nuchal line
Both the falx cerebri and tentorium cerebelli attach to the and external occipital protuberance as well as the liga
occiput (see Fig. 12.6) . mentum nuchae.
The bifurcated falx cerebri attachment is above the inter Longus capitis attaches to the inferior surface of the
nal protuberance and houses the superior sagittal sinus. basioccipu t.
Below the internal protuberance is the attachment of the Rectus capitis anterior attaches to the inferior basioc
falx cerebelli. cipuI, anterior to the condyle and to the lateral mass and
Lateral to the internal protuberance are double ridges root of the transverse process of C1 (atlas) .
formed by the bifurcated tentorium cerebelli attachments, Splenius capitis attaches to the superior nuchal line and
with the transverse sinuses located within the bifurcations. mastoid process, crossing the suture, and the spinous
(.I.L--+--- Stylohyoid
processes of the lower half of the cervical spine (Platzer Blows to the occiput from behind can cause a crowding
2004, Simons et al 1999) to T3 and the lower part of the or distortion pattern of the occipital base with the sphe
ligamentum nuchae. Gray's Anatomy (2005) notes that noid, prior to ossification.
this muscle attaches to the ligamentum nuchae and spin Any injuries or strains affecting the temporal or parietal
ous processes of C7 through T3 and their supraspinous bones w ill influence the occiput, and su tural restrictions
ligaments. relating to parietal or temporal articulations may then
Semispina lis capitis and spinalis capitis attach to the evolve.
superior and inferior nucha l lines and the transverse Muscular dysfunction in the suboccipital region can
processes of C7, T1-7 and the articular processes of C4-6. directly influence dural status and thereby cerebrospina l
Rectus capitis lateralis a ttaches to the jugular process fluid fluctuations (see notes on rectus capitis posterior
of the occipu t as well as the transverse process of the m inor above and in Chapters 3 and 11).
atlas. Internal drainage of the crani um can be directly influ
Rectus capitis posterior major is one of the suboccipital enced by changes affecting the reciprocal tension mem
m uscles (all of which lie deep) and it attaches to the lat branes that a ttach to the occiput and which house both
eral aspect of the inferior nuchal line as well as to the the superior sagittal and the lateral sinuses.
spinous process of the ax- i s.
Rectus capitis posterior minor, another of the suboccipital
muscles, attaches to the medial aspect of the nuchal line Pa lpation exerci s es
and to the posterior arch of the atlas, commonly described
Palpation of sphenobasilar synchondrosis. This exercise
as acting to bilaterally ex tend the head and maintain its
is performed using two different holds.
postural integrity. This unusual muscle has been shown
Vault hold (Fig. 12.4) . Patient is supine; the practitioner is
to attach to the posterior atlantooccipital membrane via
seated at the patient's head with forearms resting on the
dense connective tissue and to be fused to the dura by
table. Fingers are placed in a relaxed manner so that:
numerous connective tissue elements (see more detailed
notes on pp. 294-295) (Hack et aI 1995) . small finger is on the squamous portion of the occiput
Obliquus capitis superior, also one of the suboccipital ring finger rests behind the ear near the asterion so that
muscles, attaches between the inferior and superior nuchal the distal portion of finger is just on the mastoid
lines as well as to the transverse process of the atlas. middle finger is an terior to the ear to rest on the pterion
Restrictions and hypertonicity in any of these muscles, uni with the tip touching the zygomatic process
or bila terally, will strongly influence occipital function. index finger rests on the grea t wing of sphenoid
thumbs rest, touching each other or crossed, without
touching the head if possible, allowing pressure between
Range a nd d i rection of moti on them to form a base for the flexor muscles of the hand to
operate.
The concept of any flexion potential in the adult occipi
tosphenoidal junction remains questionable. There is, how The practitioner si ts quietly for at least 2 minutes or until
ever, an undoubted degree of pliability at the occiput's sutural cranial motion is noted (a sense of intermittent 'fullness' in
junctions with the parietals. A powerful pivot point also the palms of the hands may be all that is noted initially).
exists between the occiput and the temporal bone which As the flexion phase (also known as the inhalation/ ex ter
allows the temporals to 'externally rotate' when mobility nal rotation phase) of the cranial cycle commences (mani
is normal. fested by noting a sense of fu l lness, slight tingling, minute
When palpating the occiput, the motion of this bone, eas pressure in palms of hands or in wrists / forearms, by pro
ing anteriorly on inhalation and returning to its start posi prioceptors) the following might be noted:
tion on emala tion, raises the question as to what drives it.
Various hypotheses exist - respiratory influences; the recip ring and middle fingers seem to be carried caudally and
rocal tension membrane responding to intrinsic forces (CSF, laterally
for example); direct response to muscular influences, and index finger seems to be carried anteriorly and caudal ly.
others. When palpating the bone, it is suggested that the These real or apparent motions are all passive with no effort
slight degree of motion that may be noted is assessed with on the part of the practitioner.
no preconceptions as to what may be driving it (Chaitow As sphenobasilar ex tension commences (exhalation/
2005) . internal rotation phase) a sense might be noted of the pal
pated bones returning toward their starting position (index
finger moves cephalad and posteriorly, while ring and mid
Dysfu nctiona l patterns
dle fingers move cephalad and medially).
Any injury affecting the atlantooccipital joint is l ikely to Frontooccipital hold (Fig. 12.5). Patient is supine and the
nega tively influence occipital motion. practi tioner si ts to right or left near the head of the table.
12 The cranium 331
Does the movement continue when the patient holds the SPHENOID (FIG. 12.6)
breath?
The body, situated at the center of the cranium - a hollow
Is the movement accentuated by deep inhalation and /or
structure enclosing an air sinus
exhalation?
Two great wings, the lateral surfaces of which form the
There are no definitive answers at present as to what is only aspect palpable on the external cranium, the tem
actually happening, with opinions varying from orthope ples, and the anterior surfaces of which form part of the
dic to subtle energy hypotheses. Aspects of some of these eye socket
concepts are included in this chapter - see, in partic Two lesser wings, the anterior surfaces of which form
ular, the 'liquid electric' hypothesis in descriptions of part of the eye socket
sphenoidal function, immediately below (Chaitow 2005, Two pterygoid processes, which hang down from the
Ettlinger & Gintis 1991, Greenman 1989, Upledger & great wings, and which are palpable intraorally postero
Vredevoogd 1983). medial to the upper 3rd molars
Spine
The pterygoid plates, which form part of the ptery Muscu l a r attachm ents
goid processes and are important muscular attachment
The temporalis muscle attaches to the great wing and the
sites
The sella turcica (,Turkish saddle'), which houses the frontaL parietal and temporal bones, crossing important
sutures such as the coronal, squamous and the fron
pituitary gland
The sphenobasilar junction with the occiput, a synchon tosphenoidal.
Specifically the attachments of temporalis are to the tem
drosis that fuses in adult life (Gray's Anatomy 2005)
poral bone and to the coronoid process and the anterior
border of the ramus of the mandible.
Attaching to the internal pterygoid plate are buccinator
Articu l ati ons
as well as a number of small palate-related muscles.
With the occiput at the synchondrosis. Medial pterygoid attaches to the lateral pterygoid plate
With the temporal bones at the petrous portion and pos- and palatine bones running to the medial ramus and
terolaterally with the squama. angle of the mandible.
With the parietal bones at the pterion. Lateral pterygoid attaches to the great wing of the sphe
Anteriorly with the ethmoid. noid, the lateral pterygoid plate and the anterior neck of
Inferiorly with the palatine bones. the mandible and its articular disc.
Anteriorly both greater and lesser wings articulate with Various small muscles relating to movement of the eye,
the frontal bone bilaterally. as well as levator pa lpebrae which help raise the eye
Inferiorly with the vomer. brows, attach to those parts of the great wings of the
Anterolaterally with the zygomae. sphenoid that form part of the eye socket.
_+l,I.'_mI.!__-- Sphenoid
Siraighl sinuS--\+-.lJ.-tft
;;;:;:::<::::=:J
C
Figure 1 2.7 The reciprocal tension membranes of the cranium. Reproduced with permission from Chaitow (200S).
334 CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY
Cribriform plate
Posterior ethmoidal
groove
A
There are no direct associations with the reciprocal tension Dysfu n ctiona l pattern s
membranes and there are no direct muscular attachments.
In rare cases, the vomer can penetrate the palatine suture,
producing an enlargement/swelling of the central por
R a n ge a n d d i rection of m oti o n tion of the roof of the hard palate, a condition known as
torus palatinus.
The vomer's range of motion i s identical t o the ethmoid and As with the ethmoid, inflammation of the vomer is prob
opposite to the sphenoid.
able in association with sinusitis.
Direct trauma can cause deviation of the vomer and so
Other associ ati o n s a n d i nfl u ences interfere with normal nasal breathing.
Alveolar part
----':-l--- Masseter
Lateral pterygoid
--- Lingula
Temporalis ------r-
Mandibular foramen
Superior constrictor -------.,.
Genioglossus --------....1
Submandibular fossa
Geniohyoid -----p;
'----- Mylohyoid line
Attached to the posterior aspect of the bodies are the Digastric arises from two sites: the posterior belly from
rami, the vertical portions of the mandible. the mastoid notch of the temporal bone and the anterior
Each ramus forms two projections, the posterior of which belly from the digastric fossa on the internal surface of
becomes the articular condyle, via a slender neck, for the anterior aspect of the mandible. The two parts of the
its articulation with the temporal bone while the ante muscle link via a tendon that is attached to the hyoid
rior forms the coronoid process to which attaches the bone by a fibrous connection. Its actions are to depress
temporalis. the mandible, elevate the hyoid bone and assist in retrac
tion of the mandible.
Platysma's anterior fibers interlace with the contralateral
Articu lations
muscle, across the mid-line, below and behind the sym
The only osseous articulation of the mandible is with the physis menti. Intermediate fibers attach to the lower bor
temporal bone via the disc at the temporomandibular (TM) der of the mandibular body while the posterior fibers
joint. It also articulates with its teeth, which articulate cross the mandible and the anterolateral part of the mas
(occlude) with the upper teeth set in the maxillae. seter and attach to subcutaneous tissue and skin of the
There are no reciprocal tension membrane connections. lower face. The actions of platysma involve reducing the
concavity between the jaw and the side of the neck.
Anteriorly, it may assist in depressing the mandible or
Maj o r m uscu l a r attachments
draw the lower lip and corners of the mouth inferiorly,
Temporalis, which attaches to the temporal fossae, nm especially when the jaw is already open wide.
ning and converging medial to the zygomatic arch with Mylohyoid arises from the inner surface of the mandible
insertion on the coronoid process and the ramus of the and attaches to the hyoid bone. Its function is to depress
mandible. The anterior/ superior fibers occlude the teeth the mandible and to elevate the hyoid during swallowing.
as the mandible is elevated while the posterior fibers Geniohyoid attaches at the symphysis menti and runs to
assist in retraction of the jaw as well as lateral chewing the anterior surface of the hyoid bone, acting in much the
movements. same manner as mylohyoid.
Masseter attaches via its superficial fibers to the zygo
matic process and arch while the deeper fibers arise from
the deeper surface of the zygomatic arch. Superficially, it Mi no r m u scu l a r attachments (not described he re)
inserts into the lateral ramus while the deeper fibers
Buccinator
attach to the upper ramus and to the coronoid process. Its
Depressor angularis oris
functions are to occlude the jaw during chewing, to assist
Orbicularis oris
in lateral excursion, and (by means of fibers running in
Depressor labii inferioris
different directions) to alternately retract and protrude
Hyoglossus
the mandible during chewing. This is considered to be
Mentalis
the most powerful muscle in the body.
Superior pharyngeal constrictor
Lateral pterygoid attaches to the greater wing of the
Genioglossus
sphenoid (upper head) as well as to the lateral pterygoid
plate (lower head), both heads inserting via a tendon to
the anterior aspect of the neck of the mandible; a portion
Range and d i rection of m otion
of the upper head may also attach to the joint capsule and
the articular disc of the temporomandibular joint. The Involuntary motion of the mandible relates to motion of the
various actions in which the muscle is involved include temporal bones with which it articulates. This will be mod
depression and protrusion of the mandible, and assis ified by the degree of muscular contraction at their junction.
tance in contralateral excursion of the mandible, as well There is some disagreement as to the 'normal' active
as offering stability to the temporomandibular joint when range of motion of the mandible that in various texts is con
the mandible is closing. It is thought to stabilize the sidered to be between 42 and 52 mm (Rocobado 1985, Tally
condyle when the teeth are clenched to prevent it from 1990). Skaggs (1997) reports:
moving too far posteriorly (Gray's Anatomy 2005).
Medial pterygoid arises superficially from the tuberosity Rocobado (1985) states maximum. mandibular opening to be
of the maxiIla as well as from the palatine bone. A deeper 50 mm, thereby taking the periarticular connective tissue to
origin is from the medial pterygoid plate and the palatine 112% stretch. He qualifies that the stretch of the periarticu
bone. Superficial and deeper fibers merge to attach to the lar connective tissue should not exceed 70-80%, thus mak
medial ramus of the mandible close to the angle. The ftmc ing junctional mandibular range of motion approximately
tions of the muscle are to elevate and protrude the 40 mm. Okeson 's recent (1996) guidelines cite normal min
mandible (acting with the lateral pterygoid and the mas imum interincisal distance and active ranges of motion to be
seter) and contralateral excursion of the mandible. 36 to 44 mm and less in women.
1 2 The cra n i u m 339
--------i---
-1 - Frontal tuberosity
Supraorbilal notch
Glabella --------"
Supraorbital margin
Remains of frontal
(metopic) suture
Roofs of ethmoidal air cells --------, r---- Sulcus for sagittal sinus
With the maxillae via the frontal process. Muscu l a r attachments (see Fi g . 12.27, p. 353)
With the temporals (not always).
Temporalis arises from the temporal fossa and its fibers
With the lacrimal bones and the nasal bones.
converge to attach on the coronoid process and ramus of
the mandible, medial to the zygomatic arch. The origin of
Reci p roca l ten s i o n m e m br a n e relations hi ps
temporalis crosses the coronal suture between the frontal
The falx cerebri attaches strongly to the inner aspect of the and parietal bone as well as the suture between the tem
mid-line of the frontal bone at a double crest formed by its poral bone and the parietal.
bifurcated attachments, which creates a space that becomes Occipitofrontalis covers the entire dome of the skull from
the superior sagittal sinus. the superior nuchal line to the eyebrows, completely
342 C L I N I C A L A P P L I CATI O N O F N EU RO M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY
enveloping the parietal suture. The muscle also spans the but clearly could not occur if the bones had fused, as hap
lambdoidal and coronal sutures, attaching via direct or pens in most cases.
indirect linkages with the frontal, temporal, parietal and
occipital bones. Frontalis merges with the superficial fas
cia of the eyebrow area while some fibers are continuous Other associ ations a nd i nfl uences
with fibers of corrugator supercilii and orbicularis oculi
Associations with problems of the eyes and sinuses are clear
attaching to the zygomatic process of the frontal bone,
from the geography of the region alone and congestion and
with further linkage to the epicranial aponeurosis ante
discomfort in this area can at times be related to frontal
rior to the coronal suture.
bone compression or lack of freedom of motion. The con
Corrugator supercilii lies medial to the eyebrow and
nection with the falx cerebri offers other possible linkages,
comprises a small pyramid-shaped structure lying deeper
in particular to cranial circulation and drainage.
than occipitofrontalis and orbicularis oculi.
Orbicularis oculi is a broad flat muscle which forms part
of the eyelids, surrounds the eye and runs into the cheeks
Dysfunctiona l patterns
and temporal region. Parts are continuous with occip
itofrontalis. Apart from direct blows to the forehead, few problems
Procerus is a slip of nasal muscle that is continuous with seem to arise as a direct result of frontal dysfunction.
the medial side of the frontal part of occipitofrontalis. However, as with the parietals (see below), problems may
arise as a result of the accommodation of the bone to influ
ences on it, temporal, parietal, sphenoidal, or from the facial
Ra nge a nd d i rection of m otion bones.
During flexion the frontal bone is said to be:
Pa l pation exerci s es
. . . carried by the sphenoid wings and, heLd by the falx cere
bri, and so rotates about an oblique axis through the squama Hypothenar eminence application for frontal lift
so that the glabella moves posterior, the ethmoid notch (Fig. 72. 7 7)
widens, the orbital plate's posterior border moves slightly The patient is supine and the practitioner sits at the head
inferior and lateral, the zygomatic processes move anterior of the table, elbows fully supported and fingers inter
and lateral and the squama 'bend' and recede at the midline. laced so that the hypothenar eminences rest on the lateral
(Brookes 1 981) angles of the frontal bones with the fingers covering the
metopic suture.
It is the combined effect of sphenoidal flexion and the back As the patient exhales the interlaced hands exert light
wards pull of the falx during the flexion phase of the cycle compressive force to take out slack (grams only) via the
that is thought to produce the mid-line frontal bone flexion, hypothenar eminences (bringing them toward each other),
which would be conceivable if a true suture were present utilizing a very slight contraction of the extensor muscles
A B
Figure 1 2. 1 7 Hand actions and d i rections of force (A) and contact positions (B) for decom pression treatment of fronta l bone. Reproduced
with permission from Cha itow (2005).
1 2 The cranium 343
Articulates with greater wing of Articulates with squamous '----- Articulates with mastoid
A sphenoid bone -------' part of temporal bone part of temporal bone
sagittal sinus. Any restriction of the sagittal suture's normal Pa l p ation exercises
pliability (approximately 250 microns of rhythmic movement
Parietal lift (Fig. 12. 19)
in normal subjects, 8-14 times per minute) (Lewandowski &
The patient is supine and the practitioner is seated at the
Drasby 1996) might therefore be expected to negatively
head of the table.
influence the status of both the attaching reciprocal tension
The practitioner's fingers are placed so that the small fin
membrane (the falx) as well as drainage via this important
gertip rests close to the asterion anterior to the lambdoidal
sinus.
suture.
The other finger pads rest on the parietal bone just above
the temporoparietal suture so that the middle finger is
Muscu l a r attachm ents
approximately one finger width above the helix of the
Temporalis arises from the temporal fossa and its fibers ear, on the parietal bone (not the temporal).
converge to attach on the coronoid process and ramus of The thumbs act as a fulcrum, bracing against each other or
the mandible, medial to the zygomatic arch. The origin of crossed above the sagittal suture without any direct contact.
temporalis crosses the coronal suture as well as that Gentle pressure is applied - approximately 1 0 grams -
between the temporal bone and the parietal. medially with the finger pads to crowd the sagittal suture
Auricularis superior is a thin, fan-shaped muscle that arises and to disengage their temporal articulation.
from the epicranial aponeurosis, converging to insert by This pressure should be introduced by means of contrac
a flat tendon into the upper surface of the auricle. tion of the wrist flexors rather than by hand action.
Occipitofrontalis does not attach directly to the parietals The thumbs stabilize the hands as the pressure is main
although its aponeurosis covers them. tained and a light but persistent lifting of the parietals
directly cephalad is introduced from the finger pads
(while the medial compression is maintained) for between
R a nge a nd d i rection of m otion 2 and 5 minutes, during which time a sensation might be
noted of the parietals 'spreading' and lifting superiorly.
Human studies indicate that approximately 250 microns
During this procedure the other restricting influence,
of movement is available at the sagittal suture
apart from the temporal suture contact, is that offered by
(Lewandowski & Drasby 1996). There is a greater degree
the falx cerebri and sensitivity should be maintained to
of interdigitation on the posterior aspect of the sagittal
any resistance it is offering.
suture where motion potential is therefore greatest.
Successful application of this parietal lift will enhance
Osteopathic cranial concepts have the parietals flexing
drainage via the superior sagittal sinus formed by the
inferiorly (,flattening') at the sagittal suture.
falx cerebri's attachments to the parietals.
A more pragmatic view is that the pliability of the suture
Contact with the temporals should be avoided during
helps to absorb stresses imposed on the structure via
this procedure.
either internal or external forces (Chaitow 2005).
Other models (Iiquid/electric, energetic, etc.) offer differ
ent interpretations as to the motion potentials of these
TEMPORALS
bones (Milne 1995).
A complex arrangement of different bone formats.
A slim fan-shaped upper portion - the squama - with an
Other a ssociations a nd i nfl uences
internal bevel for articulation with the parietal.
The connection with the falx cerebri is one of the most A long projecting column - the zygomatic process -
important links the parietals have with the inner circulation which reaches forward to articulate with the zygoma.
and drainage of the cranium. An anchorage point for the sternocleidomastoid - the
The temporal bone articulation is a key area for evidence mastoid process.
of cranial dysfunction and for treatment, usually by means A rock-like petrous portion, the apex of which links to the
of temporal contact. sphenoid via a ligament.
V ----
c
B o
Figure 1 2. 1 9 Parietal lift tech n i q u e showing (A) h a n d positions, (B) fi nger contact sites, (C) contact sites avoiding sutu res a n d (D) d i rections
of a pp l i ed light traction force. Reproduced with permission from Chaitow (2005).
Muscular attachments
muscle that will shorten under prolonged mechanical
Sternocleidomastoid arises from heads on the manubrium stress and therefore is capable of producing sustained,
sternum and the clavicle and powerfully attaches to the virtually permanent drag on the mastoid in an infe
mastoid process (clavicular fibers) as well as to the supe rior/ posterior direction. If such traction were combined
rior nuchal line (sternal fibers). This muscular influence with a similar drag anteroinferiorly by sternocleidomas
allows enormous forces to be exerted onto one of the most toid, the temporal bone's ability to move freely would be
vulnerable and important of the cranial bones. severely compromised.
Temporalis arises from the temporal fossae. The posterior Splenius capitis arises from the spinous processes of
aspect of the origin of the muscle lies on the temporal C7-T3 as well as the lower half of the ligamentum nuchae
bone. The inferior attachment is to the coronoid process. and attaches to the mastoid process and the lateral aspect
Longissimus capitis arises from the transverse processes of the superior nuchal line. Any sustained traction from
of Tl-5 and the articular processes of C4-7 attaching to this would crowd the suture between the occiput and the
the mastoid process. This is also a powerful postural temporal bone, reducing its potential for free motion.
346 CLI N I CA L A P P L I CATI O N OF N E U R O M U S C U LAR TECH N I Q U E S : T H E U PP E R B O DY
Ra nge and d i rection of motion The jugular vein passes through the jugular foramen,
part of which is formed by the temporal bone's inferior
The motion during flexion can be visualized as a flaring
surface.
outward of the squama (as it pivots at its beveled junction
The stylomastoid foramen allows passage of the 7th cra
with the parietal) while the mastoid tip moves pos terome
nial (facial) nerve.
dially. These all return to neutral d uring the extension
The mandibular fossa forms part of the temporo
(internal rotation) phase of the cycle.
mandibular joint.
A B
Fig u re 1 2.21 H a n d positions (A) and d i rections of l i g h t force (B) i n a pplication of the b i tem pora l roll tec h n i q ue. Reproduced with permission
from Chaitow (2005).
influences on temporal mechanics, emerging from emotion Following bitemporal rolling, synchronous rolling
ally induced habits such as bruxism or upper chest breath should be performed (next exercise).
ing patterns, is clear.
Because of its di.rect l inkage with the tentoriwn cerebelli,
Synchronous temporal rolling exercise
any dysfunctional pattern of a temporal bone automatically
The hand hold and general positioning is as in the exer
influences the other bones with which tentoriwn is connected,
cise described above.
the other temporal as well as the occiput and the sphenoid.
The deep flexors of the fingers are employed to exert gen
tle pressure via the thumbs onto the mastoid p rocesses
Dysfunctiona l patterns during the inhala tion (external rota tion/ flexion) phase of
the cycle.
A wide range of symptoms may be associated with tempo
This takes the mastoids posterior and medial and encour
ral dysfunction, often following trauma such as whiplash or
ages normal flexion motion of the temporal bones.
a blow to the head. Among the commonest reported in
As exhalation (internal rotation/extension) occurs, the
osteopathic literature are:
forearm muscles are released to prevent inhibition of a
loss of balance, vertigo return to neu tral.
nausea As this return to neutral occurs, a very slight (grams
chronic headaches only) pressure can be introduced via the thenar emi
hearing difficulties and recurrent ear infections in children nences resting on the mastoid portion of the temporal
tinnitus bone, taking this slightly medial and pos terior, encourag
optical difficulties ing a slight exaggeration of the extension phase.
persona li ty and emotional fluc tuations ('mood swings') Repeating these motions will achieve an overall increase of
Bell's palsy the amplitude of both phases of the cranial motion cycle.
trigeminal neuralgia. A gradual acceleration of the rate is possible which
is thought to encourage greater cerebrospinal fluid
Bitemporal rolling exercise (Fig. 12.2 1) fluctuation.
The practitioner sits at the head of the supine patient with A slowing down of the rate is also possible, producing a
one hand cupped into the other, so that the head is cra relaxing effect.
dled, thumbs on and parallel with the anterior surfaces of This synchronous rolling should always be used to com
the mastoid processes, while the thenar eminences sup plete the treatment if alternate rolling has been used (see
port the mastoid portion of the bone. The index fingers previous exercise).
should cross each other (not shown in Fig. 12.21). Always complete contact with the temporals during the
An alternating rocking motion is introduced (one side neutral phase between the extremes of motion.
going into flexion as the other goes into extension) at the
thumb contact by pivoting the middle joints of the index
ZYG OMAE
fingers against each other.
The amount of pressure introduced at the mastoid A central broad curved malar surface
should be in grams only and should initially maintain A concave corner making up most of the lateral and half
and enhance the current rhythm of cranial motion. of the inferior border of the orbit
348 C L I N I CAL A P P L I CATI O N OF N E U RO M U SC U LA R T E C H N I Q U E S : T H E U PP E R B O DY
An anteroinferior border articulating with the maxilla There are no direct reciprocal tension membrane rela
A superior process articulating superiorly with the tem tionships.
poral portion of the frontal bone (via interdigitations)
and posteriorly with the great wing of sphenoid
Muscu l a r attachm ents (see Fig. 1 2.22)
A posteromedial border articulating via interdigitations
(not d escri bed h e re)
with the greater wing above and the orbital surface of the
maxilla below Levator labii superioris
Zygomaticus major
Zygomaticus minor
Articu l at i ons
Orbicularis oculi
See Figure 12.22. Masseter
-- ---,
=- , =-'--
- - Anteroinferior angle of parietal bone
The orbital border is said to 'roll antero-Iaterally, and the Sinus problems can often benefit from increased freedom of
tuberosi ty rolls inferior' in the classic osteopathic descrip the zygomae. They should always receive attention after
tion of flexion motion (Brookes 1981 ) . dental trauma, especially upper tooth extractions, as well as
trauma to the face of any sort, as they are likely to have
Other a ssoci ati o n s a n d i nfl u ences absorbed the effects of the forces involved.
Habits such as supporting the face/ cheekbone on a hand
The zygomae offer protection to the temporal region and
when writing (for example) should be discouraged as the
the eye and are, as with the etlunoid and vomer, shock
persistent pressure modifies the position of not just the
absorbers which spread the shock of blows to the face.
maxillae but all associa ted bones and s tructures. They
Milne (1995) suggests that ' they act as speed reducers
should be assessed and treated in relation to problems
between the markedly eccentric movements of the tempo
involving the temporals, maxillae and sphenoid.
rills and the relative inertia of the maxillae'. The zygomati
cofacial and the zygomaticotemporal foramina offer passage
MAXILLAE
to branches of the 5th cranial nerve (maxillary branch of
trigeminal). See Figure 1 2.23.
Articulates
with frontal bone
Medial palpebral ligament Nasolacrimal groove
A
Levator anguli oris Buccinator
Nasolacrimal groove
B
Fig u re 1 2.23 Latera l (A) and medial (8) aspects of the left maxi l l a showing a ttachments and a rticu l a tions. Reprod uced with permission from
Chaitow (2005).
350 CLI N I CAL A P P L I CATI O N O F N E U R O M U SC U LAR TEC H N I Q U E S : T H E U P P E R B O DY
As described above, the maxillae articulate at nwnerolls The conchal crest for articulation with the inferior nasal
complex sutures, with each other and with the teeth they concha.
house, as well as with the ethmoid and vomer, the pala tines The ethmoidal crest for articulation with the middle
and the zygomae, the inferior conchae and the nasal bones, nasal concha.
the frontal bone and the mandible (by tooth contact) and The maxillary surface has a roughened and irregular sur
sometimes with the sphenoid. face for articulation with the maxillae.
There are no direct reciprocal tension membrane rela The anterior border has an articula tion with the inferior
tionships. nasal concha.
The posterior border is serrated for articulation with the
medial pterygoid plate of the sphenoid.
Muscu l a r attachm ents (see Fig. 12.23) The superior border has an anterior orbital process (which
(not described h ere) articulates with the maxilla and the sphenoid concha) and
a sphenoidal process posteriorly (which articulates with
Medial pterygoid
the sphenoidal concha and the medial pterygoid plate, as
Masseter
well as the vomer).
Risorius
The median pala tine suture joins the two palatines.
Orbicularis oculi
Levator labii sllperioris
There are no direct reciprocal tension attachments.
Nasalis
Depressor septi
Levator anguli oris
Muscu l a r attachm ents
Buccinator
The medial pterygoid is the only important muscular
attachment. It attaches to the la teral pterygoid plate and
Range a n d d i rection of motion palatine bones, running to the medial ramus and angle of
the mandible.
These follow the pala tines (which follow the pterygoid
processes of the sphenoid) so that during the flexion phase
of the cranial cycle 'the nasal crest moves inferior and pos
R a n ge a nd d i rection of moti o n
terior, the tuberosity moves lateral and slightly posterior,
the frontal process posterior border moves la teral and the The palatines move, during flexion, to follow the p terygoid
alveolar arch widens posteriorly' (Brookes 1981) . processes of the sphenoid with the nasal crest moving infe
rior and slightly posterior and the perpendicular part mov
ing lateral and posterior.
Other associ ati ons a n d i nfl uences
Sphenopalatine notch
B Horizontal plate
Fig u re 1 2.24 A : Medial aspect of left palatine bone a rticulating with the maxilla. B : M ajor features of the palati n e bone. Reproduced w i th
permission from Cha itow (2005).
Frontalis -+-+-If:---''--':-:'c':. also the insightful observations of Philip Latey (1996) who
Palpebral
ligament points out that during a lengthy osteopathic career he has sel
Procerus ----iHry..<"-----"': dom seen anyone suffering from migraine headaches who has
a normal range of facial expression.
The scalp itself is composed of five layers. The first three (skin,
subcutaneous tissue and epicranius with i ts aponeurosis) are
best considered together as a single layer since they remain
Levator labii
superioris
connected to each other when tom or surgically reflected.
Orbicularis oculi
alaeque nasi (palpebral The deeper subaponeurotic areolar tissue allows the
Levator labii portion) scalp to glide readily on the deepest layer, the pericranium.
superioris -----.J Epicranial muscles express surprise, astonishment, atten
'---- Risorius
Orbicularis oris tion, horror and fright and are used when glancing
'----- Nasalis upwards. When p ulling from below, the fron talis can draw
A Depressor angUli Mentalis '------ Nasalis the scalp forward as in worry, grief or profound sadness,
inferioris (alar portion) especially in combination with other brow muscles.
Corrugator
supercilii OCCIPITOFR O N TALIS (FIG. 1 2.27)
>--
Attachments: Occipitalis portion: highest nuchal line of
occipital and temporal bones to the cranial aponeurosis
O rbicularis oculi
(galea a poneuro tica)
B Frontalis portion: cranial aponeurosis (galea aponeurotica)
anterior to the coronal su ture to the skin and superficial
fascia of the eyebrows, with fibers merging with pro
cerus, corrugator supercilii and orbicularis oculi
Innervation: Facial nerve (cranial nerve VII)
Muscle type: Not established
Function: To elevate the eyebrows during expression, hence
c D E F wrinkling the forehead
Effects of muscles on facial expression (from RouillE l ) Synergists: None
Fig u re 1 2.25 A: M uscles of expression. B: Orbita l m uscles of the Antagonists: Procerus, corrugator supercilii, orbicularis oculi
eye. C-F: Effects of m uscles on facial expression. Drawn a fter
Platzer (2004).
I n d i cati o n s fo r treatment
Figure 1 2.26 ARB : Distribution of relaxed skin tension l i nes of head a n d neck. Reproduced with permission from Gray's Anatomy (2005).
Fronlal belly of
occipitofrontalis -----+-H'f-+
Orbicularis oculi -----..J
Procerus ------,
Nasalis -----,
OCcipital belly of
Levator labii superioris occipitofrontalis
alaeque nasi ---____
Levator labii
superioris -----ft----,=
Figure 1 2.27 Intense deep pain i nto the orbit a n d eye may be referred from occi pita l is. Eye pathology should be considered, even when
trigger poi nts a re fou nd to reproduce the pain com p l a i nt. Note that the modiolus, a fibromuscu l a r mass that is h i g h l y mobile a nd i m m ensely
com plex, is noted but not clearly i l l ustrated here. Reproduced with permi ssion from Gray's Anatomy for Students (2005).
3 54 CLI N I CA L A P P L I CATI O N O F N E U R O M U SC U LAR T EC H N I Q U E S : T H E U PP E R BODY
Spec i a l n otes superficial fascia and to begin therapy of the muscles of the
cranium. Brisk frictional scalp massage will create heat,
The occipitofrontalis is a broad, thin, muscu lofibrous layer
which may allow the external cOimective tissue to soften.
that completely envelops the parietal suture. It additionally
Any tender areas found may be treated with combination
spans the lambdoidal and coronal sutures, attaching vi a
. friction or static pressure. Special attention should be given to
direct or indirect linkages with the frontal, temporal, pan
cranial suture lines, which may be more tender than other
etal and occipital bones, with the potential to significantly
areas and may indicate a need for further cranial attention.
influence mobility and function of cranial structures.
Light to moderate hair traction may now be applied at
Restrictions and tension in either the frontalis or occipitalis
palm-width intervals over the entire cranium, one handful
muscles will produce a ' tightening' of the scalp, which can be
at a time, if the hair is long enough to be grasped. The hair
diagnostic. Lewit (1996) states: 'The scalp should move easily
is gently lifted away from the scalp by the non-treating
in aU directions in relation to the skull. Examination of scalp
hand and the fingers of the treating hand slide into place
mobility is warranted for patients with headache and/or
close to the scalp with segments of hair lying between the
vertigo.' Tension in the occipitofrontalis, or the epicranial
aponeurosis, can also be seen to potentially interfere wl h the
fingers. As the fingers close into flexion, they also wrap
. around the hair shafts so tha t they grasp the hair close to the
minute degree of mobility that exists between the OCCipital,
scalp (Fig. 1 2.28) . The non-treating hand stabilizes the cra
parietal and frontal bones.
. . . nium while the grasping hand gently pulls the hair away
Flat palpation is used to locate and treat tngger pomts m
from the cranium until slack is taken ou t and tension pro
the occipitofrontalis. Trigger points from the frontalis belly of
duced . The hair traction is sustained for 30 seconds to
this structure refer to the forehead while trigger points in the
2 minutes. If brisk friction has been applied immedia tely
occipital fibers refer to the back of the cranium and to the area
before hair traction, the fascial tissues will usually quickly
behind the eyes. Kellgren notes referral pa tterns of occipitalis
loosen and soften. When friction is not applied first, the
giving rise to earache (KeUgren 1938, Simons et aI 1999).
release of the tissues is delayed a minute or two.
Temporoparietalis and auricular muscles lie superficial
The entire procedure may be repeated, although single
to the temporalis muscle and may be tender associated with
applications are often adequate. If craniosacral therapy is to
trigger points in the underlying tempora lis. While these
be applied, the cranial techniques may precede or follow
muscles have significant use in most animals, they have
hair traction or frictional massage.
very little obvious influence in most humans. However,
The auricularis muscles may sometimes be manually
Gray's Anatomy (2005) notes that a uditory stimuli evoke pat stretched by pulling the ear into various positions by grasp
terned responses in these muscles. They may be irrita ted by
ing the ear cartilage at i ts attachment to the head and trac
ill-fitting glasses or by telephone headsets.
tioning it posteriorly, inferiorly and an teriorly. This
The following techniques may be applied to assess the
epicranial tissues. Frictional or hair tracton techniqu s
technique may also have effects on the posi tion of the tem
poral plate and should not be applied without concern for
should be avoided where hair loss is occurrmg, where hair the cranial system. The practitioner who is unfamiliar with
transplants have been embedded or if segmenta l neurop
cranial therapy but uses ear traction for these tissues should
thy (shingles virus) is suspected, present or has occurred In
the last 6 months. If the ha ir is missing completely, myofas
cia I release may be used as needed. If the hair is too short to
grasp, the frictional applications may still be used.
If the pa tient reports a current headache, the hair traction
method may be applied and will sometimes relieve the
headache. However, the frictional techniques usually prove
too uncomfortable during active headache. Additionally,
both techniques may be given to the patient for home care
as they are easily self-a pplied .
f NMT F OR EPICRANIUM
end the treatment by p ulling the ear gently directly laterally Orbicularis oculi is divided into three parts: orbital, palpe
and holding for 30-60 seconds. bral and lacrimal. The orbital portion of orbicu laris oculi
encircles the eye and lies on the body orbit while the palpebral
Manual treatment of occipitofrontalis. Direct manual portion lies directly on the upper and lower eyelids. The
release of the fascial restrictions in occipitofron talis are rec short, small fibers of the lacrimal portion cross the lacrimal
ommended. Tension in the scalp interferes with cranial sac and attach to the lacrimal crest. Its trigger points may
motion, just as gross restriction in the thoracolumbar fascia refer to the nose or create 'jumpy prin t' when reading.
can drag on the sacrum . As a sphincter muscle, orbicularis oculi is responSible for
The methods which will achieve release of such struc closing the eye voluntarily or reflexively, as in blinking. I t
tures can involve NMT, massage methods, myofascial release also aids i n reducing the amount o f light entering the eye and
and positional release approaches. If NMT is employed, as hence is involved w ith squinting. Levator palpebrae superi
outlined above, this can be assisted by an isometric contrac oris antagonizes eye closure by elevating the upper eyelid.
tion of the muscle prior to NMT. A strongly held frown, for Corrugator supercilii" blends with the frontalis muscle and
7-10 seconds, will reduce hypertonicity and allow easier the orbicularis oculi and radiates into the skin of the eye
manual applications to the soft tissues. brows. It draws the brows toward the mid-line.
These tvvo muscles are responsible for bunching the brows
I. POSITIO N A L RELEASE METHOD FOR to shield the eye from intense light or when eyestrain pro
, OCCIPITOFRONTA L I S duces a similar 'squinting' movemen t. They create vertical
furrows between the brows that, over time, may become
With the pads of two or three fingers the practitioner
deeply entrenched lines. Additionally, orbicularis oculi pro
applies light compression, less than half an ounce, onto the
duces radia ting lateral lines commonly called 'crov,r's feet'
skin overlying those parts of the muscle tha t appear most
and expresses worry or concern while corrugator supercilii
tightly adherent to the skull, identified by light to-and-fro
is called the muscle of pathetic pain and also produces the
gliding assessments of skin on the underlying fascia.
expression associated with thinking hard.
The point of initial contact is the starting, 'neutral' point.
From this contact, assess the rela tive freedom of move
It
ment of the skin on underlying fascia in two opposite N MT FOR PA LPEBRA L REGION
directions, say moving laterally one way, then back to
The eye region contains the most delicate tissues of the face,
neutral and then in the opposite direction.
which are treated w ith the most gentle touch. Ex treme care
Decide which direction of movement is 'easiest' and
must be exercised to avoid stretching the skin of the eye
glide the skin on the fascia toward that direction.
region. Spray and stretch techniques are not recommended
Next, from this first posi tion of ease, assess the relative
near the eyes while injections into the eye region may result
freedom of glide in another pair of directions, say mov
in ecchymosis, 'a black eye' (Simons e t al 1999) .
ing anteriorly and posteriorly.
Flat palpa tion is used to press fingertip portions of the
Which of these offers least resistance?
orbicularis oculi against the underlying bony orbit (Fig. 12.29).
Ease the tissues toward the direction, so achieving a com
bination of two positions of ease.
From this second position of ease assess whether light
rotational motion is easier in a clockwise or a counter
clockwise direction. Take the tissues toward this and hold
them there for 20-30 seconds.
After this allow the tissues to return to the starting position
and reevaluate freedom of skin glide motion; it should
have improved markedly compared with the commencing
assessment .
Repeat this approach wherever there appears t o b e a
degree of restriction in free motion of the skin of the scalp
over the underlying fascia.
1 N MT F OR N A SAL REGION
Risorius --
Platysma -------'\_.l,
Mentalis
Figure 1 2 .31 O ra l group of facial muscles. Reprod uced with permission from Gray's Anatomy for Students (2005).
MUSCLES OF MASTICATION zone was lost with the following results. 'Regardless of
occlusal conditions, the weight distribution was changed
The action of fracturing food, blending i t with saliva and
during clenching . . . The weight distribution was shifted
preparing it for swallowing is a complex process collec
anteriorly during clenching regardless of the condition of
tively called mastication. Compressional forces are placed
the occlusal supporting zone.' Addi tionally, they noted
upon the food by the tooth surfaces d ue to the applied loads
that weight distribution shifted more laterally to the
of the muscles that cross the temporomandibular (TM) joint.
opposite side of the lost occlusal supporting zone during
The process of mastication is a complex, coordinated in ter
clenching when the occlusal supporting zone was lost
action of numerous muscles and glands and is tremen
more unilaterally than bilaterally. 'From the present find
dously dependent upon the integrity of the TM join t and
ings, it is suggested that the body posture may be
teeth, and the health of the associated myofascial tissues.
affected and changed to an tmusual position causing
Trigger points wi thin these tissues, intrajoint dysfunctions
neck or shoulder pain, especially when the occlusal sup
or dental factors that inhibit normal occlusion of the teeth
porting zone is lost both unilaterally and bilaterally.'
(such as the inability to chew on a particular side which, in
Fink et al (2003) examined the relationship between the
turn, overloads the contralateral side) are only a few of the
craniomandibular system, the craniocervical system and
many conditions that interrupt and affect the synchronized
the sacropelvic region. Twenty people were screened for
action of eating. Since these muscles are also responsible for
healthy dentition and TMJ, functional upper cervical ver
many of the activities needed for speaking, the dysfunc
tebrae, normally mobile SIJ, normal Patrick's test for
tions associated with TM joint and tongue movements can
adductors. Occlusal interference was provoked (Gerger
have a far-reaching impact on our daily lives.
resiliency test) by placing a 0.9-mm piece of tin foil in the
The suprahyoid muscles form the floor of the mouth and
area of the premolars on the left side. The participants
are involved in opening the mouth and deviating the
were then measured three times within 1 hour for cervical
mandible la terally. These muscles are discussed and
hypomobility, SIJ hypomobility and adductor tightness.
addressed with the intraoral treahnent approach following
The following results were recorded at the first examina
external palpa tion. The muscles of the soft palate and
tion (pre-placement), second examination (three times
tongue are also included in the intraoral approach.
within 1 hour after placement) and third examination
The muscles that directly cross the TM joint include tempo
(5 minutes after removal of interference).
ralis, massetel lateral pterygoid and medial pterygoid. These
muscles most powerfully move the mandible while others
influence its quality of movement directly (as in digastric)
or indirectly (as in those which position the head in space). Cervical region O/e l C 1 /2 C2/3
Recent research has demonstrated the far-reaching influ L R L R L R
ences that the stoma tognathic system (all of the structures First exam ination 0 0 0 0 0 0
involved in speech and in receiving, mastica ting and swal Second exami nation 11 0 2 9 5
lowing food and in speech) in general, and the occlusal sur Th ird examination 0 0 0 0 0
faces of the teeth (premolar and molar) in particular, have Sljoint
on the body as a whole. A number of studies that are partic L R L R L R
ularly worthy of consideration are detailed below.
First exami nation 0 0 0 0 0 0
Yoshino et al (2003a) explored head posi tion during Second exami nation 16 2 14 1 15 1
clenching and with loss (unilaterally and bilaterally) of Third exam ination 0 0 0 0 0 0
the occlusal supporting zone (splint). 'The results were as Adductors by Patrick's test (cm)
follows: . . . Regardless of the occlusal conditions, the L R
head position was changed by clenching . . . The occlusal
First exami nation 1 6.3 (3.8) 1 6.3 (3. 1 )
condi tions did not a ffect the changed distance of the
Second exami nation 1 8.4 (3.8) 1 6.4 (2.3)
head posi tion . . . The head position was changed forward Th ird exam ination 1 6.4 (2.9) 1 6.4 (2.9)
and down by clenching regardless of the condition of the
occlusal supporting zone.' The head position changed
more la terally to the side opposite the lost of occlusal
supporting zone during clenching when the occlusal Results showed that occlusal interfertmce produced significant
supporting zone was lost unilaterally ra ther than bila ter cervical hypomobility, Sf! hypomobility and loss of adductor
ally. 'Based on this study, it is suggested that unilateral range of motion within 1 hour of placement and this was
loss of the occlusal supporting zone may cause the neck reversed within 5 minutes after the removal of thefoil. Fink et
muscles to become inharmonious and thus affect body al concluded: ' . . . it seems to be sensible to include an investi
posture.' gation of the cervical spine and lumbar and pelvic regions in
Yochino et al (2003b) then investigated changes in weight the examination of CMD patitmts . . . and also to investigate
distribution at the feet when the occlusal supporting the craniomandibular system in neck and back pain patitmts.'
1 2 The cra n i u m 359
The significance of thls study points to the far-reaching (and myofascial therapy, cranial manipula tion and / or acupunc
often hldden) influences that simple procedures, such as ture, may significantly influence neurological activity via
filling a tooth or placing a crown, might have on the pos sensorimotor integration between the brainstem, subcortical
tural, propriocep tive and both local and distant aspects of and cortical centers, the cervical region, proprioception and
the musculoskeletal system. The astute practi tioner must body posture.
question the patient on all aspects of health history, includ Modulating (via treahnent) occlusion-related propriocep
ing dental work, which might have impacted the body and tive afferents may be considered to be a way of enhancing
necessitated an adaptive or compensatory process. A clearer postural function, balance control, oculogyric stabiliza tion
health picture will help shape the trea hnent room choices, and sporting performance (Gangloff et al 2000). Other con
including professional referral. nections include the configuration of the plantar arch
(Valentino et a1 2002) as well as physical speed, back strength
(Ishijima et al 1998) and biceps brachli function (Ferrario
NECK PAI N AND TMD
et al 2001).
A strong association has been identified between neck pain In assessing the muscles associated with primary move
and temporomand ibular symptomatology (Ciancaglini et al ment of the mandible, an external palpa tion and an intrao
1999). Sensory information from the cervical spine converges ral treahnent of the muscles can be used . While most of the
with trigeminal afferents withln the spinal tract of the trigem ex ternal palpa tion is intended as assessment (with some
inal nucleus, while fibers arriving in the subnucleus caudalis benefit of treatment), the external palpa tion of temporalis is
descend to C2-3 and even C6 (Xiong & Matsushlta 2000). primary ra ther than secondary since it lies almost entirely
Restricted spinal segments in the cervical region (espe ex terior to the oral cavity. Only its tendon a ttachment to the
cially at the CO-C3 levels), as well as tender points in the coronoid process is palpable from inside the mouth.
sternocleidomastoid and upper trapezius muscles, have Conversely, the internal applications to the remainder of
been found to be significantly more common in patients these four muscles, as well as the floor of the mouth and the
with TMD symptoms than in controls (De Laa t et aI 1998). tongue, are considered their primary trea tment. A l though a
It has been proposed (Yin et a1 2006) that therapies target general discussion is included with the extraoral examina
ing the masticatory system, including occlusal splints, mas tion below, specific anatomy details will be found with the
ticatory muscle work, lifestyle intervention of oral habi ts, intraoral protocols.
The temporomandibular (TM) joi nt, located bi laterally just anterior to a viscous synovial fl uid (synovia) which provides a l i quid environ
the tragus of each ear, is a compound (hinge-sl iding) synovial joint, ment with a small pH range, lubrication, reduction of erosion and
whose fibrocartilaginous su rfaces and interposed articular d isc a l low which is concerned with maintenance of living cel ls in the articu
for a tremendous variety of movements in response to the demands lar ca rtilages, disc or men iscus.
of eating, speaking and facia l expression. The multiple movements of
A d isc may extend across a synovial joint, d ividing it structura lly and
the mandible include protraction, retraction, lateral rotation and
functionally into two synovial cavities i n series, with the advantage
excu rsion, a degree of circu mduction, depression and elevation.
of combined ranges for the two joints.
These motions a re often in combination with each other, with each
The function of the d isc is u ncerta in and may include shock
muscle possessing components to allow a triplanar force in
absorption, im provement of fit between surfaces, facilitation of
parasag itta l, coronal and horizontal pla nes ( Gray's Anatomy 2005) as
combined movements (slide and rotation occurring in different
well as coord inated with the contralateral TM joint.
compartments), checking of translation at joi nts (such as the kneel.
Synovial a rticulations, l i ke that of the temporomandibular joi nt.
deployment of weight over larger surfaces, protection of articular
are noted by Gray's Anatomy (2005) to have:
margins, facilitation of rol l ing movements and spread of lubrication.
a fibrous capsule, usua lly having intrinsic ligamentous thicken Discs a re connected peripherally to fibrous capsules, usua l ly by
ings (often by internal or external accessory ligaments) vascularized connective tissue (vessels and afferent and motor
osseous surfaces which are covered by articu lar cartilage (hya l i ne (sympathetic) nerves).
or fibroca rtilage) and are not in continu ity with each other The term 'meniscus' should be reserved for incomplete discs.
synovial membra nes, which cover all non-articular surfaces Discs may be complete or perforated.
including non-articular osseous surfaces, tendons and ligaments Where men isci are usual, complete discs may occur or may be
partly or wholly within the fibrous ca psule slightly perforated.
synovial membrane which usually covers and projects outwardly The articular d isc of the TM joint, composed of dense non
together with any tendon that attaches i nto the joint and issues vascular fibrous tissue ( Gray's Anatomy 2005, Simons et al 1 999), is
from it bound tightly to the condyle, its inferior concave surface fitting the
an articular d isc or meniscus (composed of fibrocartilage with the condyle l i ke a cap while its concavoconvex upper su rface
fibrous element usua lly predomina nt) which may occur between corresponds to the mandibular fossa and glides against the articular
articu lar su rfaces where congru ity (conformity of the bones to tubercle. The joint su rfaces as well as the interposed disc are
each other) is low designed to remodel in response to stress, changing its shape to
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3 60 CLI N I CA L A P PLI CAT I O N O F N EU R O M U SC U LA R T EC H N I QU ES : T H E U P P E R B O DY
Articular
accommodate forces imposed, such as oral mechanics, head
emi nence posi tioning or from postural or structural compensations.
The d isc is firmly attached at the medial and lateral condylar
poles by strong bands and is attached anteriorly to the joint capsule,
as well as to fibers of the upper head of lateral pterygoid. The upper
head of lateral pterygoid a lso attaches to the condyle and pulls the
disc and condyle forward as a unit during opening of the mouth
(Ca i ll iet 1 992, Simons et al 1 999). Posteriorly is the fibrovascular
bilaminar zone where the thick fibers separate into two layers, the
inferior one made of non-elastic fibrous tissue attaching to the back
of condyle while the u pper fibroelastic layer attaches to the
posterior margin of the fossa. The area between the two layers is
loose connective tissue that is highly vascularized and richly supplied
with nerve endings. This region appears to primarily provide a firm
attachment rather than intraarticu lar support.
The in terposed d isc is a deformable pad that is thicker anteriorly
(pes) and posteriorly (pars posterior) and thinner in the center (pars
gracilis). Increasing its load thickens its annu lus (see below) ( Gray's
Anatomy 2005). Its job remains controversia l and is generally
thought to be to stabil ize the TM joint while allowing considerable
movement of roll, spin and glide of the condylar head (often
performed with fu ll loading) while red ucing the possibil ity of trauma.
Gray's Anatamy (2005) suggests otherwise, pointing out that one
must consider that:
Lower lamina The addition of a slippery disc doubles the number of virtually friction
Lateral nIA,vnrll(1 J Capsule (non-elastic) free sliding surfaces suggesting that its function is to destabilize the
Figu re 1 2_33 The t empo ro m a n d i b u l a r intraa rticu lar d isc. condyle (certainly not to stabilize it) in the same way that stepping on
Rep roduced with perm ission from Gray's Anatomy (2005). a banana skin destabilizes the foot. All otherjoints are most heavily
loaded when their articulation surfaces are closely fitted together.
Capsule
Figu re 1 2.34 AHB : Opening range and motion of the m a n d i b u l a r condyle a nd d isc. Reproduced with perm ission from Gray's Anatomy
far Studen ts (2005).
creating a large area of contact, and braced to prevent further influencing the body a n d its healing process while interfacing with
movemen t. However the condyle of the mandible is most heavily each other. Understa nding the roles the other tea m members play
loaded when it is required to move, sliding backward during the buc will assist in a wel l-form u lated overa l l plan to remove the causes as
cal phase of the power strake of a mastica tory cycle on the opposite wel l as some of the results of long-term dysfunction. Much of what
side of the jaw. is seen in the jaw may be the result of structural, habitual, postural,
nutritio na l , hormonal or emotional stresses rather than the localized
As the condyle hinges into place, in preparation for translation
TM joint syndromes so often described. likewise, reduction of
against the articular tubercle, it engages the central (thinner)
occl usal interferences, splint therapy and reduction of infection
portion of the disc, 'thereby "squeezing out" material to form a
might remove considerable stress, not only from the TM joint but
thickened zone, the annulus of Osborn, which surrounds the thin
also from the cervical reg ion. The combined efforts in the areas of
area - a recess for the mandibular condyle' ( Gray's Anatomy 1 999).
dental, musculoskeletal (especia l ly postural) and emotional wellbeing
The lateral pterygoid engages the disc and the condyle to slide down
may offer substa ntial and often im med iate pain rel ief while recovery
the articular tubercle (by virtue of its incline) until the posterior
and restoration to fu nctional stability progress.
fibroelastic elements are stretched to their l imit. The condylar head
Delany ( 1 997) notes:
may further hi nge and glide aga inst the inferior su rface of the disc
to articulate with its most anterior parts. During closure movements, TMD is characterized by many symptoms that could arise from other
the condylar head is seated in the central recess as it g l i des back up ailments, and it therefore has a reputation as an elusive, baffling candi
the incline and rests in the mandibular fossa. tion. These symptoms include headache, toothache, burning or tingling
Gray's Anatomy ( 1 999) points out that: sensations in the face, tenderness and swelling on the sides of the face,
clicking or popping of the jaw when opening or closing the mouth,
The elastic tissues may act to withdraw tissues and thus preven t
reduced range of motion of the mandible, ear pain without infection,
entrapment between the articular surfaces during mouth closure.
hearing changes, dizziness, sinus-type responses, overt pain behaviors
In pratrusion the teeth are parallel to the occlusal plane but and postures, as well as major losses in self-esteem and social support
variably separated, the lower carried forwards by both lateral caused by decreases in normal social and occupational activities.
pterygoids.
Otorh inolaryngologist James Costen ( 1 934, Kalamir et al 2007a) first
In retraction the mandible is returned to the pOSition of rest (teeth
associated ear and sinus pain with temporomandibular dysfu nction
slightly apart).
(TMD) and since that ti me, controversy has erupted regarding
In rotatory movements of mastication (in occlusal plane but
diagnostic criteria. Although h istorica lly TMD has been thought to be
clearly not in occlusion), one head with its disc glides forwards,
primarily based on mechanical dysfunction (such as disc
rotating around a vertical axis immediately behind the opposite
derangement, malocclusion, deformity or bruxism) and has been
head, then glides backwards ratating in the opposite direction, as
primarily addressed by the dental profession, a more integrated
the opposite head comes forward in turn. This alternation swings
biopsychological model has now emerged (Kalamir et al 2007a).
the mandible from side to side.
Kalamir et a l (2007a) explain:
Ideal ly, the temporomandibular joint, enhanced by its design, should
The difficulty i n predicting both the likelihood of developing TMD, as
function normally as numerous daily demands a re imposed upon it.
well as its potential chronicity. stems in part from the poor success
Conditions that improve the chances for heal thy joint function
experienced by researchers in achieving a consensus of definition.
include the following.
There have been many attempts to simplify the diagnostic criteria
The d isc stays firmly attached to the condyle and rests on it in an comprising TMD, al/ of which have met with differing degrees of
ideal position to load and transport the mandible in a variety of failure, but virtually unanimous agreement that its diagnosis is
d irections. complex and controversial [emphasis added]. As with other such
The disc deforms during these motions and reforms after term ina conditions, researchers have tried to agree on the presence of several
tion of motion (Cail liet 1 992). qualifying major signs or symptoms ... Unfortunately. a review of the
The internal joint surfaces are well nourished and l ubricated by literature gives widely differing inclusive criteria.
healthy synovia.
In their comprehensive d iscussion, based on considerable literature
The muscu lature overlying the joint is free of contractures, tris review, Ka lamir et al consider causes of parafunctional activity, such
mus, trigger points and myofascial pain and a l lows ful l ra nge of
as clenching and grinding of the teeth. In an approach that suggests
motion in all directions.
that such activity ' ... could represent physiologically normal activity
The musculature whose trigger point target zones include the rather than a subconscious stress/a nxiety response during dreaming',
temporoma ndibular joint or any of the TM joint muscles is free of
they imply function for a behavior that is otherwise accepted as
trigger points.
dysfu nctional. For example, 'It has been suggested that nocturnal
The person's posture reflects sym metrical balance and coronal
bruxism may be a physiolog ica l attempt at increasing respiratory
al ignment with head and pelvis in neutra l position when sta nding
oxygenation, since protrusion of the jaw widens the pharyngeal
or seated.
space and rhythmica l jaw movements cou ld be construed as
No significant traumas have been suffered by the joint or by the
influencing the airwaY:
cervical region.
Although a clear diagnostic criterion does not yet exist, a
Occlusion is harmonious.
diagnosis of TM joint dysfunction (TMD) is commonly g iven. The
Rea l-l ife situations seldom offer all of the above simultaneously. signs and symptoms might include one or more of the fol lowing
More often, various combinations to the contrary are observed and, biomechan ically faulted internal derangements of the disc. These
in some cases, what the patient presents is contrary to all of the may be due to gross trauma, such as that incurred in
above and with nutritional, emotiona l and structural stresses acceleration-deceleration injuries, or to stra in imposed on the joint
imposed as wel l. The causes and effects of temporomandibular joint by faulty muscles, occl usal interferences, damaging oral habits or
dysfunctions often requ i re the efforts of a team of clinicians, each postu ra l positioning.
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362 CLI N I CA L A P P L I CATI O N O F N E U R O M U SC U LAR TECH N I Q U E S : T H E U PP E R B O DY
H i l ton's law
The nerve supplying a joint supplies also the muscles that move the
joint and the skin covering the articular insertion of those muscles.
places the supra- and infrahyoids on stretch and places down problem they have often become very serious pain and/or dysfunction
ward tension on the mandible, hyoid bone and tongue cases. These patients require the practitioner to have the broadest
induces reflexive contraction of the mandibular elevators to possib le knowledge or at least the understanding of many disciplines
counteract downward traction of the mandible (which then) so that proper referrals can be made.
results i n i ncreased intraarticu lar pressure in the TM joi nts, which
Til ley ( 1 997) maintains that whatever the mode of treatment, active
could g ive rise to the development of cl icking, especially i n a pos
and thorough self-care is important.
teriorly thinned disc (see also crossed syndrome patterns in
The fol lowing shou ld be considered :
Chapter 5).
avoid gum and other sticky, chewy foods
Kalamir et al (2007b) concluded from a literature review that
avoid apples and thick sandwiches requiring excessive opening
'Manual therapy has also been shown to be more cost effective and
improve nutrition through a better diet and supplementation
less prone to side effects than dental treatment: Some of the
exercise: stretching (especially cervical and shoulders), strength
following points to why this might be so.
ening, endurance
McLean (2005) recorded su rface EMG data from the dominant
avoid long-term use of analgesics, which can result in rebound
side on 18 healthy subjects, including the fol lowing muscles: levator
headaches
scapulae, upper trapezius, supraspinatus, posterior deltoid, masseter,
learn to use self-applied acupressure or neuromuscular techniques
rhomboid major, cervical erector spinae and sternocleidomastoid.
learn relaxation techniques
Compared to forward head posture, corrected sitting posture
avoid activities that aggravate the condition (lifting, sweeping,
produced a sign ificant reduction in muscle activity:
driving)
Corrected posture in standing required more muscle activity than evaluate work station for possible postural irriton ts - keyboard too
habitual or forward head posture in the majority of cervicobrachial high, cradling phone with shoulder
andjaw muscles, suggesting that a graduated approach to postural keep headache diary
correction exercises might be required in order to train the muscles to elimination diet to identify and cut out offending substances
appropriately withstand the requirements of the task. A surprising avoid caffeine
finding was that muscle activity levels and postural changes had the evaluate sleep pasture - on back with cervical pillow and pillow
largest impact on the masseter muscle, which demonstrated under knees or on side with pillow between legs
activation levels in the order of 20% maximum voluntary electrical moist heat or cold compresses for temporal and cervical area
octivation. herbal therapy might be considered
Evcik & Aksoy (2004) investigated the relationship between continue to be active in family and church activities.
temporomandibular joint dysfu nction and head posture, using MRI, While it is outside the scope of this text to d iscuss the dental factors
x-ray and physical measurements. They reported : 'This study supports that may be involved in TM joint dysfunctions, it is recommended
that poor posture causes m uscle imbalance and pain which are that the cli nician thoroughly u nderstands the dental diagnosis and
highly correlated with developing temporomandibular dysfu nction treatment plan as well as the case h istory, i ncluding history of head
syndrome: and neck pa in, sign ifica nt fa l ls, direct traumas, motor vehicle
Tsai et al (2002) investigated masticatory muscle activity and jaw accidents, habits such as nail biting and gum chewing, pertinent
position as the subject was placed under the stress of mental dental history, indications of habitual mouth breathing, stressfu l life
arithmetic. They mon itored EMG activities of the right masseter, situations, signs of hormonal changes (such as menopause or thyroid
right posterior temporalis and suprahyoid m uscles and used a imbalance), known and suspected food al lergies, use of over-the
kinesiograph to observe the jaw position. They reported 'a significant counter and prescription medications and expected fam i ly (or other)
increase in EMG activity of all three muscles during mental support or resistance. Often a tra i l of clues is uncovered when
a rithmetic compared with baseline; different patterns of increased q uestions are asked regarding what induces and what seems to
EMG activity were noticed in the three muscles under a continuous relieve the pa in. Modifications i n both physical and emotional
stress condition. Under stress, the incidence of tooth contact at environments may be needed and may be synergistic with each other.
intercuspal position was a lso i ncreased'. Examination of the soft tissues of the neck and cranium may
Travers et al (2000) investigated the relationship of i ncisor opening reveal trigger points, postural tension, reduced ra nge of motion and
and condylar translation, questioning the degree to which opening hypertonic myofascia. Release of the soft tissue elements,
range of motion is diagnostically relevant. They concluded that: restoration of active range of motion to the cervical spine, shoulders
(7) maximum incisor opening does not provide reliable information and TM joints as well as steps toward assessing and enhancing
about condylar translation and its use as a diagnostic indicator of whole-body postural bala nce are warranted from the onset of TM
condylar movement should be limited, (2) healthy individuals may joint therapy. The dental orthosis (spli nt) or occl usion may need more
perform normal opening with highly variable amounts of condylar frequent assessment if changes in pelvic, spinal or cranial
translation, (3) the straight-line distances of the incisor and condyles positioning a lter the position of the m andible a nd, therefore, the
provide adequate information about the length of the curvilinear teeth or appliances.
pathway, ond (4) variation in maximum incisor opening is largely
explained by variation in the amount of mandibular rotation. Assessment of associated structures
The following assessments performed before and after appl ications
Larry Tilley DMD ( 1 997) notes:
of therapy will g ive basic information as to possible involved tissues
Even after finding a knowledgeable dentist we must remember that as well as assisting in assessment of response to treatment.
same patients are very 'straightforward' and respond to the most Elimination of trigger points in TM joint muscles and associated
basic treatment. Others, however, require the most comprehensive, cervical muscles, postural repositioning of head and neck and
holistic and multidisciplinary approach. By the time many of these rebalance of the agon ist and antagon ist m uscles of the TM joint may
long-suffering patients have been diagnosed as having a TMD a lter measurements, movement and tension in musculature of the
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364 C L I N I C A L A P PLI CA T I O N OF N E U R O M U S C U L A R TE C H N I Q U E S : T H E U PP E R B O DY
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1 2 The cranium 3 65
A simpler, self-appl ied assessment of two (m inimum) and three The patient is seated in front of a m i rror with lips retracted so
(maximum) knuckles (Simons et a 1 1 999) placed vertica l ly that the two toothpicks protrude from between the lips.
between the upper and lower incisors is a test read ily usable by The patient very slowly opens and closes the mouth and in doing
the patient to assess the need for self-appl ied or practitioner so concentrates on maintai ning the tips of the toothpicks in l ine,
applied neuromuscular therapy (Fig. 1 2.38). one with the other.
An opening range greater than three knuckles (over 60 mm) may Repetition of this 5- 10 times several times daily helps 'retrain'
indicate l igamentous laxity and is a ca utionary sign when apply dysfunctiona l muscle patterns.
ing intraoral work. Excessive opening may result in an open d islo Several of the myofascial treatments offered in this section ca n be
cation that is painful and frig htening and can usually be avoided
appl ied by the patient at home, including masseter, temporalis,
with special care. lateral pterygoid, tongue and floor of the mouth. Applications to the
As the mandible is depressed during open ing of the mouth, the
soft palate structures are best performed by a trai ned clinician due
practitioner may observe the lower central incisor path to note
to the delicacy of the palatine bones, vomer and hamulus and
deviations or unusual movements d uring tracking. Such devia
possible (probable in seated position) stimulation of the gag reflexes.
tions may be the result of trigger points or shortened fibers
The complexity and controversy surrounding TMD can be
within the muscu lature (deviation will usua l ly be toward the side
overwhelming to an individual as well as for the practitioner. A
of shortening), internal derangement of the d isc or other interna l
comprehensive knowledge base must be constantly assessed and
pathologies.
potentia l ly regularly revised in order for clinical treatment to be
A hard end-feel to open ing, especially when the range is sign ifi
successful. Kalamir et al (2007a) understand this and concl ude:
cantly reduced, may indicate anterior d isplacement without
reduction or onset or presence of degenerative arthritis. The current paradigm for chronic pain management emphasises a
Referral to a dental specia list for eva luation (or for a second biopsychosocial approach to potient care for comprehensive recovery.
opinion) ca n be of sign ificant value and a necessary part of the Purely mechanistic models of intervention are giving way to both
course of treatment when soft tissue appl ications are successfully multimodal and multidisciplinary strategies. In tegrated treatment
used due to their abil ity to sign ificantly a lter the position of the models of this nature are still in their infancy for TMD. However, there
head and mandible and therefore the occlusion of the teeth. is an emerging trend of cooperation between differen t health disci
plines, such as psychotherapy. dentistry. chiropractic, osteopathy.
Rehabi litation self-treatment method physiotherapy. massage and acupuncture. Viable, conservative treat
The patient gently wedges a wooden toothpick between the mid ment protocols based on all the available evidence need to be CO(1-
dle upper central incisors and another between the lower central structed, in order to overcome the historical limitations suffered by
incisors. individual health professions.
\ \\ \\
dr\\
. 1 + \\
EXTERNAL PALPAT I ON AND TREATMENT O F
Since this joint is a bilateral joint (the mandible spans the
CRANIOMANDIBULAR MUSCLES
cranium) dysfunctions affecting one side also affect the
The therapist is seated cephalad to the supine patient's contralateral side. When techniques that release the hyper
head. The ipsilateral hand is used throughout the external tonic, shortened muscles and/ or assist in toning any inhib
palpation. Each procedure is performed to both sides. ited (weakened or lax) muscles are applied to both sides, a
366 C LI N I CA L A P P LI CATI O N O F N E U R O M U SC U LA R TECH N I Q U E S : THE U P P E R B O DY
,---- Temporalis
!
Figure 1 2 .41 The pa t i e nt s mouth m ust be open wide a n d the
'
It
A very gentle myofascial release approach is achieved by
sitting at the head of the supine patient and placing the POSITIONAL RELEASE F OR MASSETER
pads of the three middle fingers onto the tissues j ust infe
5cariati (1991) describes a counterstrain method for treating
rior to the zygomatic process. The contact should be 'skin
tenderness in the masseter muscle.
on skin' with no perceptible pressure. The amount of
force applied in an inferior / posterior direction should be . The patient is supine and the operator sits at the head of
minimal, barely a half ounce (14 grams). This is held for the table.
1 2 The cranium 369
Box 1 2.6 Notes Oft the ea.r. '<..> .' o' r '
The ear serves two major purposes: hearing and maintena nce
of e q u i librium. I n formation that the brain integrates to mai ntain orthostatic
The temporal bone houses most of the structures of the ear, posture derives from the fol lowing sources:
which suggests that temporal bone dysfu nction may con
tribute to vertigo or hearing problems. retinal
This fu rther suggests that imbalances i n the m uscles attaching otolithic (vestibular)
to the temporal bone might a lso be implicated i n heari ng dys plantar exteroceptive
function or vertigo, notably: proprioceptive sou rces i n the 1 2 oculomotor muscles
1 . sternocleidomastoid w h ich a rises as two heads on the paraspinal muscles
manubrium sternum a nd the clavicle and powerfu l ly muscles of the legs and feet.
attaches to the mastoid process (clavicu lar fibers) as well Loss of bala nce may therefore resu lt from fai l u re of sensory
as to the superior nuchal line (sternal fibers) i nformation, including that from the vestibular mechanisms i n
2. tempora l is which a rises from the temporal fossae. The pos t h e ea rs, or fa u lty i ntegration o f information received b y the
terior aspect of the origin of the m uscle l ies on the tempo bra i n.
ra l bone itself, while the i nferior attach ment is to the
coronoid process of the mandible Labyri nthine test
3 . longissi mus capitis, which a rises from the transverse The patient is standing with eyes closed.
processes of T1 -5 and the a rticu lar processes of C4-7, The patient is asked to hold the head in various positions,
attaches to the mastoid process flexed or extended with rotation i n one d i rection or the other.
4. splenius capitis arises from the spinous processes of C7-T3 Changes of d i rection of swaying are i nterpreted as the result
as well as the lower half of the l igamentum n uchae and of labyrinth i mbala nce.
attaches to the mastoid process and the lateral aspect of The patient sways i n the d i rection of the affected labyrinth.
the superior nuchal l i ne.
The Eustach ian tube con nects the nasopharynx and the middle Rehabilitation choices
ear and is designed to equalize middle ear and atmospheric Sta n d i ng and walking with eyes closed, with the floor covered i n
pressure. th ick foam to reduce normal sti m u lation of receptors i n t h e foot,
Kappler Et Ramey ( 1 997) state: 'Eustach ian tube dysfu nction is retrains the vestibu lar a nd somatosensory systems.
the most co mmon cause of otitis media and benefits from ... Retra ining of vestibular mechanisms may also i nvolve use of
treatment to the cra n i u m, medial pterygoid and cervical fas hammocks and gym bal ls.
cias: The authors of this text suggest that treatment of the
tensor palatini a lso be i ncluded in th is list. (See NMT for soft
palate, p. 382).
Travel l Et Simons ( 1 983) report that ear pa i n can result from deposition which may, in turn, cause pressure or irritation
trigger points in the latera l or medial pterygoids, sternocleido to surrounding structures, including the carotid artery.
mastoid (clavicu lar) or masseter (deep). Regardless of its etiology, the abnormal elongation of the
Tensor palatini opens the entra nce to the auditory tube to styloid process resulting in facial pain is termed Eagle's
equal ize air pressure d u ring swa l lowing (Drake et al 2005,
syndrome (Stedman's Medical Dictionary 1998) or stylalgia.
Leonhardt 1 986) and hypertonicity of this muscle has im por
ta nt clinical mea n i ng as the auditory tube, when open, may Panoramic a nd frontal radiographs may confirm calcifica
provide a n easy passageway for ororespiratory tract infections tion of the styloid ligament or intraoral palpation of the
to reach the middle ear (Clemente 1 987). See further process near the tonsillar fossa may reveal elongation of the
discussion with the text of this chapter. process i tself (Grossmann & Paiano 1998).
Symptoms may include recurrent throat pain, dysphagia,
pharyngeal foreign body sensation, referred otalgia and
neck pain (Beder et al 2005, Fini et al 2000). Grossmann &
bone, drawing it backwards and elonga ting the floor of the
Paiano (1998) concur and note: 'In patients with mild symp
mouth, thus influencing speech, chewing and swallowing.
toms, it is often possible to control it with conservative ther
Stylohyoid muscle fibers lie in close relationship to
apy. However, severe cases should be treated surgically.'
digastric, which sometimes also attaches to the stylOid
Simons et al (1999) cite trigger points in posterior digas-
process (partially or wholly) (Gray's Anatomy 2005). The
tric and s tylohyoid as a factor in Eagle's syndrome.
fibers of stylohyoid and the posterior fibers of digastric are
difficult to distinguish by palpation alone (Simons et al The patient with this syndrome complains of pain in the
1999). The digastric trigger point target zone includes the angle of the jaw on the side of involvement, and also may
area of the stylohyoid muscle, whose pain pa ttern is not yet have symptoms of dizziness and visual blurring with
clearly established but is presumed to be similar (Simons 'decreased' vision on the same side . . . Active TrPs in these
et al 1999). Additionally, this referral pattern includes the muscles can result in sustained elevation of the hyoid. The
superior portion of the sternocleidomastoid muscles and tenderness at the styloid process and calcification of the sty
contrib utes to the expression 'pseudosternocleidomastoid loid ligament can represent enthesitis and subsequent calci
pain' used by some practi tioners. fica tion due to the sustained tension caused by TrP taut
Myofascial and ligamentous tension on the styloid process bands. The dizziness and blurred vision can be caused by
may result in elongation of the process due to calcium associated TrPs in the adjacent sternocleidomastoid muscle.
1 2 The cra n i u m 371
to the digastric attachment at the digastric notch of the adjustments to avoid strain and gain the best access to the
mastoid process. Friction may be used if the area is not too muscle.
tender. The treating finger remains posterior to the styloid
process and pressure on the styloid process is avoided due
to its fragility. TEMPORAl I S
\ .
side and front of the head, eyebrows, behind the eye and
upper teeth, as well as the TM joint. Temporalis lies in the
reference zone of several cervical muscles, including trapez
ius and sternocleidomastoid, and its trigger points may be
satellites of trigger points in these muscles (Simons et al V 'l II l I
I n d i cati o n s for treatment also cause unilateral tinnitus or bilateral tinnitus if both
sides are involved. Emotional problems that lead to exces
Pain in areas indica ted in Figure 12.50
sive jaw clenching can cause major problems in the muscle,
Restricted opening of the mouth
which may also be involved in malocclusion. Similarly, the
Tinnitus, unilateral unless both masseters are involved
pain and dysfunctions associated with this and other TM
Bruxism
joint muscles may contribute to emotional stress.
Repetitive habits, such as gum chewing, nail biting or
In subjects presenting with la tent MTrPs in the masseter
clenching the teeth
muscle, Blanco et al (2006) suggest that postisometric relax
ation technique is more effective than the strain/ counter
Spec i a l n otes
strain technique in improving active mouth opening. This
Masseter comprises three layers stacked onto each other. technique can be easily incorporated in the stretch portion
The deeper stratum of masseter, whose fibers lie vertically, of the steps described below, provided that the articular
is not as large as the more d iagonally oriented superficial disc is not a t risk.
portion. Its geographical position can result in disturbance Masseter is involved primarily with chewing, clenching
of the temporal bone and TM joint and its sharing of con and strong closure of the jaws. Temporalis, on the other
siderable nociceptive neurons (Simons et a1 1999) w ith the hand, is responsible for postural positioning and balancing
joint may explain i ts high tendency to be involved when TM the jaw. Advice should be given regarding irritant activity
joint pain is present. including mouth brea thing, chewing gum, bruxing, clench
Marked restriction in opening range is often associated ing and grinding the teeth as well as possible dental
with trigger points in the muscle. Deep triggers here can involvement.
NMT FOR I N TRAORAL MASSETER above is best applied first, to release muscular restrictions so
as to better determine if restriction of range of motion is due
The outside su rface of the face is supported with the dor
to myofascial or osseous (in this case disc) tissue.
sum of the external hand. The gloved index finger of the
There is often a profound change in the tension of mas
intraoral hand is placed inside the mouth and j ust inferior
seter when a thorough (not aggressive) treatment has been
to the zygomatic arch with the pad of the finger facing
applied. The patient will usually note an appreciable differ
toward the cheek. Gliding strokes are applied from the
ence when comparing the side that has been treated with
zygomatic arch to the lower edge of the mandible while
the other. Both sides are always treated to avoid unbalanc
compressing the masseter and buccinator muscles against
ing the mandible.
the dorsum of the external hand. The strokes are repeated
8-10 times in strips until the entire masseter has been
treated . The external hand's index finger is not allowed to LATERAL PTERYG OID
touch the face since it will treat the opposite side intraorally.
With the finger still in place, the patient is asked to clench Attachments: Upper head arises from the infratemporal crest
the teeth to contract the masseter 's deep portion and then to and lateral surface of the greater wing of sphenoid to
relax the jaw. It may be necessary to have the patient shift insert onto the pterygoid fovea (on neck of mandible)
the mandible toward the side being treated to allow room and to the articular disc and capsule; lower head arises
for the treatment finger. from lateral surface of lateral pterygoid plate to attach to
Static pincer compression which ma tches the tension the neck of the mandible
found in the tissues is applied at finger-width intervals Innervation: La teral p terygoid nerve from mandibular
beginning just caudal to the zygomatic arch and working branch of trigeminal (cranial nerve V)
down the muscle as far as possible, one fingertip at a time Muscle type: Not established
(Fig. 12.52) . Pressure may be applied against an external fin Function: Moves the condyle and disc complex as a unit;
ger of the opposite hand (except the index 'treating' finger) active during opening and closure of the jaw, protrusion
or between the external thumb and internal finger of the of the mandible and contralateral deviation
same hand. While most tissues respond to compression Synergists: Opening: suprahyoid muscles
within 8-12 seconds, masseter may release quickly or may Closure: masseter, temporal is, medial pterygoid
require a longer compression of 15-20 seconds or more. Protrusion: superficial masseter, anterior temporalis,
Stretch of the muscle is achieved by a sustained but not medial p terygoid
forceful forward and downward pull, taking out all available Contralateral deviation: ipsila teral medial pterygoid, con
slack and then holding to allow a 'creeping' release to evolve. tralateral masseter and contralateral temporalis
Care must be taken to avoid the use of force when opening Antagonists: To opening: masseter, temporalis, medial
the mouth as the articular disc might be dysfunctional and pterygoid
could be damaged with force. Manual treatment as listed To closure: suprahyoids
To protrusion: portions of temporalis, deep masseter
To deviation: contralateral medial and lateral p terygoids
and ipsilateral masseter and temporalis
I n d i cations fo r treatment
Repetitive habits, such as gum chewing, nail biting or
clenching the teeth
Lateral dev iation pa tterns when opening or closing the
\
jaw
Speci a l notes
Lower head
lateral pterygoid --------..
Capsule
Superficial head
medial pterygoid --------....
.. . .....
-....1--
.. ----- Deep head
medial pterygoid
F i g u re 1 2 .53 The superficia l fibers of medial pterygoid may be treated w h e n the l a teral pterygoid procedure is being performed, and may be
at least part of the source of freque n t tenderness i n t h is region. Reprodu ced with permissio n from Gray's Anatomy for Students (2005).
(Gray's Anatomy 2005, Simons et al 1999) . There is general Simons et al (1999) report a review by Klineberg ( 1991) of
agreement that both heads a ttach to the neck of the condyle s tudies examining the attachments. The results imply
but disagreement as to the amount of attachment of the that, 'The traction that is applied by the superior ptery
upper head to the disc and condyle. This portion of the con goid (superior division) during mouth closure affects the
troversy becomes clearer when we consider cadaver studies condyle and disk complex as a Lmit and does not affect
that have found a wide variation regarding lateral p tery the disk selectively'.
goid (LP) attachments. Once such study was reported by Abe et al (1997) report: 'The lateral p terygoid muscle
Naidoo (1 996), which describes 65% of specimens having fibers attach to the articular disk at the inner point of the
the upper head attached to the capsule, meniscus and medial pole. Based on this finding, we can say that the
condyle, 27.5% attaching solely to the condyle and the muscle fibers can both draw the articular disk anteriorly
remaining 7.5% having other types of attachment to the and balance it by supporting it posteriorly. That is to say,
meniscus, confirming that 'lateral pterygoid has a variable the lateral pterygoid muscle has two actions: to elevate
attachment to the meniscus'. the articular disk anteriorly and to support the articular
Kertesz et al (2003) draw a ttention to the fact that the lat disk.' They further describe that the sphenomandibular
eral pterygoid muscle is different from that reported in pre ligament is continual with the articular disc tissue medi
vious literature with significant variations in arrangement ally, suggesting that these fibers draw the disc posteri
and insertion. They point to an important finding that has orly during closure, thus enabling the articular disc to
clinical relevance. 'The degree of muscle insertion into the move smoothly.
disc capsule complex was not a predictor of anteromedial G ray's Anatomy (2005) points out that contralateral excur
disc displacement.' sion (as when grinding food) may (arguably) be the most
The actions of the lateral pterygoid are also confusing important function of this muscle. In regards to pulling
when one compares various articles and texts; particularly on the articular disk, G ray's states: ' . . . electromyography
if older texts are involved. Given the wide variations of studies have proven that the upper head is inactive during
anatomy, this is not surprising. Here are a few of opinions. jaw opening and most active when the jaws are clenched .
1 2 The cranium 377
An explanation for the surprising activity is as follows in this regipn . . . . Considering the lack of validity and reli
(Osborn 1995). Most of the power of a clenching force is ability associated with the palpation of the lateral ptery
due to contractions of masseter and temporalis. The asso goid area, this diagnostic procedure should be discarded.'
ciated backward pull of temporalis is greater than the Stelzeruniiller et al (2006) using MRI evidence counter
associated forward pull of (superficial) masseter, and so and 'reliably confirmed the palpation of the lateral ptery
their combined jaw closing action potentially pulls the goid muscle, which was controlled by two imaging pro
condyle backward. This is prevented by the simultane cedures. All three of the procedures confirmed palpation.
ous contraction of the upper head of lateral pterygoid.' The difficulty in reliably identifying the muscle seems to
Simons et al (1999) report that reciprocal activity of the be due to the fact that the medial pterygoid muscle must
two heads as antagonists during vertical and horizontal be passed before palpating the lateral pterygoid muscle.'
mandibular movements may be indica ted but la ter state: The authors of this text suggest that in clinical practice it
'Since it is now generally agreed that there is not always is doubtful that the practitioner will know which muscle
a separate attachment of the superior division to the disc, tissue is being palpated. If medial pterygoid fibers are
it is now thought that both divisions of the muscle affect present, they will likely be treated by this process and,
the condyle and disc complex as a unit. Any tendency to even in those people, a portion of lateral pterygoid might
reciprocal activity [of the two heads to each other] would be reached, depending upon the muscle's arrangement
most likely reflect mechanical advantage by one or the and perhaps influenced by the size of the practitioner 's
other division because of the difference in angulation of finger. What we have found clinically is that this region is
their fibers.' tender in most people (which is diagnostic of something)
and that treatment of this region offers relief for many in
The authors of this text suggest that the lateral pterygoids
the treatment of TMJ dysfunction. We suggest that the
(collectively) are involved in all movements of the mandible
treatment of this 'lateral pterygoid region' remain a viable
except retraction; the degree to which it is involved in each
part of the protocol even though one may not know pre
action very likely depends upon the particular architecture
cisely which fibers of which muscles are benefiting.
of the muscle in that individual.
Under considerable debate regarding manual techniques
Even the name of the muscle can be confusing since there
is the controversy as to whether the lateral pterygoid can
are various terms to i dentify the two heads of the lateral
even be palpated. Opinions are diverse, despite cadaver
pterygoid or to distinguish lateral and medial pterygoid,
and MRI evidence.
which are sometimes called the external and internal ptery
Stratmann et al (2000) studied 53 fresh and unfixed cadav goids, respectively (particularly in older texts). In this text,
ers to determine if the lateral pterygoid was palpable by the terms found in Gray's Anatomy (2005) have been used, that
first palpating and rendering an opinion, then palpating being lateral and medial pterygoid muscles and, regarding
a second time and observing through the dissected lateral pterygoid, the two portions being called upper and
infratemporal fossa to see whether the examiner's finger lower heads, except where quoted from other texts.
did or did not touch the inferior head of the LP muscle. TMJ dysfunction often involves lateral pterygoid, which,
They note tha t in 86 of 106 dissected specimens, a super due to its attachmen t sites, may also influence more wide
ficial portion of the medial pterygoid muscle was found spread cranial dysfunction, most notably of the sphenoid.
superficial to the rLP muscle and, in the 20 remain.ing Travell & Simons (1983) state: 'The external (lateral) ptery
specimens with an absent superficial fascicle, the finger goid muscle is frequently the key to understanding and
was able to reach the ILP muscle in 10 specimens. They managing TMJ dysfunction syndrome and related cran
concluded: 'It is recommended that the rLP muscle pal iomandibular disorders.'
pation technique should no longer be considered as a Upledger & Vredevoogd (1983) report that, 'It [lateral
standard clinical procedure because it is nearly impossi pterygoid] is a frequent cause of recurrent craniosacral and
ble to palpate the ILP muscle anatomically and because temporomandibular joint problems'. Along with other key
the risk of false-positive findings (by palpation of the muscles of the region, assessment and (if needed) therapeu
medial pterygoid muscle) is high.' See Figure 12.53 for a tic attention to the lateral pterygoid is an absolute prerequi
view of the superficial fibers of medial pterygoid as illus site of craniosacral therapy.
trated in Gray's Anatomy (2005). Referred trigger point pain from this muscle focuses into
Turp & Minagi (2001 ) also question the evidence that it is the TMJ area and the maxilla. Because dysfunction of the
actually lateral pterygoid that is being palpated when the upper head of lateral pterygoid may directly impact TM
finger is in the position described in the intraoral treat joint disc status (leading to clicking and possible condylar
ment below. They cite four studies that show 'the lateral and/ or disc displacement) it is important to treat associated
pterygoid muscle is practically inaccessible for intraoral trigger points in this muscle as well as those in other mus
palpation due to topographical and anatomical reasons. cles which include this area in their target zone of referral.
Other anatomical structures, such as the superficial head Intraoral palpation requires great sensitivity as this region
of the medial pterygoid muscle, may be palpated instead is often extremely tender. The intraoral technique described
378 CLI N I C A L A P PLICAT I O N O F N E U R O M U SCU LAR T E C H N I Q U E S : T H E U P P E R B O DY
\
\
Figu re 1 2. 54 A portion of lateral pterygoid may be treated i n te rn a l ly w i t h the i ndex finger o r smallest digit (shown here) if the index fi nger
is too l a rge. The mandible is sh ifted i psi latera l l y to create more roo m . Trigger point referred pattern d ra w n after Simons et al ( 1 999).
The practitioner will reach across the face to trea t the con
tralateral side. The patient's mouth is open and the jaw
deviated toward the side being evaluated to allow room for
the treating finger to be placed between the maxilla and
coronoid process, The finger nail rests against the cheek
while the finger pad rests against the maxilla.
A gloved index finger (pad facing medially) is slid on the
maxilla above the gingival margin as far posteriorly as possi
ble. Pressure is applied medially (toward the lateral pterygoid
plate). If the tissue is not tender, the finger is moved slightly
caudally and again pressed toward the mid-line, The finger
may sometimes be moved another fingertip caudally and
sometimes may be slid 'under ' the muscle(s) slightly to reach
a small portion of the caudal aspect. At each location, mild
pressure is used until the tissue tenderness is evaluated and
Figure 1 2.55 Finger position for intraora l access to lateral pterygoid. pressure is increased only if appropriate to do so (Fig. 12.55).
If the treating finger continues medially, the medial
pterygoid would be encountered, as would the sharp ptery
below most likely reaches only the anterior aspect of the goid hamulus. Pressure on the hamulus is to be avoided
lower head and likely the superficial fibers of medial ptery during this and all other intraoral palpation as the delicate
goid when they are present. The posterior aspect of the overlying tissues may be damaged by ind iscriminate or
upper head of lateral pterygoid and the posterior portion of excessive pressure.
1 2 The cranium 379
----
"
\V
(-\p-=;o-I \ I
i
:'
)
Figure 1 2.56 The fi nger is pl aced medial to the teeth to access
medial pterygoid w h i le lateral pterygoid is reached with the fi nger /
placed lateral to the teeth.
MEDIAL PTERYG OID F i g u re 1 2.57 Pal pation of mid-belly of medial pterygoid. Trigger
point referred pattern d rawn after Simons et a l (1999).
A ttachments: The palatine bone and the medial surface of
the lateral pterygoid plate of the sphenoid bone to the
pterygoid tuberosity on the posteroinferior part of the
medial surface of the mandibular ramus and angle; a
I n d ications fo r treatment
smaller head sometimes arises from the maxillary tuberos
ity and palatine bone (Gray's Anatomy 2005) (la teral Pain in TM joint, especially if increased by chewing,
pterygoid plate, according to Platzer 2004) to attach with clenching the teeth or opening of mou th
the deeper head, which allows it to course superficial to Sore throa t
the lateral pterygoid Painful swallowing
Innervation: Medial pterygoid branch of the mandibular Restricted range of mandibular opening
division of trigeminal (cranial nerve V)
Muscle type: Not established
Speci a l n otes
Function: Elevates mandible; some influence in protraction,
contralateral deviation and rotation about a vertical axis Medial pterygoid's position on the medial aspect of the
(Gray's Anatomy 2005) mandible mirrors the position of the masseter, which lies
Syn e rgi sts : For elevation: bilateral temporalis and masseter, lateral to it and they form a mandibular sling for powerful
contralateral medial pterygoid elevation of the mandible. A hypertonic medial pterygoid
For protrusion of mandible: lateral pterygoid can interfere with sphenoid function, with the maxilla and
For contralateral deviation: same side lateral pterygoid with normal motion of the palatines. It is commonly
Antagonists: To elevation: digastric and lateral pterygoid involved in TM joint problems.
To contralateral deviation: contralateral medial and lateral Observation of opening and closing of the mouth will
pterygoids usually demonstrate contrala teral deviation when medial
380 C LI N I CA L A P P L I CATI O N O F N E U RO M U S C U LA R T E C H N I Q U E S : T H E U P P E R B O DY
These steps are best done on the same side on which the
practitioner is standing. The gag reflex is easily activated in
this region and may be temporarily inh.ibited by having the
person exhale or inhale fully and hold the breath. Trus can
be further inhibited by the patient forcing the tip of the
tongue laterally and posteriorly, which is away from the
palpated side, as strongly as possible during the palpation.
The index finger of the trea ting hand is placed between the
upper and lower molars, medial to the teeth, and moved pos
teriorly until it contacts the most anterior edge of the medial
pterygoid muscle, wruch is posterior and medial to the last
molar. Static pressure or short gliding strokes may be applied
onto the belly of the medial pterygoid (Fig. 12.56) . Extreme
tenderness is likely if there is an active trigger in the muscle
so pressure should be mild until tenderness is assessed.
Fig u re 1 2.58 B i l a tera l compression of medial pterygoid m u scl es. The finger may be carefully slid up to the medial ptery
Reproduced with permission from La u g h l i n (2002). goid's attachment on the medial pterygoid plate and the
palatine bone as long as the hamulus is avoided due to its
pterygoid is hypertonic (usually in association with the lat sharp tip and the overlying delicate tissues. Pressure on the
eral p terygoid). Trigger points in this muscle involve swal palatine bones is also to be avoided . The palatoglossus and
lowing difficulties, sore throat and restriction in ability to palatopharyngeus muscles may be treated at the same time.
fully open the jaw, as well as TM joint pain. The treating finger glides caudally as far as possible wrule
The course of the superficial fibers (when present) may attempting to reach the inferior attachment on the inside sur
interfere with palpa tion of lateral p terygoid. Trus detail has face of the ramus of the mandible (Fig. 12.57). If gliding down
produced considerable controversy, particularly in the field the medial pterygoid causes too much discomfort or a gag
of dentistry, the main points of which are discussed below reflex is provoked, the lower angle may be reached by glid
with lateral pterygoid. ing the index finger along the inside surface of the mandible
When medial pterygoid contracts, this increases the force until the internal surface of the lower angle is reached. Static
of tensor veli palatini on the distal part of the auditory tube pressure or gentle friction may be applied if appropriate.
(see below); relaxation of medial pterygoid decreases it.
Hence, medial pterygoid moderates the opening pressure of
MUSCULATURE OF THE SOFT PALATE
the auditory tube. Leuwer et al (2002) suggest: 'The influence
(FIGS 1 2. 5 9 , 12.60)
of the medial pterygoid muscle on the opening pressure of
the auditory tube may have an impact on the d iagnosis and The soft palate is a mobile muscular flap that hangs down
therapy in patients with pa tent auditory tube as well as the from the hard pa late with its posterior border free and, when
middle ear pathology in patients with cleft palate.' elevated, closes the passageway between the nasopharynx
The auditory (Eustacruan) tube's function is complex, and the oropharynx, thereby preventing food from entering
including taking care of ventilation, drainage, and protection the nasal cavity. The uvula hangs from the posterior border
of middle ear. Therefore, the tension applied by both tensor and, when relaxed, rests on the root of the tongue. The ele
veli palatini and medial pterygoid may influence the mouth vated uvula aids the tensor and levator veli palatini muscles
of the auditory tube, and thereby have some bearing on the in sealing off the nasopharynx. Nearby are the palatine ton
development of chronic middle ear pathology. Sehhati sils and the sharp hamulus, around wruch the tensor veli
Chafai-Leuwer et al (2006), in their d iscussion of pathophys palatini turns to radiate horizontally into the palatine
iology of the Eustachian tube in cleft palate, suggest that aponeurosis.
integrity of the pterygoid hamulus and of the tensor veli The palatine musculature includes levator and tensor
palatini muscle impact the condition of persistent chronic veli palatini, palatoglossus, palatopharyngeus and musculus
middle ear d isease and that the medial pterygoid also play uvula. Innervation to the soft palate musculature includes
an important role in Eustachian tube function in non-cleft the trigeminal, glossopharyngeal and the cranial part of the
1 2 The cranium 381
accessory nerve via the pharyngeal plexus (Gray's Anatomy aponeurosis. This muscle, in conjunction with tensor veli
2005) . These muscles are involved in swallowing and speech. palatini and musculus uvulae, pulls the soft palate upward
Palatoglossus is discussed with the tongue and palatopha and backward. It 'has little or no effect on the pharyngo
ryngeus is considered with degluti tion later in this section. tympanic tube, although it might allow passive opening'
Levator veli palatini is a cylindrical muscle which courses (Gray's Anatomy 2005).
from the petrous portion of the temporal bone, the carotid Tensor veli palatini is a thin, triangular muscle that
sheath and the inferior aspect of the cartilaginous part of the attaches to the root of the pterygoid process, the spine of the
auditory tube to blend into the soft palate and palatine sphenoid bone and the membranous wall of the pharyngo
tympanic (auditory) tube. It wraps arow1d the hamulus
(which appears to act as a pulley) before attaching to the
palatine aponeurosis, which it elevates during swallowing
Levator veli palatini (LVP) when bilaterally contracting or, with unilateral contraction,
pulls the soft palate to one side. Its primary role, however,
Tensor veli palatini (LVP)
appears to be to open the entrance to the auditory tube (Abe
Upward and backward et al 2004) to equalize air pressure during swallowing or
pull of LVP yawning (Gray's Anatomy 2005). Hypertonicity of this mus
:;"IP-- Horizontal pull from TVP cle has important clinical meaning as the auditory tube,
when open, may provide an easy passageway for ororespi
Pterygoid hamulus ratory tract infections to reach the middle ear (Clemente
.--II--- Upward pull of PG 1 987) . Contraction and relaxation of medial pterygoid may
considerably influence this muscle's action on the auditory
_--- Palatoglossus (PG) tube opening (Leuwer et al 2002).
Ear infection in young children, and its relationship with
--- Palatopharyngeus (PPG)
tensor veli palatini hypertonicity and trigger points, is an
Elevation of pharynx by PPG area deserving of clinical research. Since these infections
readily (and most often) occur in young children who are in
'f----fiHtI--- Entrance into the larynx a chronic sucking stage (thumbs, fingers, pacifiers, toys,
nipple of the bottle or breast), the association of the tensor
veE palatini seems obvious and deserves consideration.
Kappler & Ramey (1997), however, suggest that 'Eustachian
tube dysfunction is the most common cause of otitis media'
and that this can be the result of fixation of the temporal
bone (see discussion of temporal bone earlier in this chapter
Fig u re 1 2.59 The soft pa l a te m uscles from a n a n terior view. D ra w n as well as previous discussion of auditory tube with medial
after Leonhard t ( 1 986). pterygoid).
I
tongue while approximating the pala toglossal arch, thus
N MT F OR SOFT PALATE (FIG. 12.61) closing the oral cavity from the oropharynx.
The patient tilts the head into extension and breathes through Intrinsic muscles of the tongue include the following.
the mouth slowly or holds the breath on full inhalation or
exhalation to inhibit the gag reflex. A confident but not Superior longitudinal bilaterally extends from submucous
aggressive pressure is used to avoid a tickling sensation, tissue near the epiglottis and from the median lingual
which might cause gagging. Tapping on the temples for septum to the lingual margins and apex of the tongue. It
about 10 seconds immediately prior to touching the muscle shortens the tongue and turns the tip and sides upward
may also suppress gagging. to make the dorsum concave.
The index finger of the practitioner's treating hand is Inferior longitudinal extends from the lingual root and the
placed just lateral to the mid-line of the hard palate and hyoid bone to the tip of the tongue, blending with sty
glides posteriorly on the hard palate until it reaches the soft loglossus. It shortens the tongue and turns the tip and
palate. No pressure is placed on the pala tine bones or the sides downward to make the dorsum convex.
vomer. The finger is hooked into a 'e' shape as it sinks into Transverse lingual ex tends from the median fibrous sep
the soft palate posterior to the pala tine bone and sweeps out tum to the submucous fibrous tissue at the tongue's lin
to the lateral one-third of the soft palate. A back and forth gual margin. It narrows and elongates the tongue.
medial/lateral movement of the finger or static pressure is Vertical Lingual ex tends from the dorsal to the ventral
applied into the lateral third of the soft palate w hile press aspects in the borders of the anterior tongue. It makes the
ing through the superficial tissues of the soft palate and tongue flatter and wider.
onto the palatini muscles.
The tongue muscles can act alone or in pairs and in endless
combination. They provide the tongue with precise move
MUSCLES OF TH E T O N G UE ( FIG. 12.62)
ments and tremendous mobility, which impacts not only
Extrinsic tongue muscles arise from outside the tongue to the acts of chewing and swallowing but also speech. Though
act upon it, while intrinsic muscles arise wholly within it trigger point location and referral patterns are not yet
1 2 The cra n i u m 383
Hyoglossus
----- Middle constrictor
Inferior constrictor
----------------"'....::::-
C ri cot hy roi d - . - - wt1tt'1f1h
Figure 1 2.62 M uscles of the styloid process, tongue and soft pa late. Reproduced with perm ission from Gray's Anatomy (2005).
regard to chronic sore throat and the immediate relief of the These muscles are most easily addressed b y reaching across
condition with application of static pressure and gliding the body to the opposite side of the tongue. The practi
strokes as described below. tioner's gloved index finger is placed on the lateral surface
Myofascial tissues are known to produce trigger points of the tongue as far posteriorly as possible. The finger curls
and trigger points are known to produce pa tterns of referral into a 'C' shape as it is slid forward the full length of the
as well as dysfW1ctions in coordinated movement of tongue. The curling action of the finger sinks it into the side
the muscles in which they are housed. It seems reasonable of the tongue and penetrates the musculature more effec
to assume that the tongue muscles might also contain trig tively than does sliding a straight finger (Fig. 12.63).
ger points and that they might produce pain in surrounding The gliding, curling movement is repeated 6-8 times. The
tissues, as well as being involved in dysfunctional finger is moved caudally at fingertip widths and the process
responses which interfere with swallowing or with normal repeated as far caudally as possible. Special attention
speech patterns. The tongue should be examined and, if should be given to the most caudal, most posterolateral
necessary, treated, in these conditions as well as in those aspect of the tongue, where the long gliding strokes previ
involving voice dysfunction, elevated hyoid bone or sore ously applied may become shorter and more precisely
throat. applied or static pressure may be used.
3 84 CLI N I CA L A P P L I CATI O N O F N E U RO M U S C U LA R TEC H N I Q U E S : T H E U PP E R B O DY
/
a fibrous sling that is attached to the hyoid bone and is
sometimes lined by a synovial sheath. The tendon perfo
\
the mandible (secondary to lateral pterygoid), elevates
the hyoid bone and, together with geniohyoid, can assist
retraction of the mandible. When digastric is hypertonic
it places a load onto the contralateral temporalis and
------ masseter which attempt to balance the deviation which a
Figure 1 2.64 Tongue m uscles may be gently stretched by p u l l i n g taut digastric may produce.
t h e to n g u e forw a rd.
The suprahyoid muscles usually function as a paired team
in the movements described. Since the position of the hyoid
bone is important to the maintenance of a clear air passage
The tongue may also be gently pulled forward and the way, of consistent dimension, as well as a food passageway,
muscles stretched by grasping it firmly through a clean its freedom of movement is critical in swallowing, normal
cloth (Fig. 12.64). This stretch can be held for 30-60 seconds breathing patterns and speech. When habitual mouth
and the direction of tension changed by pulling the tongue breathing is noted, these muscles, as well as any tendency to
to one side or the other. a forward head position, should be addressed, along with
Since these muscles are readily treated by the patient, the causes of the mouth breathing (allergies, deviated sep
self-care can be applied at home when indicated. Tongue tum, sinus infections, etc.). The upper abdominal area as
stretching, as described, may usefully be combined with well as the diaphragm should be evaluated (and treated if
spray and stretch methods (applied to the anterior neck) as necessary) as well as the intercostals (see respiratory sec
described by Simons et al (1999) for the suprahyoids. tion, p. 570).
1 2 The crani u m 385
Masseter
Mucous membrane
(cut edge) with Body of mandible
subtinguat ducts -----til
Sternocleidomastoid
Lingual nerve -----\'fll/-v-
Hyoglossus ----.../
-\--- Stylohyoid
Digastric - anterior belt"----..../
'------ Submandibular gland (deep part)
Mylohyoid
Platysma (cut edge)---.../ (turned down) Submandibular duct
Fig u re 1 2.65 Com p ression of the sa l ivary g la nds is avoided w h e n a d d ressin g the su prahyo id m uscles i n the floor of the m o u th. Reprod u ced
w ith permission from Gray's Anatomy (2005).
ilar (Simons et aI 1999). These muscles may be treated either ipsilaterally or con
The posterior attachment of digastriC as well as the stylo tralaterally depending upon the comfort of the practitioner
hyoid has been previously discussed together with the and the angle of the jaw. While using no pressure to position
mastoid and styloid processes (pp. 369-371). The intraoral the finger for treatment, the index finger of the practitioner's
386 CLI N I CA L A P P LI CAT I O N O F N E U R O M U S C U LA R TEC H N I Q U E S : T H E U PP ER B O DY
Helmut Leonhardt ( 1 986) has sum m a rized the processes of Th e latter protrudes like a torus due to superior pharyngea l con
deglutition as follows. strictor contraction (Passavant's ring torus), separating food pas
sage from the u pper ai rways.
Vol untary inception of swal lowing
If the palatal muscles a re paralyzed, e.g. after diphtheria, food
The m uscles of the floor of the mouth contract a nd the tongue,
w i l l enter the nose du ring deglutition.
together with the bolus (of food), is pressed against the soft
Mylohyoid, d igastric and thyrohyoid m uscles l ift the floor of the
palate.
mouth and assist in visible and pa l pable elevation of the hyoid
Subsequent movements are due to stim u lation of the receptors in
bone and the larynx, while the entrance to the larynx and the
the mucosa of the palate.
entrance to the epiglottis a pproximate.
Safeg uarding the airway by reflex action The root of the tongue lowers the epig lottis with the help of the
The palate is tensed a n d raised by the tensor and levator vel i pala a ryepiglottic muscles and the entrance to the larynx is (incom
tini m uscles to press against the posterior wall of the pharynx. pletely) closed.
Styloglossus -----
--...,."B\------:- Mandible
Middle pharyngeal constrictor -------
[10------ Hyoglossus
Stylohyoid ligamenl -=----- Mylohyoid
Greater cornu of hyoid bone -------
------ Geniohyoid
Lateral thyrohyoid ligamenl ------- ------ Lesser cornu of hyoid bone
1<---------- Internal laryngeal nerve
------ Thyrohyoid membrane
'----------- Trachea
Recurrent laryngeal nerve ------
Esophagus --------E:.
Fig u re 1 2.67 B uccinator a n d m uscles of the phar:ynx. Reproduced with permission from Gray's Anatomy (2005).
box continues
12 The crani u m 387
Box t
Simu lta neously, breath ing stops as the rima glottidis is closed. and hyoglossus muscles and pushes the bolus over the fauces into the
Thus, food passage is completely prevented from entering the pharynx. The bolus slides mainly through the piriform recesses prima
lower a irways. rily and partly over the epiglottis.
Pharyngeal constrictors ca n then push the bolus through the d i lated
Transport of the bolus through the pharynx and
esophagus 'right down to the cardia'.
esophagus
Leonhardt concludes: 'The bolus ca n a lso be propelled i nto the
Leonhardt explains further that:
stomach by continuous waves of contraction of circu lar m uscle
The slit of the pharynx unfolds upward and forward when the larynx (peristalsis). even against gravity, if the subject adopts an
ascends. Then the tongue is pulled like a piston by the styloglossus appropriate posture:
A Condyle of mandible ----, The treating finger is pressed toward the external finger,
capturing a portion of the suprahyoid muscula ture between
the two digits. The tissue may be compressed or frictioned
between the two digits at fingertip intervals until the entire
floor of the mouth has been treated. The submandibular
salivary glands should be avoided but the tissue surround
ing them should be thoroughly examined.
The external finger may also be used as the treating fin
ger with the internal finger offering stability. This reversal
of roles particularly addresses the anterior belly of digastric.
Among the many symptoms reported by Biedermann in WHAT OTHER FACTOR S D O MEDICAL
KISS children are: torticollis, reduced range of motion of the AUTHOR I TIES THIN K CAUSE SERIOUS CRANIAL
head/neck, cervical hypersensitivity, opisthotonos, restless DISTORTI ON IN IN FANTS?
ness, inability to control head movement and one upper
It is reported (Miller & Clarren 2001) that deformational
limb underused (based on statistical records of 263 babies
plagiocephaly (cranial distortion, or 'crooked head shape')
treated in one calendar year up to June 1995).
can result from three different etiological processes:
Biedermann (2001) is convinced that the most effective
treatment for such infants is removal of suboccipital strain Abnormalities in brain shape and subsequent aberrant
by manual treatment, and not direct treatment of crania l directions in brain growth
asymmetry as this is consid ered to be a symptom of the Premature fusion of a single coronal or lambdoidal suture
underlying problem (most commonly suboccipital strain). Prenatal or postnatal external constraint.
Following appropriate treatment to reestablish full range of
upper cervical motion, functional improvement is reported
WHAT ARE THE L ON G - TER M E F FECTS OF
to be common within 2-3 weeks, although normalization of
DE FORMATIONAL PLAGIOCEPHALY?
cranial asymmetry takes many months. How much trea t
ment is required? According to Biedermann, of the 263 A study was conducted to determine whether there was an
babies trea ted, 213 required only one treatment, 41 were increased rate of later developmental delay in school-aged
treated twice and the remainder more often, with just 2 children who presented as infants with deformational pla
requiring 4 or 5 treatment sessions. giocephaly without obvious signs of delay at the time of ini
tial evaluation (Miller & Clarren 2001).
A total of 181 families from the medical record review
SLEEPING POSI T I ON AND CRANIAL DEFORMITY
could be notified about the study and 63 families agreed to
One of the reasons for KISS-like problems seems to relate to participate in a telephone interview. The sample of partici
infant sleeping position. A research study by plastic and pants for the telephone interview was random to, and rep
reconstructive surgeons has concluded that the almost uni resentative of, the group as a whole. The families reported
versal acceptance of positioning neonates on their backs to that 25 of the 63 children (39.7%) with persistent deforma
avoid sudden infant death syndrome (SIDS) may well tional plagiocephaly had required special help in primary
increase the incidence of abnormalities of the occipital cra schooL including special education assistance, physical
nial sutures, causing significant posterior cranial asymme therapy, occupational therapy and speech therapy, gener
try, malposition of the ears, distortion of the cranial base and ally through an Individual Education Plan. Only 7 of 91 sib
deformation of the forehead and facial structures (Argenta lings (7.7%), serving as con trols, required similar services.
et aI 1996) . One useful finding was that affected males whose defor
The study reported that there had been a dramatic increase mity was due to uterine constraint were at the highest risk
in the incidence of deformation of the occipital structures, for subsequent school problems.
although the patient referral base has not changed appre It was also noted that the use of helmet therapy to correct
ciably. Argenta et al note that the timing of this increase the distortion (a standard medical approach) did not seem
390 C L I N ICAL APPLICAT I O N O F N E U R O M USCU LAR TECH N I Q U E S : THE U PP E R B O DY
to affect the rate of developmental delay, almost half of the movements of the craniofacial region over the past 6 years,
delayed patients having worn helmets (Miller & Clarren forty-nine children were treated successfully and 11
2001). showed no change.'
These children had been referred by general physicians
in cases where standard treatments, such as insertion of
D I F FERE N T CRA N IAL APPROACHES
grommets, paracentesis, surgery and /or antibiotic usage,
This text is not an appropriate place in which to offer pre had failed. Spermon-Marijnen & Spermon (2001) suggest
cise details of infant cranial care, as the methods required that 'passive movement of the cranium can restore the cir
for application on such delicate structures need to be learned culation and motion by which drainage of the middle ear is
in closely supervised clinical and classroom settings. Suffice stimulated' .
to say that the method of application of cranial manipula These clinicians commence the process of trea tment by
tion in infants is usually direct rather than indirect - i .e. the observation, palpation and motion palpation:
barriers of resistance are engaged and molding is applied in
an attempt to normalize distortions, utilizing very gentle Look at symmetry or deformity, paying special attention to
and sensitive holding patterns. asymmetry, the orbital line, the level of ears related to the
Biedermann applies a direct approach in cervical treat level of eyes, and the mastoids. Palpate the vault and posi
ment of KISS children, using what is described as 'minimal tion of the sutures, noting swelling, overlap and mobility.
imp ulse manipulation', commonly in a la teral direction, but Test the condylar parts of the occiput and examine the occip
with a rotational component in some cases. ito-atlantal mobility.
We measured theforce used in treatment of babies and adults Palpation and motion palpation merge readily into treat
[and found] the force used for treating babies is 15-20% of men t:
that used in adults. In most cases the direction of the impulse The techniques of passive motion testing are, in our opinion
is determined by radiological findings (85%) . , The manip
.
also effective as therapeutic movements, with the applica
tlation itself consists of a short thrust with minimal force of tion of additional or sustained pressure.
the proximal phalanx of the medial edge of the second finger.
The following list is a summary of the methods described
The amount of force involved, tested with a calibrated pres
by Spermon-Marijnen & Spermon (2001) as relevant tech
sure gauge, required no more effort than would be needed
niques used for children with chronic ear conditions.
to 'push a bell-button energetically'.
Clinical researchers and authors such as Viola Frymann 1. Transverse movement of the sphenoid: Sitting at the head of
( 1976) and John Upledger (Up ledger & Vredevoogd 1983) the supine patient, one index finger and middle finger on
record many instances of success in trea ting dysfunctional the sphenoid, and the other index and middle finger on
children, some with severe learning and behavioral prob the contralateral zygoma and frontal bone, very light
lems, as well as with a host of physical complain ts, utilizing pressure is used to gently shunt the sphenoid into a
cranial techniques (Upledger 1978). translation. Hand positions then reverse and translation
Should cranial distortion occur in infancy and childhood, to the other side is introduced. In this same way rotation
when plasticity al lows for a degree of movement not avail of the sphenoid may also be achieved.
able in the adult skull, particularly in relation to the sphe 2. Longitudinal movements of the nasofrontal region: Standing
nobasilar synchondrosis, the resulting distortion pa tterns, to the side of the supine pa tient, one hand over the crown
with their associated soft tissue imbalances of the reciprocaJ of the head, index finger contacts and stabilizes the supra
tension membranes in particular, will become 'set' and will orbital region on one side, while the other hand uses a
be largely impervious to 'corrective' trea tment in adult life. pincer contact on the superior aspect of the nose, to intro
Some modification of the associated stress patterns can stiU duce a distraction force. This may be sustained, or can be
be initiated via cranial and other therapeutic measures, even used to rhythmically 'pump' the area. One side is treated,
in adult life, but restoration of structural 'normality' and then the other, to 'influence the frontal and maxillary
symmetry becomes a virtual impossibility after childhood. sinuses'. While not identical to the 'nasal release' method
Moving away from cranial distortion to far more com described earlier in this chapter, it should achieve similar
mon patterns of ill-health affecting infants leads inevitably results.
to the topic of chronic ear infection. 3. Transverse movement of the zygoma-temporal and zygoma
maxilla region: The patient is supine and the practitioner
is seated at the head . One side is trea ted at a time.
EAR D I SEASE AND CRAN IAL CARE
Using finger and thumb contacts of each hand, one
Spermon-Marijnen & Spermon (2001 ) have treated many contact closer to the zygomatic-maxillary junction and
children with chronic middle ear disease, \Ising cranial the other closer to the zygomatic-temporal j unction, a
techniques. They report that: '60 children [with otitis media gentle distraction/ separation is introduced as the
with effusion] were inspected and treatment with passive pa tient's head is rotated contralaterally.
1 2 The cra n i u m 391
j
That the results of the present method of treating defects of vision are
Fascial Superior
far from satisfactory is something that no one would attempt to deny.
Periorbita sheath rectus muscle
Dr William Bates' insig htfu l q uote in 1 9 1 9 remains true today i n
many respects. Although genera l u nderstanding of eye health,
dysfunctions and patholog ies has considerably expanded since
Dr Bates developed his infamous 'Bates method' of eye exercises
( 1 920), a g l a nce around us at the num ber of people who requ i re
prog ressive support for visu a l cla rity (glasses, contact lenses, eye
surgeries, etc.) reflects the i nherent deficiency in ophtha lmic
medicine to prevent visual deterioration and to use natura l means
to improve vision.
box continues
1 2 The cra n i um 393
\ is_+-:. Media
Abduction ...... Lateral t ...... Adduction
"'IIIIIIIfI rectus rectus ..".
Look laterally
Superior rectus
and upward
Look laterally A
Inferior rectus
and downward
Inferior oblique
Look medially
and upward
Superior oblique
Look medially
B Inferior oblique Medial rectus Inferior rectus
and downward
box continues
394 C L I N I CA L A P P L I C AT I O N O F N E U R O M U S C U LA R T EC H N I Q U E S : T H E U PP E R B O DY
turn can be consta nt or i ntermittent, ca n alternate from eye to Today much of mai nstream medicine stil l rejects the a pplication
eye, or ca n a ppear when the person has read a lot or is very tired. of the Bates method exercises for the mature eye, a lthough these are
Esotropia - the eye turns in. commonly used to improve certa in eye cond itions in ch ildren. Bates
Exotropia - the eye t urns out. suggested that eye movements - left and right, up and down, and in
Hypertropia - the eye turns up. l a rge circu l a r patterns - a re i ntended to elongate shortened m uscles,
Hypotropia - the eye turns down. thereby decreasing pressure on the eye that changes its shape and
Amblyopia - one eye is ignored, resu lting i n a lazy eye. a l ters the focal plane of the l ens. A n umber of other steps, such as
acq u i ring proper rest (for the body as well as the eyes), a lternating
Although adu lts may develop strabismus, it most often develops i n
the foca l pla ne, palming, sun n i ng and swinging were also suggested.
infants and young children. As t h e c h i l d g rows t h e condition does not
More deta ils and descriptions ca n be found at the website for The
usua l ly improve without intervention. Causes include i nadequate
Bates Association for Vision Education
development of eye coordi nation, excessive farsightedness
(http://www.seeing.org/index.html).
(hyperopia), and variation between the vision in each eye or problems
There a re no harmful side effects from the exercises if performed
with the eye m uscles that control eye movement. Head tra uma,
appropriately (be ca utious with 'su nni ng') and they might prove
stroke or other general health problems may also be the cause.
h e l pfu l for some people who have the determination to 'stick with
Treatment plans may include eyeg lasses, vision therapy or eye muscle
the program'. As is true for much of complementary and alternative
surgery. Cranial osteopathic or craniosacral treatment may useful ly
medicine, Bates' theories remain u n p roven and fi nding a qual ified
accompany ophthalmic care i n such cases, especially in children.
practitioner can be cha llenging. Behaviora l optometrists or vision
therapists generally teach natura l vision i mprovement techniques
The Bates m ethod such as these, while also incorporating othe r visual therapy methods.
Dr Bates exp ressed ideas that were outside of mainstream However, the reader is ca utioned that a ppropriate medical treatment
ophtha l mo l ogy. He contended that faulty eyesight could be i m proved is sti l l recommended, particu la rly for cond itions such as glaucoma,
and ocular d isorders reversed by incorporating natural visual habits cataracts and other serious eye patholog ies.
and reducing mental stra i n . He first described the Bates method in One simple eye exercise, d iscussed by Leviton (1 992), can be easily
Perfect Sight Without Glasses ( 1 920. a lso titled within the cover as fashioned from a 1 0-foot string or thin rope and 1 5 brightly colored
The cure of imperfect sight by treatment without glasses), theorizing beads (varying colors a re best). The beads a re tied onto the string at
that menta l strain played a ro le i n refractive error (presbyopia, 8-inch intervals and the end of the string is tied to a doorknob or
astigmatism, hyperopia and myopia), as well as other eye cond itions distan t object. The patient sits comfortably in a chai r at a d istance
such as strabismus, am blyopia, cataracts and g laucoma. Due to the so as to p u l l the string taut. The string is held near the tip of the
fact that copyrig ht has expired on this over 85-year-old version, a nose so that the eyes gaze across its length. While breathing deeply,
copy of the original text is now available as a PDF file at attention is placed on the first bead nea rest the nose for a few
h ttp ://www.ibli nd n ess.org/books/ba tes/ seconds and a n attempt is made to visua l ly focus on it. The focus
box continues
1 2 The crani u m 395
then moves to the next bead and so forth until a l l have been while elevating it as far overhead and lowering it toward the thigh
practiced. This ca n be repeated, moving from the distant end toward while a lso fol lowing it visual ly. These movements are performed
the face until all have been add ressed. Add itional ly, it is suggested several times then the entire set of movements is repeated on the
that exercises be included that j u m p from a close bead to the l eft while using the left arm to perform the exercise. It is not
fa rthest distant bead, back to the second, then the farthest again, uncommon for the eyes to feel fatigued or to ache for a brief
then the third and so forth, u p and down the string, pausing on each time after the session d u e to the 'exercising' nature of the
to attempt to focus. movements.
Benefit may also be gained from exercises that stretch the recti For further d iscussion, i ncluding m uscle function tests, midl ine
m uscles. It is best to perform the exercises while seated in case the shift syndrome test and Ruddy's eye exercises, see Clinical
movements resu lt in l ightheadedness or vertigo. The right arm is Application of Neuromuscular Techniques: Practical Case Study
pronated and placed in horizontal adduction to outstretch in Exercises, Case Study 6 (Chaitow Et Delany 2005).
front of the person. The wrist is extended and the fingers and
thumb curled toward the pal m except for the extended index finger, Suggested websites
which is pointing toward the ceiling to produce a single d igit on The Bates Association for Vision Education -
which to focus. Focus is p laced on the tip of the index finger as the http ://www.seei ng.org/i ndex.htm I
arm is moved slowly in abduction as far latera l ly as the eye can Vision I m provement Site -
follow it without moving the head. Then it is slowly returned to the http ://www.vision i m provementsite.com/bates.htm I
original position while also fol lowing it visua l ly. This is repeated Imagination Blindness - http://www.iblindness.org/books/bates/
The upper extremity epitomizes functionality, whether performing manual therapy or surgery - or simply scra tch
this involves throwing or lifting, writing, p a inting, playing ing an itch. It is to this remarkable assembly of structures
music, comforting a baby's distress, lifting food to the mouth, that we turn our atten tion next - the upper extremity.
References
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399
Chapter 13
C H A PT E R CONTENTS
Assessment for shortness of rhomboids 439
Shoulder 401 N MT for rhomboids 439
Structure 401 MET for rhomboids 440
Key joints affecting the shoulder 401 Deltoid 441
Pivota l soft tissue structures and the shoulder 404 NMT for deltoid 443
Assessment 407 Supraspinatus 443
Repetitions are important 408 Assessment for supraspinatus dysfunction 446
Janda's perspective 410 Assessment for supraspinatus weakness 446
Observation 410 NMT treatment of supraspinatus 446
Pa lpation of superficial soft tissues 411 MET treatment of supraspinatus 446
Range of motion of shoulder structures 411 MFR for supraspinatus 447
Active and passive tests for shoulder gi rd le motion (sta nding Infraspinatus 447
or seated) 412 Assessment for i nfraspinatus shortness/dysfunction 447
Strength tests for shoulder movements 413 Assessment for infraspinatus weakness 448
Muscula r relationships 413 NMT for i nfraspinatus 448
Spinal and scapular effects of excessive tone 415 MET treatment of short infraspinatus (and teres minor) 448
Shoulder pain and associated structures 415 MFR treatment of short i nfraspinatus 449
Thera peutic choices 416 PRT treatment of infraspinatus (most suitable for acute
Specific shoulder dysfunctions 417 problems) 449
Specific muscle evaluations 420 Triceps and a nconeus 449
Infraspinatus 420 Assessment for triceps weakness 452
Levator scapula 420 NMT for triceps 452
Latissimus dorsi 420 MET treatment of triceps (to enha nce shoulder flexion with
Pectora lis major and m i nor 421 elbow flexed) 452
Supraspinatus 421 NMT for a nconeus 453
Subscapularis 421 Teres m i nor 453
Upper trapezius 421 Assessment for teres m i nor weakness 453
Is the patient's pain a soft tissue or a joint problem? 422 NMT for teres minor 454
The Spencer sequence 422 PRT for teres m inor (most suitable for acute problems) 455
Treatment 429 Teres major 456
Trapezius 429 NMT for teres major 457
Assessment of upper trapezius for shortness 431 PRT for teres major (most suitable for acute problems) 457
NMT for upper trapezius 432 Latissimus dorsi 458
NMT for m iddle trapezius 433 Assessment for latissimus dorsi shortness/dysfunction 458
NMT for lower trapezius 433 NMT for latissimus dorsi 459
NMT for trapezius attachments 434 M ET treatment of latissimus dorsi 460
Liefs NMT for upper trapezius a rea 434 PRT for latissimus dorsi (most suitable for acute
MET treatment of upper trapezius 435 problems) 460
Myofascial release of upper trapezius 435 Subsca pularis 460
Levator sca pula 435 Assessment of subscapularis dysfunction/shortness 462
Assessment for shortness of l evator scapula 436 Observation of subscapularis dysfunction/shortness 462
NMT for l evator scapula 436 Assessment of weakness in subscapularis 463
MET treatment of levator sca pula 438 NMT for subscapularis 463
Rhomboid minor and major 438 M ET for subscapularis 463
Assessment for weakness of rhomboids 439 PRT for subsca pularis (most suitable for acute problems) 464
The shoulder is an immensely complicated structure and it The clinical picture correlates mainly with changes in func
is easy to become confused by its complexity and the wide tion, much less with structural pathology. Very frequently
range of assessment protocols that are used during clinical pathological changes do not manifest themselves so long as
evaluation. Evidence from tests involving range of motion, function is not impaired. However, changes in function by
neurological reflex evaluation, muscle strength and weak themselves may cause clinical changes in the absence of any
ness assessment, postural analysis, and palpation relating (structural) pathologtJ For the same reasons, even clearly
to al tered tissue tone, pain patterns and myofascial trigger diagnosed pathology can be clinically irrelevant (disc herni
points may all be usefully ga thered and collated . A host ations at CT, spondylolisthesis), whereas dysfunction that
of other 'functional pa thologies' may also be discovered, can usually be diagnosed only by clinical means can be of
not to mention actual pathology, including inflammatory decisive importance.
processes, arthritic changes and other degenerative
possibilities Liebenson's insightful sta tements lead us to question
It is easy to see how, as a result of the availability of all how it may be possible to find a way through the maze of
these data, 'information overload' might occur, with no clear informa tion and to identify and extract the key elements
indication of where to begin therapeutic intervention. in each particular case. This is most certainly not a recom
Liebenson (1996) states the clinical conundrum as follows: mendation for skimping on assessment; however, it does
'So many structural and functional pa thologies are present offer the opportunity for meaningful evalua tion of
functional pa tterns, which can often highlight what have
been termed 'key stereotypic movement patterns' (Jull &
Janda 1987, Lewit 1991). How is the area working? Is i t
behaving normally? Are firing patterns sequential and
within normal parameters? Is the range of movement op ti
mal? Functional assessment protocols are described (see
pp. 408-410) which may be used to highlight particular struc
tures tha t may then receive primary attention. These con
cepts should be kept in mind as we work our way through
the many essential aspects of shoulder function and dys
function, the joints and soft tissue components and the tests
associated with these.
A B c
Figure 1 3.2 The th ree deg rees of freed o m of movement of the shoul der join t. A: Flexion-extension. B : Abduction -adduction.
C: Medial-lateral rotation . Reproduced w ith perm ission from Gray's Anatomy (2005).
scapulothoracic (scapulocostal) joint is a false joint com The rotator cuff muscles (supraspinatus, infraspinatus,
posed of the scapula and its gliding movements on the teres minor and subscapularis - SITS) blend their fibers
thoracic wall (thoracoscapular articula tion) with the joint capsule and offer muscular support. The SITS
acromioclavicular joint is a true joint articulation of the tendons are so closely approximated to the joint capsule
acromial process of the scapula to the lateral end of the tha t they are especially vulnerable to injury.
clavicle. lhis articulation forms an overhanging ledge that, The head of the humerus is capable of many combina
while offering protection, also can impinge on movement tions of swing and spin, producing a highly mobile joint as
of the h umeral head beneath the ledge. The only bony well as a relatively unstable one. However, it has basically
attachment of the scapula to the entire thorax is the three planes of movement (abduction/adduction, flex
acromioclavicular joint. All other attachments are muscular ion/ extension and medial/lateral rotation) which are most
sternoclavicular joint is a true joint whose movement is apparent when the scapula is fixed.
often overlooked as part of the shoulder girdle. Since the Accessory movements, such as translation of the humeral
distal end of the clavicle must elevate and rotate with the head in all directions on the glenoid face (joint play), should
acromion during elevation of the arm, its sternal articula also be manually possible. Osseous, ligamentous and mus
tion and movement are also vital cular dysfunctions can limit joint play, as well as ranges
sternocostal joint - true joint of motion, and should be corrected when joint play has
costovertebral joint - true joint. been lost.
Acromioclavicular
Clavicle joinl/ligament
Acromioo
Sternoclavicular Glenohumeral
joinUligament joinUtigament
Labrum
Sternum
+---+-- Humerus
Scapula
-lI-+-- Scapulothoracic
articulatioo OOint)
Fig u r e 1 3.3 The seven sepa rate joints that com prise the shou lder g i rdle.
Most joints of the appendicular skeleton (apart from the pubis and is because the long head of triceps does not have as close a
the tibiofibular junction) are synovia l . Synovial joints comprise a relationship with the capsule, as do the previously mentioned
thick capsule which protects the joint and somewhat restricts muscles, due to the presence of neural structures and blood
excessive movement while a l lowing it a g reat degree of mobility. vessels.
The fibrous outer layer of the capsule merges with the periosteum Further sta bil ization of the capsule derives from the three
of the bones which form the joint. glenohumeral ligaments (superior, midd le and inferior bands).
I n the case of the shoulder the following characteristics apply to These a l l attach at their scapular end to the superior aspect of
the fibrous capsule and associated ligaments. the medial margin of the g lenoid cavity, merg i ng with the glenoid
labrum (a fibroca rtilaginous rim attaching to the margin of the
The capsule attaches medially to the circumference of the glenoid
g lenoid cavity).
covity beyond the glenoid labrum.
The superior band of the glenohumeral ligament runs a long the
Superiorly it attaches to the root of the coracoid process,
medial aspect of the biceps tendon before attaching above the
enveloping the origin of the long head of the biceps.
lesser tubercle of the humerus.
Latera lly the capsule attaches to the neck of the humerus close to
The middle band of the glenohumeral ligament attaches to the
the articular margin, apart from the medial aspect where the
inferior aspect of the lesser tubercle.
attachment is approximately 1 cm lower on the bone. The capsule
The inferior band of the glenohumeral ligament attaches to the
is sufficiently lax to a llow the rem arkable degree of mobility at
lower aspect of the a natomical neck of the humerus.
the joint.
The tendons of pectora lis major and teres major further
The joi nt's stabil ity depends to a large extent on the muscles and
strengthen the anterior aspect of the capsule (and therefore the
the supporting ligaments ( glenohumeral ligaments) that merge
joint as a whole).
with and surround the capsule.
The capsule is reinforced by muscles: Additional ligamentous features of the shoulder joint include the
1. superiorly by supraspinatus fol lowing.
2. inferiorly by the long head of triceps
3. posteriorly by the tendons of infraspinatus and teres m inor The acromioclavicular ligament which covers the superior aspect
4. a nteriorly by subscapularis. and fibrous capsule of this joint before merg i ng with the fibers of
The tendons of subscapularis, supraspinatus, infraspinatus and the aponeurosis of trapezius and the deltoid.
teres minor all blend with the capsule, creating a cuff. The corococlavicular ligament attaches the clavicle to the
The inferior aspect of the capsule (and joint), which during coracoid process of the scapula, efficiently maintaining the clavi
abduction has g reat strai n imposed on it, is the least stable. This cle's contact with the acromion. If the acromioclavicular joint
Subtendinous bursa
Superior glenohumeral ligament
Coracohumeral
ligament Middle glenohumeral ligament
Long head of
biceps brachii tendon ---....
Transverse
humeral
Fibrous membrane ligament
of joint caPSUIE----1 _...
Long head of
biceps brachii
tendon ------'
Inferior
glenohumeral
ligament
Redundant synovial
Ai membrane in adduction Aii Redundant capsule
Fig u re 1 3.4 A-C: Va rious l i g a me nts of the shou lder g i rd le. Reproduced with perm ission from Gray's Ana tomy for S tudents (2005).
box continues
406 CLI N I CAL A P P L I CAT I O N OF N E U R O M U SCU LAR TECH N I QU ES: T H E U PP E R BO DY
dislocates, this ligament may tear which allows the scapula to I n some instances pectora lis minor attaches into the shoulder
drop away from the clavicle. This l igament has two pa rts, the capsu le (rather than the usual attach ment at the coracoid
trapezoid and the conoid portions. process), its tendon passing beneath the coracoacromial ligament.
1 . The trapezoid ligament ru ns almost horizontally, attaching The coracohumeral ligament is a broad structure wh ich strength
inferiorly to the upper surface of the coracoid process and ens the superior aspect of the capsule (its lower and posterior
superiorly to the inferior surface of the clavicle. borders merge with the capsule). The ligament attaches to the
2. The narrow end of the conoid ligament attaches i nferiorly to base of the coracoid process and travels obliquely i nferiorly and
the posteromedial edge of the root of the coracoid process latera lly to the a n terior aspect of the greater tubercle of the
and su periorly, at its broader end, to the conoid tubercle on humerus where it blends with the supraspinatus tendon.
the i nferior surface of the clavicle. The transverse humeral ligament runs from the lesser to the
The coracoacromial ligament comprises a strong tria ngular band g reater tubercle of the humerus, forming a canal for the retinac
that li nks the coracoid process of the sca pula with the acrom ion. ulum of the long head of the biceps.
Acromion
Supraspinatus ------II-H
W;;7-.--+---___:-'--- Coracoid process
Infraspinatus --------IIf+-_I_
box continues
13 Shoulder, arm and hand 407
Box 1 3. 1 (continued)
At the sternal end of the clavicle additional ligamentous structures This articulation is, as in the case of the shoulder i tself, sur
occur. rounded by a fibrous capsule.
The anterior sternoclavicular ligoment covers the anterior su rface
At the sternoclavicu lar joint the su rface of the sternal a rticula
of the joint attaching superiorly to the clavicle and attaching
tion is smaller than that of the surface of the clavicle, wh ich is
inferomedially to the anterior aspect of the manubrium sternum
covered with a saddle-shaped fibrocarti lage, and separated from
and the first costal carti lage.
the sternal notch by an articu lar d isc.
The posterior sternoclavicular ligament l ies on the posterior
aspect of the joint, attaching superiorly to the clavicle and i nferi
Articular disc Clavicular notch orly to the posterior aspect of the manubrium.
(capsule and ligaments r---- Anterior The interclovicular ligament merges with the deep cervical fascia
removed anteriorly Interclavicular sternoclavicular su periorly and connects the superior aspects of the sternal ends
to expose joint) l ig ament ligament of the clavicles. Some fibers a lso attach to the manubrium. I n
approximately 7% o f the population sma ll, ossified structures are
present in the l igament, the suprasternal ossicles. These usually
pyra mid-sha ped structures a re origi na lly cartilaginous, ossifying
in adolescence. They may be fused to, or articulate with , the
manubrium.
The costoclavicular ligament attaches i nferiorly to the first rib
and its adjacent cartilage and superiorly to the clavicle.
-----,.j---- Manubrium of
Costoclavicular sternum
ligament
.._.,..."""":;:--- Attachment site
First costal for rib 2
cartilage
c '----Ir---- Sternal angle
Table 1 3,2 Tests used in shoulder evaluation and significance of positive findings
Test M a neuver Diagnosis suggested by positive result
Apley scratch test Patien t touches superior a nd i nferior aspects of Loss of range of motion: rotator cuff
opposite scapula problem
Neer's sign Arm i n fu l l flexion Subacromial i mpingement
Hawkins' test Forward flexion of the shoulder to 90 and Supraspinatus tendon i mpingement
internal rotation
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-a rm test Forward elevation to 90 and active adduction Acromioclavicular joint arthritis
Spurli ng's test Spine extended with head rotated to affected Cervical nerve root d isorder
shoulder while axially loaded
Apprehension test Anterior pressure on the humerus with external Anterior glenohumeral i nstabil ity
rotation
Relocation test Posterior force on humerus while externa lly Anterior glenohu meral i nstability
rotating the a rm
Sulcus sign Pull ing downward on elbow or wrist Inferior glenohumera l instability
Yergason's test Elbow flexed to 90 with forearm pronated Biceps tendon i nstability or tendonitis
Speed's maneuver Elbow flexed 20-30 and forearm supinated Biceps tendon i nstability or tendonitis
'Clunk' sign Rotation of loaded shoulder from extension to Labral d isorder
forward flexion
Note: Not all of the above tests are fully described within this text.
Reproduced with permission from Woodward Et Best (2000).
etc.) or symptoms which can be modified manually (increase Has this happened before?
or decrease of pain as evaluation is performed, for example). And, if so, what helped it last time?
In order for the 'story' to be clinically useful it needs to
connect the patien t's presenting symptoms with something It is very important to identify what eases symptoms as
that is identified by palpation an d / or assessment as in well as what worsens them, as this may reveal patterns
some way causing, contributing to or maintaining the which 'load' and 'unload' the biomechanical features out of
symptoms. Appropriate treatment choices flow naturally w hich the symptoms emerge. The patient's own viewpoint
from such a sequence. as to what helps and what worsens symptoms, as well as
History + symptoms + 'dysfunctional features' the practitioner 's evaluation as to where restrictions and
= a 'story' which helps to determine treatment choices abnormal tissue states exist and how dysfunction manifests
d uring standard testing and palpation, should together
In taking a history of a patient and the presenting condition,
form the basis, with the history, for making a tentative ini
important questions that we should ask include the following.
tial assessment.
How long have you had the symptoms?
Are the symptoms constant?
Are the symptoms intermittent and, if so, is there any R E PETITI O N S A R E I M PO RTA N T
pattern? In performing assessments ( testing a shoulder for internal
What is the location of the symptoms? rotation, for example), if performing the action once pro
Do they vary at all? d uces no symptom, it may be useful to have the movement
If so, what do you think contributes to this? performed a number of times. As Jacob & McKenzie (1996)
What, if anything, starts, aggravates and / or relieves the explain:
symptoms?
Do any of the following movements improve or worsen Standard range of motion examinations and orthopedic
the symptoms - for example, turning the head one way tests do not adequately explore how the particular patient's
or the other; looking up or down; bending forward; spinal [or other area of the body] mechanics and symptoms
standing, walking, sitting d own or getting up again; are affected by specific movements and/or positioning.
lying down, turning over and getting up again; stretch Perhaps the greatest limitation of these examinations and
ing out the arm, and so on? tests is the supposition that each test movement needs to be
13 Shou l der, a rm a nd hand 409
J
J A N D A ' S P E R S P ECTIVE The method of the scapulohumeral rhythm test, which has
direct implications for neck and shoulder dysfunction, is as
In Chapter 5 details were given of the resea rch work of
follows.
Czech researcher Vladimir Janda MD ( 1982, 1983). He has
described the upper crossed syndrome in which the follow The patient is seated and the practitioner stands behind,
ing postural muscles shorten and tighten (see p. 34): observing.
The patient is asked to let the arm on the tested side hang
pectoralis major and minor
down and to flex the elbow to 90, thumb upwards.
upper trapezius The patient is asked to slowly abduct the arm toward the
levator scapula horizon tal .
sternocleidomastoid A normal abduction will include elevation of the shoul
while at the same time: der with rotation or superior movement of the scapula
commencing only after 60 of abduction.
lower and middle trapezius Abnormal performance of this test occurs if elevation of
serratus anterior and rhomboids the shoulder or rotation, superior movement or winging
of the scapula occurs within the first 60 of shoulder
are inhibi ted and weaken.
abduction.
As these changes take place the relative positions of the
This would indicate levator scapula and / or upper
head, neck and shoulders modify, so that cervical stress
trapezius as being overactive and therefore shortened,
develops while, more specifically, there is a change in shoul
with lower and middle trapezius and serratus anterior
der biomechanics.
inhibited and weak.
The scapula abducts and rotates due to increased tone in Objectively, the area abou t a third of the way between the
upper trapezius and levator scapula, inhibiting serratus angle of the neck and the lateral edge of the shoulder will
anterior and the lower trapezius. 'mound' during this test if levator scapula is excessively
This produces an altered direction of the axis of the glenoid overactive.
fossa so that the humerus demands additional levator Another way of viewing the test is to judge whether the
scapula, upper trapezius and supraspinatus stabilization, 'hinge' of arm abduction is occurring at the acromioclav
further stressing these already compromised muscles. icular joint or at the base of the neck.
A part of the ou tcome of such changes will be the evolu
tion of trigger points in the stressed structures and Variation
referred pain to the chest, shoulders and arms. The patient is seated or standing with the practitioner
Pain mimicking angina may be noted plus a decline in standing behind, a fingertip resting on the upper trapez
respira tory efficiency. ius muscle of the side to be tested.
The patient is asked to take the arm being tested into
Janda stresses the need to identify shortened structures
extension.
and to stretch and relax them, after which proprioceptive
If, at the very outset of this movement of the arm, there is
reeducation is indicated. Whatever local treatment these
d iscernible firing of upper trapezius, it is overactive and
trigger points receive, reed ucation of posture and use is an
by implication shortened.
essential aspect of rehabilitation.
By implication, this overactivity suggests that lower fixa
tors are weak with the same sort of imbalance noted in
Janda's sca pulohumera l rhythm test the initial findings of the test described above.
In order to obtain a rapid overview of the function of the It is always useful to confirm a functional test such as this
postural muscles associated with shoulder and scapula with evidence of actual shortening. Tests to establish this
behavior, Janda has devised a series of 'functional tests' . evidence will be described later in this section.
The reasoning is that if a normal action can be demon
stra ted to involve excessive activity of key postural (type I,
see Chapter 5) muscles, this implies that: O B S E RVAT I O N
Observe the person's shoulders simul taneously.
1. the postural muscle(s) so identified will be overactive,
therefore by definition short Is there evidence of asymmetry (one shoulder high or
2. the phasic antagonists will therefore be inhibi ted and not deviation of the neck in a scoliotic curve, for example)?
performing their roles as prime movers, so that Is one or are both of the shoulders rounded? (postural
3. synergists will probably become overactive in placement)
compensation Is the upper crossed syndrome apparent?
4. as a result most of these muscles will develop localized VVhat, if any, are the influences of spinal curves (for
areas of distress and trigger points will evolve. example, is there increased thoracic kyphosis?)
1 3 Shoulder, arm and hand 41 1
Is there al tered skin color (blanching indicating ischemia that might be involved. What is 'normal' will likely remain
or increased hyperemia suggesting inflammation, for controversial at least until latent trigger points (which
example)? restrict range of motion without pain symptoms) are
What evidence is there of muscle hypertrophy (accentu assessed and deactivated in the 'normal' patients used in
ated development of upper trapezius, for example) or the studies of ranges of motion.
atrophy (extreme laxity and weakness of lower scapula
fixators, for example)? Flexion (a nteversion) 0 - 1 800
Are there any tremors, suggesting neurological
dysfunction? 0-60 at glenohumeral joint - anterior fibers of deltoid, cora
cobrachialis, clavicular fibers of pectoraliS major, biceps
PA LPAT I O N O F S U P E R F I C I A L S O FT T I S S U E S brachii, supraspinatus (possibly); 60-120 involves scapular
rotation - the above plus trapezius, serratus anterior;
Assess skin and muscle tone and size. 120-180 involves the spinal column - all the above plus lum
Test brachial and radial pulses (brachial is medial to bar muscles which extend the trunk and stabilize the torso.
biceps tendon, radial is on ventrolateral aspect of wrist)
as well as assessment of general reflexes and range of
motion. If there exists asymmetry of rate, rhythm, Extension (retroversion) 0-500
strength or wave form in the arterial pulses, circulatory Teres major /minor, posterior fibers of deltoid, latissimus
dysfunction is probable. dorsi, long head of triceps, rhomboids, middle trapezius.
'downwardly rotate the scapula', impeding elevation of the practitioner ensures tha t the point of m uscle origin is
the humerus at the glenohumeral jOint. efficiently s tabilized
He suggests that rhomboid overactivity might also care is taken to avoid use by the patient of ' tricks' in
impact on the upper thoracic region as a whole (Tl-4), which synergists are recrui ted.
locking these segments into an extension posture. If this
situation were accompanied by overactivity of the poste
M U S C U LAR R E LATI O N S H I PS (Janda 1 983)
rior scalene, the 2nd rib might 'subluxate superiorly on
the fixed thoracic segment', leading to pain and dysfunc The prime mover in any action (agonist) performs the
tion mimicking shoulder impingement syndrome. greater part of the movement.
Boyle hypothesizes tha t mechanical interference might The assisting muscles (synergists) assist the prime mover
occur involving ' the dorsal cutaneous branch of the sec but do not carry out the actual movement unless the ago
ond thoracic nerve . . . in its passage through the tunnel nist is severely damaged or paralyzed.
adjacent to the costotransverse joint'. This nerve might be Movement in the opposite direction is performed by the
'drawn taut, due to the superior anterior subluxa tion of antagonist(s), which are passively elongated during nor
the second rib' leading to pain and associa ted restricted mal movement initiated by the agonist. Therefore, if
movement symptoms. there is shortening of the antagonist(s), movement range
The reason for a false-positive impingement test, Boyle will be l imited.
suggests, relates to the internal rotation component Muscles that stabilize parts of the body during movement
which adds to the mechanical stress of the dysfunctional of an area are stabilizers. These do not perform the move
rib area. This could also, through pain inhibition, result ment but if they are inefficient in producing stabiliza tion,
in rotator cuff muscles testing as weak, suggesting incor it becomes more difficult for the agonist to perform its
rectly that a partial tear had occurred. function and strength evalua tions may be meaningless.
The possibility of a 2nd rib involvement should not dis Some muscles act as neutralizers. Based on its anatomical
guise the possibili ty tha t this coexists wi th a true position each muscle operates in at least two directions. If a
impingement lesion. muscle can both flex and supinate (biceps for example) and
if an action of pure flexion is required, a muscle (or group of
STR E N GTH TESTS F O R S H O U L D E R M OVE M E N TS muscles) that acts as a pronator (pronator teres in this exam
ple) has to neutralize the supination potential of biceps.
In the absence of atrophy, weakness of a muscle may be
due to: Jand a (1983) states:
compensatory hypotonicity relative to increased tone in As a rule when testing a two-joint muscle good fixation is
antagonist muscles essential. The same applies to all muscles in children and in
palpable trigger points in affected (weak) muscle, adults whose cooperation is poor and whose movements are
notably those close to the attachments incoordinated and weak. The better the extremity is stead
trigger point in remote muscles for which the tested mus ied, the less the stabilizers are activated and the better and
cle lies in the target referral zone. more accurate are the results of the muscle function test.
Muscle strength is most usually graded as follows. The au thors highly recommend Janda's text and the other
referenced texts mentioned in this chapter for further explo
Grade 5 is normal, demonstrating a complete (100%) ration of the art of assessmen t.
range of movement against gravity, with firm resistance
offered by the practitioner.
Grade 4 is 75% efficiency in achieving range of motion Shoulder flexion strength (Fig. 1 3.5A)
against gravity with slight resistance. Anterior deltoid and coracobrachialis with assistance from pec
Grade 3 is 50(},0 efficiency in achieving range of motion toralis major, clavicular head and biceps: Practitioner stands
against gravity without resistance. behind pa tient whose elbow is locked in flexion at 90.
Grade 2 is 25% efficiency in achieving range of motion Stabilizing hand is on shoulder (placed so tha t it can also
with gravity eliminated. palpate anterior deltoid d uring the test). The other hand
Grade 1 shows slight contractility without joint motion. holds anterior aspect of lower arm and pa tient is asked to
Grade 0 shows no evidence of contractility.
For efficient muscle strength testing it is necessary to ensure
tha t: :'." ;:''"'-.'
l .....,. ' : ,'"..."" . -, :' ,.
.... - ," " _.-: . ...
'. _
, .':O.
"
the patient builds force slowly after engaging the barrier Neutra l izers a re of g reat i m portance in daily l ife, but in muscle
of resistance offered by the practi tioner function testing they are a nu isance. Their action is greatly
diminished by correct positioning of the extremities to a l low
the pa tient uses maximum controlled effort to move in accurate resistance and good fixation. (Janda 1983)
the prescribed direction
41 4 CLI N ICAL A P P L I CATI O N O F N EU R O M USCULA R TECH N I QU E S : T H E U PP E R B O DY
A D
B E
c F
Figure 1 3. 5 Strength tests of various a r m movements. A: Flexion (two-joint test). B : Extension (two-joint test). C: Abduction. D: Add uction.
.
E : Internal rotation. F : External rotation.
1 3 Shoulder, a r m a n d hand 41 5
flex shoulder. Strength is graded and compared with other Elevation of the scapula
side. If weakness is noted consider the nerve supply from
C4 to C8, as well as trigger point input to the active muscles. Trapezius, levator scapulae assisted In) rhomboids major and minor:
Practitioner behind patient evaluates relative strength as the
patient's attempt to sluug is resisted - this assesses spinal
Extension stre ngth [Fig. 1 3.5B) accessory nerve integrity. Strength should be recorded as
Latissimus dorsi, teres major, posterior deltoid with assistance suggested above. If weakness is noted consider the nerve
from teres minor and long head of triceps: Stabilizing hand on supply from C2 to C8, as well as trigger point input to the
shoulder palpating posterior deltoid, other hand holds pos active muscles.
terior aspect of flexed lower arm (as in previous test) as
patient is asked to extend shoulder. Strength should be Depression of the sca p u l a
record ed as suggested above. If weakness is noted consider Rhomboid major and minor, assisted by trapezius: Practitioner
the nerve supply from C4 to C8, as well as trigger point stands in front and places hands so that fingers cover shoul
input to the active muscles. ders over the upper deltoids and thumbs rest anteriorly below
the clavicles. Patient is asked to take shoulders back and down
Abdu ction strength [Fig. 1 3.5C) as practitioner resists and assesses strength. Since CS is the
sole innervation of the primary muscles involved (although
Middle deltoid, supraspinatus with assistance from serratus ante
trapezius is innervated from C2) weakness may relate to its
rior plus anterior and posterior deltoid: Stabilizing hand is on
integrity. Strength should be recorded as suggested above. If
shoulder palpating middle deltoid; increasing resistance is
weakness is noted consider the nerve supply from C2 to C8, as
offered above flexed elbow as abduction is introduced.
well as trigger point input to the active muscles.
Strength should be recorded as suggested above. If weak
ness is noted consider the nerve supply from C4 to C8, as
Protraction of the sca p u l a
well as trigger point input to the active muscles.
Serratus anterior: Examiner i s behind, patient flexes arm so
Adduction [Fig. 1 3.5D) that it is parallel to the floor with elbow flexed and forearm
at 90 to upper arm facing medially. Stabilization is offered
Pectoralis major, latissimus dorsi assisted by teres major, anterior by the practitioner in the mid-scapular region to prevent
deltoid and possibly posterior deltoid: Stabilizing hand is on spinal movement while the other hand cups the flexed
shoulder tip, patient's flexed arm is abducted and resistance elbow, offering resistance, as the patient attempts to push
is offered from a position medial to and above the elbow as the arm forwards, away from the body. If winging occurs
the patient attempts to adduct. Strength should be recorded during this, it implies weakness of lower fixators of the
as suggested above. If weakness is noted consider the nerve shoulder. If there is weakness in any of the movements
supply from C4 to C8, as well as trigger point input to the described, but particularly scapular depreSSion, CS may be
active muscles. implicated (or C4 - see Lewit's views above). Strength
should be recorded as suggested above. If weakness is
I nternal rotation [Fig. 1 3.5E) noted consider the nerve supply from C4 to C8, as well as
trigger point input to the ac tive muscles.
Subscapularis, pectoralis major, latissimus dorsi, teres minor
assisted by anterior deltoid: Arm at side, elbow flexed to 90
and with the elbow supported. Patient attempts to take the
S P I N A L A N D SCA P U LA R E F FE CTS O F
forearm medially across the trunk while resistance is
EXCESSIVE TO N E
offered. Strength should be recorded as suggested above. If Trapezius -pulls shoulder girdle medially, occiput pos
weakness is noted consider the nerve supply from C4 to C8, teroinferiorly, associated spinous processes laterally, ele
as well as trigger point input to the active muscles. vates shoulder, rotates scapula laterally.
Levator scapula pulls scapula medially and superiorly,
-
External rotation [Fig. 1 3.5F) rotates scapula medially and associated transverse
processes (Cl-4) inferiorly and posteriorly.
Infraspinatus, teres minor assisted by posterior deltoid: Flexed Rhomboid major and minor pulls scapula medially and
-
elbow rests in stabilizing hand (elbow remains at the side superiorly and associated spinous processes laterally and
throughout) with practitioner 's thumb at the elbow crease. inferiorly, rotates scapula medially (makes glenoid fossa
The other hand holds the wrist and applies increasing face downward).
resistance as the patient attempts to externally rotate the
shoulder by moving the forearm laterally. Strength should
S H O U L D E R PAI N A N D ASSO C I AT E D STR U CTU R E S
be recorded as suggested above. If weakness is noted con
sider the nerve supply from C4 to C8, as well as trigger Lewit summarizes some o f the most common sources of
point input to the active muscles. shoulder dysfunction and pain and states that if shoulder
41 6 CLI N ICAL A P P L I CATI O N O F N E U R O M U S C U LA R TECH N I QU ES : T H E U P P E R B ODY
pain exists, the following structures and their functions described by Lewit (199 1 ) and Janda (1982, 1983). In this
require evaluation and palpation. pattern of dysfunction, imbalances occur between:
1. short tight pectorals and weak (inhibited) interscapu
Cervical spine and craniocervical junction lar muscles
Cervicothoracic j unction, upper ribs 2. short tight upper shoulder fixa tors (upper trapezius,
Scapulohumeral (glenohumeral) joint (including joint levator scapula and pOSSibly the scalenes) and weak
play with arm horizontal) ened, inhibited, lower fixators (lower trapezius, serra
Clavicular joints tus anterior)
Abduction arc 3. short tight neck ex tensors (cervical erector spinae,
All available muscle insertions upper trapezius) and weak, inhibited deep neck flexors
Potential trigger point sites (longus cervicis, longus capitis, omo- and thyrohyoid)
Epicondyles
Carpal bone joint play leading to an unbalanced situation which has, as key features,
exaggerated cervical lordosis and consequent 'chin poking',
Note: Not all Lewit's suggested evaluations are described in dorsal kyphosis and a generally rounded shoulder posture,
this section (shoulder) of the book. with winged scapulae which drift laterally, leading inevitably
Lewit (199 1 ) also describes chain reactions that are rele to excessive strain on the rotator cuff muscles as they struggle
vant to shoulder dysfunction. to maintain normal position and function of the humerus,
which now meets the glenoid fossae in the wrong plane.
Craniocervical j unction restriction is often associated
with upper rib restriction (most often the 3rd rib) and
vice versa. T H E RA P E UTI C C H O I C E S
A tlantooccipital restriction is often associa ted with sub If shoulder pain i s accompanied b y muscular imbalances (as
occipital extensor dysfunction ('spasm'). described by Lewit and Janda in the upper crossed syn
If C 1 or C2 is restricted the lateral aspect of the spinous drome), the following elements are called for.
process of C2 is usually painful and trigger point activity
is likely in sternocleidomastoid inferior to the mastoid Assessment of j oint restrictions, shortened muscles and
process. local myofascial trigger points.
If postural stress is evident (forward drawn head or per Elimination of active myofascial trigger points (NMT).
sistent head extension during work) or if shoulder upper Restoration of balance between hypertonic and inhibited
fixators are excessively tight, C2 tenderness (spinous muscles (MET).
process) can be anticipated, along with cervical restric Mobilization of restricted joints (articulation and possi
tions in this region. Levator scapula attachment on the bly manipulation).
scapula and the clavicular a ttachment of SCM are likely Rehabilitation tactics, postural and, possibly, breathing
to house active trigger points at their attachment sites. reed ucation.
A chain of interconnected dysfunction may exist between If shoulder pain radiates from spinal structures the symptoms
the subclavicular pectoralis and SCM. This may be asso will be aggrava ted by head or neck movement and some
cia ted with upper chest breathing patterns, which would degree of joint blockage (restriction) will be noted. This
also involve the sca lenes and the masseter muscles (with requires normalization and among the choices available are:
resultan t trigger point activity likely in all or any of these identification and treatment of active trigger points
muscles). normaliza tion of associated muscle and soft tissues (see
Epicondylar pain may be linked with mid-cervical Lewit's discussion of chain reactions above)
restriction, which is likely to rela te to craniocervical junc use of MET to encourage normal joint function (p. 219)
tion dysfunction. More locally, 'Pain at the styloid process use of Ruddy's pulsed MET to encourage normal joint
of the radius . . . may be the only sign of blocking of the function (p. 201 )
elbow (radioulnar) j oint'. use of positional release methods to encourage normal
Pain in the epicondyles, which usually involves over joint function (p. 225)
strained forearm muscles, is likely to be related to high-velocity thrust techniques (if licensed to perform
increased muscle tension in the shoulder girdle, all of these) .
which require individual assessment.
Carpal twmel syndrome is commonly related to thoracic If shoulder pain originates in the upper ribs, treatment may
outlet dysfwKtion, involving the cervicothoracic junction, include:
upper ribs, scalenes and probably a dysfunctional breath use of MET, PRT and/or NMT (especially to the inter
ing pattern. An epicondyle connection is also probable. costal musculature and all attaching muscles)
Disturbed muscle function. It is important when consid positional release and MET methods for restoring normal
ering neck, shoulder and arm dysfunctions to recall ear function to elevated and depressed ribs, discussed on
lier discussion of the upper crossed syndrome, as p . 554.
13 Shou lder, arm and hand 41 7
Note:Some of the signs of rib involvement with shoulder 1. pain severe and worsening with some restriction
pain may include the following. 2. pain lessens but restriction remains
3. pain and restriction slowly vanish, with the whole
If the first rib is dysfunctional, shoulder pain is likely,
process lasting around a year.
with marked tenderness anteriorly when its attachment
to the manubrium sternum is palpated. Capsulitis may follow bursitis or tendinitis or it may relate
Scapula pain is noted, along with shoulder pain, in dys to chronic pulmonary disease, myocardial infarction or dia
function involving ribs 2, 3 and 4, with marked tender betes mellitus. When these more serious (potentially life
ness on palpation of the medial scapula border. threa tening) visceral conditions exist as the underlying
cause of the shoulder pain, and therapy reduces the pain to
a manageable level without addressing the cause, the vis
S P E C I F I C S H O U L D E R DYS F U N CT I O N S
ceral condition(s) may progress unnoticed. A differential
A number of upper extremity dysfunctions and pathologies diagnosiS from a physician is therefore essential.
may develop from biomechanical, biochemical and psychoso The condition may relate to overuse or to a subluxa tion
cial issues. Sorting through the numerous potential causes can which has reduced spontaneously or via treatment. If adhe
be challenging since many may be obscure. For instance, the sions form within the joint capsule, the head of the humerus
effects of stress on postural muscles have been discussed, may bond to the glenoid surface (adhesive capsulitis). The
with specific consequences on shoulder mechanics. Therefore condi tion is most common in women between the ages of 45
dysfunctional patterns of brea thing as well as habits of use and 65.
should be considered. Bodor & Montalvo (2007) hypothesize Pain is usually pronounced at the deltoid tendon attach
that vaccine injected into the subdeltoid bursa can cause a ment as well as in subscapularis. The deltoid, infra- and
periarticular inflamma tory response, subacromial bursitis, supraspinatus muscles may atrophy in severe cases and cir
biCipital tendonitis and adhesive capsulitis. They suggest that culatory changes may be noted (involving cyanosis and / or
the upper third of the deltoid is avoided with vaccine injec edema). Methods of treatment are called for which do not
tions, and 'the diagnosis of vaccina tion-related shoulder dys irritate the inflammatory processes but which attempt to
function should be considered in patients presenting with normalize associated jOint and muscle dysfunction.
shoulder pain following a vaccination'. Lewit sta tes, 'The usual mobiliza tion and manipulation
In evaluating shoulder dysfunction, there are a number techniques are useless in dealing with the shoulder joint
of screening tests that can be used to guide the treatment itself'. This highlights the critical impor tance of soft tissue
plan or to suggest referra l for further assessment. The tests evaluation and treatment in this joint in particular and in
and evalua tions described below are mainly derived from most joints of the body, in our opinion.
the following sources.
Su praspinatus tend i n itis
Janda V 1983 Muscle function testing. Butterworths,
London This may be associated with subdeltoid or acromial bursitis
Lewit K 1999 Manipulative therapy in rehabilitation of or rotator cuff dysfunction (such as a sequel to supraspina
the locomotor system, 3rd edn. Bu tterworths, London tus strain). Symptoms include:
Liebenson C 2006 Rehabilitation of the spine, 2nd edn. ache at rest, especia lly when lying on affected side
Williams and Wilkins, Baltimore increased discomfort on abduction
Lowe W 2006 Orthopedic assessment in massage ther pain may refer toward deltoid insertion
apy. Oaviau-Scott, Sisters, OR pain on activity is restricted to a pain ful arc (see tests
Petty N 2006 Neuromusculoskeletal examination and below) due to effect of acromion process on tendon dur
assessment. Churchill Livingstone, Edinburgh ing excursion of arm
Schafer R 1987 Clinical biomechanics. Williams and localized tenderness on palpa tion will be noted over the
Wilkins, Baltimore inflamed tissues.
Ward R (ed) 1997 Founda tions of osteopathic medicine.
Williams and Wilkins, Baltimore Ap/ey 'scratch' test
Seated or standing patient raises arm overhead (abduc
tion and lateral rotation) and flexes elbow, placing fin
Ca psu l itis (aka scapulohu meral dysfu nction,
gers as far down contrala teral scapula as possible.
'frozen shou l der')
The arm is then taken back to the side and the patient
Generalized rather than localized pain in the shoulder may a ttempts to place the arm behind the back to reach as far
suggest capsulitis or contracture of the joint capsule. Pain is up the contralateral scapula as possible (adduction with
usually apparent on active as well as passive movement. medial rota tion).
Pain is felt more at night and when the arm is hanging If pain is noted on either movement, one of the rotator
down, moving or when carrying. Cyriax (1982) suggests that cuff tendons is probably inflamed, with supraspinatus
there are three stages, each lasting 3-4 months. These are: the most likely.
41 8 CLI N I CA L APP L I CATI O N OF N E U RO M U S C U LA R TECH N I Q U E S : TH E U P P E R B O DY
If there is limitation but no pain, soft tissue restriction Resistance is offered to the forearm proximal to the wrist
or osteoarthritis is probable, without active inflam as the patient attempts to supinate the forearm.
mation. Pain localized to the proximal tendon attachment area
Variation: One arm performs the overhead movement indicates possible inflammation and instability (or dis
while the other arm performs the test behind the back. placement) of the long head of the tendon.
The patient can be asked to attempt to touch the hands
Note: Pain localized at the elbow with this test may impli
and the distance between the fingers noted. This is
cate supinator muscle.
repea ted while reversing the position of each arm and
the two results can be easily compared.
Yergason's (tendon stability) test (Fig. 13. 7)
The pa tient fully flexes the elbow with the forearm
'Drop-arm' test. The patient fully abducts the arm (qual pronated while the practitioner grasps proximal to the
ity of movement should be observed) and starts to slowly wrist.
lower it toward the side of the body. If the patient is unable The patient is asked to resist the attempt by the practi
to lift the arm or unable to sustain the arm when lifted and tioner to supinate and extend the forearm.
the arm drops to the side from around 90 of abduction, An unstable tendon will displace and pain will be noted
rotator cuff damage is likely with supraspinatus most prob at the bicipital groove.
ably involved. If the patient is able to sustain the posi tion,
the practi tioner can place a slight resistance load to deter Speed's test
mine if this causes the arm to drop. It is best to be prepared Patient flexes the shoulder to 60 and fully extends the
to catch the falling arm in case of abrupt d rop to avoid supinated forearm. Practitioner applies downward pres
unnecessary pain and potential trauma. sure to the forearm while the patient resists.
If pain or symptom d uplication is noted a partial rupture
of the biceps is suggested.
Bicipital ten d i n itis If pain increases in the area of the bicipital groove ten
dinitis is suggested.
There will be palpable tenderness over the inflamed por
tion of the tendon. The two bicipital tendons should be Note: Flexion and ex tension strength will be limited by
differentiated from the subscapularis tendon, which can bicipital tendinitis.
be palpated between them.
Symptoms are similar to supraspinatus tendinitis but dif Subdeltoid bursitis ( Fi g . 1 3.8)
fer in location as referral is to biceps insertion.
Inflammation produces severe, deep-seated, localized
If bicipital rupture (long head) or subluxation of the ten
pain with general weakness but especially on abduction.
don from the groove has occurred there will be pain
Movements in rotation, flexion and extension may be
noted on abduction and extension.
limited.
SpecifiC tests (below) help to localize the dysfunction.
Palpation of the bursa and region around the tendon will
reveal edema which greatly restricts the humeral
Lippman's test (Fig. 1 3.6) tuberosity in its movement into abduction.
Patient is seated with elbow passively flexed and relaxed
Tendons which pass through the bursa will be affected
on lap .
(bicipital, rotator and subscapularis).
The tendon of the long head of the biceps is palpa ted
When chronic, the condition moves from localized pain to
(approximately 8 cm below the glenohumeral joint on the
one of severe limitation of movement (particularly abduc
lateral surface of the shoulder).
tion and external rotation) as capsular adhesions form.
Pressure is applied in an attempt to displace the tendon
The condition commonly follows degenerative changes in
medially or laterally.
the rotator cuff at the base of the subdeltoid bursa, which
If this can be achieved or if symptom pain is reproduced
result in calcification and associated inflammation.
then an assessment of an unstable tendon and possible
tenosynovitis is confirmed.
Variation: Have the patient lift a 2 kg weight overhead
Su bacro m i a l bursitis (Fig. 1 3.9)
and slowly lower it to the lateral horizontal position. If Abduction of the arm which is painful or limi ted may
symptoms are reproduced by this action (whether or not suggest subacromial bursitis.
there is displacement of the tendon from the groove), a Schafer (1987) reports: 'A painful, faltering abduction arc
positive test result is noted . is characteristic of subacromial bursitis. To differentiate,
the coracoid process is palpa ted under pectoralis major.
Resistive supination test It is found by circumducting the humerus which is nor
Seated patient's arm is flexed at the elbow, palm mally tender. Once the process is found, the finger is slid
down. slightly laterally and superiorly until it reaches a portion
13 Shoulder, arm and hand 41 9
of the subacromial bursa . If the same palpation pressure might result from the practitioner losing good digital
here causes greater tenderness than at the process it is a contact on the b ursa as the deltoid tissue bunches.
positive sign of subacromial bursitis.' If pain induced by pressure remains the same, or
During this procedure care must be taken to avoid apply increases, during abduction, bursitis is not likely.
ing pressure onto the neurovascular bundle coursing
through this region.
The practitioner stands behind the patient and applies Su praspi natus calcification
pressure to the subacromial b ursa area (just below the The tendon o f supraspinatus inserts o n the superior facet of
coracoid process), producing some pain. the greater tuberosity, at which site calcification may occur.
The patient's arm just proximal to the wrist is grasped Symptoms are as follows.
and is gently taken into abduction to approximately 1 000.
Digital pressure is maintained to patient tolerance and if Severe pain (but not as severe as supraspinatus tendini
bursitis is present, pain should lessen significantly as tis), which is made worse by most shoulder movements,
abduction proceeds. Particular attention is required to is localized to the region superficial to i ts insertion at the
maintain constant palpation pressure as pain reduction greater tuberosity of the humerus.
420 CLI N ICAL A P PLICATI O N OF N E U R O M USCU LAR TECH N I Q U E S : T H E U PP E R BO DY
IS T H E PAT I E N T ' S PA I N A S O FT T I S S U E O R A
JOINT PROBLEM?
In Chapter 7 several simple screening tests devised by
Professor Freddy Kaltenborn (1980) were listed. He sug
gested that we ask:
practitioner, standing or seated at the head of the table, uses In this study, 29 elderly pa tients with preexisting shoul
a contact on the shoulder (tested side) to assess the ease with der problems were randomly assigned to a treatment
which it can be depressed (moved distally) . There should be (Spencer sequence osteopathic treatment) or a control
an easy springing sensation as the shoulder is pushed group.
toward the feet, with a soft end-feel to the movement. If The histories of those in the two groups were virtually
there is a harsh, sudden end-feel, the posterior fibers of identical: : 76% had a history of arthritis, 21 % bursitis,
upper trapezius are probably short. Rotation of the head 21 % neurological disorders, 10% healed fractures.
toward the side being tested can be introduced to evaluate 63% had reduced shoulder ROM as their chief complaint,
anterior fiber shortness in a similar manner (Fig. 13.15). and 33% pain (4% had both reduced ROM and pain) .
1 3 Shoulder, arm a nd hand 423
The Spencer sequence, wh ich derives from osteopath ic medicine in intent. Both muscle energy (MET) and positional release (PRT)
the early years of the 20th centu ry, is ta ught a t a l l osteopathic treatment possibilities cou ld be incl uded and will be outl ined in the
coll eges i n the USA. As the shoulder is put throu g h its va rious ranges shoulder treatment section (Box 1 3.9).
of motion, close attention is paid to any signs of restriction and When this assessment sequence is being emp loyed for assessment
these are noted. From what is pal pated and observed in th is and treatment. the sca pula should be held fixed firmly to the
sequence, clear ind ications can be derived as to which structures thoracic wal l to isolate i nvolvement of the g lenohu meral joi nt. The
may be involved in creating any particular restriction. patient remains in a sidelyi ng position throughout, with the side to
For example, if restriction is noted i n shoulder flexion, it is be assessed uppermost. The practitioner stands i n front facing the
reasonable to assume that one or various soft tissues i nvolved in patient at shoulder level.
shoulder extension a re involved i n whatever is restricting that
movement. These soft tissue dysfu nctions may be secondary to 1 Assessment of shou l der extension restriction
actual osseous dysfunction or soft tissue changes m ight be (indeed (Fig. 1 3. 1 6A)
usua l ly are) the main cause of restrictions in range of motion. The The practitioner's cephalad hand cups the shoulder, firmly
qual ity of end-feel helps to indicate whether restrictions a re compressing the scapula and clavicle to the thorax while the
primarily the result of osseous or soft tissues. patient's flexed elbow is held by the practitioner's caudad
Over the years the sequence of assessment has been modified to hand as the a rm is taken into extension toward the
i nclude treatment elements other than the orig inal mobil ization optimal 90.
A
\
----"'-'----
B
\
\
-- -
)1"
------
11 (j
(( \
7, /
/'
/ ,
------- /'
-------
f'
----
---
\
---
D ---
Fig u re 1 3. 1 6 Spencer sequence positions. A : Shoulder extension. B: Shoulder flexion. C: Circumduction with compression.
D : Circumduction with traction. E : Abduction w ith externa l rotation of shou lder.
box continues
424 CLI N I CA L A P PLICAT I O N OF N E U R O M U S C U LA R TEC H N I Q U E S : T H E U P PER B O DY
pressing the scapula and clavicle to the thorax, while the caudad
hand g rasps immediately proximal to the wrist and i ntroduces
slight traction, before taking the arm through slow clockwise cir
cumduction.
This is assessing range of motion in circumduction, as well as the
tion.
2 Assessment of shou lder flexion restriction Pain-free easy abduction should be close to 1 80.
(Fig. 1 3 . 1 6B} If there is a restriction towa rd abduction the soft tissues impli
The patient has same starting position as previous test. cated in maintaining this dysfunction would be the shoulder
The practitioner stands at chest level, half facing cephalad. adductors (pectoralis major, teres major, l atissimus dorsi and pos
The non-tableside hand g rasps patient's forearm while tableside sibly the long head of triceps, coracobrachialis, short head of
hand holds the clavicle and scapula firmly to the chest wa ll. biceps brachii).
The practitioner slowly i ntroduces shoul der flexion in a plane As with all Spencer movements this is a passive activity.
which is parallel to the floor as ra nge of motion to 1 80 is
assessed, by which time the elbow will be in extension.
5 Assessment of shoulder adduction restriction
The position of very first ind ication of restriction in movement
(not i l l u strated)
i nto shoulder flexion is noted and if this is less than 1 80, With the patient sidelying, the practitioner cups the shoulder and
dysfunction is assumed.
com presses the sca pula and clavicle to the thorax with the
If a ny restriction toward flexion is noted the soft tissues
cephalad hand while cupping the elbow with the caudad hand.
impl icated in mainta i n ing this dysfu nction would be the shoulder
The patient's hand is supported on the practitioner's proximal
extensors (posterior deltoid. teres major, latissimus dorsi, and
forearm/wrist to stabil ize the a rm.
possibly infraspinatus, teres m i nor and long head of triceps).
The elbow is taken in a n a rc forward of the chest so that the
compressing the sca pula and clavicle to the thorax. movement would be one that allowed the movement to progress,
The practitioner's caudad hand grasps the elbow and takes unrestricted, until the flexed elbow approached the mid-line of
the shoulder through a slow passive clockwise circumduction the thorax.
while adding compression through the long axis of the If there is a restriction toward add uction, the soft tissues impli
h u merus. cated in mainta i n ing this dysfunction would be the shou lder
This is repeated several times in order to assess range, freedom abductors (deltoid and supraspinatus).
and comfort of the circu mducting motion, as the: h u meral head Since external rotation is a lso involved, other muscles implicated
moves on the surface of the g lenoid fossa. in restriction or pa in may include internal rotators (subscapula ris,
Any discomfort or restriction is noted. pectora lis major, latissimus dorsi and teres major).
1 3 Shoulder, arm and hand 42 5
actually rise (toward the ceil ing), there is restriction. Fi g u re 1 3. 1 7 Assessment for restriction i n horizontal flexion a t
t h e sternoclavicular joint.
3 Assessment for restricted acromioclavicu lar (AC)
joint
Stiles ( 1 984) suggests this initial eval uation of AC dysfu nction at the
scapula, the mechanics of w h ich closely relate to AC function.
Each side is then tested separately.
The patient sits erect and the practitioner, who is standing behind To test the right AC joi nt, the practitioner is behind the patient
the patient, palpates the spines of both scapulae. with the left hand fingers pa lpating over the joint. The right hand
The ha nds a re moved medially until the medial borders of the holds the patient's right elbow. The arm is lifted in a plane, 45'
scapulae are identified at the level of the spine of the scapula. from the sagittal and frontal planes.
Using the palpating fingers as landmarks, the levels a re checked As the arm a pproaches 90' elevation, the AC joint should be care
to see whether they a re the same. Inequality suggests AC dys fu lly palpated for hinge movement between the acromion and the
function. clavicle.
The side of dysfu nction remains to be assessed (i.e. the scapula In normal movement, with n o restriction, the palpating fingers
might be superior or inferior on the side of dysfunction, so that shou ld m ove slightly caudad, as the arm is a bducted beyond 90'.
w h i le i nequality of scapula height suggests dysfu nction, it is the If the AC is restricted, the palpating digit w i l l move cephalad and
specific assessment (below) that identifies which side is little or no action will be noted at the joint itself, as the arm goes
dysfunctional). beyond 90' .
Treatment of the control (placebo) group involved the assessments were conducted during al ternate weeks, as
patients being placed in the same seven positions (see well as 5 weeks after the end of treatment.
descriptions and Figs 13. 16-13. 19) as those receiving the Over the course of the study both groups demonstrated
active treatment; however, the one element that was not significantly increased ROM and a decrease in perceived
used in the control group was MET (described as the pain. However, after treatment: 'Those subjects who had
'corrective force') as part of the protocol. Home exercises received osteopathic manipulative treatment [i.e. muscle
were also prescribed. energy-enhanced Spencer sequence] demonstrated
Over the course of 14 weeks there were a total of eight continued improvement in ROM, while the ROM of the
30-minute treatment sessions. Functional, pain and ROM placebo group decreased.'
426 CLI N I CAL A P P L I CAT I O N OF N E U R O M USCULAR TECH N I Q U E S : T H E U P P E R B O DY
The test for AC restriction is to be found in clavicular assessment on The process is repeated u ntil free movement of the medial clavi
p. 425. cle is achieved.
The test for horizontal flexion restriction of the sternoclavicu lar joint
M ET for restriction of AC joint
is to be found in Box 1 3.7.
Muscle energy technique is e mployed with the arm held at the
restriction barrier, as for testing as described in Box 1 3.7, i.e. at
the point just prior to a cephalad rise of the clavicle as the a rm is 16 M ET treatment of restricted horizontal flexion of
, the upper arm (sternoclavicular restriction)
elevated.
(Fig. 1 3. 1 8)
If the scapula on the side of dysfunction (fa i l u re of AC joint to
The patient l ies supine and the practitioner stands on the side
h i nge appropriately) had been shown to be more proximal than
contralateral to that being treated.
that on the normal side, then before arm elevation commences
The practitioner's non-tableside thenar emi nence is placed over
the h u merus is placed in external rotation, which takes the
the m edial end of the clavicle, holding it toward the floor.
sca pula caudad against the barrier.
The tableside hand is placed, palm upward, u nder the patient's
If, however, the scapula on the side of the AC dysfunction was
ipsilateral shou lder so that it is in broad contact with the dorsal
more d istal than the scapula on the normal side, then before a rm
aspect of the sca pula.
elevation commences the arm is interna l ly rotated, taking the
The patient is asked to stretch out the arm on the side to be
scapula cephalad against the barrier before the isometric con
treated so that the hand can rest behind the practitioner's neck
traction com mences.
or tableside shoulder.
The left hand (in this exercise we assume this to be a right-sided
The practitioner leans back slightly to take out a l l the slack from
problem) stabilizes the lateral aspect of the clavicle, with light
the patient's extended a rm and shoulder, while at the sa me time
but firm caudad pressure being a pplied by the left thumb, which
l ifting the scapula slightly from the table.
rests on its superior surface.
The patient is then asked to attempt to pull the practitioner
The arm, supported at the elbow by the practitioner (and inter
toward herself.
nally or externally rotated at the shoulder, depending on ind ica
Firm resistance is offered for 7-10 seconds.
tions gained from sca pulae imbalance), is raised until the first
Fol lowing complete release of a l l the patient's efforts, the down
sign of inappropriate movement at the AC joint is sensed (a feel
ward thenar emi nence pressure - to the floor - is maintained
i n g o f 'bi nd'). identifying t h e barrier.
(painlessly) and more slack is taken out (practitioner leans back a
It is important at this stage to ensure that all slack has been
little more).
removed from the internal or the external rotation of the upper a rm.
The process is repeated once or twice more or until the 'prayer'
An u nyielding counterpressure is offered at the point of the
test proves negative.
patient's el bow by the right hand and the patient is asked to try
No pain should be noted during this procedure.
to take that elbow toward the floor with less than fu l l strength.
After 7 -10 seconds, the patient and practitioner relax, g reater
The Spencer sequence, wh ich de rives from osteopathic medicine in At the position of very first indication of restriction i n movement,
the early years of the 20th century, is ta u g h t a t all osteopathic the patient is i nstructed to p u l l the e l bow toward the feet or pos
colleges in the USA. Over the years i t h a s been modified to include teriorly, or to push further toward the d i rection of flexion, u t i l iz
treatment elements other than the original a rticulation i ntent. The i n g n o more than 20% of ava i lable strength, building u p force
sequences ca n be transformed from an assessment/articulatory slow ly.
tech n ique into a muscle energy a pproach o r into positional release. The patient's effort is firmly resisted and after 7 - 1 0 seconds the
When used for assessment and treatment, the scapula is fixed firmly patient is i n structed to slowly cease the effort s i m u ltaneously
to the thoracic wa l l to focus on involvement of the g lenohu meral with the practitioner.
joint. I n all Spencer assessment and treatment sequences, the patient After the patient com pletely relaxes a n d upon exhalation, the
is sidelying, with the side to be assessed uppermost, arm lying at the el bow i s moved to ta ke the shoulder further i nto flexion to the
side with the e l bow (usually) flexed, with the practitioner facing next restriction barrier, where the M ET procedure i s repeated.
slig htly cephalad, at chest level (Patriquin 1 992, Spencer 1 9 1 6). A degree of active patient participation i n the movement toward
the n e w barrier is usually hel pful as i t will create an i n h i b itory
response in the tissue being stretched.
. 1 a Assessment and M ET treatment of shoulder
, extension restriction (Fig. 1 3 . 1 6A)
The practitioner's cephalad h a nd cups the shoulder, firmly
compressing the scapula and clavicle to the t h o rax w h i l e the
2 b Alternatively - PRT
If there is a restriction toward flexion the soft tissues i m p l icated
patient's flexed e l bow is h e ld by the practitioner's ca udad hand,
in m a i n ta i n i n g this dysfu nction would be the shoulder extensors
as the arm is taken i nto passive extension toward the optimal 90.
- posterior d eltoid, teres major, l a tissi m u s dorsi and possibly
Any restriction in ra nge of motion i s noted, ceasing movement at
infraspinatus, teres mi nor and long head of triceps.
the first i n d i cation of resistance.
Palpation of these should reveal areas of m arked tendern ess.
At that ba rrier the patient is i nstructed to push the e l bow toward
The most painful tender point (painfu l to dig ita l pressu re) e l icited
the feet or anteriorly, or to push further toward the d i rection of
by pa l pation should be used as a mon itoring point, as the arm i s
extension, utilizing no more than 20% of a va i lable strength,
moved into a position which w i l l reduce that pain by not less
b u i l d i n g up force slowly.
than 70%.
This effort is fi rmly resisted and after 7 - 1 0 seconds the patient is
This position of ease w i l l probably involve some degree of
instructed to slowly cease the effort. (The d i rection in wh ich the
extension and fi ne-tu n i n g to slacken the m uscle housing t h e
patient is asked to push i s arbitra ry, to investigate the benefit in
tender point.
terms of subsequent i ncreased freedom of movement.)
Th is ease state should be held for anyt h i n g from 30 to 90 seconds
After completely relaxing and upon exhalation, the e l bow is
before a slow return to neutral and a subsequ e n t reeva l u ation of
moved to take the shoulder further i n to extension, to the next
ra n g e o f motion.
restriction barrier, and the MET proced u re i s repeated (Liebenson
1 990, Mitch ell et al 1 979).
A degree of active patient participation in the movement toward . 3a Articulation and assessment of circum d u ction
the new barrier is usu a l ly hel pful as it w i l l create a n i n h ibi tory , ca pabil ity with compression (Fig. 1 3. 1 6C)
response in the tissue being stretched (Chaitow 2002). The patient is sidelying with e l bow flexed w h i l e the practitioner's
cepha lad hand cups the shoulder fi rm ly, compressing the scapula
soft tissues i m p l icated in m a inta i n i n g this dysfu nction would be compression throug h the long a x i s of the h u m e rus.
the shoulder flexors - a n terior deltoid, coracobrach i a l i s a n d the This i s repeated several times i n o rd e r to articu late the j o i n t a n d
clavicu lar head of pectora l i s major. assess range, freedom a n d comfort o f the c i rcumd uction motion
Palpation of these should reveal a reas of m arked tenderness. as the h u meral head moves on the su rface of the g l enoid fossa.
The most painfu l tender point (painfu l to d i g ita l pressure) e l i cited The sam e procedure is then performed an ticlockwise. If any
by palpation is used as a monitoring point as the a rm is moved restriction is noted Ruddy's 'pu lsed M ET' can be i ntroduced, in
into a position wh ich w i l l reduce that pain by not less than 700/0. which the patient attem pts to execute a series of m i n ute
This position of ease usua l ly involves some degree of flexion and contractions toward t h e restriction barrier (20 times i n a period
fine-tu ning to slacken the mu scle housing the tender point. of 10 seconds) at which t i m e the articulation i s con tinued (Ruddy
1 9 62) .
This ease state should be held for anyth i n g from 30 to 90 seconds
before a slow return to neutral and a subsequent reeva l uation of
the range of motion. . 3 b Articulation and assessment of circu mduction
, capabil ity with traction (Fig. 1 3. 1 6D)
. 2 a Assessment and M ET treatment of shoulder fl exion The patient i s sidelying with arm strai g h t w h i l e t h e practitioner's
, restriction (Fig. 1 3 . 1 6B) ceph a l a d hand cups the shoulder fi r m l y, compressing sca pula a n d
Pa tient and practitioner have the same sta rting position as in the clavicle t o t h e thorax.
previous test. The practition er's caudad hand grasps the patien t's arm above the
The practitioner's non-tableside hand grasps the patient's forearm elbow and i n troduces s l i g h t traction, before taking the a rm
while the tableside hand holds the clavicle and sca pula fi rmly to t h rough slow clockwise circumduction.
the chest w a l l . This process a rticu lates the joint while assessi ng range of motion
T h e practitioner slowly i n troduces passive s h o u l d e r flexion in t h e in circumd uction as well as the status of the capsu l e of the
horizontal plane, a s ra n g e of m o t i o n to 1 80 i s assessed, b y w h i ch glenohumeral joi nt.
time the elbow is fu l ly extended. The sa me process is repeated anticlockwise.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
box continues
428 C L I N ICAL A P PL I CAT I O N OF N EU RO M U S C U LA R TEC H N I Q U E S : T H E U PP E R B O DY
If any restriction is noted, Ruddy's 'pu lsed M ET' ca n be introduced The most painfu l tender point (painful to digital pressu re) el icited
in w h ich the patient attempts to execute a series of m in ute con by this pal pation should be used as a monitoring point, as the
tractions toward the restriction barrier (20 times in a period of 10 a rm is moved a nd fine-tuned i nto a position which reduces that
seconds) before a rticulation is continued. pain by not less than 70%.
Th is position of ease will probably involve some degree of
" 3c PRT for circu mduction pain or restriction adduction a nd external rotation to slacken the muscle h ousing
the tender point.
If restriction or pain is noted in either of the circumduction This ease state should be held for anyth ing from 30 to 90 seconds
sequences (utilizing compression or traction), eva luate which before a slow return to neutral and a subsequent reeval uation of
m uscles would be active if precisely the opposite movement were range of motion.
u ndertaken.
For exam ple, if on compression and clockwise rotation, a
particular part of the circumduction ra nge involves either 5a Assessment and M ET treatment of shou lder
restriction or discomfort/pain, cease the movement and eva luate ". add uction restriction (Not il lustrated)
which muscles would be required to contract in order to produce The patient is sidelying and the practitioner cups the shoulder
an active reversal of that movement (Chaitow 2003, Goodheart and compresses the sca pula and clavicle to the thorax with the
1 9 84, Jones 1 985). cephalad hand while cupping the elbow with the caudad hand.
In these a ntagon ist m uscles, palpate for the most 'tender' point The patient's hand i s supported on the practitioner's cephalad
and use this as a mon itoring point as the structures a re taken to forearm/wrist to stabil ize the arm.
a position of ease which reduces the perceived pain by at least The elbow is taken i n a n arc forward of the chest so that the
700/0. elbow moves both cephalad and medially as the shoulder adducts
This is held for 30-90 seconds before a slow return to neutral and and externally rotates.
retesting. The action is performed slowly and a ny signs of resista nce are
noted.
At the position of the very first indication of resistance to
. 4a Assessment and M ET treatment of shoulder movement, the patient is instructed to p u l l the elbow toward the
" abduction restriction (Fig. 1 3. 1 6E) cei ling or to push further toward the direction of adduction,
The patient is sidelying as the practitioner cups the shoulder and
utilizing no more than 20% of available strength, building up
compresses the scapula and clavicle to the thorax with the force slowly.
cephalad hand while cupping the flexed elbow with the caudad This effort is firmly resisted and after 7-10 seconds the patient is
hand. instructed to slowly cease the effort.
The patient's hand is supported on the practitioner's cephalad
After completely relaxing and upon exhalation, the elbow is
forearm/wrist to stabilize the arm. moved to take the shoulder further into adduction, to the next
The el bow is abducted toward the patient's head as range of
restriction barrier, where the MET procedure is repeated if restric
motion is assessed. tion remains.
Some degree of external rotation is a lso involved in this
A deg ree of active patient pa rticipation in the movement toward
abduction. the new barrier is usually helpful.
Pai n-free easy abd uction should be close to 1 80.
box continues
1 3 Shou lder, arm and hand 42 9
f
6b Alternatively PRT -
Fig u re 1 3 . 1 9 I n ternal rotation of shoulder. . 7 Spencer's general soft tissue release (and
, lymphatic pump)
The patient is sidelying w ith the practitioner half facing cephalad
at chest level.
This arm position is maintained throughout the procedure.
The patient's hand (elbow extended) rests on the practitioner's
The practitioner cups the shoulder and com presses the scapula
tableside shoulder. Both of the practitioner's h a nds enfold the
and clavicle to the thorax with the cephalad hand while cupping
patient's u pper humerus.
the flexed elbow w ith the caudad hand.
Traction is a ppl ied to the h umerus, taking out the slack in
The patient's elbow is slowly brought (ventrally) toward the
periarticular soft tissues.
practitioner's body while observing for a ny sign of restriction as
The traction is slowly released.
this movement, which increases internal rotation, proceeds.
Compression is a pplied to the glenoid fossa by gently forcing
At the position of very first indication of resistance to movement,
the h umerus into it. The cycle of compression a n d traction
the patient is instructed to pull the elbow away from the
is rhythmica l ly a lternated until a sense of freedom is
practitioner, either posteriorly or medially or both simultaneously,
achieved.
utilizing no more than 20010 of ava ilable strength, building up
In addition, tra nslatory motions can be i ntroduced, for example
force slowly.
a n terior/posterior or cephalad/caudad, in combination with the
This effort is firmly resisted and after 7-10 seconds the patient is
alternating traction and compression.
instructed to slowly cease the effort simultaneously with the
practitioner. Note: All Spencer movements are performed passively (apart from
After completely relaxing and u pon exhalation, the elbow is the M ET isometric contraction element) in a control led, slow and
moved to take the shoulder further into abduction and internal repetitive man ner.
Knebl concluded: 'Clinicians may wish to consider OMT Middle fibers: spinous processes and interspinous liga
[i .e. muscle energy technique combined with Spencer ments of C6-T3 to the acromion and spine of the scapula
sequence] as a modali ty for elderly patients with restricted Lower fibers: spinous processes and interspinous liga
ROM in the shoulder.' ments of T3-12 to the medial end of the spine of the
See Box 13.6 for detailed assessment of shoulder restric scapula
tions using this sequence, and Box 13.9 for descriptions of Innervation: Accessory nerve (cranial nerve XI) supplies
muscle energy technique and positional release technique primarily motor while C2-4 supply mostly sensory
for whatever restrictions are identified. Muscle type: Upper trapezius: postural ( type I) shortens
when stressed
Middle and lower trapezius: phasic (type II) weakens when
stressed (Janda 1996)
T REAT M E N T
Function: Entire muscle: assists extension of the cervical and
thoracic spine when contracting bilaterally
TRAP EZI U S
Upperfibers: unilaterally extend and laterally flex the head
Attachments: Upper fibers: mid-third of nuchal line and lig and neck to the same side, aid in contralateral extreme
amentum nuchae to the lateral third of the clavicle head rotation, elevation of the scapula via rotation of the
430 C L I N ICAL A P P L I CATI O N OF N E U R O M U SC U LAR TECH N I Q U E S : T H E U P PER B O DY
clavicle, assist in carrying the weighted upper limb, help Synergists: The trapezius pair are synergistic with each
to rotate the glenoid fossa upward other for head, neck or thoracic extension
Middle fibers: assist in adduction of the scapula and in Upper fibers: SCM (head motions); supraspinatus, serra
upwardly rotating the scapula after rotation has been tus anterior (Levangie & Norkin 2001) and deltoid (rota
initiated tion of scapula during abduction)
Lower fibers: a dduct the scapula, depress the scapula. Middle fibers: rhomboids (adduct scapula); deltoid,
Rota tion of the scapula remains a controversial ftmction supraspinatus and long head of biceps brachii (eleva tion
of the lower fibers (Simons et aI 1999); however, they may of the arm at the shoulder joint)
stabilize the scapula while other muscles rotate it Lowerfibers: serratus anterior (upward rotation of the gle
(Johnson et a1 1994) noid fossa); pectoralis minor (Levangie & Norkin 2001)
and latissimus dorsi (Kendall et a1 1993) (depression)
Antagonists: Upper fibers: levator scapula (scapular rota
tion) and lower fibers of trapezius
Middle fibers: pectoralis major, pectoralis minor (Kendall
et a1 1993)
Lower fibers: upper fibers of trapezius, levator scapula
Middle fibers
Burning interscapular pain
Acromial pain
Gooseflesh on the lateral upper arm
Fig u re 1 3.2 1 The com bi ned patterns of com m on tra pezius trigger points (see a lso Fig. 1 1 .31 , p. 276). D rawn after Si mons et a l ( 1 999).
1 3 Shoulder. arm and hand 43 1
]
Special notes chair set too I.ow for the desk or compu ter terminal, eleva
tion of the arm for painting, drawing, playing a musical
In assessing and treating the trapezius, the muscle is
instrument and computer processing, particularly for
divided into upper, middle and lower fibers in regards to
extended periods of time, can all shorten trapezius fibers.
nomenclature as well as function. The upper, middle and
Overloading of fibers may activate or perpetuate trigger
lower portions of the muscle often function independ
point activity or may make tissue more vulnerable to acti
ently (Gray's Anatomy 2005).
vation even when a minor trauma occurs, such as a simple
When the shoulder is fixed, trapezius extends and
fall, minor motor vehicle accident or when reaching (espe
sidebends the head and neck.
cially quickly) to catch something out of reach.
With shortening of the muscle, the occiput will be pulled
Trigger points in the upper trapezius (see pp. 276 and
inferolaterally via very powerful fibers. The potential
430) are some of the most prevalent and potent trigger
nega tive influence of trapezius dysfunction is directly to
points found in the body and are relatively easy to locate.
occipital, parietal and temporal function in cranial therapy.
They are also easily activated by day-to-day habits and
In some people upper trapezius fibers merge with stern
abuses, such as repetitive use, sudden trauma, falls and
ocleidomastoid, offering other possible areas of influence
acceleration/ deceleration injuries ('whiplash'). They are
when dysfunctional (Gray's Anatomy 2005).
often predisposed to activa tion by postural asymmetries,
The motor innervation of trapezius is from the spinal
including pelvic tilt and torsion, which require postural
portion of the Xl cranial (spinal accessory) nerve. Arising
compensations by these and other muscles.
within the spinal canal from ventral roots of the first five
The upper trapezius helps maintain the head's position
cerv ical segments (usually), it rises through the foramen
and serves as a 'postural corrector ' for deviations originat
magnum, exiting via the jugular foramen, where it
ing further down the body (in the spine, pelvis or feet).
supplies and sometimes penetrates sternocleidomastoid
Therefore, fibers of the upper trapezius may be working
before reaching a plexus below trapezius (Gray's Anatomy
when the patient is Sitting or standing to make adaptive
2005).
corrections for structural distortions or strained positions.
Upledger & Vredevoogd ( 1983) point out that hyper
Additional treatment of the cervical portion and occipital
tonicity of trapezius can produce dysfunction at the j ugular
a ttachment of upper trapezius is discussed with the cervical
foramen with implications for accessory nerve function,
region on p. 277.
so increasing and perpetuating trapezius hypertonici ty.
The instructions given below, for a prone pOSition, are
Lundberg et al ( 1994) assessed the effects of mental stress
usually the easiest for learning these palpa tion techniques.
and of physical load (both separa tely and in combination)
However, a sidelying position is also effective for examin
on perceived stress, physiological stress responses and
ing the trapezius and in some cases advantageous. When
on muscular tension by measuring the activity of the
the pa tient is sidelying with the upper arm lying on the
trapezius muscle. They concluded tha t 'psychological
(uppermost) lateral surface of the body, the upper, middle
stress plays a role in musculoskeletal disorders by increas
and lower trapezius may be easily palpa ted and lifted from
ing muscular tension both in low-load work situations
the underlying tissues. Additionally, the fibers of each may
and in the absence of physical load. It is also indica ted
be shortened or elonga ted simply by posi tioning the shoul
that the stress-induced increase in muscular tension is
der with the weight of the arm supported on the patient's
accentuated on top of a physical load'.
body. A prone or sidelying pOSition has an advantage over a
Fibers of upper trapezius initiate the rotation of the clavicle seated assessment since the trapezius would not be sup
to prepare for elevation of the shoulder girdle. The middle porting the shoulder girdle or the head during the examina
fibers then join to lift the acromioclavicular joint off the tion (as it would be with an upright posture). A supine
humeral head and to elevate the entire shoulder. Since the position is discussed with the cervical region on p. 277.
overhanging ledge created by the acromioclavicular joint
can occlude the supraspinatus tendon and the subacromial
ASSESS M E N T O F U P P E R TRAPEZ I U S FO R
bursa and can impact the humeral head, the inability to
S H O RT N E S S
fully lift it off the underlying struch.ITes is significant.
Additionally, this action is often used to support a phone to 1. See Janda's scapulohumeral rhythm test ( p . 9 1 ) which
the ear, to carry articles strapped across the shoulder (lug helps identify excessive activity or inappropriate tone in
gage, purses, backpacks, which, incidentally, compress the levator scapula and upper trapezius, which, because
working fibers) and when carrying weight in the dependent they are postural muscles, indica tes shortness.
hand (bucket of water, baggage). 2. Patient is seated and practitioner stands behind with one
Any pOSition which strains or places the trapezius in a hand resting on the shoulder of the side to be tested. The
shortened state for periods of time without rest may shorten other hand is placed on the side of the head which is
the fibers and lead to the activa tion of trigger points. being tested and the head /neck is taken into sidebending
Lengthy telephone conversations, particularly when the away from that side without force while the shoulder is
shoulder is elevated to hold the phone, working from a stabilized. The same procedure is performed on the other
432 C LI N I CA L APPLI CAT I O N OF N E U RO M USCU LAR TECH N I QU E S : T H E U P P E R B O DY
Figure 1 3.23 The m iddle tra pezius fibers may be l i fted a way from
I N M T F O R L O W E R TRAPEZ I U S
Figure 1 3.24 Th e lower trapezius fibers a re treated in the same
way as m iddle tra pezius.
When muscle fibers of the lower trapezius will not lift, The beveled pressure bar is angled posteriorly against
fla t palpa tion may be used against the ribs and underlying the superior aspect of the spine of the scapula and trans
muscles. (The grasp may be tested by lifting the fibers and verse friction is applied at tip-width intervals to the supe
allowing them to gently slip through the compressed fingers rior aspect of the spine of the scapula to trea t trapezius
to be assured of holding more than j ust skin.) Additionally, attachments. Additionally, the inferior aspect of the spine of
the lower trapezius may be freed from fascial restrictions the scapula may be addressed in the same manner.
when the skin overlying its outer fibers is lifted toward the Lubricated gliding strokes in all directions may be used
ceiling and held for 1-2 minutes. The skin should be stretched on all portions of the trapezius to soothe the tissues and
to its elastic barrier and then held, allowing the fascia to increase blood flow. This is particularly important when
soften and elonga teo As the skin becomes more mobile, the more aggressive techniques, such as manipulation and
muscular fibers deep to i t will demonstrate greater freedom pressure bar work, have been used. Gliding strokes along
of movement in relation to surrounding tissues. attachment sites may also reveal areas of enthesitis (inflam
ma tion of muscular or tendinous a ttachment to bone) and
periosteal tension which may respond favorably to applica
N MT FO R TRAP EZI U S ATTACH M E NTS tions of ice rather than heat. Gliding is pa rticularly applied
to any aspects of the trapezius that have not been addressed
The humeral head is lowered and the arm allowed to rest com during the previous steps.
fortably. Lubricated gliding strokes may be applied to the lam If central trigger points are located, pincer compression
ina groove beside the spinous processes from C7 to L1 and on may be used if the tissue can be lifted or fla t compression
the scapula and acromion. Thumb glides applied to the lam against underlying structures may be applied. Additional ly,
ina groove in progressively deeper strokes may release layers gliding strokes may be applied from the center of the fibers
of tendinous tension and reveal locations of a ttachment trig (where most central trigger points will be found) toward
ger points and enthesitis in any of the layers a ttaching into the the a ttachment sites. These techniques are intended to man
spinous and transverse processes (which form the 'walJs' of ually traction the actin and myosin elements and spread the
the groove). Additionally, a beveled pressure bar (beveled rub tense central sarcomeres toward the periosteal tension a t
ber tip) may be used in the lamina groove (see pp. 565-566) to the attachment sites. If inflammation is suspected at the
assess and treat the numerous tendons that attach there. a ttachments, stripping should defini tely be toward the
Static pressure or friction applied with the finger, thumb attachments so as to avoid placing further tension on these
or the beveled pressure bar can be used directly medial to already dis tressed connective tissues.
and against the acromioclavicular joint for the upper fiber
attachment of trapezius.
CAUTION: Friction or use of the pressure bar is con
, LI E F ' S N MT F O R U PP E R TRAPEZ I U S A R EA
traindicated when moderate to extreme tenderness is
, (see pp. 2 2 2 and 274)
present or when other symptoms indicate inflammation.
Whether using the beveled pressure bar or digital friction, In Lief's NMT the practi tioner begins by standing haJf
the pressure may be angled an teriorly against the trapezius facing the head of the table on the left of the prone patient
attachment on the clavicle (see pp. 277-278) where static with the hips level with the mid-thoracic area.
pressure or transverse friction may be lightly applied, with The first contact to the left side of the patient's head is a
the pressure increasing only if appropriate. Extreme caution gliding, light-pressured movement of the medial tip of
should be exercised when examining more than one or two the right thumb, from the mastoid process along the
fingertip widths medial to the acromioclavicular joint on the nuchal line to the ex ternal occipital protuberance. This
clavicle. Medial to this point (exact pOSition varies based on same stroke, or glide, is then repeated with deeper pres
width of trapezius a ttachment on the clavicle) lies the la teral sure. The practitioner 's left hand rests on the upper tho
edge of the supraclavicular fossa, an area in which the racic or shoulder area as a stabilizing contact.
brachial plexus lies relatively exposed. Intrusion might dam The trea ting/ assessing hand should be relaxed, molding
age the nerves and accompanying blood vessels in this area. itself to the contours of tissues. The fingertips offer bal
The beveled pressure bar or fingertip should be placed ance to the hand.
immedia tely medial to the acromioclavicular j oint and After the first two strokes of the right thumb - one shal
pressed straight in (caudally, through the trapezius) to trea t low and diagnostic, the second deeper, imparting thera
the tendon of supraspinatus and (possibly) the tendon of peutic effort - the next stroke is half a thumb width
biceps (long head). caudal to the firs t. A degree of overlap occurs as these
CAUTION: This step is contraindicated if a supraspinatus strokes, starting on the belly of the sternocleidomastoid,
tear, subacromial burs i tis or bicipital tendinitis is sus glide across and through the trapezius, splenius capitis
pected as surrounding tissues may be inflamed (see and posterior cervical muscles.
assessments on p. 412 and impingement syndrome test, A progressive series of strokes is applied in this way until
p . 418). the level of the cervicodorsal j unction is reached. Unless
1 3 Shou lder. arm and hand 435
serious underlying dysfunction is found, it is seldom shoulder toward the ear (a shrug movement) and the ear
necessary to repeat the two superimposed strokes a t each toward the shoulder. The double movement (or effort
level of the cervical region. If underlying fibrotic tissue toward movement) is important in order to introduce a
appears unyielding, a third or fourth slow, deeper glide contraction of the muscle from both ends. The degree of
may be necessary. effort should be mild and no pain should be felt.
The practitioner now moves to the head of the table. The After the 10 seconds (or so) of contraction and complete
left thumb is placed on the right lateral aspect of the first relaxa tion of effort, the practi tioner gently eases the
dorsal vertebra and a series of strokes are performed cau patient's head/ neck into an increased degree of sidebend
dally and laterally as well as diagonally toward the scapula. ing, before stretching the shoulder away from the ear
A series of thumb strokes, shallow and then deep, is while stabilizing the head, through the barrier of per
applied caudally from T1 to about T4 or 5 and laterally ceived resistance if chronic, as appropriate.
toward the scapula and along and across all the upper The patient can usefully assist in the treatment by initiat
trapezius fibers and the rhomboids. The left hand treats ing, on instruction, the stretch of the muscle (,As you
the right side and vice versa with the non-operative hand brea the out, please slide your hand toward your feet').
stabilizing the neck or head. No stretch is introduced from the head end of the m uscle
By repositioning to one side, it is possible for the practi as this could stress the neck unduly.
tioner to more easily apply a series of sensitively search
ing contacts into the area of the thoracic outlet. Thumb
strokes that start in this triangular depression move L. MYO FAS C I A L R E LEASE O F U P P E R T R A P EZ I U S
toward the trapezius fibers and through them toward the , (see p. 2 2 1 )
upper margins of the scapula.
Patient i s seated erect, feet separated to shoulder width
Several light palpating strokes should also be applied
and flat on the floor below the knees, arms hanging freely.
directly over the spinous processes, caudally, toward the
The practitioner stands to the side and behind the patient
mid-dorsal area. Trigger points sometimes lie on the
with the proximal aspect of the forearm closest to the
attachments to the spinous processes or between them.
patient resting on the lateral aspect of the muscle to be
Any trigger points located should be treated according to
treated. The forearm is allowed to glide slowly medially
the protocol of integrated neuromuscular inhibition tech
toward the scapula / base of the neck, all the while main
nique (INIT) - p. 197.
taining a firm but acceptable pressure toward the floor
(Fig. 11 .36, p. 280).
f M ET TR EATM E NT O F U PP E R TRAPEZ I U S
By the time the contact arm is close to the medial aspect
of the superior border of the scapula, the practitioner's
treatment contact should be with the elbow itself.
The patient lies supine, head/ neck sidebent away from
As this slow glide is taking place, the patient should
the side to be treated j ust short of the restriction barrier,
equally deliberately be turning the head away from the
with the practitioner stabilizing the shoulder with one
side being treated, having been made aware of the need
hand and cupping the ear / mastoid area of the same side
to maintain an erect sitting posture. The pressure being
of the head with the other.
applied should be transferred through the upright spine
In order to treat all the fibers of the muscle, MET needs to
to the ischial tuberosities and ultimately the feet. No
be applied sequentially. The neck should be placed into
slump should be allowed to occur.
different positions of rotation, coupled with the
If areas of extreme tension are encountered by the moving
sidebending as described for different fibers.
arm, it is useful to maintain firm pressure to the restricted
With the neck sidebent and fully rotated, the posterior
area, during which time the patient can be asked to slowly
fibers of upper trapezius are involved in any contraction
return the head to the neutral position and to make several
and stretch (as are levator scapulae fibers).
slow rotations of the neck away from the treated side,
With the neck fully sidebent and half rotated, the middle
altering the degree of neck flexion as appropriate to ensure
fibers are involved.
maximal tolerable stretching of the compressed tissues.
With the neck fully side bent and slightly turned toward
Separately or concurrently, the patient can be asked to
the side from which it is sideflexed, the anterior fibers are
stretch the fingertip of the open hand on the side being
being treated.
treated toward the floor, so adding to the fascial 'drag'
This maneuver can be performed with the practitioner 's
which ultimately achieves a degree of lengthening and
arms crossed, hands stabilizing the mastoid area and
release.
shoulder, or not crossed as comfort dictates, and with
practitioner standing at the head or the side, also as com
L EVATO R SCA P U LA (see Fig. 1 3.28)
fort dictates (see Fig. 13.15).
The patient should be asked to introduce a light resisted Attachments: From the transverse processes of C1 and C2
effort (20% of available strength) to take the stabilized and the dorsal tubercles of C3 and C4 to the medial
436 C L I N ICAL A PP L I CATI O N OF N E U R O M USCU LAR T E CH N I QU ES : T H E UPPER B O DY
scapular border between the superior angle and the and the site of frequent self-treatment. The anterior surface
medial end (root) of the spine of the scapula of the upper angle, while often the source of deep ache, is
Innervation: C3-4 spinal nerves and the dorsal scapular usually neglected during treatment unless special accessing
nerve (C5) positions are used. These buried fibers may be touched
Muscle type: Postural (type I), shortens when stressed directly to address attachment trigger points and for relief
Function: Elevation of the scapula, resists downward of the often accompanying enthesitis.
movement of the scapula when the arm or shoulder is
weighted, rotates the scapula inferior angle medially to
ASS ESS M E NT FO R S H O RTN ESS O F LEVATO R
face the glenoid fossa downward, assists in rotation of
SCAPU LA
the neck to the same side, bilaterally acts to assist exten
sion of the neck and perhaps lateral flexion to the same The patient lies supine with the arm of the side to be
side (Warfel 1985) tested extended at the elbow, forearm supinated and
Synergists: Elevation/medial rotation of the scapula: rhomboids with the hand and lower arm tucked under the buttocks
Neck stabilization: splenius cervicis, scalenus medius to help restrain movement of the shoulder /scapula.
Antagonists: To elevation: serratus anterior, lower trapezius, The practitioner's contralateral arm is passed across and
latissimus dorsi under the neck to cup the shoulder of the side to be tested
To rotation of scapula: serratus anterior, upper and lower with the forearm supporting the neck (see p. 421, Fig.
trapezius 13.11).
To neck extension : longus colli, longus capitis, rectus capi The practitioner's other hand supports the head .
tis anterior, scalene muscles (Levangie & Norkin 2001) Using the supporting forearm, the neck is lifted into full
pain-free flexion (aided by the other hand) and is turned
fully toward contralateral flexion and rotation (away from
I n d i cations for treatment
the side to be treated).
Neck stiffness or loss of range of cervical rotation With the shoulder held caudad and the head/neck in the
Torticollis position described, at its resistance barrier there is a
Postural distortions including high shoulder and tilted stretch on levator from both ends and if dysfunction
head exists and / or it is short, discomfort will be reported at
the attachment on the upper medial border of the scapula
and / or pain reported near the spinous process of C2.
Speci a l n otes
The hand on the shoulder should now gently 'spring' it
The levator scapula usually spirals as it descends the neck caudally.
to attach to the upper angle of the scapula. It is known to If levator is short there will be a harsh, wooden feel to
split into two layers, one a ttaching to the posterior aspect of this action. If it is normal there will be a soft feel to the
the upper angle while the other merges its fibers anteriorly springing.
onto the scapula and the fascial sheath of serratus anterior
(Gray's Anatomy 1995, Simons et al 1 999). Between the two
layers of the proximal attachment, a bursa is often found
and may be the site of considerable tenderness for this region.
N MT FO R L EVAT O R SCAPU LA
Other variations include accessory attachments to the mas The patient is prone with the arm lying on the table or hang
toid process, occipital bone, 1st or 2nd rib, scaleni, trapezius ing off the side. The practitioner stands at the level of the
and serratus muscles (Gray's Anatomy 2005). shoulder on the side to be treated.
The transverse process a ttachments are joined by numer The skin is lightly lubricated superficial to the portion of
ous other tissues attaching nearby, including scalene trapezius tha t lies directly over the levator scapula. The
medius, splenius cervicis and intertransversarii, which may practitioner's thumbs glide 6-8 times from the upper angle
be addressed at the same time with lateral (unidirectional) of the scapula to the transverse processes of C1-4. This glide
transverse friction. Medial frictional strokes are avoided remains in the most lateral aspect of the lamina groove and
since they could bruise the tissue against the underlying on the posterior aspect of the transverse processes.
transverse process. Caution must be exercised to avoid slip Unidirectional (lateral) crossfiber strumming may be applied
page of the treating fingers, which could press the nerve to the tendon attachments at the transverse processes using
roots against sharp foraminal gutters. non-aggressive pressure due to the vascular structures
Levator scapula's a ttachment onto the posterior aspect of coursing through the vertebral foramen. Only laterally ori
the upper angle of the scapula is often a site of crepitus, a ented strokes are used to avoid bruising the tissue against
sensation felt by the palpating finger when gas or air in the the transverse processes (see p. 290) and to avoid intrusion
subcutaneous tissues is encountered. Whether accompa into the suboccipital triangle where the vertebral artery lies.
nied by calcific deposits, scar tissue or inflammation, the The practitioner is repositioned to stand cephalad to the
'crunchiness' or thickness felt by the finger is often tender shoulder being treated. Gliding strokes are applied 6-8 times
1 3 Shoulder, a rm and hand 43 7
I
Figure 1 3.27 Fingers w ra p com pletely a round tra pezius to touch
d i rectly on attachments a t the a nterior a spect of the u pper a ngle of
the sca pula.
I. M ET TREAT M E N T O F L EVATO R S CA P U LA With the shoulder held caudad and the head/neck in the
, (FIG. 1 3. 1 1 ) position described, the patient is asked to bring the shoul
der into a light 'shrug' against the practitioner's hand and
The position described below is applied, just short of the simultaneously to take the neck and head back toward the
easily reached end of range of motion, and should involve table, against the resistance of the practitioner's forearm
20-30% of the patient's strength, not more. The duration of and hand. This is maintained for 7-10 seconds.
each contraction should be 7-10 seconds. On release of the effort, the neck is taken to i ts new resist
ance barrier in flexion, sidebending and rotation before
The patient lies supine with the arm of the side to be the patient is asked to slide the hand toward the foot,
tested relaxed at the side. through the resistance barrier and into stretch. The prac
The practitioner stands at the head of the table and titioner maintains this stretch for 20-30 seconds before
passes the contralateral (to the side being treated) arm repeating the procedure.
across and under the neck to cup the shoulder of the side
to be treated while the forearm supports the neck.
R H O M B O I D M I N O R A N D MAJ O R (FIG. 1 3.28)
The practitioner 's other hand supports the head at the
occiput. Attachments: Minor: From the spinous processes of C7-T1
The forearm eases the neck intofull pain-free flexion (aided to the vertebral (medial) border of the scapula at the root
by the other hand) and the contact hand on the head of its spine
guides i t fu lly toward lateral flexion and rotation away from Major: From the spinous processes of T2-5 to the verte
the side to be treated. bral (medial) border of the scapula
Deltoid ----)'-ffI'H,r/
gr--- Infraspinatus
-mtlt----- Triceps
____-----Anconeus
;!:'..:---- Brachioradialis
Extensor digitorum
Abductor pollicis
longus
Extensor pollicis
brevis
Figure 1 3.28 Su perficial and second layer m uscles of the poste rior thorax, shoulder and el bow.
13 Shoulder, arm a nd hand 439
'" N MT F O R R H O M B O I DS
Special notes
When the middle trapezius and rhomboid muscles are
placed in strained positions, such as in computer process The patient is prone. The practitioner is standing at the level
ing, painting overhead or abducting and / or flexing the arm of the rhomboids and can move as needed to support glid
for prolonged periods of time, their trigger points may be ing in all directions.
activated or their fibers shortened to produce excess The broad, flat design of the rhomboids and the fibers of
tension in the muscles. Since many trigger points refer into trapezius makes them difficult to lift. Flat palpation and
the area of rhomboid's scapular attachment, other muscles, gliding strips, which press against underlying muscles and
includ ing scalenes, serra tus anterior, infraspinatus and rib cage, are best used here. The mid-thoracic area is lightly
latissimus dorsi, should be examined as well. Other mus lubricated and the thumbs are used to glide in all directions
cles a ttaching deep to the rhomboids, including iliocostalis between the vertebral border of each scapula and the spin
thoracis (erector spinae), serratus posterior superior, multi ous processes. Superficial glides may soften the overlying
fidi and intercostals, may be the source of immediate as well fibers of the trapezius and allow deeper penetration to the
as referred pain. Since each of the rhomboid's functions is rhomboids. Still deeper pressure (through the trapezius and
also performed by stronger muscles, testing for their spe rhomboids) will influence the serratus posterior superior
cific weakness is difficult (Smith et al 2004). A 'winged and erector spinae attachments. The spinous processes on
scapula' may be an indicator of weakness in either rhom tender or inflamed tissues are avoided, especially when
boids and / or serratus anterior, as their shared function is to deeper pressure is used .
flatten the scapula to the torso while they antagonize each The following steps may be performed more easily by
other in adduction (retraction) and abduction (protraction), the practitioner reaching across the body from the opposite
respectively. side of the table. They may also be performed on the side on
Deep to the fibers of rhomboid minor lies a hidden trig which the practitioner is standing or, i f necessary, with the
ger point in serratus posterior superior (see pp. 441 and patient in a sitting position.
568). The scapula must be translated laterally (protracted) The patient's hand is placed behind the small of the back,
to reach i t, a position more easily achieved when the patient if possible without pain in the shoulder, which will elevate
is sidelying (see Fig. 1 3.30). the vertebral border of the scapula off the torso and allow
440 C L I N I CAL A PPLICAT I O N O F N E U RO M U SC U LA R T EC H N I Q U E S : T H E U P P E R B O DY
A B
Figure 1 3.29 ArtB: Applications to the anterior aspect of the medial sca pula a n d the posterior tho rax deep to the scapula.
palpation on the scapula's medial edge, medial aspect of its and mildly tender areas in the serratus posterior superior
anterior surface and portions of the rib cage deep to its as well as other mid-thoracic muscles.
medial border. When the scapula's medial edge will not ele The tissue deep to the medial edge of the scapula is more
vate, treatment of serratus anterior and scapular mobiliza easily and effectively accessed with the patient placed in
tion techniques may allow it to do so. Additionally, a sidelying position (Fig. 13.30).
treatment of the infraspinatus and teres minor may be nec The uppermost arm is draped across the pa tient's chest
essary to allow the hand to reach behind the back as these and the scapula allowed to translate laterally on the torso.
lateral rotators of the humerus, when taut, prevent the As much as 2-3 inches (5-7.5 cm) of additional access
humerus from medial rotation, a movement necessary in may be achieved and the previous steps may be easily
order to reach behind the back. performed.
This position is especially convenient to use when the
Lightly lubricated gliding strokes are applied directly to
patient is unable to reach behind the back.
the vertebral border of the scapula where the rhomboids
attach.
Additionally, the pads of the thumbs or fingertip (with
nails cut very short) may be placed under the anterior
It M ET F O R R H O M B O I D S
surface of the vertebral (medial) border of scapula with The patient is supine; the practitioner stands next to the
the pressure applied toward the scapula (Fig. 13.29A). rhomboids being assessed and faces the table.
Friction or gliding strokes may be used to examine the The patient flexes the elbow and places the arm into hor
attachments of the serratus anterior and possibly a small izontal adduction (across chest) as far as is comfortable
portion of subscapularis where they attach along the and assists this position with the opposite hand holding
entire anterior vertebral border. the elbow.
With the medial edge of the scapula still elevated, the It is important to ensure that the patient's torso does not
thumbs are placed deep to the vertebral border and pres roll as the arm is brought into adduction.
sure is applied down onto the rib cage to address the rib The practitioner's caudad hand is placed on the dorsal
attachments of the serratus posterior superior (Fig. surface of the patient's distal upper arm.
13.29B) and its important 'hidden' trigger point. The practitioner's cephalad hand is slid under the
Static pressure release may be applied to trigger points patient's scapula so that the finger pads can gain a con
and transverse friction may be applied to ischemic bands tact on its medial border.
13 Shoulder, a rm and hand 441
Specia I notes
Figure 1 3.30 Adequate scapula mobil ity a l l ows a 'hidden' trigger
point for serratus posterior su perior to be reached (see p. 439). The anterior and posterior portions of the deltoid have a
fusiform arrangement which sacrifices strength while pro
viding speed. However, the acromial' fibers are a multipen
nate design, which provides tremendous strength but not
The patient is asked to draw the scapula lightly but the speed of the other sections. While trigger points in the
firmly toward the spine, pressing against the practi anterior and posterior fibers occur primarily in the middle
tioner 's finger pads, without any effort coming from the of those fibers, trigger points in the multipennate portion
patient's arm. appear to be sprinkled throughout the lateral upper arm
After 7-1 0 seconds the patient is asked to release the due to their fiber arrangement.
effort. Numerous muscles and a ttachments of muscles underlie
The patient then ad ducts the arm further, assisted by the the deltoid. A portion of infraspinatus may be reached
practitioner applying adduction pressure to the flexed through the posterior (spinal) fibers, while pectoralis major,
arm, while also drawing the scapula away from the spine the tubular tendon of biceps short head and the broad ten
with the fingers, in order to stretch rhomboids. don of subscapularis may be addressed through the overly
ing anterior (clavicular) fibers. The lateral (acromial) fibers
overlay the synovial sheath of biceps long head and the
D E LTO I D (FIG. 1 3.3 1 )
subdeltoid and subacromial b ursae.
Attachments: From the lateral third of the clavicle, Barden et al (2005) investigated shoulder muscle activity
acromion and lateral third of the spine of the scapula to in subjects with multidirectional instability (MOl) by
the deltoid prominence (tuberosity) of the humerus recording the activity of deltoid, in fraspinatus, supraspina
Innervation: Axillary nerve (C5-6) tus, latissimus dorsi and pectoralis major in repetitive
Muscle type: Phasic (type II), weakens when stressed movements of shoulder abduction/ adduction, flexion/ exten
Function: Anterior (clavicular) fibers: flexion of humerus, sion and internal /external rotation. They noted significant
horizontal adduction of the flexed humerus, stabilization differences in the MOl subjects from the control group: 'The
of the humeral head during abduction, medial rotation of rotator cuff and posterior deltoid muscles demonstrated
humerus (questionable) and its most peripheral anterior abbreviated periods of activity when performing inter
fibers may adduct the arm nal /external rotation, despite activation amplitudes that
442 CLIN ICAL A P PLICAT I O N OF N E U R O M U S C U LAR TECH N I Q U ES : T H E U PP E R B O DY
Deltoid posterior
Figure 1 3.31 A : Deltoid referra l patterns encompass most of the u pper a rm ; its lateral fibers a re multipennate with an extensive endplate
zone. B : The com posite pattern of target zones of synerg istic l atera l rotators.
were similar to the controls. In contrast, the activa tion of the a degree of function in situations where, without them,
pectoralis major differed from the control group in both the function might be lost or further damage occur.
amplitude and time domains when performing shoulder Inflamma tion in these underlying tissues may not be
extension .' The au thors of this text suggest that the ways noticeable on the exterior surface of the thick deltoid until
these synergists and antagonists behave in the presence of the area has been overworked. The underlying tendons
moderate j oint instability, though 'neuromuscularly dys should be palpated prior to the application of friction or
function' in the general sense, might very well be adaptive deep gliding strokes to evaluate for appropriate pressure.
or compensatory in the moment toward the more finite When moderate or extreme tenderness is found in the
needs of this joint. Muscle substitution and selective recruit underlying tissues, ice and other antiinflammatory treat
ment, with all of the problems they may trigger, may provide ments should be applied before NMT techniques are used.
1 3 Shou lder. arm a nd hand 443
I N MT F O R D E LTO I D Figure 1 3 .33 Pa l pation of the deltoid tuberosity where the three
The patient is prone with the arm hanging off the table or heads of the deltoid merge i nto a com mon attachme nt.
the hand is placed next to the face to passively shorten
the deltoid fibers so they may be lifted and grasped.
Each of the three heads of the deltoid may be individually
S U P R A S P I NAT U S
compressed and manipulated in small increments until
the full length of the fibers has been treated (Fig. 13.32) . Attachments: Medial two-thirds o f the supraspinous fossa
Broad compression of the tissues will reduce general of the scapula to the superior facet of the greater tubercle
ischemia of the fibers, while roUing the fibers between of the humerus
the thumb and fingers more precisely will reveal taut Innervation: Suprascapular nerve (C5-6)
bands and nodules characteristic of trigger points often Muscle type: Postural (type I), shortens when stressed
found there. Function: Abducts the humerus (with deltoid), seats the
Compression techniques or flat palpation may be applied humeral head in the glenoid fossa, stabilizes the head of
to trigger points in the deltoid fibers for 1 0-12 seconds the humerus during arm movements
while feeling for release of the tau t band. Synergists: Abduction: middle deltoid, upper trapezius,
The position of the arm can be altered to place more or lower trapezius, serratus anterior (while rhomboids sta
less stretch on taut bands as they are being assessed and bilize the scapula during abduction) (Simons et a1 1999)
released. Humeral head stabilization: infraspinatus, teres minor, sub
Friction techniques or gliding strokes with the thumbs scapularis (while serratus anterior stabilizes scapula)
may be applied along the inferior surface of the spine of Antagonists: To abduction: pectoralis major (lower fibers),
the scapula, acromion and clavicle to reveal attachment latissimus dorsi, teres major
trigger points.
The deltoid tuberosity should be examined for tender
I n d i cations for treatment
ness or evidence of inflammation (Fig. 13.33) .
Attachment trigger points may need to be addressed as Pain during abduction of the arm or dull ache during rest
inflamed tissue which can be caused by tension placed Difficulty or pain in reaching overhead or to the head
on attachment sites; applications of ice may reduce pain Rotator cuff involvement
and tenderness.
With the deltoid lubricated, gliding strokes may be
Specia I notes
applied with the thumbs in proximal strokes from the
del toid tuberosity to the proximal attachments to further Supraspinatus, infraspinatus, teres minor and subscapu
loosen the fibers of the deltoid and soothe the tissues. laris are the four rotator cuff muscles, often called the SITS
Tenderness found in attachments deep to the deltoid tendons, so named from the combined first letters of their
should be noted and the associated muscles examined. names. These four tendons directly overlie the j oint and
444 CLI N ICAL A P PLICAT I O N O F N EU R O M U SCULAR T E C H N I Q U E S : T H E U PP E R B O DY
their fibers often blend with the joint capsule. Since the artic Supraspinatus assists deltoid in abduction while infra
ulation surface of the glenohumeral joint is shallow, exces spina tus, teres minor and subscapularis counteract the ten
sive translation in all directions makes it necessary for these dency of the humeral head to ups lip when deltoid contracts
muscles to constantly check the position of the humeral by pulling the humerus down the glenoid fossa and seating
head and stabilize the joint during all arm movements. it into the fossa. Supraspinatus is involved in all phases of
Acromion ------,.-=--:-:-__.,. abduction while infraspinatus and teres minor rotate the
-----:==;iij
: .
-::;;JII!;=!!:;;;
Subacromial bursa humerus laterally and subscapularis rotates it med ially. All
Supraspinatus four stabilize the humeral head against the glenoid fossa
and also support the weighted arm so that the head of the
biceps brachii, :;.;; humerus is not pulled downward by the weight. This posi
long head "'::;'.1:;"..;0.. tioning role is true for supraspinatus even when the arm is
not loaded, as the weight of the arm itself could cause
downward pull on the humeral head.
In the coronal plane, pure humeral abduction ends at 90
when the greater tubercle impacts the inferior aspect of the
Deltoid acromioclavicular joint. Beyond this point, the humerus
must be externally (la terally) rotated so tha t the greater
l--iiL-1+L- Posterior circumfiex tubercle passes posteriorly to the acromion (Cailliet 1996,
humeral artery
Hoppenfeld 1976) (Fig. 13.34) . When sufficient lateral rota
tion does not occur, especia lly when the lateral rotators are
not functioning properly due to ischemia or trigger points,
or when the overhanging structures compromise the space
in some other manner, such as when luggage or a heavy purse
is carried over the shoulder, the tendon of supraspinatus may
be compressed or repeatedly abused against the overhanging
Fig u re 1 3.35 Coronal section through shoulder to show acromion. This process of abuse, particularly when com
subacromial bu rsa (poste rior view). Reproduced with perm ission bined with repetitive overuse, overloading or some other
from Gray's Anatomy (2005). strain, may lead to supraspinatus tendinitis and eventually
ic vein
_IIr::.-=---- IBliceps brachii, short head
First rib ---'<-4 '"
Scapula ----:or"nH..c....__;>'--_,#'-- .
branches of supra
scapular vessels
and nerves
Figure 1 3.36 Tra nsverse section through shoulder. Reprod uced with permission from Gray's Anatomy (2005).
446 C L I N ICAL A P PLI CAT I O N OF N E U R O M USCU LAR TEC H N I Q U E S : T H E U P P E R BODY
to calcification of the tendon. This process is well explained Gliding strokes may be applied in both la teral and medial
in Shoulder Pain (Cailliet 1991). Simons et al (1999) report directions 7-8 times in the region of the supraspinous
that, with inactivation of trigger points in supraspinatus, fossa to reveal thickened or tender areas; however, if
early calcific deposits at the insertion site may resolve. inflammation of the tendon or tendon tear is suspected,
Supraspinatus is the most frequently ruptured element gliding only in a lateral direction is suggested to reduce
of the musculotendinous cuff (Gray's Anatomy 2005), potential stress on the tendon.
although portions of the conjoined tendon (infraspinatus Deeper pressure through the overlying trapezius, if
and teres minor), subscapularis or the joint capsule and appropriate, will treat the supraspinatus muscle belly.
supporting ligaments may also be damaged. If a partial or Often the trapezius will need extensive treatment to
complete tear is suspected, range of motion tests or stretch reduce upper and middle trapezius tension and associ
ing procedures should be delayed until the extent of tearing a ted trigger points before deeper pressure can be used.
is known (Simons et a1 1999) as these steps could lead to fur
The trapezius, when softened and its fiber ends approxi
ther tearing of the structures.
mated, may sometimes be displaced posteriorly to allow
The supraspinatus fibers lie deep to the trapezius and its
access to a small portion of supraspinatus which lies deep
tendon attachment lies deep to the deltoid. Therefore,
to it. This displacement procedure will usually only allow a
supraspinatus is not directly palpable except in some cases
small portion of the medial aspect of supraspinatus to be
where displacement of the upper trapezius allows a small
compressed directly. However, this procedure is worth
amount of access to the proximal end. However, tenderness
while in those cases where displacement is possible.
and trigger points within this muscle may be addressed
If trigger points are found in supraspinatus, gliding mas
through the overlying trapezius if the trapezius fibers are
sage techniques may be applied from the center of its fibers
not too tender to be pressed and are not too thick.
outvvardly toward the ends to elongate central sarcomeres
and reduce attachment tension from taut fibers. Trigger point
pressure release may also be applied through the trapezius.
A S S E SS M E NT F O R S U P R A S P I N AT U S
Since this muscle underlies the thick trapezius, which effec
DYS F U N CT I O N
tively obscures palpa tion, it may be a candidate for trigger
The practitioner stands behind the seated patient, stabi point injections when manual methods of release fail to be
lizing the shoulder on the side to be assessed with one effective.
hand while the other hand reaches in front of the patient A fingertip or the tip of the beveled pressure bar may be
to support the flexed elbow and forearm. pressed (caudally) straight into the tissues directly medial to
The patient's upper arm is adducted to its easy barrier the acromioclavicular joint to treat the tendon of supraspina
and the patient then attempts to abduct the arm. tus through the trapezius fibers. Static pressure is held for
If pain is noted in the posterior shoulder region, 1 0-12 seconds. This procedure is avoided if a supraspinatus
supraspinatus dysfunction is suspected and because it is tear, subacromial (or subdeltoid) bursitis or bicipital or
a postural muscle, shortness is implied. supraspinatus tendinitis is suspected.
The tendon attachment of supraspina tus is addressed
with the SITS tendons (in a sidelying position) after the
A S S E S S M E N T F O R S U P R A S P I N AT U S W EA K N ESS infraspinatus and teres minor muscles have been treated.
See description in the teres minor section of this text on
The patient sits o r stands with arm abducted 1 5, elbow
pp. 448 and 453.
ex tended .
The practitioner stabilizes the shoulder with one hand
while the other hand offers a resistance contact at the distal
humerus which, if forceful, would adduct the arm further. , M ET T R E ATM E N T O F S U P R AS P I N AT U S
" (see p. 42 1 , FIG. 1 3. 1 3)
The patient a ttempts to resist this and the degree of effort
required to overcome the patient's resistance is graded as The practitioner stands behind the seated patient, stabi
weak or strong (see grading scale, pp. 39 and 413) . lizing the shoulder on the side to be treated with one
See also 'drop-arm test' on p. 418. hand while the other hand reaches in front of the patient
to support the flexed elbow and forearm.
Specia l notes
Infraspinatus and teres minor have almost identical actions
and are so closely related that their tendons are often fused
together (Cailliet 199 1, Gray's A natomy 2005, Platzer 2004).
Although overlying fascia envelopes the two muscles
together as if they a re one, their innerva tions are different.
When infraspinatus trigger points are active, pa tients find
Fig u re 1 3.37 Myofascial release of su praspina tus. it difficul t to reach behind the back to tuck in a shirt or fasten
a bra, comb their hair or scratch their back. Trigger points in
infraspinatus often produce deep shoulder pain, suboccipi
tal pain and referral patterns just medial to the vertebral bor
f M F R F O R S U PRASPI NAT U S (FIG. 1 3.37) der of the scapula, an area of common complaint. Trigger
points in infraspina tus respond favorably to massage appli
This procedure is avoided if partial tear or inflamma ca tions and manual release methods (Simons et aI 1999).
tion of the supraspinatus tendon is suspected. The humeral attachment of infraspinatus is addressed
The practitioner palpates the dysfunctional muscle, seek with the SITS tendons (in a sidelying position) after the
ing an area of local restriction, fibrosis, ' thickening'. remaining rotator cuff muscles have been treated. However,
This may lie above the spine of the scapula or on the as with supraspinatus, if a partial or complete tear is sus
greater tuberosity of the humerus. pected, range of motion tests and stretching procedures
Having located an area of al tered tissue texture which is should be delayed until the extent of the injury is known.
sensitive and after the patient has abducted the arm to
about 30, a firm thumb contact should be made slightly
la teral to the dysfunctional area. A S S E SS M E N T F O R I N F RAS P I N AT U S
The patient is then asked to slowly but deliberately S H O RT N E SS/DYS F U N CT I O N
adduct the arm as far as possible, while the thumb con The patient is asked to touch the upper border o f the
tact (reinforced by the other hand, if necessary) is main opposite scapula by reaching with the forearm behind
tained. the head.
This process takes the myofascial tissue from a shortened If this effort is painful, infraspinatus shortness should be
position to its longest and modifies the tissue's status suspected.
under the thumb. Visual evidence of shortness is obtained by having the
This process should be repeated 3-5 times. patient supine, the humerus at right angles to the trunk
with the elbow flexed so that the pronated forearm is par
allel with the trunk pointing caudally.
I N F R AS P I N AT U S
This brings the arm into internal rotation and places
Attachments: Medial two-thirds o f the infraspinous fossa of infraspinatus at stretch (see p. 420, Fig. 13. 10).
the scapula to the middle facet of the greater tubercle of The practitioner ensures that the shoulder remains in
the humerus contact with the table during this assessment by apply
Innervation: Suprascapular nerve (C5-6) ing light compression onto the anterior shoulder.
Muscle type: Postural (type I), shortens when stressed If infraspinatus is short the forearm will not be capable of
Function: Laterally rotates the humerus, stabilizes the head of resting parallel with the floor, obliging it to point some
the humerus in the glenoid cavity during arm movements what toward the ceiling.
448 CLI N I CA L A P P L I CAT I O N O F N EU R O M U S C U LAR T EC H N I Q U E S : T H E U PPER B O DY
A S S E SS M E NT F O R I N FRASPI NAT U S W EA K N E S S
The patient i s prone with head rotated toward the side
being assessed.
The patient's arm is abducted to 900 at the shoulder and
flexed 900 a t the elbow.
The forearm hangs over the edge of the table and the dis
tal humerus is supported on a pad, folded towel or cush
ion to maintain it in the same plane as the shoulder and
to prevent undue pressure from the edge of the table.
The practitioner provides slight stabilizing compression
j ust proximal to the elbow to prevent any extension at the
shoulder and offers resistance to the lower forearm as the
patient a ttempts to bring the forearm from its starting
position pointing to the floor to one where i t is parallel
with the floor, palm downwards.
The relative strength of the efforts of each arm is compared.
Note that in this, as in other tests for weakness, there may
be a better degree of cooperation if the practitioner applies
the force and the patient is asked to resist as much as possi Fig u re 1 3.38 Pa lpation of the most latera l fibers of i nfraspina tus.
ble. Force should always be built slowly and not suddenly.
f N M T F O R I N F RAS P I N AT U S \
! \
The patient is prone with the arm resting o n the table or
side lying with the arm resting on the lateral surface of the
body. The infraspinous fossa of the scapula is lightly lubri
cated and gliding strokes are applied (both medially and
laterally) under the inferior edge of the spine of the scapula
where infraspinatus attaches. The gliding strokes are
repeated 7-8 times in each direction to examine the attach
\
ment site. The thumbs are moved caudally and the gliding
process repea ted, in rows, until the entire surface of the
scapula has been covered. Gliding strokes are also applied
in a diagonal and v ertical pattern as there are many direc
tions of fibers in this muscle and varying the direction of the
glides will reveal taut fibers more clearly.
Central trigger points form in the center of the various
fibers' bellies. An especially tender trigger point w i th a
strong referral pattern may be found in the center of the
most lateral fibers. The practitioner's thumbs are placed \
against the lateral edge of the muscle and pressure gradu Fig u re 1 3.39 M ET treatment of i nfraspinatus.
ally applied into these often very tender fibers (Fig. 13.38).
Tender areas or central trigger points are treated with static
pressure for 8-12 seconds as thumb pressure meets and
' M ET T R EATM E NT OF S H ORT I N FRAS P I N ATUS
matches the tension found within them. , (AN D T E R ES M I N O R) (FIG. 1 3.39)
Attachment trigger points often form under the inferior
aspect of the spine of the scapula. The beveled pressure bar The patient is supine, upper arm at right angles to the
tip is placed parallel to the spine of the scapula and angled trunk, elbow flexed so that the forearm is parallel with
at 450 underneath the inferior aspect of the scapula's spine the trunk, pointing caudad with the palm downwards.
which often has an overhanging ledge. Gentle friction is This brings the arm into internal rotation and places
used to assess the a ttaching fibers for taut bands and tender infraspinatus at stretch.
spots. Static pressure is used to commence treatment of any The practitioner applies light compression to the anterior
trigger points found there. If extreme tenderness is found, shoulder to ensure that it does not rise from the table as
ice massage may be applied to reduce inflamma tion, which rotation is introduced since this would give a false
often exists at a ttachment si tes. appearance of stretch in the muscle.
1 3 Shoulder, arm and hand 449
T R I C E PS A N D A N CO N E U S (FIG. 1 3.41 )
Attachments: Long head: infraglenoid tubercle of scapula
The practitioner applies mild resistance j ust proximal to Medial head: posterior surface of humerus (medial and
the dorsum of the wrist for 1 0-12 seconds as the patient distal to the radial nerve) and intermuscular septum
attempts to lift it toward the ceiling, so introducing exter Lateral head: posterior surface of humerus (lateral and prox
nal rotation of the humerus at the shoulder. imal to the radial nerve) and lateral intermuscular septum
On relaxation, the forearm is taken toward the floor All three heads: join together to form a common tendon,
(combined patient and practitioner action), which which attaches to the olecranon process of the ulna
increases internal rotation at the shoulder and stretches Anconeus: dorsal surface of the lateral epicondyle to the
infraspinatus (mainly at its humeral attachment). lateral aspect of the olecranon and proximal one-fourth
of the dorsal surface of the ulna
Innervation: Radial nerve (C6-C8)
Muscle type : Phasic (type II), inhibited or weakens when
I. M FR TREATM E NT O F S H O RT I N F RASPI NAT U S stressed (Janda 1983, 1988). Triceps may nevertheless
" (FIG. 1 3.40) require stretching in order to help normalize trigger
The patient is prone and the practitioner palpa tes and points located in its fibers
Function: All three heads: extension of the elbow
locates areas within the muscle with pronounced tension,
contraction or fibrosis. Long head: humeral adduction and extension, counteracts
The patient lies with the arm on the affected side flexed at downward pull on head of humerus
the elbow and close to the side of the body in order to Anconeus: extension of the elbow, may stabilize ulna dur
bring the muscle into a shortened state. ing prona tion of the forearm
Synergists: Extension of the elbow: anconeus
The practi tioner applies a firm, flat compression contact
(thenar eminence or thumb) to an area of the muscle just Humeral adduction and extension: teres major and minor,
superior and lateral to the dysfunctional area. latissimus dorsi, pectoralis major (adduction)
Antagonists: To extension of the elbow: biceps, brachialis
The patient initiates a slow abduction of the shoulder,
extension of the elbow followed by flexion of the shoul To humeral adduction and extension: pectoralis major,
der to its fullest limit, which will bring the distressed soft biceps brachii, anterior deltoid
tissues under the practitioner's pressure contact. Counteracts downward pull on head of humerus by pec
As the movement is performed, a degree of internal rota toralis major and latissimus dorsi
1+Hi..--- Triceps
brachii
medial head
Triceps
brachii
medial
head
(anterior view) -----+-+t
____....
_ .".".- Anconeus
Figure 1 3.41 Referral patterns for t riceps trigger points. Drawn after Si mons et al ( 1 999).
1 3 Shoulder, arm and hand 451
. Infraspinatus -------1--
..__ w>---- Surgical neck of humerus
Triangula r space ---- t- --
---, -
-,.1- I
--:I -It---- Medial lip of
intertubercular sulcus
Quadrangular space
Triangular interval
Teres major
Olecranon ---\t--
Fig u re 1 3.42 Right posterior sca p u l a r region. Reprod uced with perm ission from Gray's Anatomy for Students (2005) .
Teres major -
ASSESS M E NT F O R T R I C E PS W E A K N E S S
Patient i s prone with the head resting in a face cradle.
The patient's arm is flexed at the shoulder, the elbow is
flexed and the hand is resting as close to the same side
scapula as possible, arm close to the side of the head.
The practi tioner cradles the patient's elbow just proximal
to the joint and asks the patient to push the elbow toward
Fig u re 1 3.43 Pa l pation of triceps attachment to sca pula is
the floor. ach ieved by placing the thumb between teres major and teres m i nor.
The two sides are compared for relative strength of the
triceps.
Note that in this, as in other tests for weakness, there may
be a better degree of cooperation if the practitioner applies
the force and the patient is asked to resist as much as possi
ble. Force should always be built slowly and not suddenly.
T E R ES M I N O R
Attachments: Upper two-thirds of the dorsal surface of the
most lateral aspect of the scapula to the lowest (third)
facet on the greater tubercle of the humerus
Innervation: Axillary nerve (C5-6)
Muscle type: Not established
Function : Laterally rotates the humerus, stabilizes the head
of the humerus in the glenoid cavity during arm move
ments
Synergists: Lateral rotation: infraspinatus, posterior deltoid
Humeral head stabilization: supraspinatus, infraspinatus,
subscapularis (while serratus anterior stabilizes the
scapula)
Antagonists: To lateral rotation: teres major, pectoralis major,
la tissimus dorsi, anterior deltoid, subscapula ris, biceps
brachii (Platzer 2004)
I
Figure 1 3.45 M ET treatment position of triceps.
Teres minor should always be considered as a possible
contributor to upper arm or elbow pain
Specia l notes
CAUTION: If rotator cuff tear is suspected, range of
motion testing, stretches and any therapeutic intervention
which could risk further damage to the tissues are not rec
The practitioner cradles the patient's elbow just proximal ommended u n til a full diagnosis discloses the extent and
to the joint and asks the patient to push the elbow toward exact location of the tear. Only the most gentle assessment
the floor for 10 seconds, using no more than 20% of and technique steps may be used until diagnosis is clear.
strength as resistance to movement is offered. Teres minor is the third posterior rotator cuff muscle. Along
Following this isometric contraction, the patient is asked with infraspinatus and posterior deltoid, it antagonizes
to stretch the hand further down the scapula, assisted by medial rotation as well as providing stability of the humeral
the practitioner. The stretch should be held for not less head during most arm movements. Teres minor and infra
than 20 seconds. spinatus also act together to counteract the upward pull of
the deltoid during abduction of the humerus to prevent
Figure 1 3.46 T he thumb and fi ngers grasp around the teres maj or
and latissimus fibers to precisely compress teres m i nor.
f N MT FO R T E R E S M I N O R B
Specia l notes
Teres minor, teres major and latissimus dorsi together form
the posterior axillary fold. Muscle testing with resisted
medial rotation causes the fibers of teres major to contract
and distinguishes it from teres minor but not from the fibers
of latissimus dorsi, which 'cradle' teres major as they course
medially aroWld the humerus to attach anteriorly to it.
Teres major and latissimus dorsi fibers can be more easily
distinguished by separation of their fibers rather than
through muscle testing since they perform the same action.
Distinction is usually easily made since the fibers of latis
simus dorsi continue past the scapula while the teres major
fibers end there. However, occasionally teres major may be
fused with la tissimus dorsi (Platzer 2004), especially near
the scapular portion (Gray's Anatomy 2005), or a slip of it
may join the long head of triceps or the brachial fascia
(Gray's Anatomy 2005).
Celli et al (1998) report the substitution of the teres major
muscle for a detached and atrophic infraspinatus muscle in
irreparable rotator cuff tears. They suggest this is effective
' to restore continuity of the cuff and to depress the head of Fig u re 1 3.52 Compression of be l ly of teres m ajor.
the humerus'. Reed ucation of the transferred muscle is nec
essary 'because it initially contracts more in adduction and
internal rotation than in external rotation'. Gerber et al border of the scapula. The scapular attachment is often ten
(2006) provide a similar report on the use of latissimus dorsi der; therefore a l ighter pressure is used before increased
for a comparable procedure, which they report as successful pressure is applied. Trigger points in the attachment sites
W1less subscapularis function is deficient. Jost et al (2003) require that the associated central trigger points are deacti
report use of pectoralis major transfer for patients with an va ted . If inflammation is suspected, ice therapy is applied .
irreparable subscapularis tear. The teres minor a ttachment is located on the remain ing
upper two-thirds of this border and may be addressed in a
Specia l notes
If latissimus dorsi is short it tends to 'crowd' the axillary
region, internally rotating the humerus and impeding nor
mal lymphatic drainage (Schafer 1987) .
Portions of latissimus dorsi attach to the lower ribs on its
way to the lower back and pelvic attachments. La tissimus
dorsi powerfully depresses the shoulder and therefore can
influence shoulder position and neck postures as well as
influencing pelvic and trunk postures by its extensive
attachments to the lumbar vertebrae, sacrum and iliac crest
(Simons et aI 1999).
La tissimus dorsi can place tension on the brachial plexus
by depressing the entire girdle and should always be
addressed when the patient presents with a very 'guarded'
cervical pain associated with rotation of the head or shoul
der movements. This type of pain often feels 'neurological'
when the tense nerve plexus is further stretched by neck or
arm movements. Relief is often immediate and long lasting
Fig u re 1 3.53 Stra i n-co u n terstra in (PRTj position for teres major. when the latissimus contractures and myofascial restric
tions are released, especially if they were 'tying down' the
shoulder girdle.
LAT I SS I M U S D O RS I Latissimus dorsi has been successfu lly harvested to replace
subscapularis in rotator cuff ruptures (Gerber et al 2006),
Attachments: Spinous processes of T7-12, thoracolumbar
used in postmastectomy flap reconstruction (Sweetland 2006)
fascia (anchoring it to all lumbar vertebrae and sacrum),
and has even been the host site for the growing of a replace
posterior third of the iliac crest, 9th-12th ribs and (some
ment mandible for a cancer patient (Fricker 2004). While the
times) inferior angle of scapula to the intertubercular
impact on the latissimus dorsi tissues that results from the
groove of the humerus
invasive na ture of these surgeries certainly presents a
Innervation: Thoracodorsal (long subscapular) nerve (C6-8)
unique set of challenges, the almost certain improvement in
Muscle type: Postural (type I), shortens when stressed
the quality of life would likely be worth the consequences.
Function: Medial rotation when arm is abducted, ex tension
of the humerus, adducts the humerus, particularly across
the back, humeral depression; influences neck, thoracic
A S S E SS M E N T F O R LATI S S I M U S D O R S I
and pelvic postures and (perhaps) forced exhalation,
S H O RT N ESS/ DYS F U N CT I O N
such as to cough (Platzer 2004)
Synergists: Medial rotation: teres major, pectoralis major, The patient lies supine, knees flexed, with the head 1 .5
subscapularis, biceps brachii feet (45 cm) from the top edge of the table, and ex tends
Extension of humerus: teres major and long head of triceps the arms above the head, resting them on the treatment
Adduction of humerus: most anterior and posterior fibers surface with the palms facing upward.
of deltoid, triceps long head, teres major, pectoralis major If la tissimus is normal, the arms should be able to easily
Depression of shoulder girdle: lower pectoralis major, lower lie flat on the table above the shoulder. If the arms are
trapezius held laterally, elbow(s) pulled away from the body, then
Antagonists: To medial rotation: teres minor, infraspinatus, latissimus dorsi is probably short on that side.
posterior deltoid
or
To extension of humerus: pectoralis major, biceps brachii,
anterior deltoid The standing patient is asked to flex the torso and allow
To humeral head distraction: stabilized by long head of tri the arms to hang freely from the shoulders while holding
ceps, coracobrachialis a half-bent position, trunk parallel with the floor.
To depression of shoulder girdle: scalenes ( thorax elevation), If the arms are hanging other than perpendicular to the
upper trapezius floor, there is some muscular restriction involved and if
this involves la tissimus, the arms will be held closer to
the legs than perpendicular (if they hang markedly for
I n d i cations for treatment
ward of such a position, then trapezius or deltoid short
Mid-back pain in referred pa ttern not aggravated by ening is possible).
movement To assess latissimus in this position (one side at a time),
Identification of shortness (see tests below). the practitioner stands in front of the patient (who
1 3 Shoulder, arm a nd hand 459
]
Fig ure 1 3.54 Fi bers of latissi mus can be easily lifted a n d can be
d istingu ished from teres major a n d overlying skin.
N MT F O R LATI SSI M U S D O R S I (FIG. 1 3.54) from the thorax, which makes them easier to grasp. In this
position, control of the arm is easily maintained while mov
The patient remains in a sidelying position with the arm ing it into varying positions to stretch the fibers and define
supported as in the treatment of teres major. Myofascial taut bands for loca tion and palpation. Sometimes the fibers
release may be easily applied before or immediately follow are more defined and respond more quickly in a stretched
ing these techniques (Fig. 13.55). position but less pressure is usually needed when the tissue
The practitioner sits (or stands) caudal to the supported is treated in a stretched position. Once located, the fibers
arm and grasps the latissimus dorsi, which is the remaining may be more easily lifted away from the torso (and manu
muscular tissue in the free border of the posterior axillary ally stretched) if tension on them is red uced. Hence, varying
fold. Pincer compression is used in a similar manner to that the position of the humerus will assist the practi tioner in
used for teres major. Beginning near the humerus, the prac discovering the best position for accessing and also for
titioner assesses the la tissimus dorsi's long fibers at hand treating the la tissimus fibers.
width intervals until the rib attachments are reached. These The attachments onto the spinous processes, sacrum and
upper fibers ' tie' the humerus to the lower ribs. Ischemic iliac crest may be addressed with friction, glides or static
bands are often found in this portion of the muscle and cen pressure, depending on tenderness level. The beveled pres
tral trigger points are found at mid-fiber region of this most sure bar can be used to apply friction or static pressure tech
lateral portion of the muscle, which is approxima tely niques throughout the lamina groove and sacrum while
halfway between the humerus and the lower ribs. thumbs are best used along the top of the iliac crest. These
The practitioner stands with the (sidelying) pa tient's arm portions of the latissimus dorsi are discussed more thor
placed over the practitioner's upper shoulder to elevate the oughly in Volume 2 of this text (lower body) as this muscle
latissimus dorsi and lift i ts lower fibers (somewhat) away is very often associated with pelvic distortions.
460 C L I N I CA L A P P L I CATI O N OF N E U R O M U S C U LAR TECH N I Q U E S : T H E U P P E R BODY
The patient lies supine with one leg crossed over the The patient is supine and lies close to the edge of the
other one at the ankle. table. The practitioner is tableside, at waist level, facing
The practitioner stands on the side opposite the side to be cephalad.
trea ted at waist level and faces the table. Using the tableside hand, the practitioner searches for
The patient slightly sidebends the torso contralaterally and locates an area of marked localized tenderness on the
(bending toward the practitioner). upper medial aspect of the humerus, where latissimus
With the legs straight, the patient's feet are placed j ust off attaches.
the side of the table to help anchor the lower extremities. The patient is instructed to grade the applied pressure to
The patient places the ipsilateral arm behind the neck as this dysfunctional region of the muscle as a '10'.
the practitioner's cephalad hand slides under the The practitioner 's non-tableside hand holds the patient's
pa tient's shoulders to grasp the axilla on the treated side, forearm close to the elbow and eases the humerus into
while the patient grasps the practitioner 's arm at the slight extension or compression, ensuring (by 'fine
elbow. tuning' the degree of extension) before the next move
The practitioner 's caudad hand is placed lightly on the ment that the 'score' has reduced somewhat.
anterior superior iliac spine on the side to be treated, in The practitioner then internally rotates the humerus
order to offer stability to the pelvis during the subse while also applying light traction or compression in such
quent contraction and stretching phases. a way as to reduce the pain 'score' more.
The patient is instructed to very lightly take the point of When the score is reduced to '3' or less, the position
that elbow toward the sacrum while lightly trying to of ease is held for 90 seconds before a slow return to
bend backwards and toward the treated side. The practi neutral.
tioner resists this effort with the hand at the axilla, as well
as the forearm, which lies across the patient's upper back.
This action produces an isometric contraction in la tis S U B S CA P U LA R I S (FIGS 1 3.58, 1 3.59)
simus dorsi.
Attachments: Subscapular fossa (costal surface of scapula)
After 7 seconds the patient is asked to relax completely as
to the lesser tubercle of the humerus and the articular
the practitioner, utilizing body weight, sidebends the
capsule
patient further and, at the same time, straightens his own
trunk and leans caudad, effectively lifting the patient's
thorax from the table surface and so introducing a stretch
into latissimus (as well as quadratus lumborum).
This stretch is held for 15-20 seconds, allowing a length
ening of shortened musculature in the region.
Repeat once or twice more for greatest effect.
F i g u re 1 3.56 Body a n d hand positions for M ET treatment of Fig u re 1 3.57 Stra in-cou nterstra in posi tion for treatment of
latissimus dorsi. l atissimus dorsi.
1 3 Shoulder, a rm and hand 461
Innervation: Superior and inferior subscapular nerves Synergists: Medial rotation: latissimus dorsi, pectoralis
(CS-6) major, teres major
Muscle type: Postural (type I), shortens when stressed Adduction of humerus: most an terior and posterior fibers
Function: Medial rotation and adduction of humerus, stabi of deltoid, triceps long head, teres major, pectoralis
lization of humeral head major
Humeral head stabilization: supraspinatus, infraspinatus,
teres minor
Antagonists: To medial rotation: infraspinatus, teres minor
To adduction: deltoid, supraspinatus
Transverse humeral ligament
Specia l notes
Subscapularis is a rotator cuff muscle whose job is to stabi
lize the humeral head and seat it deeply into the glenoid
fossa. It is a powerful medial rotator of the humerus and is
responsible for countering downward tension on the head
of the humerus when the initial action of abduction forces
the humerus upward, toward the overhanging acromion
process (Simons et a1 1999).
When hypertonicity or trigger points in subscapularis
-irjb!f-- Tendon of biceps brachii cause excessive tension within the muscle, it holds the
humeral head fast to the glenoid fossa, creating a 'pseudo'
frozen shoulder (Simons et al 1999). That is, the humeral head
appears immobile, as in true frozen shoulder syndrome, but
without associated intrajoint adhesions. Ultima tely, how
ever, long-term reduced mobility and capsular irritation from
Figure 1 3.58 The muscles of the anterior shoulder. Reproduced with
subscapularis dysfunction may result in adhesive capsulitis
permission from Gray's Anatomy for Studen ts (2005).
Subscapularis
462 CLI N ICAL APPLI CAT I O N OF N E U RO M U SC U LAR TECH N I Q U E S : T H E U PP E R BODY
A S S E SS M E NT O F S U B S CA P U LA R I S
DYS F U N CT I O N /S H O RTN ESS
Direct palpation o f subscapularis i s an excellent means of
establishing dysfunction in it, since pain patterns in the
shoulder, arm, scapula and chest may all derive from it.
The practitioner's fingernails must be cut very short.
With the patient supine, the practitioner stands on the
side to be treated and uses the cephalad side hand to
position the humerus by grasping it just above the elbow.
The patient's arm is positioned so that the fully flexed
elbow points toward the ceiling and the patient's hand Figu re 1 3.60 ARB: Access to su bsca pularis is significantly
rests on the medial edge of the contralateral shoulder. i ncreased as the scapula tra nslates latera l ly (with assistance) with
The practitioner places the fingers of the caudad (treat proper arm posi tioning.
ing) hand so that they lie between the scapula and the
torso with the finger pads in contact with the anterior
(inner) surface of the scapula and the dorsum of the hand
O B S E RVAT I O N OF S U B S CAPU LAR I S
facing the ribs. The hand will (eventually) slide deeper
DYS F U N CT I O N/S H O RTN ESS (see p . 422)
into the subscapular space (Fig. 13.60A) .
Once the fingers are 'prepositioned', the patient is asked The pa tien t is supine with the arm abducted to 90, the
to slowly reach toward the anterior or lateral surface of elbow flexed to 90 and the forearm in external rotation,
the contralateral shoulder. While the patient slowly palm upwards.
moves the hand, the practitioner gently releases the The whole arm is resting at the restriction barrier, with
humerus and slides the cephalad hand under the torso to gravity as i ts coun terweight.
'hook' the fingers onto the vertebral border of the If subscapularis is short the forearm will be unable to rest
scapula. easily, parallel with the floor, but will be somewhat ele
The scapula is tractioned laterally by the cephalad hand vated, with the hand pointing toward the ceiling. This
as the caudal hand slides further medially on the ventral position might also implicate pectoralis minor.
surface of the scapula and presses onto the subscapularis Care is needed to prevent the shoulder lifting from the
(Fig. 13.60B). table, so giving a false-nega tive result (i.e. allowing the
There may be a marked reaction from the patient when forearm to achieve parallel status with the floor by means
this muscle is touched, indicating acute sensitivity. of the shoulder lifting) .
13 Shoulder, arm and hand 463
ASS ESSM E N T OF W EA K N E S S I N
SU BSCAPU LAR I S Figu re 1 3 .62 M ET treatment of su bsca pula ris.
Care is needed to prevent the anterior shoulder from S E R RATU S A N TE R I O R (FIG. 1 3.63)
becoming elevated in this position (moving toward the
Attachments: Superior part: outer and superior surface of
ceiling) and so giving a false-normal picture.
ribs 1 and 2 and intercostal fascia to the costal and dorsal
The patient raises the forearm slightly, rotating the shoul
surfaces of the superior angle of the scapula
der internally, pivoting at the elbow against light resist
Intermediate part: outer and superior surface of ribs 2, 3
ance offered by the practitioner on the lower forearm,
and (perhaps) 4 and intercostal fascia to the costal surface
and holds the resistance for 7-1 0 seconds.
along almost the entire medial border of the scapula
Following relaxation, gravity or slight assistance from
Inferior part: outer and superior surface of ribs 4 or 5
the practitioner takes the arm into external rotation and
through 8 or 9 and intercostal fascia to the costal and dor
through the soft tissue resistance barrier, where it is held
sal surfaces of the inferior angle of the scapula
for at least 20 seconds.
Innervation: Long thoracic nerve (CS-7), which lies on the
external surface of the muscle
Muscle type: Phasic (type II), weakens when stressed
I. PRT F O R S U B S CA P U LA R I S ( M OST S U ITA B L E
Function: Stabilization of the scapula during flexion and
" F O R A C U TE P R O B L E M S)
abduction of the arm; rotates the scapula laterally to
The patient is supine and lying so that the arm being make the glenOid fossa face upward; abducts the scapula
treated is close to the edge of the table. and therefore protracts the shoulder girdle; assists in ele
The practitioner locates a n area of marked tenderness on vating the scapula; presses the scapula to the thorax,
the anterior border of the scapula, using the procedure counteracting 'winging' of the scapula; may be an acces
outlined above for direct palpa tion assessment. sory muscle of inspiration during abnormal or demand
The patient is instructed to grade the applied pressure to ing breathing patterns
this dysfunctional region of the muscle as a '10'. Synergists: Protraction of scapula: pectoralis minor and
The practitioner's other hand holds the arm above the upper fibers of pectoralis major
elbow and eases it into slight extension and asks the Upward rotation of the glenoid fossa: trapezius
patient for a score. If no reduction is reported, 'fine-tuning' Elevation of scapula: levator scapula, upper trapezius,
of the degree of extension is carried out to achieve this. rhomboids
Once a reduction in the score is reported, the practitioner Fixation of scapula during arm movements: rhomboids, mid
then internally rotates the humerus in such a way as to dle trapezius
reduce the 'score' further. Antagonists: To protraction: rhomboids, latissimus dorsi,
When the score is reduced to '3' or less, the position of middle trapezius
ease is held for 90 seconds before the arm is slowly To upward rotation of the glenoidfossa: la tissimus dorsi, pec
returned to neu tra!' toral muscles, levator scapula, rhomboids
Serratus anterior
Figure 1 3.63 Serratus anterior trigger poi nts include one that prod uces a 'short of breath' condition as well as an often fa miliar
intersca pular pa in. D rawn a fter Simons et a l ( 1 999).
13 Shoulder. a rm and hand 465
Ind ications for treatment perpetuate myofascial trigger points as well (Simons
et al 1999).
Shortness of breath due to trigger points CAUTION: Caution m ust b e exercised in the deep axil
'Winging' of the scapula (reflexive, inhibited weakness) lary regions as lymph nodes are present and should be
Scapula fixation flat to the thorax (tense fibers) avoided, especially if enlarged. If enlarged lymph nodes
Loss of expansion of rib cage during inhalation or other masses are found, the patient should immedi
Disrupted scapulohumeral rhythm
ately be referred to the proper healthcare professional to
Restriction of adduction of the scapula confirm or rule out breast cancer, thoracic or systemic
infection or other serious pathology.
Trigger points in serratus anterior, as well as the diaphragm
Speci a l notes
and external oblique, may produce a 'stitch in the side' com
Serra tus anterior is synergistic with pectoralis minor to pro plaint, especially when a high demand is placed on it for
tract the scapula in practically all reaching and pushing excessive breathing. The pain may be accompanied by the
movements. It serves to stabilize the scapula (pressing in inability to take a full breath as serratus anterior and sur
onto the thorax to counteract 'winging'), rotate and abduct rounding tissues restrict movement of the ribs. Injection of
it, and assists in elevating it. Without the stabilization that these trigger points should only be attempted when manual
serratus anterior offers, the function of many other muscles methods of release have failed and then only by the most
that pull on the scapula will be affected. highly skilled practitioner, due to the risk of thoracic punc
Serratus anterior is also an accessory breathing muscle, ture (Simons et aI 1999).
recruited during demanding situations rather than normal
breathing patterns. Y\'hether its fibers are activated and how
ASS E S S M E N T F O R W EA K N E S S O F S E R RATU S
much they are activated will vary depending upon the con
A N TE R I O R
ditions. When it is inhibited, unusual demand may be
placed on other respiratory muscles, such as the scalenes The patient adopts a position on all fours with weight
and sternocleidomastoid, when the serratus would nor placed mainly onto the arms rather than knees.
mally be used. This overload may lead to associated trigger On slightly flexing the elbows, the scapulae are observed
point formation in these and other respiratory muscles, to see whether they wing or deviate laterally, which indi
although it is not always clear which comes first - the cates weakness of serratus anterior (there is some influ
abnormal respiratory pattern or the trigger points (Simons ence from lower trapezius in this assessment but it
et aI 1999). focuses mainly on serra tus) .
The long thoracic nerve, which innervates serratus ante The implication, according to Lewit (1985) and Janda
rior, lies vertically on the surface of the muscle in the line of (1996), is that excessive tone in the upper fixators of the
the axillary fold and is therefore vulnerable during palpa shoulder and accessory breathing muscles is probably
tion. Additionally, portions of this nerve supply may pass inhibiting these lower fixators.
through the scalenus medius muscle, where it may be
entrapped. Damage to or compression of this nerve would
produce excessive 'winging' of the scapula in which the
medial border of the scapula stands out away from the tho
N MT F O R S E R RATU S A NT E R I O R
rax. However, since 'winging' can sometimes be relieved The patient remains in a sidelying position with the arm rest
when trigger points in this muscle are inactivated (Simons ing in the supported arm position without forward pull on the
et aI 1999), the condition may be a result of a combination of arm. The practitioner stands caudad to the extended arm and
activation of antagonists (reflex facilitation) and weakness uses the thwnb of the most caudal hand to perform the ther
induced within the serratus since it is a phasic muscle and apy. The patient's arm may be placed on the practitioner 's
weakens when stressed (Janda 1996, Simons et al 1999). shoulder for support and elevation, which will also allow bet
Weakness in the serratus anterior would affect the patient's ter access to portions of the serratus anterior that lie deep to
ability to raise the arm as well as push away with the arm. the scapula, or can be supported by the patient (Fig. 13.64).
Herpes zoster lesions often run the course of intercostals The practitioner palpates the fibers of serratus anterior
nerves, forming on the skin surface superficial to the serra on the lateral chest wall to determine the level of tenderness
tus anterior. These lesions are extremely painful, have a and whether friction or gliding strokes are appropriate to
long recovery process and often recur. Care should be taken apply. Treatment begins illgh in the axilla and progresses
to avoid stimulating them through examination of tills mus down the lateral surface of the thorax.
cle, particularly during the early stages of this condition Each palpable segment of serratus anterior is wider than
when they are the most tender and prone to spread into fur the one before, forming a triangular treatment area with the
ther eruptions. During the early stages of eruption, herpes vertex of the triangle in the axilla. As the treatment pro
zoster pain may mimic that of serratus or intercostal trigger gresses down the lateral thorax, the vertical (often extremely
points and herpes viruses are likely to aggravate and tender) fibers of the pectoralis minor are encountered on the
466 C L I N ICAL A P PLICAT I O N OF N E U R O M U SC U LAR T EC H N I Q U E S : THE U PP E R BODY
Box 1 3. 1 0 M FR
Medial pectoral
nerve ----/----'r,...-t---'-iF-i
Attachment of fascia
to fioor of axilla ---+'f---+:-'--II
Pectoralis major
Figu re 1 3.65 With pectora lis major removed, pectora l i s m i nor, subcl avi us and clavi pecto ra l fascia a re revea led, as well as the neurovascular
bundle cou rsing deep to them. Reprod u ced with permission from Gray's Anatomy for Students (2005).
This repetitive contraction will activate the rhomboids, Costal portion: costal cartilage of ribs 2-6 (or 7)
middle and lower trapezii and serratus an terior, all of Abdominal portion: superficial fascia of external obligue and
which are probably inhibited if upper trapezius is hyper (sometimes) upper part of rectus abdominis; all portions
tonic. The repetitive contractions also produce an a uto converge into a tendon a ttaching to the lateral lip of the
matic reciprocal inhibition of upper trapezius. intertubercular sulcus of the humerus at its greater tubercle
The patient should be taught to place a light finger or In nervation: Medial and lateral pectoral nerves (C5-Tl)
thumb contact against the medial scapula (opposite arm Muscle type: Postural (type 1), shortens when stressed
behind back) so tha t home application of this method can Function: Adduction (and horizontal adduction), medial
be performed several times daily. rotation of the humerus, flexion of the humerus (clavicu
lar), extension of the flexed shoulder (sternal, costal),
brings the trunk toward the humerus when the h umerus
P E CTO RALIS M AJ O R (FIGS 1 3.65, 1 3.66)
is fixed (such as in pull-ups), lowers the raised arm (ster
Attachments: Clavicular portion: sternal half of the anterior nal, costal, abdominal), p ulls the shoulder girdle down
surface of the clavicle and forward (sternaL costal) or up and forward (clavicu
Sternal portion: sternum lar), accessory in deep (forced) respiration
468 CLI N ICAL A P P LICAT I O N OF N E U R O M USCULAR TECH N I Q U E S : T H E U PP E R B O DY
Pectoratis major
Pectoralis major
Subclavius
Figure 1 3. 6 6 Trigger point patterns of pectora lis major and subclavius. Drawn after Si mons et al (1 999).
1 3 Shoulder, arm and hand 469
Synergists: Adduction: teres major (and perhaps minor), a somatovisceral referral that causes irregular heart beats.
anterior and posterior deltoid, subscapularis, triceps The associated trigger points are found between the 5th and
(long head), latissimus dorsi 6th ribs on the right side while trigger points in a similar
Medial rotation: latissimus dorsi, teres major, subscapularis position on the left side mimic ischemic heart disease.
Flexion of humerus: supraspina tus, an terior deltoid, biceps In the condition of thoracic outlet syndrome, pectoralis
brachii, coracobrachialis major and subclavius should be trea ted due to their down
Protraction of shoulder: subscapularis, pectoralis minor, ward pull on the clavicle. This tension, coupled with
serratus anterior, subclavius upward pull of the 1st and 2nd ribs by the scalene muscles,
Depression of shoulder: la tissimus dorsi, lower trapezius, can close the subclavicular space, leading to impingement of
serratus anterior the neurovascular and /or lymphatic structures serving the
Assist clavicular section: anterior deltoid, coracobrachialis, upper extremity, which by definition is thoracic outlet syn
subclavius, scalenus anterior, sternocleidomastoid drome (Simons et al 1999). Additionally, pectoralis minor
Assist lower fibers: subclavius, pectoralis minor may produce a similar result a few inches further inferolat
Antagonists: To sternal section: rhomboidii, middle trapezius erally along the neurovascular course and the scalene mus
To adduction: supraspinatus, deltoid cles may entrap the cervical nerves as they exit the vertebral
To medial rotation: teres minor, infraspinatus, posterior column (especially when brea thing patterns are abnorma l).
deltoid; the clavicular and costal fibers antagonize each Chronic shortening of pectoralis major and minor pro
other in raising and lowering the arm to horizontal duces a rounded shoulder, slumping posture, which is usu
ally accompanied by a forward head position. Treahnent of
the pectoral muscles, diaphragm, upper rectus abdominis and
Indications for treatment
other muscles that influence this dysfunctional posture is
Back pain between the scapulae important in an effort to regain proper aligrunent. Further, the
Pain in front of the shoulder, in the chest and / or down rhomboids and lower trapezius are often inhibited and weak,
the arm which allows the forward slumping. A postural retraining
Intense chest pain program should be implemented which incorporates length
Breast pain ening, strengthening and awareness exercises to avoid recur
Symptoms of vascular thoracic outlet syndrome ring dysfunctional postural patterns which are often induced
by chronic work positions and recreational habits.
Overlying the pectoralis major are mammary tissues and
Special notes
the nipple of the breast. In both genders, but significantly in
The pectoralis major is one of the most complex muscles of a higher percentage of females, breast cancer is a condition
the shoulder region, having four sections, a spiraling twist for which surgical removal, various types of reconstruction
to its lamina ted layers and crossing three joints (sternoclav and significant tissue damage may be presented; 99% of
icular, acromioclavicular, glenohumeral) to influence sev breast cancer cases occur in women. Fifty years ago a
eral movements of the upper extremity. The complex woman's chance of developing breast cancer was 1 in 20
arrangement of its layers of laminae is best viewed from while today's chances are 1 in 8 (DeLany 1999, Fitzgerald
behind (as shown exquisitely by Simons et al (1999) in 1998, National Cancer Institute 2006). It is the second leading
Figure 42.5) as an anterior view primarily encompasses cause of cancer dea ths in women and is the leading cause of
only the superficial layers. To form the anterior axillary all death in women aged 40-55. Poshnastectomy care is a
fold, the dorsal layers fold under the ventral layers in a spi condition often presented to the manual practitioner for
ral so that the lowest fibers attach highest on the humerus. rehabilitation of the upper extremity and chest muscles.
Pectoralis major is one of many muscles whose trigger Since breast cancer is a life-threa tening condition, it is criti
points can refer pain that mimics true cardiac pain. While it cally important that a comprehensive treatment plan with a
is important to rule out these trigger points as the source of qualified healthcare professional be initiated as soon as a
false angina, it is even more important to rule out ischemic breast cancer diagnosis has been made. Traditional treatments
heart disease as the source of viscerosomatic chest pain. If include surgery, radiation, chemotherapy and hormonal
trigger points are a source of a mimicking angina pattern drugs (DeLany 1999, Fitzgerald 1998, National Cancer
and the pattern is abolished, an underlying true cardiac Institute 2006). Each of these treatments has its own posttreat
condition may still exist even though the external pain pat ment side effects and special precautions must be taken in
tern has been eliminated. Similarly, once a cardiac condition each case. Consulta tion with the patient's physician(s) and a
is stabilized and chest pain still exists, trigger points may clear understanding of her particular condition and trea tment
be found to be the source of the long-lasting (and fear plan is recommended before beginning myofascial therapy.
provoking) pain (Simons et al 1999), long after the source of Great care must be used when addressing poshnastec
the pain has been removed. tomy tissues, especially w i th reconstruction efforts or
Pectoralis major or underlying intercostal fibers may lymph node removal (Chikly 1999). The myofascial tissues
contain trigger pOints associated with cardiac arrhythmias, of the area may be extremely tender and the site of incision
470 C L I N ICAL A P P L I CATI O N OF N E U R O M U SC U LA R TECH N I QU E S : T H E U P P E R B O DY
may not have healed completely. In the case of radiation If pectoralis major is normal the arms should be able to
therapy, extreme cau tion must be taken with any tissue that easily reach horizontal (parallel with the floor) while
was irradiated as i ts capillaries are often more fragile. being directly in contact with the surface of the table for
Aggressive therapies, such as friction, skin rolling or even the entire length of the upper arms. There should be no
myofascial release, may result in permanent injury to the arching of the back or twisting of the thorax.
capillary vessels. This would include all muscles of the If an arm cannot rest with the dorsum of the upper arm in
region tha t was irradiated and potentially those that lie on contact with the table surface, withou t effort, then pec
the posterior surface of the body through which the radia toral fibers (major and /or minor) are almost certainly
tion would also pass. short.
Special care is advised with postmastectomy cases to avoid Assessment of the sternal portion of pectoralis major
increasing lymph congestion within the extremity (Chikly involves abduction of the arm to 90 (Lewit 1985). In this
1999), to avoid stretching the incision tissue until well healed position the tendon of pectoralis major at the sternum
and to avoid working with certain techniques when edema or should not be found to be unduly tense even with maxi
inflammation already exists. Unless otherwise contraindi mum abduction of the arm, unless the muscle is short.
cated, lymph drainage and antiinflamm a tory techniques (e.g. For assessment of costal and abdominal attachments the
cryotherapy) may be applied to these tissues until the tissue arm is brought into elevation and abduction as the mus
conditions change to allow massage applications. Special cle as well as the tendon on the greater tubercle of the
training may be needed to safely apply lymphatic drainage humerus is palpated.
and other techniques in cancer recovery therapy. Tautness will be visible and tenderness of the tissues
Other less aggressive techniques, such as myofascial under palpa tion will be reported, if the sternal fibers
release or mild stretching techniques, may be applied to have shortened.
associated muscles until the questionable tissues can be
safely treated with NMT. Ex treme tenderness to even mild
ASS ES S M E NT F O R STR E N GTH O F P E CTO R A L I S
touch, redness, swelling and heat within the tissues all indi
MAJ O R [FIG. 1 3.67)
cate an inflammatory response, which could be in tensified
or spread with NMT applica tions. Consultation with the Patient is supine with arm in abduction a t the shoulder
patient's phYSician is strongly advised and special training joint and medially rotated (palm is facing down) with the
in postmastectomy care is suggested, especially if the prac elbow extended.
titioner 's experience is limited in this area . The practitioner stands at the head and secures the oppo
site shoulder wi th one hand to prevent any trunk torsion
and contacts the dorsum of the distal humerus with the
A S S E SS M E NT F O R S H O RTN E S S I N P E CT O RA L I S
other hand.
M AJ O R
The patient a ttempts to lift the arm and to bring it across
The patient lies supine with the head several feet from the chest, against resistance, as strength is assessed in the
the top edge of the table and is asked to ex tend the a rms sternal fibers.
above the head and rest them on the trea tment surface Different arm positions can be used to assess clavicular
with palms facing up. and costal fibers.
1 3 Shoulder, arm and hand 47 1
!\
Figu re 1 3.68 Trigger point referral for the axi l lary portion of
pectora lis major is i nto the b reast tissue. Referral pattern d ra w n
after Simons e t al ( 1 999).
Figure 1 3.69 The b reast tissue self-displaces toward the treatment
table, w h ich al lows excellent access to pectoralis major's lateral
For example, with an angle of abduction with elevation portions.
of 135, costal and abdominal fibers will be involved;
with abduction with eleva tion of 45, the clavicular fibers
wil l be assessed .
The practitioner should palpate to ensure that the 'cor
rect' fibers contract when assessments are being made.
It N MT F O R P E CTO R A L I S MAJ O R
The patient remains in a sidelying position. The arm to be
treated is uppermost and rests in the supported arm position
without forward pull on it. The practitioner is seated caudad
to the extended arm at the level of the pa tient's waist and
grasps the fibers of the axillary portion of pectoralis major
with the cephalad (treating) hand. The pa tient's arm may be
placed on the practitioner's shoulder for support and eleva
tion, which may a lso allow better access to the area, or it can
be supported by the patient. The arm is pulled forward until
Figure 1 3.70 The arm is tractioned forward to pull the clavicle
the pectoralis major 'pulls away' from the chest wall. The
away from the underlyi n g neu rovascular structu res.
breast tissues will displace themselves toward the therapy
table and away from the mid-belly region of the pectoralis
major where the central trigger points can be fOLmd (Fig. pectoralis major. Thickness usually associa ted with trigger
13.68) . Although the practitioner could be standing to per points is often found in the mid-fiber region. When nodules,
form this technique, a seated posi tion is recommended to exquisitely tender spots or taut fibers are found, the practi
decrease wrist stress and avoid bending at the waist (which tioner locates and isolates the trigger points and applies
may produce low back strain). If the wrist does feel strained, static compression for 8-1 2 seconds which may provoke
the practitioner should change position in such a way that classic referral pa tterns into the breast tissues, onto the chest
the wrist rests in a neutral position, which usually involves and down the arm. Addi tionally, a ligh t stretch placed on
moving toward the pa tient's feet. the fibers may make the ta ut fibers more palpable and may
Pincer pa lpation is used to isolate and assess each section also augment the release.
of the muscle (in small portions) while avoiding intrusion To treat the clavicular a ttachment of pectoralis major and
onto breast tissues. If not too tender and unless otherwise subclavius (see p. 477) which lies deep to i t, the patient
contraindicated, each of the three sections of pectoralis remains in a sidelying position and the practitioner stands
major is manipulated by rolling the fibers between the cephalad to the pa tient's head. The patient's supported arm
thumb and fingers of the examining hand . Taut bands tha t is pulled as far forward as possible to distract the clavicle
are adhered t o one another m a y separate and can then be from the chest. The fingers of the 'face-side' (treating) hand
addressed more independently. are 'curled' onto the inferior surface of the clavicle and fric
The practitioner continues to examine the fibers i n tion is applied to the entire length of the inferior aspect of
thumb-width segments while moving toward the hwneral the clavicle to treat the clavicular a ttachment of pectoralis
insertion (Fig. 13.69) . Repeat the process for all divisions of major and subclavius (Fig. 13.70). The supraclavicular fossa
472 CLI N ICAL A P P LI CAT I O N OF N E U RO M U SCU LAR TECH N I Q U E S : T H E U P P E R B O DY
,------
A LT E R N ATIVE M ET F O R P E CTO R A L I S M AJ O R
practitioner's elbow and holds this contact throughout , (FIG. 1 3.73)
the procedure (Fig. 13.72).
Starting with the patient's a rm in a position which takes Patient is prone with face in a face hole or cradle.
the affected fibers to just short of their restriction barrier, The patient's right arm is abducted to 90 and the elbow
the patient introduces a light contraction (20% of flexed to 90, palm toward the floor, with upper arm sup
strength) involving adduction against resistance from the ported by the table.
practitioner, for 7-1 0 seconds. The practitioner stands at waist level facing cephalad
If a trigger point has previously been identified in pec and places the non-tableside hand palm to palm with the
toralis major, the practitioner should ensure, by means of patient's so that the patient's forearm is in contact with
palpation if necessary or by observation, that the fibers the ventral surface of the practi tioner 's forearm.
housing the triggers are involved in the contraction. The practitioner's tableside hand rests on the patient's
As the patient exhales following complete relaxation of right scapula area, ensuring that no trunk rotation occurs.
the area, a stretch through the new barrier is activated by The practitioner eases the patient's arm into extension a t
the patient and maintained by the practitioner. the shoulder until the first sign of resistance from pec
The stretch needs to be one in which the arm is first toralis is sensed. It is important when extending the arm
pulled away (distracted) from the thorax before the in this way to ensure that no trunk rotation occurs and
stretch is introduced which involves the humerus being that the anterior surface of the shoulder remains in con
taken below the horizontal. tact with the table throughout.
During the stretching phase i t is important for the entire The patient is asked, using no more than 20% of strength,
thorax to be stabilized . No rolling or twisting of the tho to bring the arm toward the floor and across the chest,
rax in the direction of the stretch should be permitted. with the elbow taking the lead in this attempted move
The stretching procedure should be thought of as having ment, which is completely resisted by the practitioner.
two phases: The practitioner ensures that the patient's arm remains par
1. the slack being removed by distracting the arm away allel with the floor throughout the isometric contraction.
from the contact/ stabilizing hand on the thorax Following release of the contraction effort and on an
2. movement of the arm toward the floor, initiated by the exhalation, the arm is taken into greater extension, with
practitioner bending the knees. the patient's assistance, and held at stretch for not less
Stretching should be repeated 2-3 times in each position. than 20 seconds.
All a ttachments should be treated, which calls for the use This procedure is repeated 2-3 times, slackening the
of different arm positions, as discussed above, as well as muscle slightly from i ts end-range before each subse
different stabilizing ('cushion') contacts as the various quent contraction, to reduce discomfort and for ease of
fiber directions and attachments are stretched. application of the contraction.
474 CLI N ICAL A PPLICATI O N OF N E U R O M USCULAR TECH N I Q U E S : T H E U PP E R BODY
Tissues which su rround neura l structu res, and which move Additional tests to assess for shortened muscle structures and
independently of the nervous system, are cal led the mechanical joint restrictions wou ld a lso be appropriate, as these may be the
interface (MI) (e.g. supinator muscle is the MI to the radial nerve, cause of adverse tension i n the nervous system.
as it passes through the radial tunnel).
Any pathology in the MI may produce tension on the neura l Upper limb tension tests (ULTI)
structure, with unpredictable results (e.g. disc protrusion, Both versions of the ULT test described below should be used in
osteophyte contact, carpal tun nel constriction). cases i nvolving thoracic, cervical and u pper limb symptoms, even if
Symptoms are more easily provoked in active movement rather this i nvolves only local finger pai n .
than passive tests. U LTI 1
Pathophysiolog ical changes resu lting from i nflammation or from 1 . Patient is supine and the practitioner places the tested a rm into
chemi ca l damage (i.e. toxic) a re noted as commonly leading on to abduction, extension and lateral rotation of the glenohumeral joint.
internal mechanical restrictions of neural structures in a different 2. Once these positions a re establ ished, supination of the forearm is
man ner from mechanical causes, such as those imposed by a disc introduced together with el bow extension.
lesion, for example. 3 . This is followed by addition of passive wrist and finger extension.
Adverse mechanical tension (AMT) changes do not necessarily affect
nerve conduction (Butler Et Gifford 1 989) but Korr's ( 1 981) research If pa in or sensations of tingling or n u mbness are experienced at a ny
shows it to be likely that axonal transport wou ld be affected. stage during the positioning into the test position or during addition
Maitland (1 986) suggests that treatment (placing the neura l of sensitization maneuvers (below), particularly reproduction of neck,
structures at tension, i n t h e test positions) involves 'mobil ization' shoulder or arm symptoms previously reported, the test is positive;
of the neural structures, rather than sim ply stretching them, and this confirms a deg ree of mechanical in terference affecting neural
recommends that these tests be reserved for conditions which fa il structu res.
to respond adequately to normal mobil ization of soft and osseous Additional sensitization is performed by:
structures (muscles, joints and so on), for example by use of adding cervical lateral flexion away from the side being tested, or
tech niq ues such as NMT or MET. introduction of U LTI 1 on the other arm simultaneously, or
the simu ltaneous use of straight leg raising, bi- or u n ilateral ly, or
Notes
introduction of pronation rather than supi nation of the wrist.
1 , When a tension test is positive (i.e. pain is produced by one or
another element of the test - initial position alone or with ' ULTI 2
sensitizing' additions) it only indicates that AMT exists some Butler maintains that ULTI 2 replicates the working posture i nvolved
where in the nervous system. in many instances of u pper limb repetition disorders.
2. The restriction is not, however, necessa rily at the site of reported
pain. 1 , To perform right-side ULTI 2, the patient l ies close to right side of
3. When tissues housing myofascial trigger poi nts a re stretched, the table, i.e. sca pula is free of the su rface.
pain and other sensations may result. This can add a deg ree of 2. Tru n k and legs are a ngled toward the left foot of the table.
confusion when evidence derived from use of the tension tests is 3, The practitioner stands to right side of the patient's head facing the
being eva luated. feet with the left thigh depressing the patient's right shoulder g irdle.
4. The patient's fu lly flexed rig ht a rm is supported at both elbow
GEN ERAL PRECAUTIONS AND CONTRAINDICATIONS and wrist.
Care shou ld be taken when introducing sideflexion of the neck 5. Variations in the degree and angle of shou l der depression ('l ifted'
d u ring the u pper limb tension test. toward cei l i ng, held toward floor) may be used.
If any a rea is sensitive, care should be taken not to aggravate 6. Holding the shoulder depressed, the practitioner's right hand
existing cond itions d uring the performance of tests. grasps the patient's right wrist while the el bow is held by the
If obvious neurological problems exist special care shou l d be practitioner's left hand.
taken not to exacerbate the condition by vigorous or strong
stretching. Sensitization options include:
Similar precautions apply to d iabetic, MS or recent surgica l shoulder internal or external rota tion
patients or where t h e area being tested i s much affected by elbow flexion or extension
circulatory deficit. forearm su pi nation or pronation.
The tests should not be used if there has been recent onset or
A com bi nation of shou lder internal rotation, el bow extension and
worsening of neu rological signs or if there is any cauda equina forearm pronation is the most sensi tive.
or cord lesion. The practitioner then sl ides the right hand down onto the
General advice regard ing use of these methods patient's open hand, with the thumb between the patient's thumb
Usua lly treatment positions that encourage release of mechan ical and i ndex fi nger and i ntroduces supi nation or pronation, ulnar or
restrictions impinging on neura l structures involve rep lication of radial deviations or stretching of fi ngers/th umb.
the test positions. Further sensitization may involve:
Butler ( 1 99 1 ) suggests that initial stretching should commence well neck movement (e.g. side bend away from tested side) or
away from the site of pain in sensitive individuals and conditions. altered shoulder position, such as increased a bduction or extension.
Retesting regu larly during treatment is usefu l, in order to see
N M T F O R P E CTO R A LI S M I N O R
The patient i s placed in a sidelying position with the arm
supported by the patient or placed on top of the practi t '/'l) ),
tioner's shoulder when the practi tioner is seated at the level
of the patient's chest. The arm is pulled forward sufficiently
to allow the thumb of the practitioner's caudal hand to be
placed posterior to pectoralis major and directly on the cau
dal end of pectoralis minor. The practitioner presses onto
the lateral head of pectoralis minor a t its 5th rib attachment - - ---' '--' ----
to assess for tenderness. Static pressure may be used for
8-12 seconds or, if not too tender, light-pressure transverse
friction may be applied. This muscle, when non-tender or
only mildly tender, responds well to a unidirectional snap
ping friction which transverses i ts fibers.
The practitioner's treating thumb is moved up the muscle
at thumb-width intervals and applies static pressure and/
or crossfiber friction to the entire length of pectoralis minor Figure 1 3.76 Trigger point ta rget zones for pectora l is m i nor. Draw n
(Fig. 13.75). This m uscle may become significantly wider at after Si mons et al ( 1 999).
the 4th and then a t the 3rd rib a ttachments. The treatment
techniques are stopped approximately 2 inches (5 cm) caudal
to the coracoid process to avoid compressing the neurovas
cular blmdle that supplies the arm. If pectoralis minor is not Gentle friction may also be applied through pectoralis
too tender, these steps are repeated (gently) 2-3 times. Often, major while transversing the fibers of pectoralis minor,
static compression will release the fibers more readily, espe coracobrachialis and short head tendon attachment of
cially after the light friction has been applied at least once. biceps brachii as long as the supporting structures of the
With the patient in the supine position, pectoralis minor breast mentioned above and neurovascular structures deep
may be further addressed through pectoralis major. With the to the coracoid are respected. Biceps tendon and coraco
elbow flexed to 90, the arm is placed in an abducted, exter brachialis l ie laterally and perpendicularly oriented to pec
nally rotated ('Hi') position (Fig. 13.76). Myofascial release toralis minor in this arm position.
may be used superficial to pectoralis minor (through pec The muscle fibers are all stretched when the arm is in this
toralis major). The pressure should be toward the clavicle position of extreme lateral rotation and less pressure is used
rather than toward the breast to avoid stretching the fascia to avoid tearing the fibers or provoking a reflexive spasm.
and ligaments that support the breast tissue. This step may MET and MFR treatments of pectoralis major (pp. 472-474)
also help to bring the shoulders back into coronal alignment. would a lso involve (to an extent) pectoralis minor.
1 3 Shoulder, arm and hand 477
S U B C LAVI U S
Attachments: From the first rib at its j unction with its costal
cartilage to the middle third of the clavicle on its caudad
surface
Innervation: Subclavian nerve (C5-6)
Muscle type: Not determined
Function: Assists in bringing the shoulder down and for
ward, seats the clavicle onto an articular disc at the stern
oclavicular joint
Synergists: Protraction of the shoulder: pectoralis major, sub
scapularis, pectoralis minor, serra tus anterior
Antagonists: Trapezius, rhomboidii
Proprioceptive neuromuscular fac i litation (PNF) methods have been On complete relaxation, the practitioner, with the patient's
incorporated into useful assessment and treatment seq uences assistance, takes the arm further into flexion, adduction and
(McAtee Et Charland 1 999). These ideas have been modified to take external rotation, stretching these m uscles to a new barrier.
account of MET principles (Chai tow 2003). The sa me procedure is repeated 2-3 ti mes.
Fig u re 1 3.78 Spira l M ET a pp lication to increase range of Fig u re 1 3.79 Spiral M ET a p p l ication to increase ra nge of
flexion, add uction a n d externa l rotation of shoulder. extension, a b d u ction and i nternal rotation of shou lder.
1 3 Shoulder, arm a nd hand 479
Box 1 3. 1 3 Sterna lis ",d chest pam of a ventraL longitudinaL coLumn muscle Layer arising at the
ventral tip of the hypomeres (Sadler, 1995). Sadler claimed
Chest pain referred from this muscle [sternal is) has a terrifying that this muscle is represented by rectus abdominis in the
quality that is remarkably i ndependent of body movement. abdominaL region and by the injrahyoid muscuLature in the
(Simons et a 1 1 999) cervicaL region; in the thorax, this Layer usuaLLy disappears
but occasionally remains as a sternalis muscle. Kitamura et
aL (1985) reported a case of congenitaL partiaL deficiency of
The patient is then asked to adduct and externally rotate
pectoralis major accompanied by an enormous sternalis.
the shoulder slowly and delibera tely while firm digital
BarLow (1934), on the other ha.nd, claimed that sternaLis
pressure is maintained.
represents the remains of a panniculus carnosus.
This should be repeated 3-5 times.
NMT techniques for sternalis are presented with pectoralis
major (pp. 471-472).
STE R N A L I S
Attachments: A vertical slip ascending from the sheath of C O RAC O B RAC H IA L I S (FIG. 1 3.80)
rectus abdominis, fascia of the chest or costal cartilages of
the lower ribs to merge with the fascia of upper chest, Attachments: From the coracoid process to mid-way a long
attach to the sternum or blend with sternocleidomastoid the medial border of the humera l shaft (between the tri
Innervation: Varies considerably, but usually intercostal ceps and brachialis muscle)
nerves or the medial pectoral nerve Innervation: Musculocu taneous nerve (C6-7)
Muscle type: Not determined Muscle type: Postural (type I), shortens when stressed
Function: Unknown Function: Flexes the arm forward and a dducts it, seats the
Syn ergis ts : Not applicable humeral head into the glenOid fossa d uring abduction,
Antagoni sts : Not applicable may assist in returning the arm to neutral position
Sy nergi s ts : FLexion of humerus: anterior deltoid, biceps
brachii (short head), pectoraliS major
Ind ications for treatment Antagonists: To flexion: latissimus dorsi, posterior deltoid,
Soreness on surface of the sternum teres major, triceps (long head)
Deep, intense pain internally deep to the sternum
I nd i catio ns for treatment
Special notes Pain in front of shoulder and down the posterior arm
Sternalis remains one of the great mysteries of modern Pain when reaching across the lower back
anatomy. Since function is unknown and no apparent
movement has been determined, the evolu tion of this mus Speci a l notes
cle continues to intrigue those who study the locomotor sys
tem. To add to the mysterious nature of this anomalous This muscle's position allows it to be stretched with both
muscle, i ts presence is highly variable: it may be unilateral medial and lateral rotation of the humerus. It assists in
or, if bilateral, may not be symmetrical in length or size and adduction and may (uniquely) also assist in hyperabduc
its attachments as well as innervation are unpredictable. tion by pulling the arm toward the mi d-line in both of these
It is present on average 4.4% of the time but cadaver stud vertical positions.
ies range from 1.7 to 14.3% (Simons et al 1999). It is half as Approximately half of i ts belly can be touched directly
likely to be bilateral as unilateral; however, when present, it is beneath the skin before it courses deep to pectoralis major
likely to develop trigger points following acute myocardial on its way to the coracoid process. The practitioner 's thumb
infarction or angina pectoralis and needlessly prolong the fear may slide under pectoralis major to touch an additional
associated with the pain of heart a ttack (Simons et aI 1999). small portion of this muscle. The practitioner must exercise
Trastour et al (2006) note that sternalis is present in 5-8% caution on the inner surface of the upper humerus to avoid
of people. They note that since physicians are usually not pressing on the neurovascular bundle which courses poste
familiar with it this might lead to misdiagnosis as it 'may be rior to (musculocu taneous nerve usually pierces) coraco
misinterpreted as a breast mass on mammogram'. brachialis by palpating for the arterial pulse and remaining
In a published correspondence, Jeng & Su (1998) offer a anterior to the pulse.
few more ideas regarding sternalis.
A S S E S S M E N T F O R ST R E N GT H O F
Although the importance of this muscle is still a mystery,
C O RAC O B RAC H I A LI S (Ja nda 1 983)
various different interpretations have been made. CLemente
(1985) considered sternaLis to be a mispLaced pectoraLis Patient is seated, arm alongside trunk, in ternally rotated,
major, although some embryoLogists have viewed it as part elbow flexed.
1
Coracobrachialis
Biceps
brachii
Brachialis
Fig u re 1 3 .80 B i ceps a n d b rachial is both refer simi lar patterns to the a n teri o r upper arm w h ile brach ialis a lso extends to the thumb. Drawn
after Simons et a l ( 1 999).
1 3 Shoulder, arm and hand 48 1
The palpa ting hand cups the shoulder while a finger of Antagonists: To supination: pronator teres, prona tor quadratus
tha t hand makes contac t on the tender point and applies To elbow flexion: triceps brachii
pressure to i t, sufficient to have the pa tient ascribe a To flexion of shoulder: posterior del toid, triceps brachii
value of '10' to the discomfort. (long head)
With the other hand the practi tioner eases the ipsilateral To adduction of the arm: middle deltoid, supraspinatus
arm into extension and introduces internal rotation at the To abduction of the arm: pectoralis major (clavicular por
shoulder, with the dorsum of the patient's hand being tion), coracobrachialis
placed fla t against the back.
The pa tient is asked to report the pain score and fine
I n d i cations for treatment
tuning of the a rm position is carried out to achieve a
reduction in the pain score of at least 50%. Shoulder pain (superficial anterior)
Fine-tuning is then increased; for example the pa tient's Pain when supina ting or when forearm flexion is
flexed elbow may be eased anteriorly, increasing internal overloaded
rotation at the shoulder, to further reduce the reported Snapping or crackling sounds as the arm is abducted
score. Pain or weakness when eleva ting the hand higher than
Add itional fine-tuning methods to reduce pain scores the head
further might include:
1. the hand on the shoulder applying light (l Ib (0.5 kg)
Speci a l notes
maximum) inferomedial 'crowding' of the shoulder
contact towards the painful point, or The biceps brachii is discussed here with the shoulder and
2. crowding of the acromioclavicular joint by long-axis is followed by a full discussion of the elbow joint since it
compression of the humerus in a cephalad direction crosses both of these joints. Additionally, note that the tri
(l Ib (0.5 kg) force at most). ceps also crosses both joints and is discussed briefly with
Once pain is reduced by 70%, the position is held for not the elbow (supine position). The reader is referred to p. 449
less than 90 seconds, before a slow return of the arm to a for a full discussion of the triceps brach ii.
neu tral position and a reassessment of function and ten The biceps brachii is a complex shoulder muscle as it
derness is performed . crosses three joints (glenohumeral, humeroulnar, humerora
dial) and consists of two heads (sometimes three) whose
shape and length a re different from each other. A third head
B I C E PS B RACH I I
anomaly is noted by some authors as present in 1-10% of
Attachments: Short head: Apex of the coracoid process cases (Gray's Anatomy 2005, Platzer 2004, Simons et aI 1999) .
Long head: supraglenoid tubercle of the scapula at the "The long, narrow tendon of the l a teral head lies in the
apex of the glenoid cavity to a common tendon merging intertubercular groove and courses through the joint cap
the two heads and attaching to the posterior surface of sule enclosed in a double tubular sheath, which is continu
the ra d i a l tuberosi ty w i t h a d d itional expansions (bicipi ous with the joint capsule. It is held in the groove by the
tal aponeurosis) blending into the deep fascia of the fore transverse humeral ligament. When this ligament is torn
arm on the ulnar side free, the long head tendon may 'pop' as it dislocates from
Innervation: Musculocuta neous nerve (C5-6) the groove during lateral and medial rotation. When the
Muscle type: Postural (type I), shortens when stressed tendon ruptures completely, the humeral head rises con
Function: Supina tion of the forearm (when elbow is at least spicuously and the muscle belly bulks on the anterior sur
slightly flexed), elbow flexion (strongest with the fore face of the arm. Research by Warner & McMahon (1995)
arm supinated), assists flexion of the shoulder j oint confirms biceps brachii long head as a stabilizer of the
(when medially rotated), stabilizes the h umeral head humeral head in the glenoid d u ring abduc tion of the shoul
against upward translation when deltoid contracts and der in the scapular plane.
against downward translation when the dependent arm The short head tendon is thick and f1a ttened. It does not
is weigh ted, assists abduction of the arm (when laterally a ttach to or pierce the jOint capsule but instead runs slightly
rotated), horizontal adduction of the arm, eccentric d iagonally (anterior to the subscapularis tendon) to a ttach
(lengthening) contractions when ex tending the weighted at the coracoid process with the coracobrachialis and pec
forearm, brings the humerus toward the forearm when toralis minor. It lies deep to the deltoid and pectoralis
the forearm is fixed (such as in pull-ups) major's usually thick mass.
Synergists: Supination: supina tor Passive supination of the forearm and slight lateral rota
Elbow flexion: brachialis and brachioradialis tion of the humerus places biceps brachii in the most ideal
Flexion of shoulder: anterior deltoid, pectoralis major position for palpation. The long head tendon may be more
Abduction of the arm: middle deltoid, supraspina tus easily felt with full lateral rotation of the humerus.
Adduction of the arm: pectoralis major (clavicular portion), Additionally, strumming laterally across the medial tendon
coracobrachia I is (short head) and medially across the lateral tendon (long
1 3 Shoulder, arm and hand 483
if the movement starts from maximal extension. and compressed between the t h u m b a n d fi ngers.
Patient is supine with elbow extended, arm abducted and
externally rotated from the shoulder to 90, palm facing
f N M T F O R B I C E PS B RA C H I I
upward.
The practitioner places one hand, palm upward, on the
posterior surface of the distal upper arm, above the elbow
The patient is lying supine with the arm resting on the table
so that the hand supports the patient's arm.
for support and the forearm passively supinated. The ante
The other hand is placed palm downward on the distal
rior humerus is lightly lubricated and the thumbs are used
forearm, above the wrist.
to glide proximally, in thumb-width segments, from the
The practitioner introduces light hyperextension of the
crease of the elbow to the head of the humerus to address
patient's elbow, utilizing the contact on the lower arm for
the entire belly of the biceps brachii. Medially placed glid
leverage.
ing strokes address the short head while la terally placed
The patient is asked to introduce flexion at the elbow
s trokes assess long head fibers and are repeated 7-8 times
against this resistance.
on each segment while evidence of tenderness, thickness or
Relative strength of biceps brachii is compared on each side.
taut fibers is assessed within the bellies of the biceps brachii.
If ischemia is found, these gliding steps are repeated several
ASS ES S M E N T F O R S H O RT N E S S A N D M ET
times with a short break in between, possibly incorporating
T R EAT M E N T O F B I C E PS B RAC H I I
hot packs to encourage additional blood flow.
The patient sits on the treatment table with legs hanging Gently applied transverse friction can be used on both
off the side, with the practitioner seated alongside, on the bicipital bellies to assess for muscular nodules and taut bands,
side of the dysfunctional arm. both characteristic of trigger points. When thickness, taut
The practitioner supports the elbow with the hand near fibers or trigger point nodules are located, pincer compression
est the patient while the other hand holds the patient's can be used to lift and differentiate the biceps brachii from the
proximal wrist area (patient's forearm supinated), intro brachialis, which lies deep to it (Fig. 13.83). Trigger points
ducing slight elbow extension (the slack is removed; this found within its bellies may be treated with compression
is not a forced extension). techniques, either by lifting and compressing the fibers or by
If there is biceps brachii shortness, elbow extension will pressing them against the deeper belly of brachialis.
be limited and possibly painful. With the forearm passively supinated, the groove
To treat this shortness using MET, the patient is asked to between the ulna and radius is located and the patient is
attempt to flex the elbow for 7-1 0 seconds, using mini asked to mildly flex the elbow against resistance while the
mal effort, resisted by the practitioner. practitioner contacts the tendon area with a thumb or finger
Following the contraction the degree of extension is (Fig. 13.84) . Contraction of the radial attachment of the
increased with patient assistance and the stretch held for biceps brachii and the ulnar attachment of brachialis will
not less than 20 seconds. make their location obvious. The patient should relax the
The process is repeated 2-3 times more. arm before the tendon is treated with static pressure or mild
484 C LI N I CAL APPLICAT I O N OF N E U R O M U SC U LAR TECH N I Q U E S : T H E U P P E R B O DY
Fig u re 1 3 .84 Lightly resisted flexion with the forea rm supi nated
w i l l contract the tendon of biceps to identify i ts specific a ttach ment
so as to avoid the neu rovascu l a r structu res nea rby.
Figure 1 3.86 M ET treatment fo r biceps tendon dysfu nction.
. M ET F O R PA I N F U L B I C E PS B RACH I I T E N D O N
, ( LO N G H EA D ) (FIG. 1 3.86)
Patient is seated with practitioner behind.
Figure 1 3.85 The short a n d long tendons of b i ceps a re iden tified
w ith tra nsverse pa l pation. Su bsca pu laris tendon fi l l s the space The patient is asked to take the hand behind the back and
between the two. to place the dorsum of that hand against the contralateral
buttock.
The practitioner holds the patient's hand and gen tly
takes i t into pronation (palm toward floor), taking out the
friction. A bicipitoradiai bursa protects the tendon from the slack.
radial tuberosity (see discussion of the elbow joints next). The patient is asked to a ttempt to lightly turn the hand
To address the proximal tendons of the biceps brachii into a supina ted position against resistance offered by the
(through the deltoid), the short head tendon on the anterior practi tioner.
upper humerus and the long head tendon on the lateral After 7-1 0 seconds the patient ceases the effort and the
upper humerus are both located (Fig. 13.85). These tendons practitioner (assisted by the patient) increases the degree
feel very tubular and are slightly larger in diameter than the of pronation at the same time as extending the elbow and
shaft of a pencil. The strumming techniques ]..l sed to locate further adducting the arm.
the tendons (mentioned above) may also be used as a treat This stretch is held for a t least 20 seconds.
ment step or transverse (snapping) friction may be used if The process is repeated 2-3 times.
1 3 Shoulder. arm and hand 485
There are two tender points associated with biceps brachii: Before beginning treatment of the elbow, postural distor
in the bicipital groove (long head) and on the inferola teral tions of the body's framework should be observed and a
surface of the coracoid process (short head). distinction made between struc tural and muscular causes.
Inability of the arm to hang straight at the side, loss of range
of motion at the elbow joint, functional arm length differ
Long head ences and vertical plane devia tions of the torso all suggest
biomechanical challenges for which the elbow (and other
The practi tioner loca tes an area of tenderness in the
joints) may be compensating. For instance, when shoulder
bicipital groove and applies sufficient pressure to have
motion is restricted, compensations might involve more
the patient ascribe a value of '10' to the discomfort.
distal portions of the extremity, placing undue stress on the
The practi tioner eases the patient's arm into a posi tion in
elbow, wrist or hand.
which it rests, elbow flexed, with the dorsum of the lower
The patient should be asked to demonstrate to the practi
arm against the patient's forehead.
tioner the sort(s) of work activities and positions, seated and
The practitioner fine tunes this position until the
standing, which are performed on a daily basis. Long hours
reported tenderness score is reduced by at least 70%.
without breaks are often spent at office and home office desks
A greater degree of 'score' reduction is usually possible
with little a ttention given to ergonomic (postural) design of
by the addition of a small degree of pressure (l Ib (0.5 kg)
the workspace. The postural and use ca uses of repetitive
maximum) appl ied from the elbow through the long axis
stress disorders involving the forearm muscles and strains of
of the humerus to 'crowd' the shoulder joint.
the arm, wrist, shoulder, neck and torso need to be addressed
if long-lasting relief is to be achieved. Frequent breaks, cou
Short head pled with stretches and movement therapy, should be part of
both recovery and preventive programs.
The practitioner loca tes an area of tenderness on the
When addressing pain in the elbow, forearm and hand, it
inferola teral surface of the coracoid process and applies
is important to treat trigger points in the torso and shoulder
sufficient pressure to have the patient ascribe a value of
girdle muscles as well as nerve compression possibilities at
' 10' to the discomfort.
the spinal level and potential entrapment sites along the
The position of ease which reduces the pain score in this
nerve's pa th. The cervical region should be assessed in a ll
tender point is found by the practitioner taking the
hand, arm or shoulder pain patterns, including the thoracic
patient's interna lly rotated arm, flexed at the elbow, into
ou tlet and subclavicular area (such as pectoralis minor,
adduction.
which should be tested for potential encroachment upon
Once pain is reduced by 70% in either of these pOSi tions,
neurovascular space).
it is held for not less than 90 seconds, before a slow return
of the arm to a neutral pOSition and a reassessment of
function and tenderness is performed.
STR U CTU R E A N D F U N CT I O N
H U M E R O U L N A R J O I NT
This joint is formed where the trochlea of the humerus, a
spoon-shaped surface, is met by the trochlear notch of the
ulna. The longitudinal ridge of the ulnar head fits into the
channel of the trochlea while the concave surfaces on either
side of the ridge correspond to the lips of the trochlea. The
ulnar head's anterior edge, the coronoid process, and its
posterior edge, the olecranon process, slide within the chan
nel during flexion a nd extension, this joint's only move
ment. Posteriorly, on the distal end of the humerus, the
olecranon fossa receives the protrusive olecranon process of
the ulna when the elbow is fully extended.
H U M ERORADIAL J O I NT
This joint is formed where the capitulum of the h umerus, a
hemispherical surface, is met by the concave fovea of the
radial head. This ball and socket joint allows for flexion and
ex tension as well as rotational movements. The radial head
is stabilized by the annular ligament. This ligament, which
encircles the radial head and a ttaches at both ends to the
ulna, allows rotation and flexion /extension while forbid Figure 1 3 .87 1 . Medial epicondyle. 2. O lecranon. 3. Lateral
ding lateral and medial excursions of the head of the radius. e picondyle. Horizo n ta l bony a lignment becom es equilatera l tria ngle
By stabilizing the ulna and radius together, the annular lig d u ring e l bow fl exion.
ament ensures tha t these two j oints act as one during flexion
and ex tension.
When elbow is fully extended the three contacts should
form a straight line.
RADIOU LNAR J O I NT
When the elbow is flexed to 90 they should form an
This pivotal joint is formed where the rounded circumfer inverted triangle.
ence of the radial head fits against the radial notch of the Traumatic insults, for example to radioulnar articulation,
ulna. While the proximal ulna remains stable during prona may alter these alignments.
tion and sup ination, the radius spins inside the annular lig
ament against the ulna and against the ball-shaped distal
T H E L I G A M E N TS O F T H E E LB O W
surface of the capitulum of the humerus. During this spin
ning action, the shaft of the radius rota tes around the ulna, The joint capsule i s thin and lax and i s continuous with the
which flips the forearm and hand over. Pronation and annular ligament, a strong band which encircles the head
supination can occur at any point during flexion and exten of the radius.
sion if these radial joints are functional. The medial ligament (ulnar collateral ligament) is a thick trian
The interosseous membrane provides a continuing gular band, comprising an anterior and a posterior band
fibrous joint between the radius and ulna for the full length which unite a t a thin intermediate portion (Fig. 13.88).
of the two bones. This membrane prevents upslip or dis The anterior part attaches superiorly, via its apex, to the
placement of the two bones and also acts to transmit pres medial epicondyle of the humerus and inferiorly, via its
sure stresses from one bone to the other. It is an extremely base, to the medial margin of the coronoid process.
strong fibrous network, which provides a place for muscu The posterior part is also triangular which attaches supe
lar a ttachment as well as tremendous structura l support for riorly to the posterior aspect of the medial epicondyle
the forearm. In fact, d uring structural distress, the radius and inferiorly to the medial margin of the olecranon.
and ulna are prone to fracture before the fibers of the mem The intermediate fibers run from the medial epicondyle to
brane are torn (Pia tzer 2004). an oblique band which joins the olecranon and the coro
noid processes.
A S S E S S M E NT O F B O N Y A L I G N M E N T O F The lateral ligament (radial collateral ligament) is attached
TH E E P I CO N DYLES (FIG. 1 3.87) superiorly to the distal aspect of the lateral epicondyle of
the humerus and inferiorly to the annular ligament.
Patient's arm is hanging at the side.
Practitioner, standing behind, places thumb on medial Ruch et al (2006) implicate synovial plicae of the elbow as a
epicondyle, index finger on olecranon, middle finger on possible cause of lateral elbow pain in pa tients with vague
lateral epicondyle. clinical symptoms. Although these pa tients failed to
1 3 Shoulder. arm and hand 487
EVALUAT I O N
Figure 1 3.88 The head of the radius 'spins' inside t h e confi nes of
the a n n u l a r ligament (a nterior view). Reprodu ced w i th perm issio n CAUTION: Avoid testing (active or passive) for range of
from Gray's Anatomy for Students (2005). motion if there exists the possibility of dislocation, fracture,
advanced pathology or profound soft tissue damage (tear).
There are three important reflex tests tha t help to evalua te
the neural integrity of the upper extremity. They are placed
here with the elbow since they are examined at the elbow,
but they are commonly also used when evalua ting the
shoulder and cervical region.
B I C E PS R E F L E X
This evaluates the integrity o f nerve supply from CS level.
The seated pa tient's forearm is placed so that it rests on
Radial
the practitioner 's forearm.
collateral
ligament ----\,\- \ The practitioner cups the medial aspect of the patient's
elbow so that his thumb can be placed in the cubital fossa.
Annular ligament Ulnar The p atient's arm must be relaxed.
of radius ----t collateral The practi tioner taps his own thumbnail with a neuro
ligament logic hammer and the biceps should jerk slightly to the
Sacciform recess extent that it is both visible and palpable.
of synovial
membrane -_-...../
B RAC H I O RA D I A L I S R E F L E X
This evalua tes the integrity o f nerve supply from C6
level.
The arm is supported in precisely the same ma nner as in
the biceps reflex test above.
The brachioradialis tendon at the distal end of the radius
is tapped (the tendon is tapped, not the prac titioner 's
Fig u re 1 3.89 Joint capsule a n d l igaments of the el bow. Reproduced thumbnail) with the neurologic hammer and a palpable
with perm ission from Gray's Anatomy for Studen ts (2005). and visible jump should occur in brachioradiaIis.
488 CLI N I CA L A P P L I CATI O N OF N E U RO M U S C U LA R TECH N I Q U E S : T H E U P P E R BODY
T R I C E PS R E F L E X
This evaluates the integrity o f nerve supply from C7
level.
The arm is supported in precisely the same manner as in
the biceps reflex test above.
The triceps tendon where it crosses the olecranon fossa is
tapped (the tendon is tapped, not the practitioner's
thumbnail) with the neurologic hammer and a palpable
and visible jump should occur in triceps.
Note:
1. An increase in normal reflex activity may indicate
upper motor neuron disease.
2. A decrease in normal reflex activity may indicate a
lower motor neuron lesion (e.g. a herniated disc).
RAN G E S O F M OTI O N OF T H E E L B O W
Triangular Interval
Figure 1 3.91 Nerve pathways of posterior aspect of u pper l i m b. Reprod uced with permission from Gray's Anatomy for Students (2005).
held in a less than ideal pOSition, pressure may be further similar symptoms to cubital tunnel syndrome, such as a
increased within the tunnel. Resting the elbow of the medial epicondylar ache with accompanying shooting
pronated arm on the desk while working may also irritate points to the li ttle finger and ulnar portion of the hand
this superficial portion of the ulnar nerve. (Cailliet 1996). The flexor carpi ulnaris may entrap the ulnar
A few inches more proximally, the nerv e . passes under nerve, as it lies deep to this muscle and superficial to the
the 'arcade of Stru thers' as the nerve enters deep to the flexor digitorum profundus. Additionally, an anomalous
medial head of the triceps. This dense fascial arch is another muscle, the anconeus epitrochlearis (Simons et al 1999),
possible site of ulnar nerve entrapment and may produce may cause ulnar nerve compression when it is present.
1 3 Shoulder, arm and hand 49 1
Lateral cord
Radial nerve --
Lateral cutaneous
nerve of forearm ---+:A-fl
Figure 1 3.92 M uscu locutaneous, median and u l n a r nerves in the arm. Reprod uced with perm issio n from Gray's Anatomy for Students (2005).
Near the medial side of the wrist, the ulnar nerve can be primary cause. A tight grip on tools, such as screwdrivers or
compressed within Guyton's canal (or tunnel), resulting in handles, can cause a compression of the nerve as the gripforces
Guyton's canal syndrome (aka ulnar tunnel syndrome). the hard object into the palm. If the symptoms arise as a result
Symptoms include paresthesia and numbness in the d istri of an acute injury, like falling on an outstretched hand, carpal
bution of the ulnar nerve, and a trophy and weakness of fractures or dislocations may cause the nerve compression.
muscles innervated by the ulnar nerve (hypothenar emi Long distance cyclistsfrequently experience this condition. The
nence), but not tenosynovitis since no tendons run through position of the hands on the handlebars places pressure directly
the canal. Lowe (2006) notes: over the Guyton's canal; thus the condition's alternate name of
handlebar palsy (Capitani & Beer 2002, Noth et al 1980)
Because GCS [Guyton's canal syndrome] mainly develops People who use walking canes develop the condition as
from external compression, occupational disorders are a well.
492 CLI N ICAL A P P L I CATI O N OF N E U R O M U SC U LAR TECH N I QU E S : T H E U P P E R B O DY
T R EAT M E NT
B RAC H I A L I S
Attachments: Distal half o f the anterior su rface o f the
F i g u re 1 3.93 With both t h u m bs deep to the b i ceps, b rachialis may
humerus and intermuscular septa to the ulnar tuberosity, be compressed as g l i d i n g strokes a re appl ied s i m ultaneously with
coronoid process and the joint capsule of the elbow both t h u m bs.
Innervation: Musculocutaneous and radial nerve (C5-6)
Muscle type: Postural (type I), shortens when stressed
Function: Flexion of the forearm at the elbow joint
Synergists: Flexion: biceps brachii, brachioradialis, supinator positioned. The practitioner places one thumb on the
Antagonists: Triceps brachii medial side of the exposed portion of the brachialis and the
other thumb on the la teral side of the exposed portion of
the brachialis. The thumbs will be deep to the belly of the
I nd ications for treatment
biceps and opposite each other on the sides of the anterior
Soreness of the thumb (referred zone) upper arm (Fig. 13.93).
Anterior shoulder pain With lubrica tion, the practitioner glides the thumbs prox
imally, while simultaneously pressing them toward each
other. This 'double-thumb' technique will entrap the
Specia l notes
brachia lis as pressure is applied . The gliding process is
While most muscles perform more than one function, repeated 7-8 times from the distal end until the deltoid is
brachialis is one of the few muscles that provides only a sin reached. Ca ution is exercised to avoid p ressing on the neu
gle motion, i.e. flexion of the forearm. It provides this func rovascu lar bundle on the medial upper arm by ending the
t ion whether the arm is supinated, pronated or resisted . It is stroke with both thumbs near the deltoid tuberosity as
quiet (no activity) when the arm is loaded in a fully depend brachialis shifts laterally on the humerus.
ent position and works best when the elbow is flexed to 90. The b iceps brachii can usually be displaced slightly on
Brachi alis has the ability to entrap the radial nerve (cuta both the medial and lateral aspects to allow access to a small
neous branch) and thereby causes symptoms of tingling, portion of brachialis fibers. The forearm should be passively
numbness and dysesthesia of the thumb and the webbed flexed and supinated for best access. Short, gliding strokes
space beside it. These symptoms may also be referred from or pressure release methods may then be applied directly
trigger points in brachioradialis, supinator and other mus onto the brachialis muscle. Pressure applied through the
cles of the thumb, which should be treated as part of an biceps bellies will address the central portion of brachialis
overall examination. and can be used if the biceps brachii is not too tender.
N MT F O R B RACH I A LI S T R I C E PS A I\I D A N C O N E U S
A full discussion of triceps i s offered on p . 449. Triceps is
With the patient resting supine, the arm being treated is also placed here to offer an additional supine position treat
slightly passively flexed and tucked under the practi ment and to remind the reader tha t it should be assessed
tioner 's arm. This position will allow room for the practi with all elbow dysfunctions as well as the previous shoul
tioner's hands to glide proximally when they are correctly der conditions.
494 CLI N I CAL A P PL I CATI O N OF N E U R O M U S C U LA R TECH N I Q U E S : T H E U P P E R B O DY
Tests for strength of triceps are given earlier in this chap between the two fingers, which are removed when treatment
ter on p. 415. is applied. Short glides between the ulna and radius (in the
space between what the fingers have outlined) will address
this small muscle which is often involved in elbow pain.
'6 N MT F O R T R I C E P S ( A LT E R N ATIVE S U P I N E MET for triceps is described earlier in this section on
" POSITI O N ) p. 452.
The patient is supine and the practitioner stands cephalad
to the shoulder to be treated. The shoulder may be placed in B RAC H I O RA D I A L I S
flexion with or without flexion of the elbow. If both joints
Attachments: Proximal two-thirds o f the lateral supra
are simultaneously moderately flexed, the triceps may be
condylar ridge of the humerus and intermuscular sep
placed under excessive tension and may respond as
tum to the (proximal) lateral surface of the styloid
extremely tender, especially at its a ttachment si tes. It is
process of the radius
therefore better to maintain one or both of these joints in
Innervation: Radial nerve (C5 and C6)
partial flexion rather than full flexion.
Muscle type: Postural (type I), shortens when stressed
The practitioner applies lubricated gliding strokes in seg
Function: Flexes the elbow and stabilizes it during exten-
ments to cover the entire surface of the posterior upper arm
sion, brings it to neutral pOSition (semisupina ted)
to assess the lateral and long heads of triceps brachii. The
Synergists: Biceps brachii, brachialis
radial nerve lies deep to the lateral head and is vulnerable to
Antagonists: Triceps
entrapment by triceps (Simons et aI 1999). The practi tioner
should avoid compression of the nerve while treating it.
The proximal glides may be repeated with increased I n d ications for treatment
pressure, if appropriate, to address the medial head of the
Limited forearm movement
triceps, which lies deep to the lateral and long heads.
Weakness
Additionally, the medial head lies superficial on both the
Pain
medial and lateral aspects of the posterior a rm just above
the elbow and can be a ddressed in a marmer similar to
brachialis by using a 'double-thumb' technique. Specia l notes
To isolate the a ttachment of the long head of triceps on
Brachiorad ialis is a forearm flexor in neutral position, acting
the infraglenoid tuberosity of the scapula, the thumb is slid
on only one joint, the elbow. Con troversy about i ts actions
proximally along the tendon, which courses between teres
began when it was wrongly named supinator longus as its
major and teres minor. When the scapular a ttachment is
action was thought to supinate the forearm (Simons et al
reached, static pressure or mild friction can be used to
1999). While its supposed function to return the arm to neu
assess and treat the a ttachment. Elbow ex tension is resisted
tral from either a supinated or a pronated position has
to assure direct tendon contact. It may also be necessary to
inspired deba te, it does help prevent distraction of the
muscle test for the two teres muscles since triceps passes
elbow joint d uring rapid elbow movements.
between them before attaching to the scapula.
While functioning as a flexor of the elbow, brachioradi
The olecranon attachment of the triceps is examined with
alis is sometimes grouped with the extensors of the wrist
finger friction or the beveled pressure bar. Pressure is placed
due to i ts proximity to them and i ts innervation by an exten
directly on the tendon while the areas medial and la teral to
sor nerve. Its trigger point activity, somewhat like the wrist
the tendon are avoided d ue to v ulnerable nerve passage.
ex tensors, is into the elbow, forearm and the hand (web of
the thumb) (see Fig. 13.94, p. 496). It often becomes tender in
The patient is asked to resist the practitioner's effort to S U P I N ATO R (see Fig. 1 3.94)
push the forearm into extension.
Attachments: Supinator crest of the ul na, lateral epicondyle
The rela tive strength of each brachioradialis is tested.
of the humerus and the ligaments and joint capsule of the
elbow to the lateral surface of the proximal third of the
It N M T F O R B RAC H I O RA D I A L I S radius
Innervation: Radial nerve - deep (posterior interosseous)
With the forearm in a relaxed, semisupinated position and branch (C5 and C6, sometimes C7)
passively flexed at the elbow to near 90, brachioradialis is Muscle type: Postural (type I), shortens when stressed
grasped with pincer compression near its humeral a ttach Function: Supinates the forearm by spinning the radius;
ment. Tau t bands within the muscle are compressed forceful elbow flexion
between the thumb and fingers for 8-12 (up to 20) seconds Synergists: Supination : biceps brachii
and the compression techniques are applied at thumb Elbowflexion: biceps brachii, brachioradialis
width intervals as far dista lly as possible. If tension and Antagonists: To supination: pronator quadratus, pronator
referred pain are discovered and compression is applied to teres
the associated tissues, the patient should feel the discomfort To elbow flexion: triceps, anconeus
fade as the pressure is sustained. If the discomfort or
referred sensation does not begin to fade within 8-12 sec
onds, the techniques are applied again with slightly less pres I nd i cations for treatment
sure. A deeper grasp may also address the extensor carpi Elbow pain, such as in tennis elbow and golfer 's elbow
radialis longus and brevis, which lie deep to brachioradialis Lateral epicondylitis
and are discussed with the forearm and wrist on p. 498. Pain when supinating, such as to twist a doorknob, open
The muscle fibers may also be rolled between the thumb a jar or use a screwdriver
and fingers to discover tau t bands and nodules characteris Elbow pain when using the elbow in any movement
tic of trigger points. Trigger points are treated with pressure Pain in the web of the thumb (referral zone)
release techniques followed by stretching of the involved
tissues.
The practitioner follows the manipulation of the fibers Specia l notes
with lubricated gliding strokes from the s tyloid process to
The supinator muscle comprises two flat layers of muscles
the humeral a ttachment. Hydrotherapy applications may
that spiral around the radius to attach to the ulna.
precede or follow these procedures. Inflammation of the
Contraction of its fibers will spin the radius against both the
supinator muscle and epicondyles of the humerus should
humerus (proximally) and the ulna (located to its medial
be ruled out before applying hea t to the elbow region. Ice
side) to turn the palm and forearm toward the ceiling.
therapy may be applied to any of the muscles following
Cou rsing betvveen these two layers of muscle is the deep
therapy, unless contraindicated.
branch of the radial nerve, which lies vulnerable to entrap
ment by the supinator's fibers (Simons et aI 1999). Weakness
M FR F O R B RAC H I O RA D I A L I S in the supinator itself is not likely to be caused by this partic
ular entrapment syndrome since innervation to the supina tor
The patient i s seated with the arm at the side, elbow branches off the radial nerve before it enters the muscle.
flexed, fist closed, thumb uppermost. Supinator trigger points and ischemic fibers are often cre
The practitioner identifies brachioradialis by having the ated with overuse or strain of this muscle. Common supina
patient flex the elbow against resistance. tor symptoms may be initiated by manual use of a
The patient releases the fist, relaxes the muscle and pal screwdriver, either with a difficult-to-turn screw (strain) or
pation is performed to identify areas of contraction, with numerous screws (repetitive), sorting envelopes by flip
fibrotic change or other evidence of altered tissue status. ping them into stack trays or postal boxes or straining to
The practitioner applies a broad, flat, thumb compres open a stuck jar lid or turn a stiff doorknob. Supinator may
sion, one thumb width distal to the dysfunctional tissues. very rapidly become overly tender following overuse or
With this thumb contact, slight soft tissue traction is strain, while tending to rather urgently exhibit inflamma tory
introduced, from the attachments above the lateral epi symptoms and weakness (very likely from trigger points).
condyle, to lengthen the fibers slightly. Weakness in the muscles innervated by the radial nerve,
With the arm relaxed and semisupinated, the patient is when not accompanied by pain, suggests nerve entrapment
asked to extend it fully (drawing the dysfunctional tis and may be caused by a tumor pressing on the nerve or
sues under the compression force of the thumb) and then some other lesion along its path (Simons et aI 1999) . While
to return to the neutral starting position, while the firm pain in the supinator area (tennis elbow) suggests a myofas
compression contact is maintained. cia I cause, including trigger points or enthesi tis, it may or
This proced ure is repea ted 3-4 times. may not be accompanied by weakness of muscles supplied
496 CLI N I CAL APP LICATI O N OF N E U R O M USCULA R TEC H N I Q U E S : THE U PP E R B O DY
r
niques, assisted pronation stretches and posttreatment ice
applications usually achieve a degree of improvement.
The patient is seated with elbow flexed t o 90, forearm
pronated fully.
The practitioner stabilizes the arm against the patient's
trunk at the elbow and applies a resistance contact with
the other hand to the proximal forearm.
The patient is asked to supinate the forearm against
resistance for 7-10 seconds using minimal force.
After the isometric contraction the pa tient relaxes the
arm completely and then a ttempts, with the practi
tioner 's assistance, to pronate the forearm further.
This stretch is held for a t least 20 seconds.
This treatment can be usefully self-applied, especially in
cases of ' tennis elbow'.
f M F R F O R S U P I N AT O R
The practitioner palpates the supinator from the lateral
epicondyle to its radial attachments and locates areas of
dysfunction, fibrotic change or contraction.
Figure 1 3.94 Supi nator can entrap the rad i a l nerve as well as refer
The patient's arm is flexed at the elbow and prona ted and
to the elbow and web of thu mb.
a fla t thumb contact is made distal to the restricted soft
tissue area.
A light traction is applied to the soft tissues via the thumb
by the radial nerve. When both pain in the supina tor area
along the long axis of the muscle and, while this is sus
and weakness of muscles supplied by the radial nerve are
tained, the patient is asked to slowly and deliberately
present, the cause is most likely myofascial trigger points
move the forearm from pronation to supination while
with nerve entrapment due to tau t bands within the muscle
extending the elbow and then to return to the starting
(Simons et al 1999).
position (pronated forearm, flexed elbow).
This is repeated 3-4 times.
A S SE SS M E N T F O R STR E N GTH O F S U P I N ATO R
The patient is seated with elbow flexed to 90, forearm P R O N AT O R T E R E S
pronated fully.
Attachments: Humeral head: medial epicondyle of humerus
The practi tioner stabilizes the arm against the pa tient's
(common flexor tendon) and medial intermuscular septum
trunk at the elbow and applies a resistance contact
Ulnar head: coronoid process of the ulna to a common ten
with the other hand to the distal forearm (Daniels &
don at the pronator tuberosity of the radius approxi
Worthingham 1980).
mately mid-shaft on the lateral surface of radius
The patient is asked to supinate the forearm as the prac
Innervation: Median nerve (C6-7)
titioner evaluates the relative strength and compares one
Muscle type: Not established
side with the other.
Function: Pronates the forearm by spinning the radius and
contributes to flexion of the elbow against resistance
It N MT F O R S U PI N AT O R Synergists: Pronator quadra tus, brachioradialis (aSSistance
to a neutral position)
The brachioradialis and extensor carpi muscles are displaced Antagonists: Supina tor, biceps brachii
laterally and lubricated gliding strokes are applied directly
on the supinator, which lies deep to it (Fig. 13.94). The super
I n d ications for treatment
ficial muscles are displaced medially and the gliding strokes
repeated on the remainder of the supinator muscle. Only a Deep pain on radial side of the anterior surface of the
small piece of the muscle may be reached from each side of wrist
13 Shoulder, arm a nd hand 497
Specia l notes
Pronator teres assists pronator quadratus (below) during
rapid or forceful pronation of the forearm. The median
nerve usually passes between the two heads of pronator
teres as it enters the forearm (Gray's Anatomy 2005) and in
some cases pierces the humeral head (Simons et al 1999).
Sometimes the ulnar head is absent (Platzer 2004).
Median nerve entrapment by the pronator teres is clini
cally Significant. Koo & Szabo (2004) d ifferentiate between
pronator syndrome and carpal tunnel syndrome (CST).
" M F R FO R P R O N ATO R T E R ES
or when pronation is resisted. It occupies the deepest layer
in the distal anterior forearm, occasionally has fibers reach
ing more proximal than noted or reaching distaJ iy to the
The practitioner palpates and identifies an area of fibrotic carpal bones and is sometimes absent (Pla tzer 2004). Stuart
or contracted tissues in pronator teres. (1996) suggests tha t the deeper of two heads 'is a dynamic
The practi tioner places a broad, fla t thumb contact dista l stabilizer of the distal radioulnar joint' .
to the dysfunction, applying traction to the tissues along Hwang et al (2005) have documented two myofascial
their fiber direction. referral patterns for pronator quadratus (PQ).
To maintain firm and precise compression contact, the
other thumb may be superimposed on the first. The most common pattern involved pain spreading both dis
The patient is asked to slowly and deliberately fully tally and proximally from the injection site, along the
pronate and then supinate the forearm. medial aspect of theforearm (57%). 111 half of these cases, the
This is repeated 4-5 times for each area of dysfunction. pain area extended to the medial epicondyle proximally and
the fifth digit distally. The second main pattern revealed
FOREARM
W R IIST A N D H A N D
Fig u re 1 3.96 The i nte rosseous membrane prevents
u pslip or displacement of the u l n a and radius and a lso
acts to transmit pressure stresses from one bone to the other. The carpus, the true wrist joint, i s a n ellipsoid synovial
During struct u ra l distress, the bones a re prone to fract u re radiocarpal joint formed by the distal end of the radius and
before the fibers of the membrane a re torn. Rep rod uced the articular disc of the radioulnar join t and their articula
with perm ission from Gray's Anatomy for Studen ts tion with three proximal carpal bones (Kappler & Ra mey
(2005). 1997). This disc separa tes the true wrist joint from the distal
radioulnar joint and prevents the carpal bones from touch
ing the distal end of the ulna, while still moving in relation
500 CLI N I CAL A PPLI CATI O N OF N E U R O M U SCU LAR TECH N I QUES : T H E U P PER BO DY
Phalanges ---\
Metacarpats -------\
Hook of
hamate
Tubercle of scaphoid
Scaphoid
Lunate
Wrist joint
Ulna Radius
Tubercle
Pisiform
Trapezium
Triquetrum
Trapezoid
Hamate Capitate Carpal arch
Carpal arch
Fig u re 1 3.97 Bones of the hand and wrist. Reprod uced with permission from Gray's Anatomy for Students (2005J.
to it. To each side of the wrist extends the styloid processes The carpus contains two rows of small bones that are
of the ulna and radius, with the latter being longer. Fracture arranged so that the proximal row forms a palmar arch
of the styloid process of the radius (Colles' fracture) is a whose proximal end is convex and whose distal end is con
common fracture of the wrist. cave. Though four bones lie in the proximal row, only three
1 3 Shoulder. arm and hand 501
Capsule of
metacarpophalangeal
joint
articulate with the radius (scaphoid, lunate and triquetral the design of its articular su rfaces. In con trast, the
bones) . The fourth, the pisiform, functions as a sesamoid metacarpal joints of the remaining digits are limited, as are
bone in the tendon of flexor carpi ulnaris and articulates the intermetacarpal articulations, each permitting slight
only with the palmar surface of the triquetrum. gliding to allow some flexion, extension and rotation. These
In the second row of carpal bones lie the trapezium, trape minor movements are especially important when opposing
zoid, capitate and hamate, which articulate proximally with the thumb and small finger, grasping an object or when
the first row and distally with the metacarpal bones. The car reaching precisely with individual fingers, as when playing
tilaginous surfaces of each of the eight bones articulate with a violin.
other bones while the rougher volar and dorsal surfaces The terminology used in various texts in relation to wrist
accept ligamentous attachments. The two rows slide upon movement is confusing. The terms 'flexion', 'extension' and
each other to a small degree (mid-carpal joint) and collec 'ulnar and radial devia tion' of the wrist seem to offer the
tively upon the radius and articular disc. The distal row of simplest and most accurate choices and have been used in
carpal bones is bound tightly to metacarpal heads as well as this section regarding movement of the hand, though occa
to each other, making them together a functional unit. sionally other terms are used as well.
The metacarpus consists of five miniature long bones Within the carpus, flexion (palmar flexion) of the wrist
(metacarpa ls), each of which has a base, shaft and distal provides 85 of movement while extension (dorsi or volar
rounded head tha t articulates with the proximal phalanges flexion) of the wrist (from neutral) also allows 85. The hand
to form what is commonly called the knuckles. Their pal may also be placed in ulnar deviation (adduction) of approx
mar surfaces are longitudinally concave which allows space imately 40--45 or radial deviation (abduction) of 15 (Gray's
for the palmar muscles. Though they appear to be parallel, Anatomy 2005, Kapandji 1982) (see Fig. 13.99). All of those
they actually radiate from the carpal bones, with the first movements may be combined to produce circumduction.
metacarpal ( thumb) placed more anteriorly, proximally and
rotated medially approximately 90 so that its palmar sur
CAPS U LE A N D L I GA M E NTS O F TH E W R I ST
face faces medially ( toward the other metacarpals) (Gray's
(FIG. 1 3.98)
Anatomy 2005), a condition which allows the thumb to have
opposition with the fingers and which makes the human The articular capsule of the radiocarpal (true wrist) joint
hand the remarkable instrument it is. has a synovial lining which is strengthened by the pal
The metacarpal joint of the thumb (trapezium with first mar radiocarpal, ulnocarpal, dorsa l radiocarpal, radial
metacarpal) is a saddle joint which is highly mobile due to and ulnar collateral ligaments.
502 CLI N I CA L A P P L I CATI O N OF N E U R O M USCU LA R TECH N I Q U E S : TH E U P P E R BODY
The palmar radiocarpal ligament attaches to the anterior metacarpal bone and are continuations of the tendon of
margin of the distal radius and its styloid process, passing flexor carpi ulnaris.
medially to connect to the anterior surfaces of the The radial and ulnar collateral ligaments of the mid-carpal
scaphoid, lunate and triquetral bones. joint are short. The radial collateral connects the scaphoid
The palmar ulnocarpal ligament runs from the base of the and the trapezium, and the ulnar collateral connects the
styloid process of the ulna and the anterior margin of the trapezium with the triquetrum and the hamat . These
articular disc of the distal radioulnar joint to a ttach to ligaments are continuous with the correspondlOg liga
the l unate and triquetral bones. ments of the wrist joint.
The palmar ligaments have apertures which accommo
The 'true' elbow and the ' true' wrist joints are connected
date passage of blood vessels and have a functional rela
functionally to the radius by means of the synovial jOi.iltS
tionship with the tendons of flexor pollicis longus and
(distal and proximal) as well as by an interosseous structu e
flexor digitorum profundus.
tha t binds and supports the bones of the forearm. ThiS
The dorsal radiocarpal liga ment a ttaches proximally to the
interosseous membrane forms wha t is in effect the fibrous
posterior border of the distal radius, traveling obliquely
middle radioulnar joint. This fibrous 'joint' provides stabil
medially to a ttach to the dorsal surfaces of the scaphoid,
i tv for the forearm, reducing stress on ligaments as add uc
tin or abduction of the ulna occurs. This interosseous
lunate and triquetra I bones, where it is continuous with
the dorsal intercarpal ligaments. There is a functional rela
membrane helps to spread compressive forces on the fore
tionship with the extensor tendons of the fingers and
arm structures, whether they are transmitted downwards
wrist. Anteriorly it blends with the inferior radioulnar
from the shoulder or upwards from the hand.
artiCLtia tion.
If examina tion of elbow, forearm or wrist dysfunction
The ulnar collateral ligament a ttaches to the end of the sty
fails to investigate for, or to treat, patterns of dysfunction in
loid process of the ulna, dividing into two fasciculi, one
the interosseous membrane, results may be disappointing.
of which attaches to the medial aspect of the triquetrum
Kappler & Ramey (1997) state: 'Interosseous membrane
and the other to the pisiform bone.
dysfunction can perpetuate elbow or wrist disability long
The radial collateral ligament extends from the tip of the
after orthopedic care and apparently complete heallOg of
styloid process of the radius to the radial aspect of the
strains, sprains, or fractures of the elbow or wrist should
scaphoid bone, with some fibers continuing to the trape
have taken place:
zium. The radial artery separates the ligament from the
Kuchera & Kuchera (1994) describe the relationship
tendons of abductor pollicis longus and extensor pollicis
between the radius, the ulna and the radiocarpal joints as
brevis.
that of a parallelogram.
L I G A M E NTS O F T H E H A N D The ulna is part of the elbow joint, relatively fixed at the
ulnohumeral joint.
Dorsal and palmar ligaments run transversely and connect
The radius is part of the wrist joint, rela tively fixed at the
the scaphoid, lunate and triquetra I bones in the proximal
radiocarpal joint.
row of carpal bones. The dorsal ligaments are stronger
The radius has a greater degree of movement than the
than the palmar ones. In the distal row of carpal bones
ulna due to i ts rotational component.
the dorsal and palmar ligaments ex tend transversely
Adduction or abduction of the ulna leads to reciprocal
repositioning of the hand; for example, when te lna
between the trapezium and the trapezoid, the trapezoid
and the capita te, and the capitate and hamate bones. A t
abducts, the radius glides distally, forcing the wnst lOto
the mid-carpal joint, on the palmar surface, the fascicles
increased adduction. The reverse occurs during ulna
radiating from the head of the capita te to the surround
ad duction, which automatically creates an abducted wrist.
ing bones are known as the radiate carpal liga rr:ent
When pronation of the hand occurs, the distal radius
.
hand grasps the forearm just proximal to the wrist and alter radioulnar joints (usually the proximal joint) may require
nately prona tes and supinates it. The movements described a ttention.
above are felt for near the end of full pronation (radial head Posterior radial head dysfunction is common following a
glides posteriorly) and supination (radial head glides anteri fall forward onto the palm of an outstretched hand,
orly). This palpa tion should be performed on a 'normal' as whereas an an terior radial head dysfunction is common
well as on a 'dysfunctional' symptomatic forearm so that the following a fall backward onto the palm of the out
differences in the movements described above can be noted. stretched hand of the extended arm.
K EY (OST E O PATH I C) P R I N C I P L E S F O R C A R E O F
E L B OW, F O R EA R M A N D W R I ST DYS F U N CT I O N ACTIVE A N D PAS S I V E T E STS F O R
(mod ified from Ka ppler Et Ramey 1 997) W R IST M OTI O N
Minor restriction - for example, in gliding potential - is CAUTION: Avoid testing (active o r passive) for range of
commonly the only symptom of dysfunction in this area. motion if there exists the possibility of dislocation, frac
Passive bilateral compa rison of minor gliding motions is ture, advanced pathology or profound soft tissue damage
an accurate means of identifying sites of dysfunction. (tear).
Dysfunction of the ulnohumeral joint is commonly the Both active and passive range of mohon tests may be used to
primary feature, with radioulnar dysfunction being sec assess limits of movement of the wrist joint. Bilateral com
ondary, seldom primary, in elbow dysfunction. pa rison is possible, performing action on each side simulta
Any dysfunctional state of any joint in the arm will cause neollsly in most cases. If active testing shows normal range
adaptive demands on all other joints of the arm, leading without pain or discomfort, passive tests are usually not
to compensatory problems. necessary. Remember the evidence and advice offered in
If wrist symptoms are reported, the elbow should be Chapter 11, pp. 254-255, that whereas a single movement in
examined. a test situation may not produce symptoms or evidence of
If elbow flexion is restricted after all ulnohumeral fea dysfunction, repetitive motions replicate 'real life' and are
tures have been treated and if inflamma tion is absent, the more likely to be informa tive.
Box 1 3. 1 5 Focal hand dystonia (FHd) - 'repetitive stra i n i nj u ry' (Byl 2006)
Dr Nancy Byl (2006) has made a study of the effects of repetitive the workplace seem to be a major risk factor for this d isorder
and ina ppropriate movement on the function of the hand. The notes (Hochberg et al 1 990).
on this topic, as set out below, are largely based on her years of The evidence for m icrotrauma from repetitive overuse of the
research and findi ngs. u pper l i m b is convincing. Rest, ant iinflammatory med ications,
Focal dystonia is a movement disorder that affects more change in biomechanics and good ergonomics are usua l ly effective
than 1 mill ion individ uals in the US alone (Marsden & Sheehy treatment modalities. Unfortunately, some i nd ividuals m ust continue
1 990). In contrast to genera lized dystonia, which may affect the to work despite their symptoms and rest is a limited option i n such
entire body, focal dystonias present in the context of performing a cases. Thus, the repetitive stra i n i nj u ry becomes chronic with
specific motor task usually with only one part of the body. When degenerative cha nges found i n tendons and m uscles (Barbe et al
patients attempt to perform that target task, they experience 2003). restricting soft tissues and joint mobil ity (Barr & Barbe 2002).
involuntary co-contractions of flexor and extensor muscles together with com pression of peripheral nerves (Stock 1 99 1 ).
(Altenmueller 1 988). When that happens the abil ity to perform I n some cases of cumu lative trauma, chronic neuropathic pain
finely graded and seq uenced movements is d isrupted and develops (Vi ikari-Juntura & Silverstein 1 999). In other cases fatigue
replaced by crude, uncontrol led movements (Rosenbaum & and clumsiness of the hand is reported, often associated with a
Jankovic 1 988). tremor (Fernandez-Alvarez et al 2003).
In some people, an enduring FHd is expressed only in the context While there may be preexisting musculoskeletal risk factors (e.g.
of one specific posture and task; in others, it can slowly generalize to decreased range of motion in finger spread, pronation and supination.
other related hand postures and uses, a nd can u ltimately d isable the or shoulder external rotation), psychologica l factors (perfectionism,
entire hand (Utti et a l 1 995). Although the disorder is typically perseverance, impatience, anxiety) or social factors (work or personal
painless, some patients may have painful spasms and others can stress) are also often associated with the origin of focal hand dystonia.
experience increased sensitivity or a sense of dull ness or even There is i ncreasing evidence of degradation of the somatosensory
numbness of the affected l i mb. representation of the hand in patients with dyston ic hand
FHd typica lly develops during adu lthood and has been reported in movements. If the orig i n is aberrant learning with degradation of the
about 0.5% of office workers and between 7 and 25% of musicians cortical hand representation i n the brain, treatment should i nclude
(Hoch berg & Hochberg 2000, Lim & Alten mul ler 2001 , Tubiana learning-based training strategies to reorga nize the bra i n (Sanger &
2003). In the majority of cases, repetitive movements performed in Merzenich 2000).
box continuES
504 C L I N ICAL A P P L I CAT I O N O F N E U R O M U SCU LAR TECH N I Q U E S : T H E U P P E R B O DY
Etiology of occu pational hand cramps: aberrant selective movements must be practiced to engage specific and
learn ing relevant sensory neurons and increase u ncorrelated movement
Individuals perform ing tasks requ iring intensive repetitive components.
movements (e.g. working at a computer, playing an i nstru ment,
pitching a ball, screwing nails, playing golf) a ppea r to be at highest Exa mination
risk for focal hand dystonia. During the musculoskeletal exa m ination the patient may complai n
o f weakness b u t the muscles are usually strong unless there are
Performing artists often report having achieved a new high level signs of clear peripheral nerve compression with secondary atrophy
of performance using new techniques or a new i nstru ment, (e.g. thoracic outlet, cubital tunnel, carpal tunnel). However, there
sudden ly followed by involuntary, abnormal end-range postures may be an imbalance in strength, with the extrinsic muscles
of the fingers, making normal m usical performance impossible u nusually strong compared to the i ntrinsic muscles (Byl et al 1 996).
(Altenmul ler 2003). Poor posture is common (forward head and protracted shoulders)
It is hypothesized that dystonia, particularly focal dystonia of the and there may also be end-range li mitations in finger spread,
neck, is genetic (Ozelius et al 1 997). forearm rotation or shoulder external rotation (Wilson et aI 1 993).
I n both general and focal dystonia, there is also strong evidence The neurological examination will usually be normal (e.g. normal
of an imbalance of i n h ibitory and excitatory pathways in the tendon reflexes, good coordination, stable gait, normal light touch)
g lobus palliduslsubstantia nigra (Black et al 1 998). with some complai nts of ulnar neuropathy, but with normal nerve
Some researchers report hand dystonia cou ld result from cortical cond uction (Charness 1 993).
motor dysfu nction (Toro et al 2000), degradation in the sensory However, some individua ls do note a worsening of normal
thalamus (Lenz Et Byl 1 999) or disruption in cortical sensory physiolog ical tremors, uncontrollable excitabil ity and possibly some
activation, somatosensory representation or spatial perception dullness in the pads of the fingers when placed on the target
(Tinazzi et al 2003). surface. These patients may also perform poorly on tasks demanding
Other researchers report abnormal gating of somatosensory inputs cortical sensory d iscrimination (e.g. stereognosis or graphesthesia)
(M urase et al 2(00), abnormal presynaptic desynchronization of (Byl et al 1 996).
movement, abnormal muscle spindle afferent firing (Toro et al 2000)
or disruption of inh ibition in the spinal cord (Chen et al 1 995). Treatment
Some researchers have documented evidence suggesting FHd To date, there are no i n tervention strategies that are 1 00% effective
develops as a consequence of peripheral trauma, peripheral nerve for restori ng normal motor control in patients with FHd. Botu linum
entrapment or a natomic restrictions i n soft tissue (Weiner 2001 ). toxin i njections or baclofen can decrease the severity of dystonic
cramping by interfering with neural signals to the muscle (van Hilten
The most controversial hypothesis is that FHd results from a berrant et al 2000).
learning (Byl et al 2000). Byl Et Melnick ( 1 997) proposed the Surgery such as nerve decompression at the el bow or wrist may
sensorimotor learning hypothesis as one etiol ogy of work-related be helpful (Cha rness et al 1 996).
focal hand dystonia. This suggests that repetitive use, simulta neous Surgical release of tight retinaculum or fascia has been tried with
fi ring, cou pling of m u ltiple sensory signals and vol u ntary limited success. Surg ical implantation of deep brain sti mu lators is
coactivation of muscles lead to a degradation of the sensory cortical sometimes used for patients with focal hand dystonia. None of these
representation of the hand and disruption in sensorimotor feedback medication or surgical approaches actually targets the defined
(Xerri et a l 1 999). somatosensory degradation.
Sanger Et Merzenich (2000) elaborated on this hypothesis, Conservative exercise strategies based on the principles of
proposing an integrated m u ltisystem computational model to explain neuroplasticity have been tried as alternatives, or supplementary, to
the origin of FHd. If the sensorimotor and the neural circu itry medications and surgery. Some of these learning approaches include
connecting the deep cortical n uclei, basa l ganglia and thalamus are constrai nt-induced therapy (also cal led sensory motor retuning)
u nstable, then a focal or a genera l dystonia cou ld develop, (Candia et al 2003), sensitivity training (Tubiana 2003), conditioning
depending on the extent of the i mbalance across mu ltiple sensory techniques (Liversedge 1 960), ki nematic tra i ning (Mai Et Marguardt
and motor systems (Sanger Et Merzen ich 2000). 1 994), immobilization (Priori et al 200 1 ) and learning-based
The computational model could explain why symptoms: sensorimotor training (Byl et al 2000).
1 . develop in otherwise healthy individuals who perform highly While some l i mited research has been carried out on these
attended repetitive movements tech niques, none has been confirmed by randomized clinical trials.
2. evolve variably over time The strongest validation for learning-based behavioral training for
3. a ppear only during the performance of a target-specific task of the treatment of FHd is based on basic science evidence that the
dystonic movements, persisting even when the task is no longer central nervous system is ada ptable and focal hand dystonia may
performed repetitively result from aberrant learning.
4. decrease, but a re not remediated, with dopamine-depleting drugs People who successfu lly rehabil itate are those who can stop the
or botu l i n u m toxin activities that lead to the abnormal movements, integrate healthy,
5. are associated with a bnormalities i n somatosensory, sensorimotor stress-free, normal biomechan ics i nto fu nctional hand use, create a
and motor representations of the dystonic limb. positive, su pportive environment, manage stress, use good
ergonom ics, engage in wellness and fitness activities, and can carry
Based on the sensorimotor learning hypothesis integrated into the out a learning-based sensorimotor training program to reorganize
computational model, a ppropriate treatment must help to the somatosensory maps of the hand.
redifferentiate cortical and subcortical representations. If the Within this context the authors of this text strongly maintain
dystonia is severe, it may be necessary to tempora rily break the cycle that NMT approaches - such as those described in this chapter
(e.g. botu linum toxin i njections) before retra i ning can be effectively that evaluate and assist in normalization of structural soft tissue and
i m plemented. This retra i n ing needs to be based on t he principles of osseous patterns of dysfu nction can create a useful complementary
neuroplasticity. Pathol ogical connections m ust be uncoupled and background to reeducation of appropriate use.
13 Shoulder, arm and hand 505
B
Figure 1 3.99 The range of movement of the wrist joi nt. A: U l n a r and rad i a l deviation. B: Flexion and extension. C: Para l lel og ra m mecha nics
of wrist and u l n a r movements.
A B
Figure 1 3. 1 00 Strength tests for (Al carpa l flexors a n d (8) extensors.
Kal tenborn (1989) sta tes tha t if a passive movement and the same movements are repeated with the patient offer
an ac tive movement in the same direction produce painful ing resistance and if pain then results, a soft tissue dys
symptoms, this suggests an osseous problem. function probably exists (strain, tendinitis, etc.) . The
If, however, a passive movement in one d irection and an reader is reminded of the previous advice (pp. 254-255)
active movement in the opposite direction produce symp regarding repeating tests several times in order to repro
toms (pain, for example), this suggests a soft tissue duce 'real-life' situa tions. Such tactics are more informa
problem. tive than performing tests once only.
The practitioner supports the wrist in one hand and with
Supina tion and pronation tests of the forearm are listed
the other takes the pa tient's hand into radial and ulnar
with the elbow on p. 488.
deviation (abd uction and adduction). If pain results a
wide range of possibilities exist including sprain, fracture,
tendinitis, arthritic change or subluxa tion. If no pain is
R E F L E X A N D STR E N GTH TE STS
reported and the same movements are repeated with the
Strength testi ng patient offering resistance and pain then results, a soft tis
sue dysfunction probably exists (strain, tendinitis, etc.).
The patient clenches the fist and takes it into a flexed
Kappler & Ramey ( 1997) suggest that transla tion (gliding)
position. Stabi lizing the proximal wrist with one hand
restrictions are often the only evidence of dysfunction,
and covering the clenched fist with the other, the practi
either producing pain or when the joint in one
tioner a ttempts to ex tend the wrist against resistance.
hand /wrist demonstrates a limitation when compared
This evalua tes strength of flexor carpi radialis and flexor
with the same joint on the other hand/ wrist. The metacar
carpi ulnaris. Neural supply is from C7, C8 and T1 (Fig.
pophalangeal and interphalangeal joints can usefully be
13.100A).
passively tested for anteroposterior glide, mediola teral
The practitioner holds the patient's extended clenched
glide and internal and external rotation potentials, none
fist (Fig. 13.1008) and resists as the patient a ttempts to
of which can be initiated by direct muscular action.
ex tend this. This evaluates strength of ex tensor carpi
The most common dysfunction affecting carpometacarpal
rad ialis longus and brevis and extensor carpi ulnaris.
joints (apart from that of the thumb), according to
Neural supply is from C6 and C7 (Fig. 13.1008).
Kappler & Ramey (1997), is evidenced by a restriction in
the ability to glide ventrally, such as would occur if the
d igi t were moving into ex tension.
Wrist stress tests
The practitioner supports the wrist in one hand and wi th
G A N G LI O N
the other, takes the patient's hand, fingers relaxed, into
flexion and ex tension. If pain results a \-\Tide range of The development of a cyst-like swelling in association
possible causes exist, including sprain, fracture, tendinitis, with a tendon sheath or joint is thought to result from a pro
arthritic change or subluxation. If no pain is reported and tective process related to repetitive stress or to trauma
13 Shoulder, arm and hand 507
Ca uses of carpa l tun n el syn d rome trimmed). If pain is noted in all fingers apart from little
finger, carpal tunnel syndrome is strongly indicated (Fig.
The most widely accepted explanation is that this condi
13.1018).
tion results from a neural compression condition involv
3. Oriental prayer test. The patient fully extends abducted
ing the median nerve.
fingers and thumb of each hand and places palms
In this model, causes are thought to vary from increased
together. If thumbs cannot touch, this indicates paralysis
structural volume of the nerve to a narrowing of the tun
of abductor pollicis brevis due to median nerve palsy
nel size. There is commonly a history of trauma to the area.
resulting from carpal tunnel syndrome (Fig. 13.101C).
Other etiological suggestions include:
1 . cervical arthritis as a precursor to carpal tunnel syn
drome (Hurst 1985), suggesting that cervical mechanics Associated wrist tests
should always be evaluated, and treated, if appropriate 1. Oschner's test. Patient is asked to interlock fingers by plac
2. venous and lymphatic congestion (Sunderland 1976), ing palms together and interlacing the fingers, so that their
suggesting tha t blood and lymph flow should be nor palmar surfaces rest on the dorsum of the contralateral
malized by means of attention to soft tissues as well as hand. If the index finger on the suspected side cannot flex
to excessive sympathetic tone, possibly by correction in this way, median nerve paralysis is indicated. The lesion
of upper thoracic and rib dysfunction is likely to be at or above where branching of the nerve to
3. altered vasomotion as a result of upper thoracic dys flexor digitorum superficialis occurs (Fig. 13.102).
function (Larson 1972) 2. Froment's test. If the ulnar nerve is paralyzed the patient
4. interference with axoplasmic flow (see Box 3.1, p. 47) will be unable to form an '0' with thumb and index finger.
as a result of minor compression somewhere along the 3. 'Pinch ' test and u lnar nerve entrapment signs. If the ulnar
course of the median nerve, leading to the evolution of nerve is entrapped there will be weakness of the ability to
distant denervation changes and symptoms (Upton & 'pinch', weak thumb abduction ('hitcher's thumb' posi
McComas 1973). tion) and an inability to actively flex the metacarpopha
langeal joints. Interosseous a trophy may be apparent.
Symptoms 4. Bracelet tes t. The practitioner encircles the patient's wrist
with thumb and index finger and applies firm compres
Symptoms include pain and numbness, worse at night,
sion to the distal radius and ulna . If sharp pain is
weakness, swelling and muscular hypertrophy. The
reported arising in the wrist and/ or radiating to the hand
thenar eminence may display atrophy.
or forearm, rheumatoid arthritis is suspected.
There may be difficulty in pronating and supinating the
forearm.
Direct manual compression or percussion of the carpal PHALA N G ES
tunnel (Tinel's sign) commonly provokes symptoms but
these can be confused with normal response to percus Movements of the fingers are described in relation to the axis
sion of a nerve and are now considered by some to be an of the hand and not that of the whole body. In other words, the
unreliable test (Cailliet 1994). hand has its own mid-line, which lies longitudinally along the
When holding the wrist at a full flexed position causes 3rd metacarpal bone and the middle digit (ray). Adduction
tingling and numbness (paresthesia) of the median nerve and abduction of the fingers and thumb are in relation to the
distrib ution (fingers of the radial side of hand), this is mid-line, so that separating the fingers from each other is
considered a more reliable sign (see also Phalen's test abduction and approximating them is adduction.
below) for carpal tunnel syndrome. The metacarpophalangeal joints are composed of an
The diagnosis is confirmed by nerve conduction and irregularly convex surface articulating with a 'socket' that is
EMC tests. shallow, which allows for considerable movement. The
If such tests are negative and symptoms persist, one of phalanges, however, are hinge joints and are limited to flex
the other etiological pa tterns, as listed above, may be ion and extension.
operating. Like the metacarpals, the phalanges have a proximal base,
shaft and (distal) head, which are conveniently designed to
Tests for carpal tu nnel syndrome stack one upon the other. The fingers are composed of three
phalanges laid end to end while the thumb has two.
1. Phalen 's test.Patient places the dorsum of both flexed
wrists against each other and applies pressure (light) for The proximal end of the proximal phalanx carries a con
a full minute. Symptom increase (pain, numbness, etc.) is cave, oval facet which conforms to its convex associated
a positive sign (Fig. 13.101A). metacarpal head.
2. Tine/'s tes t. Patient has elbow flexed and hand supinated. The distal end (head) of the proximal phalanx is
The practitioner taps the volar surface of the wrist with a smoothly grooved (like a pulley) to receive the base of
broad reflex hammer or the tip of an index finger (nail the middle phalanx.
13 Shoulder, a rm and hand 509
B
Figure 1 3. 1 0 1 Tests for carpal tunnel syndrome. A: Phalen's test. B: Tinel's test. C: Oriental prayer position.
CAR P O M ETA C A R PA L L I G A M E N TS (2 N D , 3 R D ,
4TH , 5TH)
Dorsal ligaments connect carpal bones with metacarpals
Figure 1 3. 1 02 Oschner's test. Median neNe para lysis may be on dorsal surface, passing transversely from one bone to
ind icated if the index finger can not flex. another.
510 C LI N I CAL APPLI CATI O N O F N E U RO M U SC U LAR TECH N I QU E S : T H E U PP E R B O DY
M ETACA R PO P H A LA N G EA L L I G A M E NTS
The palmar ligaments are thick fibrous structures on the
palmar surfaces of the joints between the collateral liga
ments wi th which they are connected. They are also
blended with the deep transverse ligaments of the palm.
The deep transverse metacarpal ligaments are made up of
three short, wide bands which connect the palmar liga
A ments of the 3rd, 4th and 5th metacarpophalangeal joints.
The collateral ligaments are strong, rounded cords lying
at the sides of the joints attached to the tubercle on the
side of the head of the metacarpal bones, passing
obliquely distally to attach to the ventral aspect of the
base of the phalanx.
RA N G E O F M OTI O N
Metacarpophalangeal ranges of motion (of fingers) should be:
flexion - approximately 90, with the index finger falling
just short of 90 and each finger increasing progressively
B
extension - from a few degrees to up to 40 of active
Figure 1 3. 1 03 ARB : Range of flexion and extension of movement and up to 90 passive movement in individu
metacarpophalangeal joints. Reproduced with perm ission from als with lax ligaments (Kapandji 1982)
Kapandji ( 1 998) . adduction - relatively small, negligible in flexion
C P
A c
Figure 1 3. 1 04 A-C: Range of motio n of phalangeal joints. Reproduced with permission from Kapandji ( 1 998).
13 Shou lder. arm and hand 51 1
The carpal and digital flexors (along with the pronators pre
RAN G E OF M OT I O N AT TH E J O I NTS O F
viously discussed in cormection with the elbow region,
T H E TH U M B
p. 488) all lie on the anterior (flexor) surface of the forearm
Metacarpal flexion 50 - movement is parallel to the in two layers. The superficial layer flexors have their origins
plane of the palm so that the ulnar side of the thumb primarily on the medial epicondyle of the humerus while
sweeps across the palm the deeper layer flexors arise from the ulna and radius. The
Metacarpal extension 0 - 'relative extension' moves the most superficial layer includes the flexor carpi ulnaris and
thumb back to neutral from any point of flexion but the radialis, pronator teres, palmaris longus and flexor digito
thumb should not be extended beyond neutral rum superficialis. (Note: The flexor digitorum superficia lis
512 CLI N I CAL APPLICATI O N O F N E U RO M USCU LA R TECH N I Q U E S : T H E U PP E R B O DY
Figu re 1 3. 1 05 A : T h u m b in neutra l position. B : I nterphalangeal joint flexion. C: I nterphalangeal a n d metaca rpophalangea l joint flexion.
D : Radial adduction. E : Pa l m a r a bd uction. F and G : Radial a bd uction.
is included in the superficial layer even though it is covered perform occur within that joint. Since they are encountered
almost completely by the other superficial muscles.) The during forearm palpation, the pronators and supina tors are
deeper layer is composed of the flexor d igitorum profun discussed in relation to the other muscles of that region.
dus, flexor pollicis longus and pronator quadratus (dis They should be evaluated and, if necessary, treated in rela
cussed w ith the elbow). tion to dysfunctions of the wrist or hand since normal
The extensors occur in two layers on the posterior sur elbow function is necessary for normal use of the hand.
face, many of which arise from the lateral epicondyle of the Additionally, trigger points lying in the pronators or
humerus. The superficial posterior forearm includes bra supina tors (and those of brachialis, brachioradialis and
chioradialis and anconeus (both discussed with the elbow), many shoulder cuff muscles) have been shown to have tar
extensor carpi radialis longus and brevis, extensor carpi get zones in the wrist, thumb or hand (Simons et aI 1999).
ulnaris, extensor digitorum and extensor digiti minimi. The
deeper layer contains supinator (discussed with the elbow),
T E R M I N O LOGY
extensor poliicis longus and brevis, abductor pollicis longus
and extensor indicis. The remaining forearm muscles are easily identified by
The forearm muscles should also be considered in terms function since their names denote the work they do.
of function. For instance, even though the pronators and Unfortunately for the reader who is struggling to identify
supinator of the forearm lie within the forearm they are con the anatomy, it can at times seem as though the forearm
sidered primary to the elbow, since the movements they muscles all have the same name. Understanding why they
1 3 Shou lder, arm and hand 513
are named as they are assists in demystifying the apparent seeking just one trigger point that may be producing the
confusion as the names start to make sense. In fact, knowl entire pattern (or syndrome). The combined trigger point
edge of the sometimes lengthy names should assist the target zones for the neck and upper extremity muscles leave
practitioner in readily identifying and locating the muscles. virtually no part of the distal arm untouched, as many of
The following terminology is basic to the nomenclature them have wrist, thumb or hand target zones. Simons et al
of the forearm and while this listing might appear simplis (1999) offer (at the beginning of each section) regional chart
tic, combinations of these terms will be found to result in a ing of areas of pain together with a list of the muscles that
muscle's name which not only usually identifies its function refer into those regions. These lists can be used as a shortcut to
but often also its location and whether it has an assistant (as consider which muscles are most likely to be referring pain
with longus and brevis). to a particular area and are particularly helpful when time is
limited. A more thorough, detailed examination and treat
Carpi muscles move only the wrist (extensor carpi radi
ment plan should also include assessment of the synergists
alis longus may weakly flex the elbow)
and antagonists of muscles housing trigger points, as well as
Digitorum muscles move the fingers (and assist with the
range of motion assessments and postural considerations.
wrist since they cross that joint as well)
Pollicis pertains to the thumb
Indicis refers to the index finger ANTE R I O R F O R E A R M T R E AT M E N T
Digiti minimi is the smallest finger
Radialis muscles lie on the radial (thumb) side of the The muscles o f the superficial layer of the anterior forearm
forearm are addressed together and, unless contraindicated, fol
Uinaris muscles lie on the ulnar side of the forearm lowed by treatment of the deeper layer. Identification of
If there is a longus, there is surely a brevis (shorter version dysfunctional muscles may require tests for strength and
of muscle with similar function to 'longus') weakness and in some cases for length. Joints associated
If there is a flexor, there is also an extensor (although if there with the muscles under review require evaluation for their
are t"vo flexors, there are not necessarily two extensors) influence on patterns of use and presenting symptoms.
When the muscle names are considered, one can quickly Manual palpation, including NMT assessment methods,
decipher what each term means for that muscle. For instance: offers a direct means for the localization of altered tissue
status, whether this be tense, flaccid, fibrotic, edematous or
flexor carpi ulnaris occurs on the ulnar side of the flexor indurated, and for the presence (or lack) of active trigger
(anterior) surface of the arm and serves to flex the wrist points, so allowing treatment to target the most involved
extensor carpi radialis longus lies on the radial side of the structures, as well as distant infl uences on them.
extensor (posterior) surface of the forearm to serve the
wrist and (somewhere) has a companion, the brevis. PAL M A R I S L O N G U S (FIGS 1 3. 1 06, 1 3. 1 07)
Since most of the flexors attach to the medial epicondyle
Attachments: From the common flexor tendon on the
and the extensors to the lateral epicondyle, one can quickly
medial epicondyle to the palmar fascia (aponeurosis or
identify the anatomy by considering the terms used. This
pretendinous fibers) and the transverse carpal ligament
concept is more true for the forearm musculature than any
(flexor retinaculum)
other region of the body.
Innervation: Median nerve (C7-8 or Tl)
Muscle type: Postural (type I), shortens when stressed
N E U RA L E N TRAP M ENT Function: Tenses the palmar fascia to cup the hand; flexes
the wrist; may assist pronation against resistance and
The medial and ulnar nerves can each b e entrapped by (weakly) assist elbow flexion (Simons et a1 1999)
anterior forearm muscles, including (for ulnar nerve) flexor
Synergists: For cupping the hand: thenar and hypothenar
carpi ulnaris, flexor digitorum superficialis and profundus
muscles
and (for median nerve) pronator teres and flexor digitorum
For wrist flexion: flexor carpi ulnaris, flexor carpi radialis,
superficialis. Entrapment of the radial nerve is (rarely)
flexor digitorum superficialis and profundus
caused by an anomalous flexor carpi radialis brevis muscle Antagonists: To wrist flexion: extensor carpi ulnaris, exten
(Simons et aI 1999).
sor carpi radialis brevis and longus, extensor digitorum,
smaller finger and thumb muscles
D I STANT I N FL U E N CE S
I n d ications for treatment
I t i s important when addressing hand and wrist pain and
dysfunction to include examination of function and dys Prickling t o palm and anterior forearm
function of (including the presence of trigger points) the cer Diagnosis of Dupuytren's contracture (see below)
vical, shoulder, upper arm and elbow regions and to consider Tenderness in the palm, especially when working with a
combined patterns of several trigger points rather than hand tool
514 C L I N I CA L A P PLICAT I O N O F N E U RO M U SC U LA R TE C H N I Q U ES : T H E U PP E R B ODY
Biceps-------,
Brachia III s--------='a
Brachial artery ------
Median nenle------
Common fascia -------
Radial ner'le -------__'"'
Bicipital a
Ulnar arte'rv -------
up to 25% of its grip power as a result. He also notes a non For deviation: extensor carpi ulnaris
surgical intervention of injection of trypsin, chymotrypsin A, Antagonists: To flexion: extensor carpi radialis brevis and
hyaluronidase and lidocaine, coupled with forceful finger longus, extensor carpi ulnaris
extension. Since the progression is often very slow, observa To deviation: flexor carpi radialis and extensor carpi radi
tion and minimal or no treatment are often indicated. alis brevis and longus
Simons et al (1999) point out that heredity is a factor in
Dupuytren's contracture and suggest ruling out trigger
points as part of the problem. A distinguishing feature is that I n d ications fo r treatment of wrist fl exors
while Dupuytren's may cause a painful palm, only trigger
Loss of range or pain upon extension
points in palmaris longus produce the prickling sensation.
Medial epicondylitis
Simons et al describe a spray and stretch technique that cov
Carpal tunnel syndrome (some symp toms may be from
ers the anterior forearm and hand, which may be beneficial.
wrist flexor trigger points)
Despite the fact that palmaris longus does not pass
through the carpal tunnel, Keese et al (2006) point to its abil Flexor carpi ulnaris and radialis work together to power
ity to increase intracarpal canal pressure during loading in fully flex the wrist while they unilaterally work with their
wrist ex tension and suggest that it may play a role in the extensor counterpart(s) to produce radial and ulnar devia
development of carpal tunnel syndrome. tion of the hand at the wrist. Since these two muscles arise
from the common tendon of the medial epicondyle, they
Palmaris longus loading increases canal hydrostatic pres
should be evaluated and, if necessary, treated when epi
sure rHore than any tendon passing through the carpal tun
condylar inflammation or tenderness is found.
nel when loaded beyond 20 of wrist extension (Keir et al
As with many forearm trigger points, those in the flexor
1 997). In this study, palmaris longus loading beyond 45 of
carpi radialis and u lnaris tend to refer to the portion of the
wrist extension was associated with the greatest absolute
j oint which the muscle serves, in this case the radia l and
carpal tunnel hydrostatic pressure. Despite the results of
ulnar aspects of the flexor surface of the wrist, respectively.
biomechanical studies, the palmaris longus is not yet a
These trigger points, especially when combined with oth
proven indl?pendent risk factor for carpal tunnel syndrome.
ers, such as those in subscapularis, will present many of the
common complaints associa ted with carpal tunnel syn
F L EX O R CA R P I RAD I A L I S drome and should always be examined in association with
that diagnosis. Trigger points and intlamma tion found in
Attachments: From the common flexor tendon o n the
attachment sites (such as the medial epicondyle) will often
medial epicondyle of the humerus and from the ante
resolve unaided if central trigger points associated with
brachial fascia and intermuscular septa to the base of the
them are deactivated (Simons et aI 1999).
2nd and 3rd metacarpals
Innervation: Median nerve (C6-7)
Muscle type: Postural (type I), shortens when stressed F LE X O R D I G ITO R U M S U P E R F I C I A L I S
Function: Flexes the wrist; deviates the hand toward the (FIG. 1 3. 1 0B)
radius (thumb)
Attachments: Humeroulnar head: from the common tendon
Synergists: For flexion: flexor carpi ulnaris, flexor digitorum
of the medial epicondyle of the humerus, the coronoid
superficialis and profundus, palmaris longus
process of the elbow and (radial head) from the oblique
For deviation: ex tensor carpi radialis brevis and longus
line of the radius in a common tendon sheath through the
Antagonists: To flexion: extensor carpi ulnaris, extensor
carpal canal to end in four tendons attaching (after split
carpi radialis brevis and longus
ting for profundus) to the sides of each middle phalanx
To deviatioll: flexor and ex tensor carpi ulnaris
Innervation: Median nerve (C7-Tl)
Muscle type: Postural (type I), shortens when stressed
F L E X O R CA R P I U LN A R I S
Function: Flexes the middle phalanx on the proximal one,
Attachments: From the common flexor tendon on the flexes the proximal phalanx on the metacarpal and tlexes
medial epicondyle of the humerus and from the medial the hand at the wrist
border of the olecranon to the pisiform bone and by liga Synergists: For finger flexion: flexor digitorum profundus,
mentous fibers to the hamate and 5th metacarpal. A few palmaris longus
fibers blend with tlexor retinaculum For flexion of MCP joint: flexor digitorum profundus, pal
Innervation: Ulnar nerve (C7-8) maris longus, lumbricales, palmar and dorsal in terossei
Muscle type: Postural (type I), shortens when stressed For wrist flexion: flexor carpi radialis and ulnaris, flexor
Function: Flexes the wrist; devia tes the hand toward the digitorum profundus, palmaris longus
ulna Antagonists: To finger flexion: ex tensor digitorum
Synergists: For flexion: flexor carpi radialis, flexor digito To flexion of MCP joint: ex tensor digitorum, extensor indi
rum superficialis and profundus, palmaris longus cis, extensor digiti minimi
51 6 CLI N I CA L A P PL I CATI O N O F N E U R O M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY
Specia l notes
Flexor digitorum superficialis (sublimis) lies in the superfi
Flexor pollicis longus cial layer of the anterior forearm, although it is covered for
I t+-- Flexor digitorum superficialis the most part by the remaining muscles of the superficial
layer, while the profundus (perforatus) lies deep to it in the
second layer of the forearm. Near its distal attachment to
the middle phalanx, each superficialis tendon splits and the
profundus passes through it to terminate on the distal pha
lanx (Fig. 13.110) . Profundus acts a lone to flex the distal
interphalangeal joint but is assisted by superficialis for flex
ion of other hand and finger joints. While together they pro
vide powerful and speedy movements of the fingers, gentle
digital flexion is provided by the profundus alone.
Biceps ---:rA-:-
------ Brachia artery
------- Median nerve
,----"""7"- Brachioradialis
Brachialis
....
. ------------------ Superficial branch of
radial nerve
Superficial fiexor muscles (cut) ------''-- . -
....,--- -- ---------------- Posterior interosseous nerve
Variable slip of fiexor pollicis longus M!----- Radial recurrent artery
from medial epicondyle --"'r-\.. ,----- Anterior interosseous nerve
Supinator------,--l,
-\ ...... ------- Radial artery (cut)
Fig u re 1 3. 1 09 The deepest a nterior forearm m u scles. Reproduced with permission from Gray's Anatomy (2005).
I ndications for treatment and may be partially or completely absent (Gray's Anatomy
2005).
Difficulty with fine work requiring control of the thumb,
such as sewing, fine painting or writing
Pain in the thumb and extending beyond the tip Trigger th u m b
Trigger thumb Trigger thumb (like trigger finger) presents with locking in
flexion and the inability to straighten the thumb without
assistance (Simons et al 1999). It is usually caused by
Special notes
enlargement of the tendon (nodule) where it passes through
Flexor pollicis longus courses through the carpal tunnel and a fibrous shea th. Cailliet (1994) notes (regarding trigger fin
between the two heads of flexor pollicis brevis before termi gers) that steroid injection to expand the sheath may allow
nating at the distal phalanx of the thumb. It is sometimes passage of the nodule, surgical intervention to slit the
connected to either flexor digitorum superficialis or profun sheath may be necessary and that 'Excision of the nodule
dus, or to pronator teres (Gray's Anatomy 2005) or may arise invariably causes formation of a new and often bigger
from the medial epicondyle of the humerus (Platzer 2004) nodule'.
518 CLI N I CAL A PPLICATI O N O F N E U R O M U S C U LAR TECH N I Q U E S : T H E U P P E R B O DY
L--
_ __ Dorsal digital expansion
Radial artery ____ --I-_____.l
L--
_ ___ First lumbrical
N MT F O R ANTE R I O R F O R EA R M
The patient i s seated comfortably opposite the practitioner
with a table placed between them on which to support the
arm. The forea rm to be treated is supinated w ith the hand in
neutral position and rests comfortably on the table with the
fingers di rected toward the practitioner. This treatment may
also be performed with the person supine as long as the
table provides enough support for the a rm .
The superficial layer o f muscles is addressed first with
lubrica ted gliding strokes along the course of the muscle,
from the wrist to the medial epicondyle. The gliding strokes
a re repeated 6-8 times on each muscle until the entire sur
face of the anterior forearm has been treated. The order of
treatment is not important but when learning to identify
these muscles, the following order may be helpfu l .
From the mid-line of the wrist t o the medial epicondyle
will address the palmaris longus.
On the ulnar side of this landmark 'mid-line', a portion of
the flexor digitorum superficialis is available and next to
it (medially) on the most lunar portion of the anterior
forearm lies the flexor carpi ulnaris.
On the radial side of the 'mid-line' lies the flexor carpi
Figure 1 3. 1 1 1 Superficial g l iding strokes add ress the w rist and hand
radialis.
flexors while deeper p ressure (if a ppropriate) treats the digital flexors.
Directing inferolateraJly across the most proximal por
tion of flexor carpi radialis is the pronator teres (see
pp. 496-497), which can be p alpa ted transversely while muscles, a portion of which is a lso v isible from the poste
pronating the forea rm. rior aspect.
The most lateral (radial) aspect of the anterior forearm Near the an terior elbow region, the short pronator teres
will include brachioradialis, radial wrist extensors and may be easily palpated, as it lies diagonally across the
the supinator, which are sometimes called the radial central aspect of the uppermost portion.
13 Sh o u l der, arm and hand 519
Mobilization with movement (MWM) involves a pain less, I. MWM for flexion or extension restriction of
g l iding, translation pressure, applied by the pracition r, almost " the wrist
.
always at right angles to the plane of movement In whIch restnctlOn
The patient is seated with the elbow of the (in this example)
is noted. At the same time the patient actively (or sometimes the
right arm flexed, forearm pronated.
practitioner passively) moves the joint in the di rection of restriction
The practitioner holds the distal aspects of the radius and ulna
or pain.
w ith the left hand, so that the web between the finger and
thumb lies over the dista l aspect of the radius.
It
The web between the finger and thumb of the right hand is
placed on the other side of the hand, covering the proximal row
MWM for flexion restriction of finger joint
of the carpal bones.
The patient is seated and the practitioner stabil izes t h dista l end
. These contacts allow the practitioner to effectively translate
of the proximal bone of the pair which make up the JOi nt, W ith a
(glide, shu nt) the wrist joint so that as one of the practitioner's
finger and thumb hold, one contact on the lateral and one on the
ha nds moves medial ly, the other moves lateral ly.
medial aspect of the bone.
Mul ligan states, 'I have found in every case the successfu l glide
The practitioner's other finger and thumb hold the proximal end
has been a l ateral one [of the ca rpal bones]'.
of the distal bone of the pair making up the joint, again with one
While the practitioner holds the least uncomfortable direction of
contact on the medial and the other on the lateral aspects of the
translation - al most a l ways, according to Mu lligan, a lateral
bone. The patient could be asked to do th is.
translation of the carpals - the patient is asked to actively
With these contacts the practitioner is able to easily translate (or
move the wrist into the restricted direction, flexion or
glide or shunt) the bones on each other, by gently taking one lat
extension.
era l and the other medial, and vice versa.
'If the mobilization with movement procedure is indicated
The practitioner tests to see which of these options is the least
the range of movement will improve instantly and
pai nfu l , as the finger is flexed.
painlessly:
Mu lligan ( 1 992) states that, 'In nearly every case you will find
This is repeated several times.
that one d i rection is painful, and the other is not. You choose
If any aspect of the procedure is painful it should be modifIed
the direction which is pai nless and ask the patient to flex his
until it is painless, possibly by a ltering the angle of translation
stiff finger while you sustain the mobi lization. This active
very sl ightly or marginally modifying the practitioner's hand
movement should be pa in free and the ra nge should
positions.
increase'.
Reversing the practitioner's hand positions as i l lustrated
The procedure is repeated several times and the ra nge of
facilitates translation as described above.
movement and pa in previously experienced is reassessed.
Mul ligan bel ieves that this method normal izes tracking
dysfunctions, such as are known to occur with the patel la,
but which are not com monly considered to occur in other
joints.
, PRT FO R W R I ST DYS F U N CT I O N ( I N C LU D I N G
, CA RPAL TU N N E L SYN D RO M E)
Jones (1985) w rites:
Because there are eight bones in the wrist, I had visions of
venj complicated maneuvers being necessary. I was sur
prised how easy wrist treatment usually is. I treat it as if it
Figu re 1 3. 1 1 5 Su perficial posterior forea rm. Reproduced with
were just one joint . . . if the wrist is tender on the dorsal side, perm ission from Gray's Anatomy (2005).
r extend [dorsiflex] and rotate. If it is on the palmar side, I
flex and rotate. Occasionally I fine tune with sidebending.
There are many [patients] with tender spots on the flexor Once the reported pain score has reduced to '3' or less,
tendons that have been diagnosed [as having] carpal tunnel the position is held for 90 seconds before a slow return to
syndrome, which responds to this type of treatment. I can neutral .
only guess that they have been misdiagnosed. Tender point pain o n the palmar surface i s treated i n the
same way but with flexion instead of dorsiflexion.
The practitioner palpates and locates an area of extreme Several tender points can usefully be treated at one session.
sensitivity to light pressure on the dorsum or palmar sur It is our clinical experience that functional improvement is
face of the hand or wrist (see p. 497, Fig. 13.95B). often immediate (improved range, etc.) but that reduction
Using sufficient digital pressure to create discomfort in existing pain may take several days to manifest follow
which the patient can grade as a '10', the practitioner ing PRT trea tment (see notes on PRT, pp. 427 and 498) .
positions the hand and wrist to remove, as far as possi
ble, the perceived tenderness/pain.
, M F R F O R A R EAS O F F I B R O S I S O R
Tender point pain on the dorsum of the hand is usually
, HYPE RTO N I C ITY
relieved by dorsiflexion and slight wrist rotation one way
or the other and possibly by additional sideflexion or The practitioner identifies a localized area of hypertonic
translation. i ty, fibrosis, 'adhesion'.
522 CLI N I CAL A P P L I CATI O N OF N E U RO M U S CU LA R T EC H N I QU E S : THE U PP E R B O DY
POST E R I O R F O R E A R M T R EAT M E NT
Brachioradialis ----if....)
Extensor carpi .,---T-,..-- riceps
radialis longus ---f-HtIIJn The superficial layer of the posterior forearm contains two
muscles of the elbow joint - brachioradialis, anconeus - and
five extensor muscles - extensor carpi radialis longus and
Exlensor carpi Flexor carpi ulnaris brevis, extensor digitorum, extensor d igiti minimi and
radialis brevis --f---i'-+
Anconeus
extensor carpi ulnaris. The deep extensors include supina
Supinator
tor (elbow region), extensor indicis a nd three thumb mus
r'r--+- Posterior interosseous cles - abductor pollicis longus, extensor pollicis brevis and
recurrent artery
extensor pollicis longus.
Poslerior
interosseous nerve --..,...., S U P E R F I CI A L LAY E R
Extensor digitorum and
extensor digiti minimi On the most lateral aspect o f the forearm lies the radial
Abductor poliicis group - brachioradialis, extensor carpi radialis longus and
longus ----1-1' brevis - and the supinator, as if stacked upon each other.
Extensor pollicis The most superficial and the deepest of these are discussed
brevis
with the elbow, while the two wrist extensors are included
here. These four muscles can be conveniently addressed
(palpated and treated) together in the semisupina ted fore
arm with applications of gliding strokes, pincer compres
Abductor pollicis longus sion and flat palpation. This 'la teral forearm' position may
Extensor pollicis brevis be varied toward greater pronation or supination to best
-+-- Extensor retinaculum
Extensor pollicis longus access or evaluate the muscles. They are also accessible with
Extensor carpi ulnaris
Extensor carpi the arm pronated and a portion can be palpated with the
radialis longus -i-"-- Extensor digiti minimi arm in supination.
Extensor carpi '------ Extensor digitorum The lateral epicondyle of the humerus, where many of
radialis brevis
these muscles share a common tendon attachment, can be
Figure 1 3. 1 1 6 Deep posterior forearm. Reprod uced w i th permission readily examined at the same time. When any (or several) of
from Gray's Anatomy (2005). the muscles attaching into the tendon develop contractures,
tension will be placed on the common tendon, which is
capable of provoking an inflammatory response. Commonly
called 'tennis elbow', lateral epicondylitis may be initiated,
aggravated and perpetuated by hand, wrist and finger
extension activi ties, especially if these are repetitive and / or
The muscles involved are placed in a shortened (i.e. not stressful (Cailliet 1994) .
stretched) position; therefore, jj the treatment were being Cailliet (1994) suggests three theories of etiology for
applied to the flexors of the forearm, the wrist would be symptoms that include deep tenderness accompanied by an
in slight flexion. ache at the lateral epicondyle, the muscula ture of which is
Firm finger or thumb pressure is applied to the tissues, painful upon palpation:
slightly distal to the restricted tissues.
The patient is asked to slowly and deliberately extend tendinitis at the lateral epicondyle
and then flex the wrist. radial nerve entrapment
In this way the flexors are placed at stretch (during wrist intraarticular or osseous disorders.
ex tension) and the area of restriction passes under the He notes that pain is intensified with resisted wrist exten
fixa tion produced by the practitioner's finger or thumb sion or radia l devia tion and that tenderness in the posterior
contact. interosseous nerve is reported when supina tion of the
As the wrist is flexed again the muscular and fascial tis extended wrist is resisted.
sues, under pressure, shorten and relax . Treatment for such symptoms may include the following
This process is repeated 6-10 times. (Cailliet 1994) .
Alternatively, the practitioner can introduce the a lternat
ing flexion and extension if the patient is unable to do so.
Acute
Precisely the same method can be used on any tissues
that can be compressed manually. Rest the wrist and elbow by avoiding the activities tha t
Self-treatment can be taught to the patient, with cau tions provoke the pain, avoid pronation of the forearm or wrist
as to overtrea tmen t. or finger extension.
1 3 Shoulder, arm and hand 523
Postacute
Gentle active and passive range of motion of wrist and
elbow.
Gentle wrist exercises, including extension, radial and
u lnar devia tions (in pronation and supination), wrist flex
ion and circumduction,followed by a period of relaxation.
When exercises can be painlessly performed, light
weight may be added and gradually increased (in weight
and repetitions).
Surgical intervention may be considered as a final resort.
We would a dd to this list - especially in the acute phase -
Extensor Extensor carpi
the use of alternating (short) hot and cold applica tions (see radialis brevis
carpi ulnaris
Chapter 1 0), positional release methods (see Chapter 10),
gently applied spray and stretch techniques and anti
inflamma tory nutritional stra tegies (see Chapter 7), includ
ing increased EPA (fish oil) supplementation and enzymes,
such as pineapple bromelaine.
EXTE N S O R CA R P I RAD I A L I S LO N G U S
Attachments: From the distal third of the latera l supra
condylar crest of the humerus and lateral intermuscular
septum (including fibers from the common extensor ten
don) to the base of the 2nd metacarpal on the radial side
of the posterior surface
Innervation: Radial nerve (C6-7)
Muscle type: Phasic (type II), weakens when stressed
Function: Extension and radial devia tion of the wrist,
weakly flexes and influences pronation and supination of
elbow (Platzer 2004)
Synergists: For wrist extension: extensor carpi radialis bre
vis, extensor carpi ulnaris, extensor digitorum, extensor
digiti min.imi
For radial deviation: extensor carpi radialis brevis and Extensor carpi
radialis longus
flexor carpi radialis Brachioradialis
Antagonists: To wrist extension: flexor carpi radialis and
Figure 1 3. 1 1 7 Composite of w rist extensors and b rachiorad ialis
ulnaris, flexor digitorum superficial is and profundus,
trigger point patterns. Drawn after Simons et a l ( 1 999).
palmaris longus
To radial deviation: flexor carpi ulnaris, extensor carpi
ulnaris Synergists: For wrist extension: extensor carpi radialis bre
vis, extensor carpi ulnaris, extensor digitorum, extensor
digi ti min.imi
EXTE N S O R CAR P I RAD I A L I S B R EV I S
For radial deviation: extensor carpi radialis longus and
Attachments: From the common extensor tendon o f the lat- flexor carpi radialis
eral epicondyle to the base of the 2nd and 3rd metacarpals Antagonists: To wrist extension: flexor carpi radialis and
Innervation: Deep radial nerve (C7-8) ulnaris, flexor digitorum superficialis and profundus,
Muscle type: Phasic (type II), wea kens when stressed palmaris longus
Function: Extension and radial deviation of the wrist To radial deviation: flexor carpi ulnaris, extensor carpi ulnaris
524 CLI N I CA L A P PLICATI O N OF N EU RO M USCULAR T ECH N I Q U ES : T H E U PP E R B O DY
EXT E N S O R CAR P I U L N A R I S the fingers grasp and work and are essential in this role
when a power grip is used (Simons et aI 1999).
Attachments: From the common extensor tendon and the
Brachioradialis is sometimes grouped with the extensors
posterior border of the ulna to the base of the 5th
of the wrist due to its proximity to them and its innervation
metacarpal
by an extensor nerve. Its trigger point activity, somewhat
I nnervation: Deep radial (C7-8)
like the wrist extensors, is into the elbow, forearm and hand
Muscle type: Phasic (type II), weakens when stressed
(web of the thumb) (see p. 496, Fig. 13.94). Since it is often
Function: Extension and u lnar deviation of the wrist
tender in association when the wrist extensors are tender, it
Synergists: For wrist extension: extensor carpi radialis brevis
is included together with their examination, which is easily
and longus, extensor digitorum, extensor digiti minimi
accomplished due to their proximity.
For radial deviation: flexor carpi ulnaris
Antagonists: To wrist extension: flexor carpi radialis and
Neural entrapment. Simons et al (1999) point out that
ulnaris, flexor digitorum superficialis and profundus,
extensor carpi radialis brevis and supinator have both been
palmaris longus
noted to entrap the radial nerve. Such entrapment may pro
To radial deviation: flexor carpi radialis, extensor carpi
duce motor weakness of the muscles it serves, as well as
radialis brevis and longus
sensory loss or numbness and paresthesias, depending
upon which portion of the nerve is impinged. The ulnar
I nd i cations for treatment of w rist extenso rs nerve may also be entrapped nearby, at the cubital tunnel,
by the flexor carpi ulnaris muscle.
Lateral epicondylar pain (tennis elbow)
Painful supination
Weakness of the grip EXT E N S O R D I G ITO R U M
Pain in elbow, wrist or web of thumb Attachments: From the common extensor tendon of the lat
Reduces range of motion in wrist flexion or wrist eral epicondyle, antebrachial fascia and intermuscular
deviations septa to end in four tendons (which split into three inter
tendinous connections) which attach to the dorsal sur
face of the middle phalanx (1) and the base of the distal
Speci a l n otes
phalanx (2) of the 2nd-5th fingers (see below)
While all three carpi extensors are active during forceful Innervation: Deep radial (C6-8)
wrist extension, extensor carpi radialis brevis primarily Muscle type: Phasic (type 11), weakens when stressed
extends the hand during less demanding use. The wrist Function: Extends the fingers at all phalangeal joints, assists
extensors are also important during flexion activities where in wrist extension and finger abduction, counteracts fin
they stabilize the wrist to prevent excessive wrist flexion as ger flexion in a power grip
L L \
Figure 1 3. 1 1 8 Composite trigger point referral patterns of fi nger extensors. Drawn after Simons et a l ( 1 999).
1 3 Shoul der, arm and hand 525
Synergists: For finger extension: lumbricales, dorsal interos missing, the digitorum provides an additional tendon to
sei, extensor indicis, extensor digiti minimi take over its function (Platzer 2004).
For wrist extension: extensor carpi radialis longus, brevis
and ulnaris
For finger abduction: dorsal interossei f N M T F O R S U P E R F I C I A L POSTE R I O R F O R EA R M
Antagonists: To finger extension: flexor digitorum superfi
With the forearm in a relaxed, semisupinated posi tion and
cialis and profundus, lumbricales, palmar interossei
flexed at the elbow to near 90, the brachioradialis is easily
To wrist extension: flexor carpi radialis and ulnaris
located and treated with pincer compression, lubricated
To finger abduction: palmar interossei
gliding strokes and flat palpation. This muscle should be
released before the radial wrist extensors are attended to,
since it is superficial to them.
EXT E N S O R D I G ITI M I N I M I
After the brachioradialis is treated, the extensor carpi
Attachments: From the common extensor tendon to join radialis longus may be grasped with pincer compression,
with the extensor digitorum at the proximal phalanx to near its humeral attachment, by placing the treating thumb
attach to the dorsal expansion of the 5th digit on one side of the muscle and the treating fingers on the
Innervation: Deep radial (C6-8) other side, while grasping around the brachioradialis. Taut
Muscle type: Phasic (type II), weakens when stressed bands within the muscles are examined for trigger pOints,
Function: Extends the smallest finger, extends the wrist and which may be compressed by flat palpa tion against the
ulnarly deviates the hand underlying tissue or grasped with pincer compression as
Synergists: For finger extension: extensor digitorum previously described . A deeper placement of the fingers
Antagonists: To finger extension: flexor digitorum superfi may also address the extensor carpi radialis brevis, which
cia lis and profundus, lumbricales, palmar interossei lies deep to the longus. A small portion of the supinator
To wrist extension: flexor carpi radialis and ulnaris may be reached by gliding the thumb on the radial a ttach
To hand deviation: flexor carpi radialis, extensor carpi radi ment (see p. 484). Only a small portion of supinator can be
alis brevis and longus accessed directly but application of repeated gliding tech
niques, assisted pronating stretches and posttreatment ice
applications usually achieve satisfactory res ults, especially
Ind ications for treatment if the source of the muscular irritation (such as overuse) is
Pain in elbow or fingers eliminated.
Weakness of the grip Hydrotherapy applications may precede or follow these
Pain at elbow when gripping (such as shaking hands) procedures. Inflammation of the supinator muscle and epi
Loss of full flexion of the fingers condyles of the humerus should be ruled out before apply
Pain in the elbow, posterior forearm, wrist and fingers ing heat to the elbow region. Ice therapy may be applied to
due to trigger points any of the muscles following therapy.
The patient is sea ted comfortably opposite the practi
tioner with a table placed between them on which to sup
Special notes port the arm. The forearm and hand to be treated a re
pronated and rest comfortably on the table with the fingers
The ex tensor digitorum muscle has an interesting and com
directed toward the practitioner, as the table provides sup
plex tendon arrangement at its distal attachment, which
port for the arm.
attaches to the capsules of the metacarpophalangeal joints,
The superficial layer of muscles is addressed first, with
bases of the proximal phalanges and to the middle and dis
lubricated gliding strokes along the course of each muscle,
tal phalanges. The interossei and lumbricales participate in
from the wrist to the lateral epicondyle. The gliding strokes
the fibrous dorsal expansion of the extensor digitorum ten
are repeated 6-8 times on each muscle until the entire sur
don, which is described in detail in Gray's Anatomy (2005,
face of the posterior forearm has been treated. The order of
see Fig. 53.43, p. 917) .
treatment is not important but when learning to identify
Variations o f extensor digitorum include additional bel
these muscles, the following order may be helpful.
lies (2nd finger), missing bellies (5th finger) and a doubling
of the tendons to the individual fingers (Platzer 2004). From the midline of the wrist to the lateral epicondyle
Simons et al (1999) also note a rare extensor digitorum bre will address the extensor digitorum.
vis magnus, which may be misdiagnosed as a ganglion cyst On the ulnar side of this landmark 'mid-line' lies the
or tumor, and an anomalous ex tensor digitorum profundus. extensor digiti minimi and, next to it, the extensor carpi
The extensor digiti minimi may easily be considered as ulnaris.
part of the extensor digitorum since they arise together On the radial side of the ' mid-line' lies the brachioradi
from the common tendon, are joined at the distal attach alis, extensor carpi longus and brevis and supinator, one
ment and often are fused at the bellies. When the minimi is stacked upon the other as previously described on p. 522.
526 C L I N ICAL A P PLICATI O N O F N E U R O M USCU LAR TECH N I Q U E S : THE U P PER B O DY
Branch to
brachioradialis ---___.
Branch to extensor
carpi radialis longus----'"
Branch to extensor
carpi radialis brevis
Anterior view
Posterior view
Figure 1 3. 1 2 1 Deep posterior forearm with cou rse of posterior interosseous nerve (deep branch of rad ial nerve). Reproduced w i th perm ission
from Gray's Anatomy for Students (2005).
Innervation: Deep radial (C7-8) grasping a ball) take on mechanical complexities requiring
Muscle type: Phasic (type II), weakens when stressed simultaneous coordinated contraction of multiple muscles.
Function: Abducts the thumb, extends the thumb at the car- When painfully dysfunctional, the thumb deserves due
pometacarpal joint attention as the actions it performs are indispensable.
Synergists: For abduction: abductor pollicis brevis The bellies of these thumb muscles lie wholly within the
For extension: extensor pollicis longus and brevis forearm with the long tendons projecting distally to attach
Antagonists: To abduction: adductor pollicis to the thumb. When examining for central trigger points
To extension: flexor pollicis longus and brevis (trigger point referral patterns have yet to be established in
these tissues), it is useful to remember that central trigger
points occur in the fibers only and the tendons are disre
EXT E N S O R P O L L I C I S B R EV I S garded when considering their locations. The attachments
Attachments: From the dorsal surface o f the ulna distal to on the forearm are often tender and are palpated through
abductor pollicis longus, interosseous membrane and extensor digitorum.
middle third of posterior radius to the dorsolateral base
of the proximal phalanx of the thumb and sometimes to
the distal phalanx EXT E N S O R I N D I C I S
Innervation: Deep radial (C7-8 or Tl) Attachments: From the posterior distal third of the ulna and
Muscle type: Phasic ( type II), weakens when stressed interosseous membrane to the extensor digitorum ten
Function: Extends and abducts the thumb don for the index finger
Synergists: For extension: extensor pollicis longus, abductor Innervation: Deep radial (C7-8)
pollicis longus Muscle type: Phasic ( type 11), weakens when stressed
For abduction: abductor pollicis longus Function: Ex tends the index finger and wrist
Antagonists: To extension: flexor pollicis longus and brevis Synergists: For extension of indexfinger: extensor digitorum
To abduction: adductor pollicis For extension of wrist: extensor carpi radialis brevis and
longus, extensor digitorum, extensor d igiti minimi
For radial deviation: flexor carpi ulnaris
EXT E N S O R PO L L I C I S LO N G U S
Antagonists: To finger extension: flexor digitorum superfi
Attachments: From the middle third of the dorsal surface of cia lis and profundus
the ulna and the interosseous membrane to the base of To wrist extension: flexor carpi radialis and ulnaris, flexor
the distal phalanx of the thumb digitorum superficialis and profw1dus, palmaris longus
I nnervation: Deep radial nerve (C7-8)
Muscle type: Phasic (type II), weakens when stressed
I n d i cations for treatment
Function: Extends the distal phalanx of the thumb, extends
the proximal phalanx and metacarpal and adducts the Limitation of flexion of index finger
first metacarpal. Platzer (2004) notes it dorsiflexes and Pain in radial side of dorsal wrist extending to but not
radially deviates the hand i nto finger
Synergists: For extension: extensor pollicis brevis, abductor
pollicis longus
For abduction: abductor pollicis longus
Antagonists: To extension: flexor pollicis longus and brevis It N MT F O R D E E P POSTE R I O R F O R EA R M
To abduction: adductor POllicis The bellies o f abductor pollicis longus and extensor pollicis
brevis are palpated with short, 3-4 inch (7.5-lO cm) gliding
strokes on the radial side of the distal forearm as the tissues
I n d i cations for treatment
are pressed against the underlying bone. The diagonally
Pain at the base of the thumb oriented fibers are more easily palpated where they overlie
Loss of range or pain during flexion of the thumb the bone and become less distinct after they pass deep to the
Pain with thumb movement extensor digitorum. Their attachments along the ulna may
Tenderness to direct palpa tion be tender and are often palpable when the muscles are
tested against resistance.
Abductor pollicis longus and extensor pollicis brevis, as
Speci a l notes well as extensor pollicis longus and extensor indicis, may
These three thumb muscles, joined by the flexor pollicis also be influenced with gliding strokes tha t offer increased
longus (deep layer of anterior forearm), work with five pressure through the overlying extensor digitorum.
i n tr i n s i c thu mb m u scles to provide a n amazing mobi lity Transverse snapping palpation may be used through the
which greatly exceeds that of the fingers. When this highly extensor digitorum, provided it is not too tender. Since most
mobile digit interacts with the fingers, simple acts (such as muscles of the forearm refer their trigger point pa tterns
1 3 Shoulder, arm and hand 529
Arthritic conditions are broadly d ivided into i nflammatory and Some researchers have identified a connection between both
non-inflam matory forms, although the latter (such as osteoarthritis) seronegative spondyloarthropathies and seropositive rheumatic
often have periods of i nflam matory activity. conditions and bowel overgrowth with specific bacteria - for
Some of the major cha racteristics of i nflam matory a rthritis exa mple, ankylosi ng spondyl itis is commonly associated with
include: Klebsiella overgrowth and rheumatoid a rth ritis with Proteus
(which is also commonly associated with b ladder i nfections i n
joints are stiff i n the morn ing, usually with a g radual reduction i n
women) (Ebri n ger 1 988).
stiffness during the day
Infectious a rt h ritis may be caused by gonococcal (or non-gono
the affected joints are swollen and painful
coccal) bacterial i nfection and, more rarely, by viral or fu ngal
rest eases the pain and activity exacerbates it
agents. Usua l l y only one joint is i nvolved and this will be swollen
with rheumatoid arthritis, the commonest form of i nflammatory
and tender. Other symptoms may i nclude fever, chills and skin
arth ritis, there is usually a symmetrical d istribution (i.e. both
lesions. The patient is usually young and sexually active.
hands and/or elbows and/or knees, etc.).
I nfectious arthritis is regarded as a medical emergency although
Examination commonly reveals warmth, redness, a degree of synovia l fatal outcomes have declined as physicians have become more
thickening, deformity, swel ling, weakness o f associated m uscles and aware of the n eed for ra pid flu id drainage from the joint together
loss of range of motion. with appropriate antibiotic thera py.
All diagnosis shou ld be based on evidence wh ich builds a c l i nical Juvenile rheu matoid arthritis may affect only a few joi nts and is
picture and which ulti mately confirms the l i kelihood of a condition. usually chara cterized by the a bsence of rheu matoid factor and
For exa mple, laboratory tests can confirm a n arthritic cond ition but anti n uclear antibodies. Older boys who a re also HLA-B27 positive
may sometimes be related to conditions other than rheumatic ones. (see a n kylosi ng spondylitis a bove) may progress to develop AS.
Crysta l-induced a rthritis usually occurs in middle age or later.
Elevated sedi mentation rate (present in a l l types of i nfla mmation
Commonly o n ly a single joint is affected. The cond ition is either
and infection including i nflam matory arthritis)
true or pseudo-gout with the diagnosis being made by micro
Positive antinuclear antibodies (a lmost always present in rheuma
scopic exa m i nation of the synovia l fl uid to identify the type of
toid arthritis)
crystal.
Abnormal creatine phosphokinase may (or may not) confirm
polymyositis
Non-inflammatory a rthritis
Rheumatoid factor is com monly found in asymptomatic people
Osteoa rthritis (OA) is usually caused by a combination of joint
over the age of 60
'wear and tear' together with an i n herited tendency (transmitted
A combi nation of features, sym ptoms and tests is therefore req u i red by autosomal dominant genes in women) which produces defects
before a suitably qual ified and licensed i ndividual can make a i n col lagen synthesis (Knowlton 1 990).
diag nosis. Primary genera lized osteoarth ritis affects any (and someti mes a l l)
of the joints of the extremities.
Radiographic evidence Sometimes obvious overuse relating to occupational stresses
Inflammatory rheumatic conditions usu a l ly show x-ray evidence clearly contributes to the sites affected by OA. Leg length d is
of erosion, osteopenia, loss of joint substance. In other words, crepancy seems to contribute to the evolution of OA on the long
there is a 'subtractive' picture - tissue has 'd imin ished'. leg side.
Non-i nflammatory rheumatic conditions, such as osteoarthritis, Erosive OA involves self-limiting inflammation affecting the distal
tend to display an 'additive' picture, where an increase in bone interphala ngeal joi nts, producing erosion at the marg i ns and pos
has taken place (osteophytes, for example). sible fusion.
toward the joints that they serve, it would be reasonable to extrinsic muscles. The intrinsic muscles of the hand are con
assume that these would as well, but clear patterns have yet sidered in three groups.
to be established for these muscles.
1. Thumb muscles include thenar muscles abductor pollicis
-
All of these muscles are served by the ulnar nerve except for The dorsal ex tensor expansion, a fibrous branching of the
abductor pollicis brevis, opponens pollicis, superficial head ex tensor digitorum tendon on the posterior aspect of the
of flexor pollicis brevis, and the 1st and 2nd lumbricales, proximal phalanges, plays an important role in association
which are all innerva ted by the median nerve. None is nor with the intrinsic muscles. It is into this ex tension that the
mally served by the radial nerve. interossei, lumbricales and abductor digiti minimi fibers
merge, to act upon the fingers. This expansion forms a 'ten
don hood' that moves proximally and distally respectively
as the finger is extended and flexed to assist in movement of
the finger.
A
T H E NA R M U S C L ES A N D A D D U CTO R PO LLI C I S
The abductor pollicis brevis arises from the scaphoid tuber
cle, trapezium, flexor retinaculum and the tendon of abduc
tor pollicis longus to attach to the radial sesamoid bone,
base of the first proximal phalanx (thumb) and the dorsal
digital expansion of the thumb. It provides palmar abduc
B
tion, which abducts the thumb at right angles to the palm.
Opponens pollicls, lying deep to abductor pollicis brevis,
F i g u re 1 3 . 1 22 ARB: The dorsal extensor expa nsion forms a 'tendon arises from the flexor retinaculum and tubercle of the trape
hood'. Reprod uced with permission from Gray's Anatomy (2005). zium and a ttaches to the entire length of the first
A5 ------
C3 ------------
A4 ------7_--_7--
C2 -------- -+---r-----...;--:O---!-- Cleland's ligament
A3-----r----7_--J
C1 ------
-=-"--+--"-------::-----:------+------------------- Grayson's tigament
A2 -------+---'l,--'---'-
1 st dorsal
Long ftexor tendons -------Ill" r------interosseous
----- Adductor pollicis
eili
Recurrent branch of
Superficial branch of ulnar nerve -------- " =::-""-------------- median nerve
Deep branch of ulnar nerve -------':;---'-'''\' i
Guyon's canal -----------=
;-::---- Flexor retinaculum
Palmar cutaneous branch of ulnar nerve ---------:.=-----+-.....
Palmar cutaneous branch of median nerve ----,., -r--;'41hLf-r ----- Abductor pollicis brevis
Ulnar nerve --------..,
I-+--:r---#,'_r7"--- Median nerve
Ulnar artery --------''--;,L-,6r.
Figure 1 3 . 1 23 Pa l m a r aspect of hand, su perficia l layer with palmar fascia removed. A = fi brous arch; C = cruciate ( cross-shaped ) ligaments.
Reproduced with perm ission from Gray's Anatomy (2005).
13 Shoulder. a rm and hand 53 1
metacarpal's radial margin and its palmar surface. It pro sesamoid bone) shared with the first palmar in terosseous
vides adduction, opposition and flexion of the thumb. muscle, which attaches to the base of the proximal phalanx
Flexor pollicis brevis, lying medial to abductor pollicis of the thumb. It adducts and assists in opposition and flex
brevis, has a superficial head arising from the flexor retinac ion of the thumb.
ulum and trapezium tubercle and a deep head arising from In summary, the following muscles contribute to the
the trapezoid and capitate bones. These two heads merge listed movement:
together into a tendon attaching to the radial sesamoid bone
and base of the first phalanx. It flexes, abducts and adducts adduction - adductor pollicis, flexor pollicis brevis,
the thumb. opponens pollicis
Adductor pollicis arises from an oblique head, which abd uction - abductor pollicis brevis, flexor pollicis brevis
attaches to the capi tate, bases of 2nd and 3rd metacarpals, opposition - opponens pollicis, flexor pollicis brevis,
palmar carpal ligaments and the tendon sheath of flexor adductor pollicis
carpi radialis, and a transverse head, which attaches to the reposition (return to neutral) - extrinsic thumb muscles
distal two-thirds of the 3rd metacarpal. These two tendons (extensor pollicis brevis, extensor pollicis longus, abduc
converge into a common tendon (which contains a tor pollicis).
Area of distribution of
superficial branch of ulnar
nerve in hand
Dorsal view
Figure 1 3. 1 24 Pa l mar aspect of hand w i th superficial m uscle layer and pa l mar fascia removed. Reprod uced with perm ission from Gray's
Anatomy for Students (2005).
532 C L I N ICAL A P P L I CATI O N OF N EU R O M USCULAR T EC H N I Q U ES : T H E U PP E R B O DY
Figure 1 3. 1 2 5 Deep structu res of the palm and wrist. Reproduced with perm ission from Gray's Anatomy (2005).
HYPOTH E NA R E M I N E N C E M ETACA R PA L M U SC L E S
Palmaris brevis attaches the skin of the ulnar border of the Dorsal interossei (4) arise from two adjacent metacarpal
hand to the flexor retinaculum and palmar aponeurosis. It bones to insert into the base of the proximal phalanx of the
deepens the hollow of the palm by making the hypothenar adjacent (medial) finger and its tendon expansion. They flex
eminence more prominent. the metacarpophalangeal joints and extend the interpha
Abductor digiti minimi arises from the pisiform, tendon langeal joints, abduct the fingers from the mid-line of the
of flexor carpi ulnaris and pisohamate ligament and divides hand and can rotate the digit at the metacarpophalangeal
into two slips, one of which attaches to the ulnar margin of joint.
the base of the 5th proximal phalanx while the other merges Palmar interossei (4) arise from the medial aspects of the
into the dorsal digital expansion of the extensor digiti min 1 st, 2nd, 4th and 5th metacarpal bones and attach to the
imi. It serves to abduct the little finger. extensor expansion (and possibly the base of the proximal
Flexor digiti minimi brevis lies next to abductor digiti phalanx) of the same digit. They flex the metacarpopha
m inimi and arises from the hook of the hamate and the langeal joints and extend the interphalangeal joints, adduct
flexor retinaculum to a ttach to the ulnar margin of the base the fingers toward the mid-line of the hand and can rotate
of the 5th proximal phalanx . It flexes the metacarpopha the digit at the metacarpophalangeal joint.
langeal joint of the 5th digit. Lumbricales (4) arise from each of the tendons of flexor
Opponens digiti minimi arises from the . hook of the digitorum profundus and course to the radial aspect of the
hamate and the flexor retinaculum to attach to the entire metacarpal bone of the same finger, where each attaches to
ulnar margin of the 5th metacarpal. It brings the 5th digi t the respective extensor expansion (tendon hood). The lum
into opposition with the thumb. bricales extend the interphalangeal joint and may weakly
1 3 Shoulder, arm and hand 533
Opponens
" N MT F O R PA L M A R A N D D O R SA L H A N D
The treatment o f the hand may be performed with the
patient lying supine or seated across the table from the prac
titioner. The surface of the table may be needed to support
the hand when pressure is applied.
With the hand supine, the thenar eminence is grasped
between the thumb and finger of the same hand (Fig.
13.127). This is most easily applied if the thumb is relaxed
and mildly, passively flexed. Each of the thenar muscles
may be compressed and examined for tenderness in their
Heberden's bellies, at thumb-width intervals. Flat palpation against the
nodes underlying tissue and metacarpal is also useful as well as
flat compression of the tendon a ttachments.
The muscles lying in the web of the thumb are most eas
ily compressed with one digit on the palmar surface and the
other on the dorsal surface. The compression techniques
should be applied alongside the thumb as well as the index
finger.
The hypothenar muscles are compressed in a similar
manner, using pincer compression and fla t compression.
Very mildly lubricated, short gliding strokes can be applied
to the hypothenar muscles as well as the entire palmar sur
Abductor digiti face of the hand.
minimi
The beveled pressure bar is used to examine the interos
Figure 1 3. 1 26 Heberden's nodes at the dista l phalangeal joi nts sei muscles by wedging it between the metacarpals and
may be associated with t rigger poi nts in interossei. Drawn after angling it toward the bones (a beveled typewriter eraser
Simons et al ( 1 999). may be substituted). Gentle friction is applied at tip-width
intervals to each palmar and dorsal interossei muscle. The
flex the metacarpophalangeal joint. In addition, they appear small pressure bar may also be used to scrape the palmar
to have a significant role in proprioception based on their fascia and to apply very short, 'scraping' type strokes to
numerous muscle spindles and long fiber length (Gray's each joint of the fingers (unless contraindica ted by arthritis,
Anatomy 2005). inflammation, infection or pain) (Fig. 13.128).
534 CLI N I CAL A P P L I CATI O N OF N E U R O M USCU LAR T EC H N I Q U E S : T H E U PP E R BODY
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van Hilten B, van de Seek W-J, Hoff J et al 2000 intrathecal Bone and Joint Surgery 77(3):366-372
baclofen for the treatment of dystonia in patients with reflex Weiner W 2001 Can peripheral trauma induce dystonia? No'
sympathetic dystrophy. New England Journal of Medicine Movement Disorders 1 6 ( 1 ) : 13-22
343(9):625-630 Wilson F R, Wagner C, Homberg V 1993 Biomechanical abnormali
Viikari-Juntura E, Silverstein B 1999 Role of physical load factors in ties in musicians with occupational cramp/ focal dystonia.
carpal tunnel syndrome. Scand inavian Journal of Work, Journal o f Hand Therapy 6(4) :298-307
Environment and Health 25(3):163-185 Woodward T, Best T 2000 The painful shoulder: part I. C l inical eval
Walther D 1988 Applied kinesiology. Systems DC, Pueblo, CO uation. American Family Physician 61 (10) :3079-3088
Ward R (ed) 1997 Foundations for osteopathic medicine. Williams Xerri C, Merzenich M, Jenkins W et al 1999 Representational plas
and Wilkins, Balti more ticity in cortical area 3b paraBeling tactual-motor skill acquisi
Warfel J 1985 The extremities, 5th edn. Lea and Febiger, tion in adult monkeys. Cerebral Cortex 9(3):264-276
Philadelphia
539
Chapter 14
The thorax
The posterior aspect of the thorax is represented by a mobile and records that articular discs or little 'menisci' of syn
func tional unit - the thoracic spinal column - through ovial tissue are found in these costal joints, as in almost all
which the sympathetic nerve supply emerges. In addition, other synovial articulations of the spinal column.
the thorax acts as a protective cage for the hear t and lungs, Erwin et al (2000) have also reported the presence of large
inside which respiratory function, with its powerful lym intraarticular inclusions or 'meniscoids' in the costover
phatic and circula tory influences, occurs. Muscular attach tebral joint complexes.
ments to the thorax that serve other areas are numerous and The thoracic facet joints, which glide on each other and
include muscles of the shoulder, neck and lower back. The restrict and largely determine the range of spinal move
extrinsic thoracic musculature is responsible for positioning ment, have typical plane-type synovial features, includ
the torso and, therefore, a lso the placement in space of the ing an articular capsule.
shoulders, arms, neck and head. The intrinsic thoracic mus Hruby et al (1997) describe a useful method for remem
cles move the thoracic vertebrae or the rib cage (and possibly bering the s tructure and orientation of the facet joints:
the entire upper body) and / or are associated with respiration.
The degree of movement in all directions (flexion, exten The superior facets of each thoracic vertebrae are slightly con
sion, sideflexion and rotation) allowed by the relatively rigid vex and face posteriorly (backward), somewhat superiorly
struc ture of the thorax is less than that available in the cer (up), and laterally. Their angle of declination averages 60
vical or lumbar spines, being deliberately limited in order to relative to the transverse plane and 20 relative to the coronal
protect the vital organs housed within the thoracic cavity. plane. Remember the facet facing by the mnemonic, 'BUL'
(backward, upward, and lateral). This is in contrast to the
cervical and lumbar regions where the superior facets face
backwards, upwards, and medially ('BUM'). Thus, the
STRUCTURE
superior facets [of the entire spine] are BUM, BUL, BUM,
from cervical, to thoracic, to lumbar.
ST R U CT U RA L F EAT U R E S O F TH E TH O RA C I C S PI N E
In most individuals the thoracic spine has a kyphotic (for
ward bending) profile that varies in degree from individual
to individual.
The thoracic spinous processes are especially prominent --
f
and therefore easily palpated. C2
The angles of orientation of the thoracic spinous processes
are increasingly caudad, from Tl to T9, with a modification
toward an almost horizontal orientation from TlO to Tl2.
The transverse processes from Tl to TlO carry costotrans
verse join ts for articulation with the ribs.
Edmonston & Singer (1997) have reported that degenera
tion and osteophyte forma tion can be seen in these joints
by the third and fourth decades of life. Figure 1 4.2 Facet angles. Orientation of zyga pophysea l joi n ts.
Grieve (1988) describes acute fixations of the rib joints Reprodu ced with permission of the Cha rtered Society of
which show all the characteristics of synovial joint locking, Physioth e ra py from Physiotherapy 1996; 81(12}:724-729.
--->._
...l. _ Facet for articulation
As with most synovial joints, small intra articular synovial Ribs 11 and 12 do not articulate with the sternum (,float
folds (IASFs), also known as meniscoids, may be located ing ribs'), whereas all other ribs do so, in various
within the thoracic zygapophyseal (facet) joints (Singer ways, either by means of their own cartilaginous
et aI1990) . synovial joints (i.e. ribs 1-7 are 'true ribs') or by means
Grieve (1988) comments that the facet joints of the thoracic of a merged cartilaginous structure (ribs 8-1 0, which
spine contain meniscoid structures like those found in are 'false ribs').
the cervical spine. The head of each rib articulates with its thoracic vertebra
Bogduk & Engel (1984) cite European literature that at the costovertebral joint.
describes fibrous annular menisci as being well devel Ribs 2-9 also articulate with the vertebrae above and
oped in the thoracic spine. below by means of a demifacet.
In the thoracic zygapophyseal jOints, the IASFs originate Ribs 1, 11 and 12 articulate with their own vertebrae by
medially from the ligamentum flavum, or laterally from means of a unifacet.
the fibrous joint capsule, and extend towards the medial Typical ribs (3-9) comprise a head, neck, tubercle, angles
joint cavity. These structures may act as passive space and shafts and connect directly, or via cartilaginous struc
fillers during axial rotation (Bogduk & Engel 1984, Singer tures, to the sternum
et aI1990) . A typical ribs and their key features include:
Additionally, there are larger fibroadipose synovial folds 1. rib 1 which is broad, short and flat, the most curved .
that project between the articular surfaces (Singer et a l The subclavian artery and cervical plexus are anatom
1990). ically vulnerable to compression if the 1st rib becomes
Bogduk & Engel (1984) also describe these structures compromised in relation to the anterior and / or mid
in the lumbar zygapophyseal joints. They have been dle scalenes, or the clavicle
implicated by Bogduk & Jull (1984) in their meniscus 2. rib 2 carries a tubercle that attaches to the proximal
extrapment theory of acute locked lumbar spine. Since portion of serratus anterior
these structures also exist in the thoracic spine it is possi 3. ribs 11 and 12 are atypical due to their failure to
ble that meniscus extrapment may also occur in the articulate anteriorly with the sternum or costal
thoracic spine. cartilages.
The disc structure of the thoracic spine is similar to that
of the cervical and lumbar spine. The notable difference
is the relative broadness of the posterior longitudinal lig STR U CT U R A L F E ATU R E S O F TH E ST E R N U M
ament, which, together with the restricted range of motion There are three key subdivisions of the sternum.
potential of the region, makes herniation of thoracic discs
an infrequent occurrence. 1. The manubrium (or head), which articulates with the clav
Only a small proportion of all disc disease occurs in the icles at the sternoclavicular joints. The superior surface of
thoracic spine, generally estima ted at about 1-2%, mainly the manubrium (jugular notch) lies directly anterior to the
in the fourth decade. Onset is usually insidious, with 2nd thoracic vertebra. The manubrium is joined to the
trauma being a causative factor in a minority. Many will body of the sternum by means of a fibrocartilaginous sym
often report a long history of months or years of symp physis, the sternal angle (angle of Louis) which lies directly
toms (Arce & Dohrmann 1985). anterior to the 4th thoracic vertebra.
Grieve (1988) mentions that the etiology of the thoracic 2. The body of the sternum provides the attachment sites
disc lesion is primarily degenerative, and affects, in par for the ribs, with the 2nd rib attaching at the sternal
ticular, the lower thoracic spine. angle. This makes the angle an important landmark when
Edmonston & Singer (1997) comment that disc space nar counting ribs.
rowing at multiple levels is a common finding from the 3. The xiphoid process is the 'tail' of the sternum, joining i t
third decade of life, and is associated with d isc degenera a t the xiphisternal symphysis (which fuses i n most peo
tion, decreased d isc height and osteophyte formation, ple during the fifth decade of life) - usually anterior to
particularly in the mid-thoracic segments. the 9th thoracic vertebra.
Degenerative changes due to osteoporosis and aging, as
well as trauma, are relatively common in this region.
PO STERIOR THORAX
STR U CTU RAL F EATU R E S O F TH E RIB S
The thorax can be described both structurally and function
The ribs are composed o f a segment o f bone and a costal ally in order to make sense of i ts numerous complex fea
cartilage. tures. It can be thought of in terms of a thoracic spinal
The costal cartilages a ttach to the costochondral joint of column as well as a thoracic cage. Each approach will have
most ribs (see variations below), depressions in the bony features and functions that are considered both separately
segment of the ribs. and together.
542 C LI N I CAL A P P L I CATI O N O F N E U R O M USCULAR TECH NIQU ES: T H E U PP E R B O DY
In regional terms, the thoracic spine is usually divided degrees of addi tional coupled extension also occur in the
into (White & Panjabi 1978): lower thoracics during rotation (Grice 1980).
1. upper Tl-4 where, at each segment, approximately 4 of
-
Lacrimal gland
..
.. GY-
....
.
.
.
Eye
Gray rami
communicantes
1- .... ............1..........
C
... ... Parotid gland
.... ...........
Larynx
Trachea
Bronchi
Lungs
T1
Heart
Kidneys
L1 --
I ntestines
Descending colon
Sigmoid cclon
Rectum
S1 --
Urinary bladder
Prostate
Preganglionic fibres
Figure 1 4.3 Visceral pathology can refer pain to associated somatic tissues, as illustrated here rega rd ing hea rt pa i n referra ls i nvolving Tl-4.
Drawn after Netter (2006).
suggests someone far older than the chronological age of the abdominal excursion is altered by the proximity of the
the individ ual . anterior ribs and pubis.
With SSS the gluteus maximi tend to be deconditioned
and weak because of limited hip extension. The hamstrings
S PI N A L S E G M E NTS
commonly tighten due to the modified gait, while the abdom
inal muscles are inclined to be deconditioned and weak. The The process of facilitation, described in Chapter 6, results in
thoracolumbar spine becomes excessively stiff due to spinal spinal segments - and their paraspinal musculature - becom
osseous-viscoelastic resistance . As a result, respiration will ing dysfunctional in response to nociceptive bombardment
be compromised due to reduced diaphragmatic activity, as from the organs they supply when the organs become
544 CLI N ICAL A P PLICAT I O N O F N E U RO M USCULA R TECH N I QUES: THE U PPER B O DY
diseased or distressed (BeaI 1985). Clinically the practitioner It is suggested that such palpation be performed on peo
may consider that a paraspinal region involves a facilitation ple with and without known cardiovascular dysfunction,
process when the soft tissues fail to respond to normal treat in order to develop a degree of discrimination between
ment procedures. In such circumstances consideration of normal and abnormal tissue states of this sort.
visceral involvement is warranted and organ pa thologies It is also suggested that the 'red reflex' assessment method
may need to be ruled out. (discussed below) be performed to evaluate its ability
to identify areas of reflexively active tissue (possibly
facilitated).
Segmental facilitation example
Myron Beal DO, Professor in the Department of Family
HOW ACCU RATE A R E CO M M O N LY U S E D
Medicine at Michigan State University, College of
PAL PATI O N M ETH O D S?
Osteopathic Medicine, conducted a study in which over 1 00
pa tients with diagnosed cardiovascular disease were exam Three types of palpation of the thoracic spine, commonly
ined for patterns of spinal segment involvement (BeaI 1983). used by therapists and practitioners, were evaluated for
Around 90% had 'segmental dysfunction in two or more accuracy (Christensen et al 2002):
adjacent vertebrae from T1 to T5, on the left side'. More than
1. motion palpation with patient prone, evaluating joint play
half also had left-side C2 dysfunction. Beal reports that the
2. motion palpation with patient seated for end-play restric
estimation of the intensity of the spinal dysfunction corre
tion, for example involving lateral flexion or rotation
lated strongly with the degree of pathology noted (ranging
3. paraspinal palpation for tenderness (or altered tissue
from myocardial infarction, ischemic heart disease and
texture).
hypertensive cardiovascular disease to coronary artery dis
ease). He further reports that the greatest intensity of the It was found that, in regard to the motion palpation assess
cardiac reflex occurred at T2 and T3 on the left. The texture ments, 'an experienced observer can achieve acceptably low
of the soft tissues, as described by Beal, is of interest: 'Skin hour-to-hour and day-to-day variability after a training ses
and temperature changes were not apparent as consistent sion as long as exact anatomic localization is less important
strong findings compared with the hypertonic state of the than the presence or absence of a positive finding in the tho
deep musculature.' racic spine'.
The major palpatory finding for muscle was of hyper Brismee et al (2006) examined the reliability of a passive
tonicity of the superficial and deep paraspinal muscles with physiological intervertebral motion (PPIM) test of a mid
fibrotic thickening. Tenderness was usually thoracic spinal segment. They were able to demonstrate
this was not specifically assessed in this study. Superficial that PPIM testing demonstrated a fair to substantial degree
hypertonicity lessened when the patient was supine, mak of interrater reliability (see Figs 14.1 and 14.4).
ing assessment of deeper tissue states easier in that position.
PA LPATI O N M ETH O D F O R U P P E R TH O RA C I C
S E G M E NTAL FAC I LITATI O N
With the patient supine, the thoracic spine is examined
by the practitioner (who is seated or standing at the head
of the table) by sliding the fingers of both hands (one on
each side of the spine) under the upper thoracic trans
verse processes.
An anterior compressive force is applied with the fingers
(Fig. 14.4) to assess the status of the superficial and deep
paraspinal tissues and the response of the transverse
process to the 'springing'.
This compression is performed, one segment at a time,
progressively down the spine, until control becomes dif
ficult or tissues inaccessible.
A positive test (indicating probable facilitation of the seg
ments being tested) would involve a 'wooden', non-elastic
response to the springing effort produced by the fingers,
involving two or more segments.
It is also possible to perform the test with the patient seated
or sidelying, though neither is as accurate as the supine Fig ure 14.4 Springing assessment for tissue resistance associated
position. with segmental facilitation.
14 The thorax 545
Overall the evidence suggests that manual assessment regard to diagnosing spinal tenderness in the thoracic
can be as accurate as mechanized measuring methods, if the spine'.
practitioner is welJ trained. When the accuracy of the An Australian study (Fryer et a12004) found that the nature
paraspinal tenderness palpation was assessed, the findings of abnormal paraspinal tissue texture located by palpation
were that 'after some training, it is possible to obtain an was not readily identifiable, although palpation for tender
acceptably low intra- and interobserver variability with ness can commonly reliably locate dysfunction. The
researchers note that although li ttle direct evidence exis ts of
the nature of clinically detected paraspinal tissue texture change,
the concept of reactive muscle contraction appears plausi
ble (Solomonow et al 1998). In other words, when palpating
paraspinal musculature, tenderness can quite accurately be
identified, and while this is associated with a different 'feel'
of the tissues, exactly what that difference is cannot be accu
rately iden tified with any certainty.
As with so much in manual therapy assessment, these
studies suggest that it is wise to be cautious, and to attempt
to correlate one set of findings with others before deciding
on a therapeutic plan.
R E D R E F L E X A S S E SS M E N T ( R EACTIVE
HY P E R E M I A)
Late in the 19th century Carl McConnell DO ( 1962) stated:
Figure 14.5 G raphic representation of the position of the t h u m b of I begin at thefirst thoracic [vertebral and examine the spinal
the practitioner blocki ng the rotation of the spinous process of T7 column down to the sacrum by placing my middle fingers
and fee l i n g the seg mental motion of rotation of T6 spinous process over [each side of] the spinous processes and standing directly
on T7 with the t i p of the thu mb. Reproduced with perm ission from back of the patient draw theflat surfaces of these two fingers
Brismee et al (2006). over the spinous processes from the upper thoracic to the
Figure 14.6 Thoracic PPIM testing proce d u re. A: Passive extension of the thoracic spine into T6-7 spinal seg ment. B: Sidebending toward the
practitioner into T6-7 spinal seg ment. C : Rotating opposite to the side of sidebe n d i n g until the practitioner detects with the thumb the
beg i n n i n g of seg mental rotation in the T7 spinous process and eva l u a tes seg mental rotation of T6 vertebra on T7. The sa me proced u re can be
repeated with the practitioner rema i n i n g on the same side of the patient and perform i n g s i m i l a r extension and rotation motions, but
sidebending the patient i n a d i rection i psilateral to the side of rotation. Reprod u ced with perm ission from Brismee et a l (2006).
546 C L I N I CA L A PP L I CAT I O N O F N E U R O M US C U LA R TECH N I QU E S : T H E U P P E R B O DY
sacrum in such a manner that the spines of the vertebrae pass Hruby et al (1997) describe the thinking regarding this
tightly between the two fingers; thus leaving a red streak phenomenon:
where the cutaneous vessels press upon the spines of the ver
tebrae. In this manner slight deviations of the vertebrae lat Perform the red reflex test byfirmly, but with light pressure,
erally can be told with the greatest accuracy by observing stroking two fingers on the skin over the paraspinal tissues
the red line. When a vertebra or section of vertebrae are too in a cephalad to a caudad direction. The stroked areas briefly
posterior a heavy red streak is noticed and when a vertebra become erythematous and almost immediately return to their
or section of vertebrae are too anterior the streak is not so usual color. If the skin remains enjthematous longer than a feu)
noticeable. seconds, it may indicate an acute somatic dysfunction in the
area. As the dysfunction acquires chronic tissue changes,
In the 1 960s Hoag (1 969) wrote: the tissues blanch rapidly after stroking and are dnj and cool
to palpation.
With firm but moderate pressure the pads of the fingers are
repeatedly rubbed over the surface of the skin, preferably with The reader is reminded that Hilton's law (see p. 3) confirms
extensive longitudinal strokes along the paraspinal area. The simultaneous innervation to the skin covering the articular
appearance of less intense and rapidly fading color in certain insertion of the muscles, not necessarily the entire muscle.
areas, as compared with the general reaction, is ascribed to
increased vasoconstriction in that area, indicating a distur
bance in autonomic reflex activity. Others give significance B I O M E CHA N I CS O F R OTATI O N I N TH E
to an increased degree of erythema or a prolonged lingering TH O RA C I C S PI N E
of the red line response. In the cervical spine between C3 and C7 a coupling occurs,
in which sidebending and rotation take place toward the
Upledger & Vredevoogd (1983) suggest:
same side (type 2).
Skin texture changes produced by a facilitated segment are There is a great deal of disagreement among experts as to
palpable as you lightly drag your fingers over the nearby what is 'normal coupling behavior ' in the thoracic spine.
paravertebral area of the back. I [Upledger] usually do skin The upper four thoracic segments are said by some (Grice
drag evaluation movingfrom the top of the neck to the sacral 1 980) to behave in the same manner as the cervical spine
area in one motion. Where your fingertips drag on the skin (type 2) when the spine is in neutral (not flexed or
you will probably find a facilitated segment. After several extended), i.e. rotation and sidebending take place toward
repetitions, with increased force, the affected area will appear the same sides.
redder than nearby areas. This is the 'red reflex'. Muscles This is contradicted by Grieve (1981) who says that
and connective tissues at this level will: between T3 and no, 'in neutral and extension, sidebend
ing and rotation occur to opposite sides (type 1). In flex
1. have a 'shotty' feel (like buckshot under the skin) ion, they occur to the same side (type 2)'.
2. be more tender to palpation The mid-thoracic segments also represent a confusing
3. be tight, and tend to restrict vertebral motion, and mixture of types in their coupling behavior, so that dur
4. exhibit tenderness of the spinous processes when tapped ing sidebending, rotation may occur to either the concave
by fingers or a rubber hammer. (type 2) or the convex side (type 1), depending on whether
the spine is in flexion, extension or neutral.
Korr (1970) described how this red reflex phenomenon cor
The lower thoracic coupling pattern is generally agreed to
responded well with areas of lowered electrical resistance,
be similar to the lumbar spine (type 1 ) in which sidebend
which themselves correspond accurately to regions of low
ing and rota tion coupling are toward opposite sides (e.g.
ered pain threshold and areas of cutaneous and deep ten
sidebend right, rotation of vertebral body left).
derness (termed 'segmentally related sympa theticotonia').
Korr was able to detect areas of intense vasoconstriction
that corresponded well with dysfunction elicited by manual
clinical examination.
Grieve (1981) comes to the rescue of the (by now) confused Confirmation of findings in this test is available by obser
practitioner, by saying that it is wise 'to allow the joints of vation - see stages 9 and 1 0 of the C-curve observation
individual pa tterns to speak for themselves, in the prime test, below.
matter of the na ture and direction of the most effective
therapeutic movement'. He suggests that, 'individual
O BS E RVAT I O N O F R E STR I CTI O N PATT E R N S I N
responses and clinical assessment should take precedence
TH O RA C I C S PI N E ( C- C U RVE O BS E RVAT I O N TE ST)
over "theories of biomechanics'''.
The patient is seated on the table with the legs fully
extended, pelvis vertical, and bends into fu l lest flexion
C O UP L I N G TEST possible.
A sequential (C-shaped) curve should be observed when
In order to establish the specific coupling pattern in an indi
the profile of the spine is viewed from the side with the
vidual segment, the following simple sidebending and rota
patient in full flexion.
tion palpa tion procedure is used.
No knee flexion should take place and all movement
The patient is seated or standing with arms folded on should be spinal .
chest, hands on opposite shoulders. Any areas of 'fla tness' should be noted as these represent
The practitioner stands behind and to the side of the regions where normal flexion of one segment on the
patient and passes an arm across the chest to cup the other is a bsent or reduced.
patient's hand that is resting on the opposite shoulder. The pa tient then sits with knees flexed, thus relaxing
The practi tioner 's other hand is placed so that the index hamstrings, and again bends into fullest flexion possible
and middle fingers lie on one side and the ring and small with hands resting on the crest of the pelvis.
fingers on the other side, wi th the fingertips pointing Observation from the side should indicate which seg
cephalad para llel with the thoracic spinal segment under ments remain unable to move fully into flexion.
review. If there is a greater degree of flexion possible in this posi
A horizontal line drawn through the fingertips would tion (knees flexed) as compared to that noted with knees
place them on a line dissecting the one collectively repre straight, then hamstring restriction is a factor.
sented by the spinous processes, although not necessar All flat a reas should be charted.
ily the spinous process of the one tha t is being assessed The practitioner should at this time view the spine from
due to the inclination of the thoracic spinous processes. the perspective gained by looking at it along its length,
These fingers monitor the rotational pattern followed by from the head or from the lower lumbar area, while the
the segment when i t is sidebent. patient is flexed.
The practitioner introduces slight sideflexion precisely at Segments that are in a rotated state will be easily identi
the segment, by means of contact on the pa tient's shoul fied and the direction of their rotation observed by
der, and repeats this in both directions as the rotational means of the rotational devia tion caused by their trans
response, which has to accompany sideflexion, is verse processes. The transverse processes and ribs will
palpated. produce a 'mounding' or fullness on the side toward
If 'fullness' (,backwards pressure') is noted on the side which the vertebra has rotated. Any such findings can be
toward which sideflexion is taking place, this represents a compared with those of the palpation evaluation (cou
type 2 response. If sideflexion is toward the right and the pling test described above), which palpates for fullness
fingers on the right register greater pressure or 'fullness' during sideflexion.
during this movement, this indicates that the body of
that vertebra has rotated toward the right (the concavity)
B R EATH I N G WAVE ASS E SS M E NT
so that the right side of the transverse process is produc
ing the fullness, pressure, on the palpating fingers. The patient should now be placed lying prone, ideally
Alternatively if, on right sideflexion, fullness is noted on with the face in a cradle or padded hole, for comfort and
the left, this indicates that rotation of the vertebral body to avoid cervical rotation (Fig. 14.7).
is toward the left side (the convexity) and the palpated The operator squats at the side and observes the 'spinal
response therefore represents a type 1 coupling. breathing wave' as deep breathing is performed (see
This same assessment can be carried out at each segment below). Areas of restriction, lack of movement or where
and with the spine in relative neutral, as well as flexion motion is not in sequence should be noted and com
and extension, to experience the variations in the biome pared with fi ndings from the observation of the C-curve
chanica I coupling responses that occur. (above).
This knowledge is of clinical value when attempting to Commonly, areas of the spine that appea r to move as a
increase range of motion in restricted segments, as will block during this evaluation are areas where there is lim
become clear when specific MET protocols are suggested ited flexion potential, as observed during the C-curve
toward this objective later in this chapter. assessment.
548 CLI N I CA L A P P L I CATI O N OF N E U RO M USCULAR TECH N I QU ES: T H E U P P E R B O DY
F L EX I O N AN D EXT E N S I O N ASS E SS M E N T
O F T1 -4
The patient is seated and the practitioner is standing to
the side with one hand on top of the patient's head.
Figure 14.7 Fu nctional (top) a n d dysfu nctional breathing wave
The practitioner's other hand is placed, palmar surface
movement patterns.
on the patient's posterior upper thoracic region, so that
the ring and middle fingers can be placed between the
spinous processes of three vertebrae (between T1 and T2
and between T2 and T3, for example).
B R EATH I N G WAVE - EVA L U AT I O N O F S PI N A L The hand on the head guides the neck into unforced flex
M OT I O N D U R I N G I NHALAT I O N/ EXHALAT I O N ion and extension until the palpating fingers note motion.
The patient is placed prone and the 'breathing wave' A normal response in both flexion and extension would
observed. be for the most cephalad segment to move before the
When the spine is fully flexible this wave-like motion more caudad one. It is worth recalling that the entire
commences in the lower lumbar region, near the sacrum, range of flexion /extension in these vertebrae is less
and spreads as a wave up to the base of the neck. than 5.
If there is restriction in any of the spinal segments or if The practitioner evaluates whether there is an appropri
associated muscles of the region are short and tight, the ate degree of separation of the spinous processes on flex
pattern will vary. ion and of closure on extension and also takes note of the
Movement may start somewhere else (the patterns quality of end-feel in these movements.
observed will differ as widely as the patterns of restric
tion in individual spines) so that areas which are lacking
F L E X I O N AN D EXTE N S I O N A S S E S S M E NT O F
in flexibility may be seen to move as a block, rather than
TS-12
as a wave.
Once the upper four segments (including movement
The observing practitioner should question: between T4 and T5) have been evaluated for flexion and
extension, the palpating fingers are placed between T5
Does movement start at the sacrum? and T6.
Does it start elsewhere? The practitioner passes the other arm across the patient's
Does it move caudad, cephalad or in both directions? upper chest to cup the opposite shoulder, enabling flexion
Where does the wave cease - in the mid-thoracic area or and extension to be controlled via this contact (control
as it should, at the base of neck? is further enhanced if the practitioner's axilla can con
How does this relate to the observations already made tact the superior aspect of the patient's ipsilateral
and the patient's symptoms? shoulder).
It is worth recalling that the entire range of flexion/
As spinal, rib or muscular restrictions are removed or extension in the lower eight segments ranges from approx
improved - by treatment or exercise - the breathing wave imately 6 (at T5) to 12 (at T12).
should be seen to gradually benefit, with the wave com The spine is sequentially flexed and extended as the
mencing closer to the sacrum and finishing closer to the practitioner evaluates whether there is an appropriate
neck. The breathing wave observation test can therefore be degree of separation of the spinous processes on flexion
used as a means of monitoring progress; it is not in itself and closure on extension and also takes note of the qual
diagnostic. ity of end-feel in these movements.
1 4 The t h orax 549
. .,. ':j
The practitioner stands on the prone patient's left side at the position) in rhomboids major and mi nor, infraspinatus, and a
level of the patient's waist, facing diagona l ly toward the head of number of sma l l er lamina muscles (Melzack 1 977).
the patient. A series of tsubo, or acupressure points, lie symmetrica l ly on
With the right hand resting at the level of the lower thoracic either side of the spine and a long the m id-line and are said to
spine where its function is to distract tissue, the left thumb com have great reflex i mporta nce (Serizawe 1 980).
mences a series of strokes cephalad from the mid-thoracic area, The Bladder meridian points lie in two lines running para llel with
immediately to the left of the spinous processes. the spine, one level with the medial border of the scapula a nd the
Each stroke covers two or three spinal segments and runs in a other mid-way between it and the lateral border of the spinous
cephalad direction, immediately lateral to the spinous process, so processes (Ma n n 1 971 ).
that the angle of pressure imparted, via the medial tip of the Goodhea rt's work suggests that rhomboid weakness indicates l iver
thumb, is rou gh ly toward the contra latera l n ipple. Note: While problems and that pressure on C7 spinous process and a point on
this series of strokes is cephalad, the pressure exerted by the the right of the interspace between the 5th and 6th dorsal spinous
thumb tip is not toward the floor, rather it angles toward the processes assists its normalization. Latissi mus dorsi wea kness
contralateral side. apparently indicates pancreatic dysfunction. Lateral to the 7th and
A series of light assessment and deep therapeutic strokes are 8th dorsal interspace is the posterior pressure reflex to normal ize
employed and a degree of overlap is suggested with successive this (Wa lther 1 988). These and other reflexes wou ld appear to
strokes (see Fig. 1 4.24). derive from Chapma n's reflex theories (Mannino 1 979, Owens
In this way the first two strokes might run from T8 to T5 followed 1 980). Caso (2004) has reported on the usefu l ness of these reflex
by two strokes (one light, one deeper) from T6 to T3 and fin a l ly points in assessment of a congen ita l intestinal abnormal ity. I n
two strokes from T4 to Tl . addition, research relating t o Chapman reflex points h a s demon
Deeper and more sustained pressure is exerted upon discovering strated a statistical ly significant relationship between the pres
marked contraction or resistance to the gl iding, probing thumb. ence of Chapman reflex points and pneumonia in hospitalized
In the thoracic area a second line of upward strokes is employed patients (Washington et al 2003). However, the findings of this
to include the spinal border of the scapula, as well as one or two research have been questioned (Testa 2006), rendering certainty as
searching, latera l ly directed, probing strokes along the inferior to the value of Chapman's reflexes inconclusive at this time.
spine of the scapula and across the muscu lature inferior to and Viscerosomatic infl uences that produce dysfunction of the erector
inserting into the scapula. spinae g roup of m uscles between the 6th and 1 2th thoracics
Treatment of the right side may be carried out without necessar ind icate liver involvement B ( eal 1 985).
ily changing position, other than to lean across the patient, as Sim i larly 4th, 5th and 6th thoracic area congestion or sensitivity
long as this causes no d istress to the practitioner's back. may involve stomach reflexes and gastric d isturbance, whereas
A shorter practitioner shou ld change sides so that, standing ha lf facilitation at the levels of Tl 2 a nd/or L2 indicates possible kid
facing the head of the patient, the right thumb can perform the ney dysfu nction.
strokes outlined above. The connective tissue zones affecting the arm, stomach, heart,
l iver and gallbladder are noted in this region (Ebner 1 962) and
What may be found? Chapman's neurolymphatic reflexes relating to the arm, thyroid,
Apart from trigger points in the lower trapezius fibers, other trig lungs, throat and heart are located in the upper thoracic spine,
ger points may be sought (while in this assessment/treatment including the scapular area (D iGiova nna 1 99 1 ) .
550 C L I N ICAL A P P L I CATI O N OF N EU RO M U SC U LAR TECH N I Q U ES : T H E U P P E R B O DY
Many spinal restrictions a re 'held' by soft tissue restrictions Category: Does breathing involve the diaph.ragm, the
and can be normalized by release of the soft tissue compo lower rib cage or both?
nent. Almost all the positions of assessment described above Locus of abdominal motion: Does it move as far as the
can immediately become the commencement positions for umbilicus or as far as the pubic bone?
the application of muscle energy techniques, via the introduc Rate: Rapid, slow? The rate should be recorded before
tion of isometric contractions, either toward or away from and after trea tment.
the restriction barrier, or by means of Ruddy's pulsed MET Duration of cycle: Are inhala tion and exhalation phases
procedures. See MET notes on pp. 199-200, which explain equal or is one longer than the other?
these concepts.
R ESP I RATO RY F U N CT I O N A S S E SS M E NT
Assessment of breathing function should begin by means
A NT ER IOR THORAX of palpa tion and observation with the patient both seated
and supine and should be accompanied by a general evalu
In earlier chapters emphasis has been given to the profound ation of overall posture and especially head, shoulder and
negative influence on emotions, structure and function when torso positioning. Treatment of associated myofascial tissues
breathing function is disturbed (Chapter 2). In purely struc will be enhanced by the addition of b reathing awareness
tural terms, Lewi t (1 999) states: 'The most important distur exercises tha t will, in part, reduce stressful loading of tissues
bance of breathing is overstrain of the upper auxiliary tha t are assisting in dysfunctional brea thing patterns.
muscles by l ifting of the thorax during quiet respira tion l
In order to normalize brea thing function, a focus is
Seated
required which evaluates structural and functional elements
and which offers appropriate therapeutic and rehabilita tion The patient places one hand on the upper abdomen and
approaches to wha t is revealed. the other on the upper chest (Fig. 14. 10). The hands are
1 4 The thorax 551
box continues
552 C L I N ICAL A P P L I CATI O N OF N EU RO M USCULAR TECH N I Q U E S : T H E U PP E R B O DY
observed as the person inhales and exhales several times. (midway between base of neck and tip of shoulder). The
If the upper hand (chest) moves superiorly rather than patient is asked to inhale and the practitioner notes
anteriorly and moves significantly more than the hand whether the hands move toward the ceiling significantly.
on the abdomen, this is noted as indicating a dysfunc If so, scalenes are exceSSively active and since these
tional pa ttern of upper chest brea thing. are (or may have become - see p. 314) type I postural
The practitioner stands behind the seated patient and muscles, the indication is that shortening will have
places both hands gently over the upper trapezius area occurred.
14 The thorax 553
Sidelying
Quadratus lumborum is assessed by palpation and obser
vation (leg abduction, look or palpate for 'hip hike') (see
Janda's functional assessment, p. 90) .
P rone
The practitioner observes the breathing wave - the
movement of the spine from the sacrum to the base of the
neck on deep inhalation, as described on p. 548.
Scapula stability is observed as the patient lowers the
torso from a push-up position. A normal functional eval
uation reveals the scapulae stable and moving medially
toward the spine. If, however, winging occurs or if either
or both scapulae move significantly cephalad then the
rhomboids and serratus anterior are weak and inhibited,
which could impact on respiratory function. A further
implication of weakness in these lower scapula fixators is
that the upper fixators (levator and upper trapezius in
Figure 1 4. 1 0 Hand positions for brea thing fu nction assessment. particular) will usually be overactive and short.
554 CLI N I CAL A PP L I CATI O N O F N E U R O M U SC U LAR TECH N I Q U E S : TH E U P PER B O DY
!
B
The patient inhales and exhales fully as the practitioner
observes movement of the fingers overlying the upper
ribs during pump handle motion.
Is movement symmetrical and equal as the inhalation
ends and as the exhalation ends?
Each rib from 1 to 6 is assessed individually in this manner.
The fingers are then placed on the mid-axillary lines and
bucket handle motion is observed in the same manner,
looking for asymmetry at the end of the inhalation and
exhalation phases.
Each of the lower ribs, down to the 10th, is assessed indi
vidually in this manner.
Ribs 11 and 12 are assessed with the pa tient prone, as
described above.
Dysfunctional patterns
If the ribs (fingers) rise symmetrically on inhalation, com
pleting the excursion at the same time, but on exhalation
one seems to continue falling toward its exhalation posi
tion after the other has ceased, then the one that ceased
Figure 1 4. 1 1 Movement of thoracic wa l l during breathing. A : Pu m p
moving earlier is regarded as an elevated rib, restricted in
handle movement o f ribs and sternum. B : Bucket h a n d l e movement its ability to exhale and 'locked' in the inhalation phase.
of ri bs. Reproduced with permission from Gray's Anatomy for Conversely, should the ribs commence inhalation together
Studen ts (2005). with one ceasing to rise while the other continues, then
the one that has ceased to rise is regarded as a depressed
exhalation to assess the comparative rise and fall of the ribs rib, restricted in its ability to inhale and 'locked' in the
on either side (pump handle movement, mainly in the five exhalation phase.
or six upper ribs) as well as lateral excursion (bucket handle
movement mainly in the lower six or seven ribs) . Treatment hints
The patient is supine and the practitioner stands at waist Most rib restrictions are found in groups of two or more,
level and places the middle or index fingers on the infe suggesting that they are in this state as a result of an
rior borders of the clavicle, 1 inch (2.5 em) or so lateral to adaptive compensation process (see Chap ter 5 for discus
the sternum. sion of adaptation patterns).
556 C L I N ICAL A P P L I CATI O N OF N EU RO M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY
When a single rib is found to be dysfunctional i t almost This 'key rib' concept has a long tradition in osteopathic
always can be shown to have resulted from direct trauma medicine.
rather than a compensation process.
In a group of depressed ribs, there is usually no need to
D I SC U S S I O N
release any rib other than the most superior (cephalad) of
the group. All the rib restrictions described are usually capable o f being
In a group of elevated ribs the most inferior (caudad) is usu successfully treated by either positional release or muscle
ally the key rib requiring treatment. If this is successfully energy approaches. NMT (as described for intercostal
achieved, the others in the group will release automatically. treatment) may also be beneficial. This suggests that the
An association has frequently been shown between thoracic outlet The possibility of a 2nd rib involvement should not disgu ise the
syndrome and 1 st rib restriction (Nichols 1 996, Tucker 1 994). possibil ity that this coexists with a true im pingement lesion.
However, a connection between 2 n d rib restriction and shoulder pain
has not been recorded i n the literature until recently. Pa l pation
Boyle (1 999) reports on two case h istories in which symptoms With the patient prone and the sca pula protracted to expose the
were present which resembled, in a l l respects (diagnostic criteria, angle of the rib, practitioner standing at the head of the table,
etc.), shoulder i m pingement syndrome or rotator cuff partial tea r, direct thumb pressure (both thumbs) a pplied at the angle of the
which responded rapidly to mobil ization of the 2nd rib. The patients rib in an a nterocaudal direction will demonstrate relative rigid ity,
both had positive tests for shoulder impingement, implicating compared with normal rib motion. This palpation will probably
supraspinatus and/or bicipital tendon dysfunction (see I mpingement produce pain if the rib is dysfu nctional.
test description below). The test for assessment of depressed rib function is described on
Boyle (1 999) describes evidence to support the way(s) in wh ich pp. 554-555.
2nd rib restrictions (in particular) might produce fa lse-positive test
results and give rise to shoulder symptoms. Treatment possi b i l ities and choices
The dorsal ra mus of the 2nd thoracic nerve contin ues laterally to If the posterior aspect of the 2nd rib is 'subluxated' superiorly,
the acrom ion, providing a cutaneous d istribution in the region because of a combination of excessive activity and subsequent
of the posterolateral shoulder (Maigne 1 99 1 ). hypertonicity and shortness of the rhomboids and/or the poste
Rotational restrictions i nvolving the cervicothoracic region have rior sca lene m uscles, NMT attention to these should assist in res
been shown to produce a variety of neck and shoulder symptoms. olution of the problem.
Since the 2nd rib a rticu lates with the tra nsverse process ofT1 If the posterior aspect is 'subluxated superiorly', this will automat
(costotransverse joi nt) and the superior border of T2 (costoverte ically produce a 'depressed' rib appearance a nteriorly, i.e. the rib
bral joi nt), rotational restrictions of these vertebrae could pro will be relatively locked in its exhalation phase. Positional release
duce rib dysfu nction (Jirout 1 969). and MET methods exist to assist in releasing such restrictions.
Habitual overactivity involving scalenus posterior can produce Boyle describes a treatment method (successfu l in both the cases
'chronic subluxation of the 2nd rib at its vertebral articulation' reported) based on Maitla nd's ( 1 986) oscillatory mobilization
(Boyle 1 999). This could resu lt in a superior glide of the tubercle technique.
of the 2nd rib at the costotransverse ju nction. 1 . The patient lies prone, with the scapula on the side to be
Boyle reports that 'true' i mpingement syndrome is often related treated passively protracted.
to overactivity of the rhomboids which wou ld 'downwardly rotate 2. Thumb pressure (both thumbs adjacent to each other), suffi
the scapula', impeding elevation of the h umerus at the g leno cient to take out a l l slack, is applied to the angle of the rib in
h umeral joint. an anterocaudal d i rection.
He suggests that rhomboid overactivity m ight a lso impact on 3. Depending on the degree of acuteness, oscillatory movements
the upper thoracic region as a whole (Tl -4), locking these are applied using a small or a large amplitude. A series of
seg ments into an extension posture. If this situation were ra pid, rhythmic osci l lations is executed for 30-60 seconds,
accompanied by overactivity of the posterior scalene, the 2nd rib repeated three or more times, u ntil retesting indicates
might 'subl uxate superiorly on the fixed thoracic segment', lead improved mobility.
ing to pa in and dysfu nction m imicking shou lder impingement 4. Attention to the m usculature, particularly the posterior sca
syndrome. lene and possibly serratus a nterior m uscles, is ind icated.
Boyle hypothesizes that mechanical interference might occur
involving 'the dorsal cutaneous branch of the 2nd thoracic nerve I m p ingement syndrome test
... in its passage through the tunnel adjacent to the costotrans The patient is supine with the arms at the sides with the elbow
verse joint'. This nerve might be 'drawn taut, due to the superior on the side to be tested flexed to 90' and internally rotated so
anterior subl uxation of the 2nd rib', leading to pain and associ that the forearm rests on the patient's abdomen.
ated restricted movement symptoms. The practitioner places one hand to cup the shoulder in order to
The reason for a fa lse-positive impingement test, Boyle suggests, stabil ize it, while the other hand cups the flexed elbow.
relates to the i nternal rotation component, which adds to A com pressive force is applied through the long axis of the
the mechanical stress of the dysfu nctional rib area. This cou ld h u merus, forcing the humerus against the inferior aspect of the
a lso, through pain in hibition, result i n rotator cuff m uscles test acromion process and glenohu meral fossa.
ing as weak, suggesting incorrectly that a partial tea r had If symptoms are reproduced or if pain is noted, supraspinatus
occurred. and/or bicipital tendon dysfunction is indicated.
1 4 The thorax 557
muscular ('soft tissue') component of these restrictions is a aponeurosis, iliocostalis lumborum and iliocostalis tho
major influence on their continued existence. racis (among others).
Puckree et al (2002) examined nine healthy subjects as to 2. Gluteus maximus force is transmitted superiorly via the
changes in tidal volume, breathing frequency and inspira lumbodorsal fascia and latissimus dorsi.
tory / expiratory durations when stretch was applied to
Gracovetsky (1997) continues:
selective intercostal muscles.
Inspiratory Ie stretch of either the third or eighth Ie space As a consequence, firing hip extensors extends and raises
resulted in a slower, deeper breathing pattern and phase the trunk in the sagittal plane. The chemical energy liber
dependent increases in diaphragm and parasternal Ie activ ated within the muscles is now converted, by the rising
ity. . . . The enhancement of inspiratory muscle activity In) Ie trunk, into potential energy stored in the gravitationalfield.
stretch is most likely due to stimulation ofIe muscle spindles. When a person is running, so much energy needs to be
stored that the necessary rise in the center of gravity forces
They suggest stretch applied to in tercostal muscles of some the runner to become airborne.
patients with pulmonary disorder may al ter breathing suf
ficiently to improve gas exchange. The authors of this text A more detailed review of these and other gait-related influ
suggest that this may be enhanced even further if combined ences is to be found in Volume 2 of this text.
with NMT, MET, PR and other techniques described in this The intrinsic thoracic muscles are largely responsible for
book, and those of postural corrections as described in movement of the thoracic spinal column or cage, as well as
Volume 2. respiratory function. Though many of these muscles have
very short fibers and therefore may appear relatively unim
portant, they are strategically placed to provide, or initiate,
precisely directed movement of the thoracic vertebrae and / or
THORAC IC TREAT ME NT TECH N I QUE S ribs. They therefore demand due attention in the develop
ment of treatment plans.
Positioning and movements of the thorax and upper body
are strongly influenced by muscles that attach to the lower
back and pelvis. These extrinsic muscles of the thorax move
PO STERIOR S U PER FICIAL T HORACIC M U S C LES
it as a unit and offer it many options when postural com
pensa tions are necessary. While many osseous elements of When viewing the posterior thorax, the trapezius is imme
the lower body influence upper body posture, such as leg diately obvious as it lies superficially and ex tensively covers
length differential or anterior pelvic tilt, the muscles which the upper back, shoulder and neck. In addition to trapezius,
most readily adjust the position of the torso for these and the la tissimus dorsi - which superficiaUy covers the lower
other compensations include erector spinae, quadratus lum back, as well as the rhomboids, serratus anterior and pec
borum, obliques, psoas and rectus abdominis, all of which toralis major and minor - should be assessed and treated
are discussed in detail in Volume 2 of this text. prior to the development of a thoracic protocol since they
Interesting new research shows tha t many of the m uscles overlie the deeper tissues to be examined and may also be
supporting and moving the thorax and / or the spinal seg involved. They are all discussed in Chapter 13, which dea ls
ments (including erector spinae) prepare to accommodate with the upper ex tremity.
for subsequent movement as soon as arm or shoulder activ A complex array of short and long extensors and rotators
ity is initiated, with deep stabilizing activity from transver lies deep to the more superficial trapezius, latissimus dorsi
sus abdominis, for example, occurring miniseconds before and the rhomboids.
unilateral rapid arm activity (Hodges & Richardson 1997).
Those muscles that support and laterally flex the spinal
Stabilization of the lumbar spine and thorax has been
column (including erector spinae group) a re oriented for
shown to depend, to a large extent, on abdominal muscle
the most part vertically.
activity (Hodges 1999). These concepts are explored in more
Those muscles that rotate the column (such as multifidi)
detail in Volume 2 of this text.
are oriented more diagonally.
Gait significantly involves the spine in general and the
thoracic spinal muscles in particular. Gracovetsky (1997) Platzer (2004) further breaks these two groups into lateral
reports: (superficial) and medial (deep) tracts, each having a vertical
(intertransverse) and a diagonal (transversospinal) compo
In walking, the hip extensors fire as the toe pushes the nent. It is useful to envisage this subdivision, especially
ground. The muscle power is directly transmitted to the spine when assessing rotational dysfunctions, as the superficial
and trunk via two distinct but complementary pathways. rotators are synergistic with the contrala teral deep rotators.
1. Biceps femoris has its gait action extended by the sacro The la teral (superficial) tract consists of the iliocostalis
tuberous ligament, which crosses the posterior superior and longissimus groups and the (cervical) splenii mus
iliac spine and continues upwards as the erector spinae cles, with the vertical components bilaterally ex tending
558 CLI N ICAL A P P L I CATI O N OF N E U RO M U S C U LAR TECH N I Q U E S : T H E U P PER B O DY
/-11'-10\-.=.__
. --- - Longissimus cervicis
Iliocostalis thoracis
I liocostalis ----.,."..-7"'H-
The trigger points for these vertical muscular columns refer treatment is indicated. Later in the protocol, when the inter
caudally and cranially across the thorax and lumbar costal muscles are examined, the practitioner may encounter
regions, into the gluteal region and anteriorly into the chest tender a ttachment sites that appear to lie in the erectors.
and abdomen (Fig. 14. 16). Marking each tender spot with a skin-marking pencil may
The erector spinae system is discussed more fully in the reveal vertical or horizontal patterns of tenderness. Clinical
second volume of this text due to its substantial role in experience suggests that horizontal patterns often represent
postural positioning and its extensive attachment to, and intercostal involvement, as they are segmentally innervated,
influence on, the lumbar and sacral regions. Its thoracic whereas vertically oriented p atterns of tenderness usually
components warrant its mention here and its numerous relate to the erector spinae muscles.
attachments onto the ribs require that it be released before Vertical lines of tension imposed by the erector system
the deeper tissues are examined. While a more extensive can dysfunctionally distort the torso and contribute signifi
treatment of erector spinae may be necessary, the practi cantly to scoliotic patterns, especially when unilaterally
tioner can apply NMT strokes (described below) in order to hypertonic. Leg length differential, whether functional
assess tenderness in the muscles and to note if a lengthier or structural, may need attention in order to sustain any
560 C LI N I CA L A P P L I CATI O N OF N EU R O M USCULAR TECH N I Q U E S : T H E U P PER B O DY
Spinous process of C7 -
- --- --,It''4TfT1
4 .:;...
;
EI- Levatores(short,
costarum
long)
Multifidus ------flH'-A
\-I<'\--'t--- t ntertransversarius
-
-'-....'f--- Erector spinae
long-term improvement in the myofascial tissue brought positions of balance and the body's cen ter of gravity is
about by treatment or exercise. altered. The patient's home-care use of stretching, applied
The posterior fascial lines (of potential tension) which to the neck, shoulder girdle, lower back and pelvis, coupled
run from above the brow to the soles of the feet (see fascial with postural exercises, should be designed to normalize
chains, p. 11) are a critical line of reference to altered biome the induced adaptational changes.
chanics of the spine and thorax. There may be widespread
effects on postural adaptation mechanisms following any
, N MT : POST E R I O R TH O RAC I C G LI D I N G
substantial release, for example, of the middle portion (erec " T E CH N I Q U E S ( F I G . 1 4. 1 7)
tor group) of tha t posterior line. If the lamina myofascial tis
sues are also released, the tensegrity tower (the spine) could Long, gliding strokes may be applied to the posterior thorax
then more effectively adapt and rebalance. However, the w ith the patient prone and with the practi tioner posi tioned
practitioner should note that following such a series of at the head end of the table (facing caudally) or near the
releases, a requirement for structural adaptations will be waist or lower ribs (facing cranially). By posi tioning at the
imposed on the body as a whole, as the arms move to new head, the practitioner 's own body weight can be centered
1 4 The thorax 56 1
--t----(J...--I+-_+_ T1 1
/
Y
Longissimus thoracis
--+++---A---+- T10, 11
(or near centered) over the tissues in order to avoid back (e.g. in reducing anterior pelvic positioning) when glides
strain during application of the techniques. The glides may be are applied toward the pelvis over lines of normal myofas
reapplied in two or three shorter vertical segments, one after cial tension, such as those provided by the erector group.
the other. Clinically there appear to be postural benefits Lengthening these lines, between the upper thorax and
562 CLI N I CAL A P P L I CATI O N OF N EU RO M U SCU LA R TEC H N I Q U E S : TH E U P P E R B O DY
most important tools in neuromuscular therapy. Treatment Function: Acting unila terally, it rotates the spine contralat
of this sort can beneficially influence segmental spinal erally; bila terally, it extends the spine
mobility, postural integrity and the potential for tensegrity Synergists: For rotation: multifidi, rota tores, ipSila teral
processes to function more effectively in dealing with the external obliques and external intercostals and contralat
stresses and strains to which the body is exposed . eral internal obliques and internal intercostals
A repeat of these gliding strokes at the end of the session For extension: posterior spinal muscles (precise muscles
will allow a comparative assessment, which often demon depending upon what level is being extended)
strates the changes in the tissues (and discomfort levels) to Antagonists: To rotation: matching contrala teral fibers of
the practitioner as well as the patient. semispinalis as well as contralateral multifidi, rota tores,
Many muscular a ttachments will be assessed with the external obliques and external intercostals and the ipsi
use of a small pressure bar, or finger friction, applied to the lateral internal obliques and internal intercostals
lamina groove, as described below. These attachments may For extension: spinal flexors (precise muscles depending
include trapezius, rhomboids, latissimus, splenii, spinalis, upon what level is being extended)
semispinalis, multifidus, rotatores and serratus posterior
superior and inferior, depending upon which spinal level is
being examined . Determining exactly which fibers are Indications for treatment of spinalis and
involved is sometimes a difficult task and success is based semispinalis
strongly on the practitioner 's skill level and knowledge of Reduced flexion of spine
anatomy, including the order of the multiple layers overly Restricted rotation (sometimes painfully)
ing each other and their fiber directions. Fortunately, the tis Pain along spine
sue response is not always based on the practitioner's Tenderness in lamina groove
ability to decipher these fiber arrangements (especially in
the lamina) and the tender or referring myofascia may
prove to be responsive, even when tissue identification is M U LTI FIDI ( F I G S 1 4. 1 8 , 1 4. 1 9)
unclear.
Not every muscle attaching to the lamina is discussed Attachments: From the posterior surface or the sacrum,
below, as some have been detailed together with the iliac crest and the transverse processes of all lumbar and
descriptions of the upper extremity and / or the cervical thoracic vertebrae and articular processes of cervicals
region. Because of an overlap in their actions and influ 4-7; these muscles traverse 2-4 vertebrae and attach
ences, additional coverage of many of these muscles is superiorly to the spinous processes of all vertebrae apart
found in volume 2 of this text, which deals with the lower from the a tlas
Innervation: Dorsal rami of spinal nerves
body. Most of the remaining deeper muscles of the thorax
Muscle type: Postural (type I), shortens when stressed
are either discussed here or together with the muscles of
Function: When these contract unilaterally they produce
respiration.
ipsilateral flexion and contralateral rotation; bilaterally,
they extend the spine
S PI N A LIS T H O RACIS Synergists: For rotation: multifidi, semispinalis, ipsilateral
Attachments: Spinous process of T11-L2 to the spinous external obliques and external intercostals and contralat
process of T4-8 (variable) eral internal obliques and internal intercostals
I nnervation: Dorsal rami of spinal nerves
For extension: posterior spinal m uscles (precise muscles
Muscle type: Not established
depending upon wha t level is being extended)
Antagonists: To rotation: matching contralateral fibers
Function: Acting unilaterally, flexes the spine laterally;
bilaterally, extends the spine of rotatores as well as contralatera l multifidi, semi
Synergists: For lateral flexion: ipsilateral semispinalis,
spinalis, external obliques and external intercostals
longissimus and iliocostalis thoracis, iliocostalis lumbo and the ipsila teral internal obliques and internal
rum, quadratus lumborum, obliques and psoas intercostals
Antagonists: To lateral flexion: contralateral semispinalis,
For extension: spinal flexors (precise muscles depending
longissimus and iliocostalis thoracis, iliocostalis lumbo upon wha t level is being extended)
rum, quadratus lumborum, obliques and psoas
y
Antagonists: To rotation: matching contralateral fibers of
Serratus posterior
rotatores as well as contralateral multifidi, semispinalis,
superior --------:;l
external obliques and external intercostals and the ipsi
lateral internal obliques and internal intercostals
For extension: spinal flexors (precise muscles depending
upon what level is being extended)
Levator
costae brevis --hb"""""'c-;;;;-""'-7f'r Ind ications for treatment
Pain and tenderness of associated vertebral segments
Tenderness to pressure or tapping applied to the spinous
Levator processes of associated vertebrae
costae longus -++--r'=--
Special notes
Multifidi and rota tores muscles comprise the deepest layer
of the laminae and are responsible for fine control of the
Multifidi ----1-+-_----"'-11'/
rotation of vertebrae. They exist through the entire length of
the spinal column. In addition, the multifidi also broadly
attach to the sacrum, after becoming appreciably thicker in
the lumbar region.
Figure 1 4. 1 9 Levatores costae elevate a n d 'spin' ribs d u ring
i n h a l ation. These muscles are often associated with vertebral seg
ments that are difficult to stabilize and should be addressed
throughout the spine when scoliosis is present, along with
R OTATO R E S LO N G U S A N D B R EVI S
the associated intercostal muscles and pelvic positioning.
( s e e F I G . 1 4. 1 9)
Note: Balance mechanisms seem to strongly influence the
Attachments: From the transverse processes of each verte evolution of scoliosis. Unilateral labyrinthine stimulation
bra to the spinous processes of the second (longus) and (or removal) results in scoliosis, pointing to the relationship
first (brevis) vertebrae above (ending at C2) between the righting reflexes and spinal balance (Michelson
Innervation: Dorsal rami of spinal nerves 1 965, Ponsetti 1 972). In one study, the majority of 1 00 scoli
Muscle type: Postural (type I), shortens when stressed otic patients were shown to have associated equilibrium
Function: When these contract unilaterally they produce defects, with a direct correlation between the severity of the
contralateral rotation; bilaterally, they extend the spine spinal distortion and the degree of proprioceptive and optic
Synergists: For rotation: multifidi, semispinalis, ipsila teral dysfunction (Yamada 1971).
external obliques and external intercostals and contralat Discomfort or pain provoked by pressure or tapping,
eral internal obliques and internal intercostals applied on the spinous processes of associated vertebrae, a
For extension: posterior spinal muscles (precise muscles test used to identify dysfunctional spinal articulations, also
depending upon what level is being extended) often indicates multifidi and rotatores involvement. Trigger
1 4 The thorax 565
points in rotatores (see Fig. 14. 18) tend to produce rather patients, when compared with healthy volunteers
localized referrals whereas the multifidi trigger points refer (Parkkola 1993).
locally and also to the suboccipital region, medial scapular Hides et al (1994) showed that there was unilateral, seg
border and top of shoulder. These local (for both) and dis mental wasting of multifidus in acute low back patients.
tant (for multifidi) patterns of referral continue to be These changes occurred rapidly and were not consistent
expressed through the length of the spinal column. In fact, with 'disuse atrophy' .
the lower spinal levels of multifidi may even refer to the Other researchers have shown type 1 fiber hypertrophy
anterior thorax or abdomen. on the symptomatic side and type 2 atrophy bilaterally in
Local tissue changes in these important muscles (multi multifidus, in chronic low back pain patients (Fitzmaurice
fidi and rotatores), including chronic hypertonus and 1992).
ischemia that are precursors to the evolution of trigger
points, may result from segmental facilitation (see p. 544).
, NIVI T F O R T H O RA C I C (A N D L U M BAR)
When segmental facilitation occurs, as a result of either " LAMI N A G RO OV E M U S C L ES
organ disease (i.e. involving viscerosomatic reflexes) or
spinal overuse factors, the local musculature becomes hyper To prepare the superficial posterior thorax for treatment of
tonic. Denslow (1944) first described this phenomenon, as the tissues that lie deep to them, lubricated gliding strokes
follows: 'Motor neuron pools in spinal cord segments related may be applied repeatedly with one or both thumbs in
to areas of somatic dysfunction were maintained in a state of the lamina groove and then alongside the lamina from Tl to
facilitation.' He later concluded (Denslow et al 1947): the sacrum or iliac crest. The thumbnail is not involved in the
'Muscles innervated from these segments are kept in a state stroke nor allowed to encounter the skin, as the thumb pads
of hypertonus much of the day with inevitable impediment are used as the treatment tool (see p. 184 for hand positioning
to spinal motion.' These concepts were confirmed by and cautions in gliding). Each gliding stroke is applied sev
research in later years, especially by Korr (1976). eral times from Tl through the sacrum while progressively
Elkiss & Rentz (1997) summarize: increasing the pressure (if appropriate) with each new stroke.
The lubricated glides are applied alternately to each side
In the early stages [offacilitation} a continued barrage (noci
until each has been treated 4-5 times with several repeti
ceptive, proprioceptive, autonomic) and a widening zone of
tions each time. Excessive pressure on the bony protuber
involvement maintain the state of chronic facilitation. With
ances of the pelvis and the spinous processes throughout
chronic lesions a more lasting mechanism must be at work.
the spinal column should be avoided. Progressive applica
Sustained patterns of excitability and synaptic transmission
tions usually encounter less tenderness and a general soft
become learned behavior in the spinal cord and brain . . . [and
ening of the myofascial tissues, especially if moist heat is
there will be} increased signs of somatic dysfunction.
applied to the tissues while the contralateral side is being
In practice this means that tense, ta ut paraspinal tissues that treated. Unless contraindicated, a hot pack may be placed
are unresponsive to normal treatment procedures should alternately on each side while the other side is being treated
always be considered to possibly involve facilitation and to so as to 'flush' the tissues between applications of strokes.
require further investigation as to underlying causes. The fingertip (with the nail well trimmed) may be used to
Multifidus should co-contract with transversus abdo friction or assess individual areas of isolated tenderness and
minis to assist in low back stabilization (Richardson & Jull to probe for ta ut bands that house trigger points. Trigger
1995), which suggests that any chronic weakness (or atro points lying close to the lamina of the spinal column often
phy) is likely to impact strongly on spinal stability. While refer pain across the back, w rapping around the rib cage,
shortness and tightness are obvious indicators of dysfunc anteriorly into the chest or abdomen and frequently refer
tion, it is therefore important, when considering muscular 'itching' patterns. The trigger points may be treated w ith
imbalances, to also evaluate for weakness. Actual atrophy static pressure or may respond to rapidly alternating appli
of the multifidi has been reported in a variety of low back cations of contrasting hot and cold (repeated 8-10 times for
pain settings (see below). Liebenson (1996) observes: 10-15 seconds each), always concluding with cold (see
hydrotherapy notes in Chapter 10).
The initial muscular reaction to pain and injury has tradi The beveled pressure bar (as described in Box 14.7) may
tionally been assumed to be an increased tension and stiff also be used to assess the fibers attaching in the lamina (Fig.
ness. Data . . . indicates inhibition is at least as significant. 14.20). The tip of the bar is placed parallel to the midline
Tissue immobilization occurs secondarily, which leads to and at a 45 angle to the lateral aspect of the spinous process
joint stiffness and disuse muscle atrophy. of Tl. In this way it is 'wedged' into the lamina groove where
cranial to caudal to cranial friction is applied at tip-width
Atrophy and fibrosis of multifidus are associated with intervals. The assessment begins at T1 and the process con
disc herniation in the lumbar spine (Lehto et aI 1989). tinues to (but not onto) the coccyx. Each time the pressure
Increased fatty deposits in multifidus ('fatty metaplasia') bar is moved, it is lifted and placed at the next point, which
was a common finding in a population of low back pain is a tip width further d own the column. The beveled tip is
566 C L I N I CA L APPLICATI O N OF N E U RO M USCULAR TEC H N I QU E S : T H E U PP E R BODY
/
/ " --'
The pressure bars are NEVER used on extremely tender tissues,
/
at vulnerable nerve areas (such as the clavicular area) or to /, /
PR M ET H O D F O R PA RASPI N A L
M U S C U LATU R E : I N D U RAT I O N TE C H N I Q U E
( C h a i t o w 2 0 0 2 , M o rr i s o n 1 9 69)
The practitioner stands on the side of the prone patient
opposite the side in which pain has been discovered in
paraspinal tissues.
Tender or painful points (lying no more lateral than the
tip of the transverse process) are palpated for the level of
their sensitivity to pressure.
Once confirmed as painful, the point is held by firm
thumb pressure and the patient is told that the pain being
(
felt represents a score of '10'.
With the soft thenar eminence of the other hand, the tip
of the spinous process most adj acen t to the painful point
is very gently eased toward the pain (ounces of pressure
only), crowding and slackening the tissues in which the
Figure 1 4.20 A beveled rubber tip pressure bar can be used in the tender point is being palpated until pain reduces by a t
lamina groove to assess the many layers of tissues that attach there. least 75%.
Pressure on the spinous process, extremely lightly directed
not used as a gliding tool, although it is sometimes used to toward the painful point, should lessen the degree of tis
'scrape' tissue, such as the palmar fascia. The short frictional sue tension and the sensitivity.
stroke may also be applied unidirectionally (in either direc If it does not do so, then the angle of 'push' on the spinous
tion), which sometimes more clearly defines the fiber direc process toward the painful spot should be varied slightly,
tion of the involved tissue. The location of each involved so that, somewhere within an arc embracing a half circle,
segment may be marked with a skin-marking pencil so that an angle of push toward the pain will be found to abolish
it may be retreated several times during the session_ The the pain totally and will lessen the objective palpated
'collection' of skin markings may provide clues as to pat sense of tension.
terns of involved tissues. This position of ease is held for not less than 20 seconds
Friction may also be applied between spinous processes after which the next point in the paraspinal musculature
(pressure bar or fingertip) in order to treat the supraspinous is treated.
ligament ( throughout the spine) and the interspinalis mus If possible, Caymans' (1 980) principles relating to alter
cles (lumbar region only). Although the interspinales mus nate segmental response to inhalation and exhalation, as
cles are also present in the cervical region, the pressure bar outlined on p. 558, should be incorporated into the pro
is not used there as fingers provide a sufficient and more cedure. However, if holding of the breath (in or out)
precise treatment as well as protective of these more mobile causes the patient any distress, this aspect of the proce
vertebrae (see cervical region, pp. 243 and 321 ) . dure should be ignored_
1 4 The thorax 567
If the segment being treated is an odd one (i.e. T3,5,7,9,11), respiratory muscle mechanics, leading to diaphragmatic
the sidebend, which is being initiated by light pressure weakness. She points out that:
on the spinous process toward the painful point, should
All myopathies involving the thoracoabdominal and respi
involve the patient inhaling and holding thatfor as long as
ratory accessory muscles will impair breathing during sleep
is comfortable, during the 20 seconds or so of applied gen
and cause breathing pattern changes including hypoventila
tle pressure.
tion, obstruction, and central apnea. - Indeed, trigger points,
If the segment being treated is an even one (i.e. T2,4,6,8,
hypertonicity, myofascial restrictions, and resulting weakness
10,12), the sidebend, which is being initiated by light pres
could be considered myopathies; abnormal conditions or dis
sure on the spinous process toward the painful point,
ease of skeletal muscle. Exactly howfaulty breathing mechan
should involve the patient exhaling and holding that for
ics, along with hypocapnia and pH alterations, affect
as long as is comfortable, d uring the 20 seconds or so of
ventilation during nocturnal sleep in humans has yet to be
applied gentle pressure.
determined.
For Tl the phase of breathing is irrelevant and the patient
should breathe normally during the procedure.
A full spinal treatment is possible using this extremely S E R RATU S P O S T E RI O R S U P E RI O R
gentle approach which incorporates the same principles
as strain/ counterstrain (SCS) and functional technique, Attachments: Spinous processes o f C7-T3 t o attach t o the
with the achievement of ease and pain reduction as the upper borders and external surfaces of ribs 2-5, lateral to
treatment focus (see Chapter 10 for details of the princi their angles
Innervation : Intercostal nerves (T2-5)
ples involved).
Muscle typ e : Phasic (type II), weakens when stressed
There are no contra indications to this method, which
Function: Uncertain role but most likely elevate the ribs
was designed specifically for the fragile and sensitive
individual. (Gray's Anatomy 2005) and perhaps function primarily in
proprioception (Vilensky et al 2001)
Synergists: Diaphragm, levatores costarum brevis, scalenus
M US C L E S OF R E S PI RATI O N posterior
Antagonists: Internal intercostals
The deeper elements of the thoracic musculature represent
a remarkable system by means of which respiration occurs.
Some of these muscles also provide rotational components Indications for treatment
which carry similar, spiraling lines of oblique tension from
the pelvis (external and internal obliques) through the entire Pain that seems to be deep to the scapula
torso (external and internal intercostals), almost as if the Pain may radiate over the posterior deltoid, down the
ribs were 'slipped into' this supportive web of continuous back of the arm, ulnar portion of the hand and to the
muscular tubes. Rolfer Tom Myers (1997), in his brilliant smallest finger
'anatomy trains' concept (p. 11), describes the continuity Numbness into the ulnar portion of the hand
which occurs between these muscles (obliques and inter
costa Is) as part of his 'lateral line'. Above the pelvic crest this
myofascial network creates a series of crossover (X-shaped)
Special notes
patterns. Trigger points for serratus posterior superior lie hidden
under the vertebral border of the scapula. When the scapula
The obliques tuck into the lower edges of the basket of ribs.
is in the resting position, the trigger point is unavailable and
Between each of the ribs are the internal and external inter
may be missed d uring examination. Pressure of the scapula
costals, which taken all together form a continuation of the
imposed against the trigger point by the patient's sleeping
same 'X',formed by the obliques. These muscles, commonly
position may irritate and activate the trigger point. Displace
taken to be accessory muscles of breathing, are seen in this
ment of the scapula to reach the trigger point is imperative
context to be perhaps more involved in locomotion [and sta
and can be accomplished in a seated position (Simons et al
bility], helping to guide and check the torque, swinging
1 999) or the sidelying position offered here.
through the rib cage during walking and running.
The patient is supported in a sidelying position (see
See Chapter 1 for more of Myers' ideas. p. 316) with the affected arm uppermost. The arm is draped
Obstructive pulmonary diseases, neuromuscular diseases, across the patient's chest and the hand allowed to hang
poliomyelitis, obesity, heart failure and craniofacial anomalies toward the floor so that the scapula translates laterally as
are all risks for disordered breathing during sleep. Coffee far as possible. Having the patient curl the torso into flexion
(2006a,b) proposes that chronic hyperventilation syndrome may also assist in exposing more tissue.
(HVS) and other upper chest breathing pattern disorders If the scapula can be sufficiently protracted (best achieved
(BPD) are also risk factors for sleep apnea-hypopnea with the patient in sidelying posture), serratus posterior
because of persistent hypocapnia (in chronic HVS) and poor superior's rib a ttachments may be palpated j ust lateral to
568 CLI N I CAL A P P L I CATI O N OF N EU R O M USCULAR TECH N I Q U E S : T H E U PP E R B O DY
the angles of the ribs and medial to the vertebral border of S E R RATU S P O S T E RI O R I N F E RI O R
the scapula. However, this m uscle is often relatively thin
Attachments: Spinous processes o f Tll-L3 and the tho
and its fiber direction is similar to overlying tissues. The
racolumbar fascia to the inferior borders of the lower
practitioner is more likely to locate the exquisite tenderness
four ribs
of any trigger points that may be present, and reproduce
Innervation: Intercostal nerves (T9-12)
their referral patterns, than to locate the associated taut
Muscle type: Phasic (type II), weakens when stressed
bands, although sometimes these may be felt (Fig. 14.22).
Function: Depresses lower four ribs and pulls them posteri-
orly, not necessarily in respiration (Gray's Anatomy 2005)
Synergists: Internal intercostals
Antagonists: Diaphragm
Serratus posterior
superior Indications for treatment
Leg length differential
Rib dysfunction in lower four ribs
Lower back ache in area of the muscle
Scoliosis
Special notes
Trigger points in this muscle may produce lower back ache
similar to that of renal disease. While its trigger points and
attachments should be treated, kidney disease should also
be ruled out as the source of viscerosomatic referral, espe
cially when the myofascial pain keeps returning after treat
ment. The quadratus lumborum muscle, located nearby,
should also be examined. This is discussed in more detail in
Volume 2 of this text and is also considered on p. 93.
Figure 1 4.22 The target zone for serra tus posterior superior is CAUTION: As detailed earlier in this chapter, the lower
sign ifica nt w h i l e its h i dden trigger point often remains anonymous. two ribs are 'floating ribs', varying in length, and are not
Drawn after Simons et a l ( 1 999). attached anteriorly by costal cartilage. The distal ends of
the ribs may be sharp, requiring that palpation be carried
out carefully. Add itionally, excessive pressure is avoided,
especially in patients w i th known or suspected osteo
porosis due to possible fragility of the bones.
The practitioner's thumb can be used to glide laterally along
the inferior aspect of each of the lower four ribs (through the
latissimus dorsi fibers). The patient will often report tender
ness and a 'burning' discomfort as the thumb slides laterally.
Repetitions of the stroke usually rapidly reduce the discom
fort. Spot tenderness associated with a central trigger point
may be found but taut fibers are difficult to feel through the
overlying muscles (Simons et aI 1999).
exercised due to the fact that the tenderness may be the first of the neurovascular supply to the upper ex tremity and the
sign of an oncoming eruption. Though the condition is self pectoralis minor. Lief's NMT incorporates assessment and
limiting, inappropriate treatment of the tissues may irritate treatment of the lower intercostal spaces with the patient
the condition. supine, as part (usually the commencement) of an abdomi
A skin-marking pen may be used to record tender tissues nal NMT sequence. This is outlined fully in Volume 2 of
found during the palpa tion exercise below. Marking each this text.
tender spot may reveal vertical or horizontal patterns of In the la teral thorax, the region high in the axilla is avoided
tenderness. Horizontal pa tterns often represent intercostal due to lymph nodes. In the posterior thorax, caution is exer
involvement whereas vertically oriented patterns of tender cised regarding the floating ribs (noted with serratus poste
ness are usually indicative of erector spinae muscle rior inferior). Additionally, in the upper posterior thorax,
dysfunction. palpa tion of the intercostal space is obscured by overlying
tissue, and location of the intercostals may be unclear.
It N M T F O R I NT E RCOSTALS
Fingertip or thumb glides, as described in Box 14.8, are I N F LU E N CES O F A B D O MI N A L M U S C L E S
applied to the intercostal spaces of the posterior, lateral and
Like the erector system o f the posterior thorax, the abdomi
anterior thorax for initial examination as to tenderness and
nal muscles play a significant role in positioning the thorax
rib aligrunent. A beveled-tip pressure bar or fingertips may
and in rotating the entire upper body. They are also now
be used to friction the intercostal spaces and more precisely
known to play a key part in spinal stabilization and inter
located trigger points or tender tissue, or to address the tis
segmental stability, particularly transversus abdominis
sue specific to rib approximation when the intercostal space
(Hodges 1 999). The rectus abdominis, external and internal
is decreased. The pressure bar tip or fingertips can be
obliques and transversus abdominis are also involved in
pressed into the intercostal space (pressure toward the cen
respiration due to their role in positioning the abdominal
ter of the thorax) or angled superiorly or inferiorly against
viscera as well as depression of the lower ribs, assisting in
the rib attachments (if space allows) (Fig. 14.27).
forced expiration and especially coughing.
On the anterior thorax, all breast tissue (including the
While the abdominal muscles are discussed in detail in
nipple area on men) is avoided with the intercostal treat
Volume 2 of this text, the following brief NMT assessment
ment. Specific lymphatic drainage techniques may be applied
of their uppermost fibers and a ttachments to the ribs will
to the breast area but the frictional techniques used in this
assist the practi tioner in determining if a more thorough
procedure are inappropriate for breast tissue. Additionally,
examination is warranted. Stretching and strengthening
the area cephalad to the breast is avoided due to the location
of the abdominal muscles is indicated in many respiratory
and postural dysfunctions, as they are often significantly
involved. Additional (to NMT) assessment methods are
also detailed in Volume 2 .
NMT A S S E S S M E N T
When these overlying muscles are hypertonic, they may By holding tissues in their 'loose' or ease positions and
prevent penetration into the underlying diaphragm and waiting for a release (usually 30-90 seconds), the practi
positional release or muscle energy techniques may be used tioner can encourage changes which will allow more nor
instead or to prepare for subsequent NMT. mal diaphragmatic function, accompanied by a relaxation
of associated soft tissues.
PR O F D I A P H RAG M ( F I G . 1 4. 2 8 )
The patient i s supine and the practitioner stands a t waist It M ET R E LEAS E F O R D IA P H RAG M
level facing cephalad and places the hands over the The same assessment procedure is carried out as for
lower thoracic structures w ith the fingers along the lower positional release above. However, rather than seeking
rib shafts. the direction of ease for rotation and sideflexion of
Treating the structure being palpated as a cylinder, the the thorax, the 'tight' (most restricted) directions are
hands test the preference this cylinder has to rotate identified.
around its central axis, one way and then the other. 'Does This time, by sidebending and rotating toward the tighter
the lower thorax rotate more easily to the right or the left?' directions, the combined directions of restriction are
Once the rotational preference has been established, the engaged, at which time the patient is asked to inhale and
preference to sidebend one way or the other is evaluated. hold the breath and to 'bear down' slightly (Valsalva
'Does the lower thorax sideflex more easily to the right or maneuver).
the left?' These efforts introduce isometric contractions of the
Once these two pieces of information have been estab diaphragm and intercostal muscles.
lished, the combined positions of ease, so indicated, are On release and complete exhalation and relaxation,
introduced. the diaphragm should be found to function more
For example, the rotation may well be easier toward the normally, accompanied by a relaxation of associated soft
(patient's) right. This is therefore gently introduced by tissues.
the practitioner, followed, while still in that position, by
whichever sidebending preference was indicated during
testing, possibly toward the left. I NT E R I O R T H O RAX
In this way a compound (stacked) position of ease (or D I A P H RAG M
bind) can be established (see functional technique discus
sion, Chapter 10). Attachments: Inner surfaces of lower six ribs and their
costal cartilages, posterior surface of xiphoid process (or
sternum) and the body of the upper 1--4 lumbar verte
brae, vertebral discs and the arcuate ligaments, thereby
forming a circular attachment around the entire inner
surface of the thorax
Innervation: Phrenic nerves (C3-5) for motor and lower 6-7
intercostal nerves for sensory (Gray's Anatomy 2005,
Simons et al 1999)
Muscle type: Not established
Function: Principal muscle of inspiration by drawing its
central tendon downward to stabilize it against the
abdominal viscera at which time it lifts and spreads the
lower ribs
Synergists: Accessory muscles of inhalation The lumbar part arises from two aponeurotic arches
Antagonists: Elastic recoil of thoracic cavity and accessory (medial and lateral lwnbocostal arches or arcuate liga
muscles of exhalation ments) as well as from the lumbar vertebrae by means of
two crura (pillars).
The lateral crus is formed from a thick fascial covering
Indications for treatment
which arches over the upper aspect of quadratus lumbo
Dyspnea or any breathing difficulty rum, to attach medially to the anterior aspect of the trans
Dysfunctional breathing patterns verse process of L1 and laterally to the inferior margin of
Chronic respiratory problems (asthma, chronic cough, the 12th rib.
etc.) The medial crus is tendinous in nature and lies in the fas
'Stitch in the side' with exertion cia covering psoas major. Medially it is continuous with
Chest pain the corresponding medial crus and also attaches to the
Hiccup body of L1 or L2. Laterally it attaches to the transverse
process of Ll.
The crura blend with the anterior longitudinal ligament
Special notes
of the spine, with direct connections to the bodies and
The diaphragm is a dome-shaped muscle with a central ten intervertebral d iscs of Ll, 2 and 3.
don whose fibers radiate peripherally to attach to all mar The crura ascend and converge to join the central tendon.
gins of the lower thorax, thereby forming the floor of the With attachments at the entire circumference of the tho
thoracic cavity. It attaches higher in the front than either rax, ribs, xiphoid, costal cartilage, spine, discs and major
side or back. When this muscle contracts, it increases the muscles, the various components of the diaphragm form
vertical, transverse and anteroposterior diameter of the a central tendon with apertures for the vena cava, aorta,
internal thorax (Kapandji 1974) and is therefore the most thoracic duct and esophagus.
important muscle in inspiration. When all these diaphragma tic connections are considered,
Figure 14.29 shows clearly the structural relationship the direct influence on respiratory function of the lumbar
between the diaphragm, psoas and quadra tus lumborum. A spine and ribs as well as psoas and quadratus lumborum
brief summary of some of the diaphragm's key attachments becomes apparent.
and features indicates the complex nature of this muscle. Patients who suffer from hiatal hernia pain may find that
pain is reduced by treatment (and self-treatment) of the
The sternal part of the diaphragm arises from the internal
diaphragm, as well as by breathing retraining. Simons
surface of the xiphoid process (this attachment is some
et al (1999) note that referred pain from trigger points in
times absent).
transversus abdominis may be confused with pain from
The costal part arises from the internal aspects of the
those associated with the diaphragm and suggest that
lower six ribs, interdigitating with the transversus abdo
transversus trigger points will more likely produce pain
minis (Gray's Anatomy 2005).
on deep inhalation, whereas full exhalation (with added
compression from the abdomen near the end of exhala
tion) will reproduce diaphragmatic trigger point refer
rals. They also note that diaphragmatic trigger points are
Esophageal opening commonly satellites of primary trigger points found in
f--- Costal margin the ipsilateral upper rectus abdominis.
Lateral arcuate ...._
. Median arcuate ligament
ligament ------'c::-"F='-
::'>'-""""'I-- Medial arcuate ligament N MT FOR DIAPHRAG M ( F I G . 1 4. 3 0)
1K7''''''"---- Left crus The patient is supine with the knees flexed and feet resting
Right crus -----f-t+tl'-r.lP --- Quadralus lumborum flat on the table. This position will relax the overlying abdom
inal fibers and allow a better penetration to the diaphragm.
:Sj.!!::::--- Psoas major As noted previously, the upper rectus abdominis is treated
before the diaphragm. The trea tment of the diaphragm is
contraindicated for patients with liver and gallbladder dis
ease or if the patient's right side is significantly tender or
swollen.
The practitioner stands at the level of the abdomen on the
contralateral side and reaches across the person to treat the
opposite side of the diaphragm. The fingers, thumbs or a
Fig u re 1 4.29 I nferior view of d iaphragm. Reproduced with combination of thumb of one hand and fingers of the other
permission from Gray's Anatomy for Students (2005). may be used.
574 CLI N I CAL APPLICAT I O N OF N E U R O M U SC U LA R TECH N I QUES: T H E U PP E R B O DY
The practitioner will work with the flow of the brea th, margins of the ribs and static pressure or gentle friction is
sliding the palpating fingers or thumbs under the lower applied toward the diaphragm's attachment. The treatment
border of the rib cage. As the patient brea thes out, the fin may be applied on full exhalation or at half-breath and is
gers will slide further in. As the patient brea thes in, the repeated to as much of the internal costal margins as can be
diaphragm will press against the treating d igit(s) and move reached .
the fingers out of position unless the practi tioner resists this While it is uncertain if and how much of the diaphragm's
movement. When penetration appears to be as far as possi fibers may be reached by this exercise, the connective tissue
ble, the finger ( thumb) tips are directed toward the inner associated with its costal attachment is probably influenced.
Simons et al (1999) describe a similar procedure, which ends
in an anterior lifting of the rib cage ( instead of friction or
static pressure) to stretch the fibers of the diaphragm.
TRA N SV E R S U S T H O RACI S ( F I G . 1 4. 3 1 )
Attachments: Inner surface of the body of sternum and
xiphoid process superolaterally to the lower borders of
the 2nd-6th costal cartilages
Innervation: Intercostal nerves (2-6)
Muscle type: Not establ ished
Function: Depresses the costal cartilages during exhalation,
ribs 2-6
Synergists: Muscles of exhala tion
Antagonists: Muscles of inhala tion
J--- Sternothyroid
Diaphragm
-+------ Aponeurosis of transversus abdominis
Transversus abdominis ----\
1 4 The thorax 575
Specia l notes the practitioner 's other arm or by the use of a seatbelt around
the patient's iliac crest. The abdomen should be avoided as
This muscle, also called the sternocostalis or triangularis ster
an area for tills restraining contact as it is likely to be
nae, lies entirely on the interior chest and is not available to
uncomfortable for the patient.
direct palpation. It varies considerably, not only from person
In order to stabilize the pelvis, so that the practi tioner is
to person but also from side to side in the same person (Gray's
certain that the majority of rotation is taking place in the
Anatomy 2005) and is sometimes absent (Platzer 2004).
trunk, the patient should be seated at the end of a treatment
Latey (1996) reports that this muscle has the ability to gen
table, straddling it, with the back toward the end (i.e. facing
erate powerful sensations, with even light contact some
the length of the table). If the patient cannot straddle the
times producing reflex contractions of the abdomen or chest
treatment table, then an acceptable if less effective alterna
with feel ings of nausea and choking, as well as anxiety, fear,
tive is to have the patient seated on the edge of the table
anger, laughter, sadness, weeping and other emotions. Latey
(Fig. 14.32).
believes that its closeness to the internal thoracic artery is
probably significant since when it is contracted, it can exert
direct pressure on the artery. He believes that physiological Case example of thoracic S NAGs
breathing involves a rhythmical relaxation and contraction
Patient. 23 years old, male, student
of this muscle and that rigidity is often seen where 'control'
dampens the emotions which relate to it (see Chapter 4).
Complaint. Sharp stabbing pain at T4-5 during right rota
tion. The symptoms had started 7 months previously and
T H O RACIC M O B I LIZAT I O N W ITH M OV E M E N T - worsened following manipulation, 4 months previously.
S N A G s M ET H O D
Presentation. Active movements of the thoracic spine
Mobilization with movement (MWM), the modahty in willch were restricted, with left rotation limited . Attempts to rotate
joint glide/ translation (sustained natural apophyseal glide left provoked a strong pain at T5, with radiation to the pos
SNAG) is utilized to assist in pain-free mobilization of terior aspect of the ribs. Extension was limited and painful.
restricted joints, is described in Chapter 1 0 . Flexion was slightly restricted . Sidebending to the right was
A n article published by Edmonston & Singer (1 997) painful. There was evidence of muscle spasm in the right
explains: paravertebral muscles.
The sustained natural apophyseal glide (SNAG) described
by Mulligan is of particular importance in the context of Treatment. SNAGs - rotation with slight axial traction
painful movement associated with degenerative change. In was applied three times to the right as well as three times to
contrast to most other mobilization techniques, SNAGs are the left before retesting.
performed with the spine under normal conditions of physi
ological load bearing. Further they combine elements ofactive
and passive physiological movements with accessory glides
along the zygoapophyseal joint plane. These techniques facil
itate pain-Jree movement throughout the available range and,
since movement is under control of the patients, reduce the
potential problems associated with end-range passive move
ments in degenerative motion segments.
Horton (2002) published a case report of a student with
acute left side back pain adjacent to the level of the TS-9
intervertebral joint. A central SNAG was applied in a cepha
lad direction to the spinous process of TS . He concluded
that the thoracic spine is ideally suited to SNAGs and there
fore may be the treatment of choice in acute presentations of
thoracic pain when the zygapophyseal joints are impli
cated. Tills case report is illustrated and discussed below.
Method
Because thumb pressure is uncomfortable in tills region, and
is difficult to maintain, the ulnar border of the 5th metacarpal
(blade of hand) is used in contact with the vertebrae being Figure 1 4.32 Starting position and a pplication of modified SNAG.
treated (T3-12) . Patient stabilization is achieved by either Reprod uced with permission from Horton (2002).
576 C LI N I CA L APPLICATI ON O F N E U R O M USCULAR TEC H N I QU ES : T H E U P P E R BODY
Outcome. Mobility increased by about 50% and there was In this volume, we have discussed the foundational plat
less pain during rotation. No change in pain was noted dur form of neuromuscular techniques as well as a number of
ing left sidebending. The patient was sent home with self supporting modalities. Step-by-step protocols have been
treatment instructions. On the following day SNAGs was offered, together with a full anatomy discussion, to assist
applied to the ribs at the level of T4-5, bilaterally. the practitioner in acquiring skiUs to treat myofascial pain
syndromes and dysfunctions of the upper half of the body.
Results. After three treatments the patient was pain-free The reader is now referred to Volume 2 for the lower half of
for thoracic movement, except for slight pain at the end of the body and to Clinical Application of Neuromuscular
range. The patient received another treatment and was Techniques: Practical Case Study Exercises for comprehensive
referred to a spinal stabilization program. One week after strategies for chronic pain care.
discharge the patient was pain free.
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579
I n dex
Page numbers in bold refer to boxes, to habits of use, 67 Anterior deltoid, 413, 415
illustrations and tables to trauma, 67 Anterior forearm, 513-522
Adduction deep muscles, 517
arm, 489 NMT for, 5 1 8-519, 518
A coracobrachialis, 481 superficial layer, 514
metacarpophalangeal joints, 510 trigger points, 514
Abdominal muscles, 551, 571 Patrick's test, 358 Anterior longi tudinal ligament, 251, 253
NMT assessment, 571-572 pectoralis major, 473, 474 Anterior neck m uscles, MET for, 299-300, 300
Abduction, 478 shoulder, 4 1 1 , 412, 478 Anterior sternoclavicular ligament, 407
a rm, 489 Adduction restriction, shou lder, 424 Anterior thorax, 550-557
bilateral, 412 MET for, 428 Antidiuretic hormone (ADH), 132
coracobrachial is, 481 PRT for, 428 Antiinflammatory stra tegies, 130, 167,
glenohumeral, 444 Add uctor pollicis, 530-531 168-170
humeral, 445 Adenosine triphosphate (ATP), 26, 27, 1 00, nu trients, 129-130
metacarpophalangeal joints, 511 m, 112, 179 techniques, 470
pectora lis major, 472, 474 energy production, 28, 75 Apical ligament, 251
shoulder, 4 1 1 , 4 1 2, 449 synthesis, 130 Apley scratch test, 408, 417-418
teres minor, 455 Adhesive capsulitis, 402 Apoptosis, 146
test for hips, 90, 90 Adiponectin (AD), 137 Apoxia see Hypoxia
Abduction restriction, shou lder, 424 Ad ipose tissue, 140 Applied compression, 183
MET for, 427, 428 Adrenal glands, 132 Applied pressure, 383
P RT for, 428 Adrenaline, 135, 136 Apprehension test, 408
Abductor pollicis brevis, 531 Adrenocorticotropin (ACTH), 132 'Arcade of Struthers', 489
Abductor pollicis longus, 527-528 Adson's test for subclavian artery Ardnt-Sch u l tz's law, 3
Accessory atlantoaxial ligaments, 251 compression, 257 Arm
Acetyl-L-carnitine (ALC), 139 Adverse mechanical tensions (AMT), adduction, 484
Acetylcholine (ACh), 1 00, 111 223-230 extensor, 54
Acid glycosaminoglycans (AGAGs), 4 Agonists, 35, 267, 413 flexor, 54
Acromioclavicular (AC) jOint, 403, 425 Agouti, 137 muscles, 461
MET for, 426 'Ah shi' acupuncture points, 10, 207 pectoralis major, 473
Acromioc lavicular ligament, 405 Alar ligament, 251 range of motion, 411
Actin, 26-27 Algometers, 117, 117, 118, 1 89-190, 190 and shoulder pain, 475
Active isolated s tretching (ArS), 236 Alkalosis see Respira tory alkalosis see also Forearm
Acture, 248 Allergic mya lgia, 168 Arthritis, 529
Acupuncture, 120, 359, 507 Allodyrtia, 144 Arthrography, 407
points, 8, 9-10, 9, 10, 207 Allostasis, 56 Articular capsule, wrist, 502
trigger points and, 207 Anaerobic energy (ATP) pathways, 28 Articulation
Acute conditions 'Anatomy trains', 567 mobilization and, 217-218
definition, 254 Anconeus, 449-452, 493-494 movements, 267
inflammation, 1 28, 128 NMT for, 453, 494 Assessment
injury, 181-182 Anconeus epitrochlea ris, 490 NMT framework, 196
Acute response (lag) phase, 126 Annular fibers, 244 protocols, 189-190, 189
Adaptation, 141 Annular ligament of radius, 487 tools, 189-190
GAS and LAS, 63-64, 64 Annular mertisci, 541 Atherosclerotic cardiovascu lar disease,
posture a nd respiratory function, 64-67 Ann ulus fibrosus, 246, 253 138
slow, 66-67 Antagonists, 35, 37, 267 Atlantoepistrophic ligament, 251
580 I N D EX
Atlantooccipital jOint, 256, 269, 313 Biomechanics, 68, 162-163 Calcium, 100, 139
see also Occipitoa tlantal area cervical, 255 Cancer recovery therapy, 470
Atlantooccipital ligament, 251 insult, 141 Cantu & Grodin
Atlas ( C I ), 248-249, 249, 321 laws, 3 deformation characteristics, 6
Atrophy, muscle, 409 'looseness and tightness', 163-165 fascial dysfunction, 1 6
and chronic back pain, 39 shoulder, 409-41 0 therapeutic sequencing, 1 9
Attachment trigger points (ATrPs), 100, 112, thoracic spine rotation, 546-547 Capitis, 256
189, 448 trigger points, 178-179 Capsular liga ments, 251, 511
Auditory canal, 346 upper chest breathing, 77-78 Capsu le, wrist, 501-502, 501
Auditory tube see Eustachian tube Biopsychosocial model of rehabilitation, Capsulitis, 417
Auricular muscles, 254, 352, 354 1 72-173 adhesive, 402
Au ricularis superior, 344 Bipennate muscle fibers, 27 Carbon Dioxide (C02), 75
Au togenic inhibition, 50 Bitemporal rolling exercise, 347, 347 loss of, 77
Autogenic training, 231 Blackbur, Trager-style approach, 232 'Cardiac arrhythmia' trigger points, 472, 472
Awad's analysis of trigger points, 109 Blood supply Carnosine, 139
Axis (C2), 249-250, 249 to head, 256, 259 Carotid artery, 307, 307
Axis-atlas joint, 256 to muscles, 28-29 Ca rpal tunnel syndrome (CTS), 489, 497,
Bohr effect, 32, 149 507-508
Bolus, 387 PRT for, 521
B Boyle tests for, 509
ribs and shoulder pain, 556 see also Median nerve, entrapment
Babies, newborn, 388 2nd rib restrictions, 412-413 Carpi muscles, 513
Back of the arm lines, Myers', 12 Bracelet test, 508 Carpometacarpal ligaments, 509-51 0
Back line, M yers' superficial, 11 Brachial plexus, 256, 314 Cathie, trigger 'spots', 8
Balaban & Theyer, ba lance control and Brachial pulse, 410 Central nervous subsystem, 31, 67
anxiety, 74 Brachialis, 54, 480, 493 Central nervous system (CNS)
Balance, 24, 74-75, 370 NMT for, 493, 493 diseases of, 146
Ballistic movement, 37, 236 Brachioradialis, 494 signals to muscles, 25
Barbagallo, magnesium and insulin, 130 assessment, 494-495 trigger points and, 8-13
Barnes, John, MFR, 221, 466 MFR for, 495 Central trigger pOints (CTrPs), 101, 112,
Barnes, Mark NMT for, 495 187-188
fascial restrictions, 16 reflex, 411, 487-488 anterior forea rm, 519
ground substance, 1 7 Bradley infraspinatus, 448
MFR, 222, 466 key trigger pOints, 110 levator scapula, 437
Bates method, 394-395 pain management, 171 pectoralis major, 471
Becker, soma tizers, 152-153 Brain electricity activity mapping (BEAM), posterior forearm, 526
Behavior and persona lity, 71-72 56 teres major, 457
hardiness, 72 Breast cance 469-470 thumb muscles, 528
life events, 71 Breathing trapezius attachments, 434
stages of change in, 171 cooperation, 218-219 Centralization mechanisms, 58-59
type A personality, 71-72 pattern assessments, 92-94 Cerebral insu fficiency, 257
Bending loading, 166 unbalanced, 149-150 Cerebrospinal fluid (CSF), 373
Bennett, physical exercise, 172 wave, 93, 547, 548, 548 Cervical column, head balance, 302
Beveled-tip pressure bars see also Respiratory function Cervical lamina
hand, 534 Buccinator, 350, 356, 386 NMT for, 320, 320
shoulder, 434, 446, 448, 459 Buccolabial muscles, 351-352, 357 prone, 319-320
thorax, 565-566, 566, 571, 571 Buccolabial region, 356--357, 357 Cervical region, 243-321
Biceps, 413, 480 NMT for, 357, 357 assessment, 253-273
reflex, 411, 487 Bucket handle motion, 554, 555 circulatory features, 256, 2 57, 259
Biceps brachii, 482-483 Bucklew, goal setting and pacing, 172 flexor muscles, 40
assessment, 483 Bursitis, 417 functional features, 255-256
MET for, 484, 484 B utler & Moseley, nociceptors, 46 intervertebral foramina, 256
NMT for, 483-484, 483, 484 landmarks, 255
PRT for, 485 ligaments, 251-253
Biceps tendon dysfunction, MET for, 484, 484 c muscle strength tests, 260, 262-266, 263
Bicipital tendinitis, 4 1 8-419, 418 muscular and fascial features, 256
Bidirectional transverse friction, 320 C-curve observation test, 547 neurological features, 256
Biedermann, 'KISS' children, 388-389 Caffeine, 150-151, 150 planes and layers, 274-275
'Bind', 1 63 Cailliet posterior see Posterior cervical region
Bindegewebsmassage, 183, 185 coHagen, 17 receptors, 51
Biochemical perspectives disk n utrition, 247 sequencing treatment, 273-321
influences on health, 68 forward head posture, 247 symmetry of movement palpation, 262-264
neurosomatic disorders and, 55-57 lateral epicondyle, 522-523 upper see Upper cervical region
nu trition, 169-170 posture, 245 Cervical spine, 246, 546
and pain, 167-170 temporal arteritis, 366 assessment, 260, 262-266
terms relating to fascia, 3 temporomandibular joint (TM]), 362 becoming treatment, 266--268
Index 581
Mastication, muscles of, 351-352, 358-359 Motor endplate hypotheSiS, 111 imbalance, 165, 416
Mastoid Motor units, 33, 78-79 layers, 274-275
palpa tion, 371-372 types, 34 motor control and respiratory alkalosis,
process, 248, 296, 371 Mouth see Suprahyoid muscles 31-32
Maxillae, 35, 349-350, 349, 351 Mu lligan's mobilization techniques, 217, 520 organization detail, 25, 33
Mechanical interface (MI), 224 Mu ltidirectional instability (MOl), 441 pain and, 40-41
Mechanoreceptors, 46 Multifidi, 281, 287, 557, 558, 563, 564-565, 564 planes, 274-275
Mechanotransduction, 24 Multipennate muscle fibers, 27 range of motion, 87
Medial epicondyle, 492, 519 Multiple chemical sensitivity (MCS), 148-149 somatization and, 41-42
Medial epicondylitis (golfer'S elbow), 127, Muscle energy technique (MET), 199-200, spasm, 37-39
492, 519 218-221, 219 strength, 259-260, 262
Medial p terygoid, 338, 350, 358, 376, 379-380 acromioclavicular (AC) joint, 426 tests, 39, 260, 262-266, 263
NMT for, 369, 369, 379, 380 anterior neck muscles, 299-300, 300 structural continuum and, 23-25
Medial scapula, 440 biceps brachii, 484, 484 subsystems, 31, 67
Medial tracts, 281, 557-558 cervical region, 267, 270, 272 terminology, 33
Median nerve diaphragm, 572 tone, 65, 86-87
entrapment, 489, 491, 507 fascia, 6 assessment, 87-88
see also Carpal tunnel syndrome forearm flexors, 519, 519, 521 trick patterns, 39-40
paralysis, 509 Golgi tendon organs, 58, 216 two-joint, 39
Melanotropin, 132 iniraspinatus, 448-449, 448 types of, 25, 27, 34-35, 35
Melatonin, 139 internal rotation restriction, 428-429 vulnerable areas, 34
Melzack & Katz, pain rating tools, 190-191 latissimus dorsi, 460, 460 weakness, 39, ll8
Meniscoids see Intraarticular synovial folds leva tor scapula, 291, 291, 421, 438 Musculoskeletal dysfunction, causes, 63-79
(IASFs) longus capitis, 312 postural and emotional influences, 69-73,
Meniscus extrapment theory, 541 occipitoatlantal restriction, 269 69
Mense pectoralis major, 472-473, 473-474, 473 Musculus uvula, 381
dysfunctional muscle spindle, llO-lll posterior forearm, 526 Myalgia, allergic, 168
trigger point connection, 102 p rotocols, 547 Myers
Mentalis, 356 rectus capitis anterior, 313 fascial trains, 11-13, 567
Mercury, 144, 145-146 rhomboids, 440-441 shoulder muscles, 404
Metacarpal muscles, 529, 532-533 Ruddy's pulsed, 201 tensegrity, 15
Metacarpophalangeal joints, 510 scalenii, 318-319, 319 Mylohyoid, 338, 384
range of motion, 51O-5ll semantic confusion, 178 Myocardial infarction, 417
Metacarpophalangeal ligaments, 510 serratus anteriol 466, 466-467 Myofascial pain and FMS, 105, 105
Middle deltoid, 415 shoulder, 416, 427, 428 Myofascial pain syndrome (MrS), 167
'Middle fist' concept, 69, 70 soft tissue, 66, 164 Myofascial release (MFR), 221-223,
Middle trapezius Spencer 's sequence, 427-429 222, 466
NMT fOl 433, 433 spiral, 478 active, 267
weakened, 82, 409 sternoclavicular, 426 adherent tissue, 186
Mills test, 492 sternocleidomastoid (SCM), 303-304, 304 brachioradialis, 495
Milne stretching, 235 coracobrachialis, 481, 481
mandible range of motion, 339 subscapularis, 463-464, 463 epicranial tissues, 354
newborn babies, 388 supina tor, 496 hypertonicity, 521-522
tissue separation, 334-335 supraspinatus, 421, 446 latissimus dorsi, 459, 459
M imetic muscles, 351, 351-352, 352, 353 teres minor, 448-449, 448, 455 masseter, 368, 368
buccolabial region, 356-357, 357 triceps, 452-453, 453 pectoralis major, 472, 474, 474
circumorbital and palpebral region, 355 trigger points, 120 pectoralis m inor, 477, 477
of the epicranium, 352 upper cervical dysfunction, 268 posterior forearm, 526
nasal region, 356 upper trapezius, 278-279, 422, 435 postmastectomy, 470
Minimal impulse manipulation, 390 wrist and hand extensors, 521 pronator teres, 498
Mobilization Muscle fibers, 27, 218 serra tus an terior, 223, 466
adverse mechanical tensions (AMT), parallel, 25 soft tissue, 166
223-230 postural, 218 subclavius, 477, 479
and articulation, 217-218 types, 28, 34-35 supinator, 496
of cervical spine, 272-273 Muscle spindle, 5 1-52 supraspinatus muscle, 447, 4467
Mobilization with movement (MWM), 166, hypothesis, llO-I11 trigger points, 121, 164
217, 520, 575 Muscles, 23-42 upper trapezius, 279, 280-281, 435
thoracic spine, 757-756 alternative categorization, 36-37, 554 Myofascial therapy, 359
wrist and hand, 520 atrophy, 37-39, 409 Myofascial tissue problems, guidelines,
Mock, MFR, 222, 466 blood supply and, 28-29 183
Monosodium glutamate (MSG), 146, 147, 148 central nervous system signals, 25 Myofascial trigger points (MTrPs), 8, 38,
Mood disturbances, 153 contraction see Contraction 1 1 3-114, 1 1 8-122, 119, 154-155, 164,
Motion palpation, ear disease, 390 cooperative activity, 35, 37 374
Motor control energy production, 27, 28 Myofibroblasts and fascia, 181-182
injury prevention and, 67-68 essential information, 25 Myosin, 26-27
see also Respira tory a I ka losis facilitation in, 108 Myotendinoses, 142
588 I N D EX
latissimus dorsi, 459 Posterior longitudinal ligament, 250, 251, 253 contrad ictions, 53, 57
palmar and dorsal hand, 533 Posterior scapular region, 451 dysfunction, 52-53
teres major, 457 Posterior sternoclavicular ligament, 407 fascia and, 2, 46--47
teres minor, 454 Posterior suboccipital muscles, 40 hypothesis, 225-226
for trapezius attachments, 434 Posterior superficial thoracic muscles, manipulation, 58
for upper trapezius, 432 557-560, 559 Proprioceptive neurom uscular fac i l i tation
Pincer palpation, pectoralis major, 471 Posterior thorax, 440, 541-550, 559 (PNF), 6, 235-236
'Pinch' test, 508 muscles, 438 posterior forearm, 526
Pineal gland, 132 NMT for, 560-562 techniques, 478
Piriformis syndrome, 83 Postisometric relaxation (PIR), 211, 218, Psoas, 553, 557
Pisohamate ligament, 502 219-220, 219, 221, 236, 267 Psychological d istress, 41
Pisometacarpa l ligament, 502 isometric contraction, 199 Psychosocia I factors, 153
Pituitary gland, 132, 334 Posttrauma fibromyalgia, 256 int1uences on health, 68
Pizzorno & M u rray, functional Postural fibers, 36, 218 pa in managemen t, 170-171
hypothyroidism, 133 Posture, 245 Psychosomatic symptoms, 144
Placebo power, 153-154 active, 248 Pterygoid, 333
Plastic and elastic features, fascia, 3, 5-6 distortion, forearm and, 499 Pulsed muscle energy technique (Ruddy's
Plasticity, 244 forward head, 247, 293, 362, 364, 469 method), 201, 212, 416, 550
Pla tysma, 298-299, 298, 338 imbalance, 73-75, 293 Pump handle movement, 554, 555
NMT for, 299 inappropriate, 213-214
Pollicis, 513 influences, 179
Polymodal rece ptor (PMR), 46 interpretations, 69 Q
Polyphenol sources, 150-151 movement, 37
Position of ease see 'Ease' muscles, 35, 210, 554 Quadratus l umborum, 91, 93, 552, 557
Positional release technique (PRT), 198, orthosta tic, 370 expiration fWlCtion, 552
225-230 patterns, 18-19, 65, 264-266, 499 shortens, 83
biceps brachii, 485 perfect alignment, 248 sidelying, 553
carpal tunnel syndrome, 521 respiratory function and, 64-67 Quebec Task Force, 261
cervical region, 267, 268, 271 retra ining program, 469
circumduction pain or restriction, 428 slumping, 571
coracobrachialis, 481--482 Potassium, 129 R
ease and bind, 163, 164 Practice, scope of, 409
infraspinatus, 449 Precontemplative behavioral attitude, 171 Radial collateral ligament, 502
internal rotation restriction, 429 Pressure bars, 1 9 1 , 191, 494, 566, 571 Rad i a l. nerve, 493, 495--496, 496
latissimus dorsi, 460, 460 see also Beveled-tip pressure bars entrapment, 492, 507
leva tor scapula, 291-292, 292 Pressure release, 1 79 Rad ia l pu lse, 410
masseter, 368-369 brach ialis, 493 Radial tunnel syndrome (RTS), 492
occipitoatlantal restriction, 269 brachioradia lis, 494, 495 Radialis muscles, 513
occipitofron talis, 355 diaphragm, 572, 572 Radiate carpal ligament, 502
pronator teres, 498 paraspinal musculature, 566-567 Radicular pain, 142
reporting station manipulation, 58 supraspinatus, 446 Radiculopathic model, 111
scalenii, 319, 319 Pressure techniques, 2 1 6 Radioulnar jOint, 485--486
shoulders, 416, 427, 428 serra tus anterior, 466 Rapid isotonic eccentric contraction /stretch
soft tissue, 166 static, 369 (isolytic), 200
Spencer's sequence, 427--429 'Pressure threshold', 1 1 7 Reactive hyperemia, 545-546
spinal levels, 542 'Prime mover ' , 35 Reactive oscillatory methods, 231
sternocleidomastoid (SCM), 304, 304 Proactive OSCillatory methods, 231 Receptor (publ ication), 110
suboccipital region, 298 Probiotics and mercury, 146 Receptor-tonus techniques, 109-1 11, 191
subscapula ris, 464 Procerus, 342, 356 Reciprocal inhibition (RI), 35, 211, 219, 236, 267
teres major, 457, 458 Prolactin, 132 isometric contraction and, 199, 218, 219, 220
teres minor, 455, 455 Prolotherapy, 130-131 Reciprocal tension membranes
trigger points, 120 Pronation, resisted, 497 ethmoid, 335
upper trapezius, 279-280, 279 Prona tion / supination frontal bone, 341
wrist dysfunction, 521 humeroradial joint, 485 occiput, 329
see also Stra i n / cou nterstrain (SCS) radioulnar joint, 485--486 parietals, 343-344
Posterior atlantooccipital ligament, 248 Pronator quadratus, 498 sphenoid, 333, 333
Posterior atlantoaxial membrane, 251 NMT for, 498 temporals, 344
Posterior auxiliary fold, 457 Pronator syndrome, 497 Rectus abdominis, 557, 571
Posterior cervical region, 275-292 Pronator teres, 496--497 Rectus capitis anterior, 256, 313, 329
Posterior deltoid, 4 1 3, 415 assessment, 497 Rectus capitis la tera lis, 256, 313, 330
Posterior forearm, 521, 522-529, 522 MFR for, 498 NMT for, 313-314, 313
deep l ayer, 527, 527 NMT for, 497, 497 Rectus capitis posterior major (RCPMa), 292,
NMT for, 528-529 PRT for, 498 295, 297, 330
-
gliding strokes, 526 Prone h ip extension, firing sequence, 88 Rectus ca pitis posterior minor (RCPMin), 52,
superficial layer, 522-523 Proprioception, 45--47 252, 292-293, 294-295, 294, 296, 330
NMT for, 525-526, 526 a ltering, 52 evaluation and treatment, 53
Index 59 1
Shoulder elasticity, 120, 121 Splenii, 280, 283-284, 283, 284, 557
and arm pain, 475 mobility, 120 Splenii tendons, NMT for, 284-285, 285
assessment see Shoulder assessment receptors, 51 Splenius capitis, 303, 329, 345, 370
key joints, 401-403, 401, 404 texture, 119 Splenius cervicis muscles, 321
ligaments, 405-407 Skin rolling, 183, 1 86, 356 Splinting (spasm), 37-39, 40, 151
muscles, 438 Skull Spontaneous electrical activity (SEA), 111,
evaluations, 420-422 disarticulated, 327 116, 118
relationships, 413 inferior view, 329 Spray and stretch techniques, 166, 355
soft tissue and, 404, 422 muscular a ttachments to, 329 posterior forearm, 526
structure, 400-404 Sliding filament theory, 26-27 trigger point treatment, 233-235
transverse section, 445 Slow isotonic eccentric contraction/stretch Springing, 420, 422, 544, 544
treatment, 429-485 (SEIS), 200 Spurling's test, 408
trigger points, 410 Slow-adapting joint receptors, 51 Stabilizers, 413
Shoulder assessment, 404-429 Slump posture, 69, 474 State dependent processing, 59
imaging studies, 407 Smooth Muscle cells (SMCs), 31-32, 181 Static compression
Janda and, 409-410 SNAGs see Sustained natural apophyseal pincer, 375
muscle evalua tions, 420-422 glides (SNAGs) pronator teres, 497
observation, 410 Snapping, 283 teres minor, 455
range of motion, 410-412 friction, 286 Static pressure, 380, 383
repetitions, 408-409 palpation, 187, 187, 454, 457, 519 infra spina tus, 448
soft tissue palpation, 410 Social rehabilitation goal, 172 la tissimus dorsi, 459
Spencer sequence, 422, 423-424, 425, Soft palate musculature, 380-382, 381, 383 pectoralis minor, 476
427-429, 429 NMT for, 382, 382 release, 440
tests, 408 Soft tissue subscapularis, 463
specific dysfunctions, 4 1 7-420 dysfunction, 214 supraspinatus, 446
strength, 413-415, 414 neuromuscular management of, 166-167 trapezius attachments, 434
Shoulder pain, 410, 415-416, 422 manipulation, effects of, 216 Static stretching, 236
scalene muscles and, 403 pain, 143 Staubesand
therapeutic choices, 416-417 palpation, 410 au tonomic nervous system, 9
Shoulder Pain (CaiUiet), 446 release, Spencer 's general, 429 proprioception, 2, 46
Shoulder-arm syndrome, 409 shoulder and, 404 Steiner, disc and facet syndromes, 259
'Sick building syndrome', 148 techniques, 51, 1 83, 211, 308 Sterling
Side-to-side translation, atlantooccipital treatment and barriers, 164 flexor withdrawal reflex, 165
joint, 269 Somatic dysfunction, 114, 121 m usculoskeletal pain, 40
Sidebending Somatization, 41-42, 1 52-153 Sternalis, 479
atlantooccipital joint, 269 Somatosomatic reflexes, 47 chest pain and, 479
cervica l region, 262, 269, 272 Somatotropin, 132 Sternoclavicular jOint, 403
levator scapula, 438 Somatovisceral reflexes, 47, 299, 305 MET for, 426
longus capitis, 3 1 2 Spasm, muscle, 37-39, 40, 151 restricted abduction, 425
palpation procedure, 547 Specific adapta tion to imposed demand Sternocleidomastoid (SCM), 300-301, 300,
spinal region, 256, 269 (SAID), 64 346, 359, 370
Sideflexion, 540 Speed's maneuver, 408, 419 attachments, 303, 345
Sidelying position, 316, 318, 318 Sphenobasilar synchondrosis (SBS), 295, clavicular head, 318
anconeus, 453 330-332, 334, 390 MET for, 303-304, 304
latissimus dorsi, 459 Sphenoid, 332-335, 332, 372 NMT for, 301, 302, 303, 316
pectoralis major, 471 transverse movement, 390 PRT for, 304, 304
SITS tendons, 455 Spinalis capitis, 285-286, 330 respiration function, 552
subscapularis, 463, 463 NMT for, 286 shortened, 409
teres major, 457 Spinalis cervicis, 285-286 Sternocostal joint, 403
Simons NMT for, 286 Sternocostalis see Transversus thoracis
dysfunctional muscle spindle, 110-111 Spinalis muscle group, 281, 558 Sternohyoid, 305-306, 308
Eagle's syndrome, 370 Spinalis thoracis, 563 Sternomastoid, 82
endplate noise, 116 Spine Sternosymphyseal syndrome (SSS), 542-543
nutritional balance, 167 area facilitation, 108 Sternothyroid, 306, 308
trigger points, 98, 1 02-103, 115, 118 curvatures, 245 Sternum, 542
Simons & Mense, resting muscle tone, 87 mobilization, 288 pump handle movement, 555
Simons' integrated hypothesis, 111 rhythmic treatment, 232-233, 232 structural features, 541
Simons, myofascial trigger points (MTrPs), 8, segments, 543-544 Stiff elbow, 492
113-114 stability, 31-32, 75-76, 245 Stiffness, 5, 87, 141
Sinus inflammation, 336 structures, 416 Stiles' procedu re, 272
SITS (rotator cuff) muscles, 402 see also Cervical spine; Thoracic spine Stomatognathic system, 358
SITS (rotator cuff) tendons, 446, 447, 455, 455 Spinous p rocesses, 250, 255, 542, 546, Storungsfeld (focus of disturbance), 223
Sitz baths, 210 566-567 Straight leg raising (SLR) test, 224, 293
Skaggs, mandible range of motion, 338 Spiral lin e, Myers', 12 Strain, 3
Skin Spiral MET, 478 and co-contraction, 54-55
'drag' palpation, 356 Spiral muscle fibers, 27 and spra ins, 489
Index 593
Strain /coWlterstrain (SCS), 198, 225 Sudden infant death syndrome (SIDS), 389 dysfunction (TMD), 306, 359, 359-365,
.
cervical extension restriction, 271-272, Sulcus sign, 408 361-362, 374
272 Superficial cervical plane, 274 pain, 362
cervical flexion restriction, 271, 271 Superficial heat, upper trapeZius, 121 problems, 84, 380
cervical spine dysfunction, 267 Superficial lymph p a thways, 365 trea tment, 339
latissimus dorsi, 460 Superficial posterior forearm, 521 Temporoparietalis, 352, 354
methodology, 227-228, 229 Superior head of lateral p terygOid (SLP), 375 Tender points
rules and guidelines, 230 Superior longitudinal, 382 biceps brachii, 485
Strap muscle fibers, 25 Supinator, 495--49 6 cervical spine, 271 , 272
Strength continuum, 27 assessment, 496 ma rking, 559
Strength tests, 229-260, 262 MET for, 496 scalene muscles, 319
for cervical spine, 262, 263 MFR for, 496 strain/ counters train (SCS) and, 228
elbow, 488 NMT for, 496, 496 teres minor, 455
muscle, 39 trigger pOints, 495 wrist dysfunction, 521
shoulder, 413-415, 414 Suprahumeral joint, 402 Tend initis, 417
wrists, 506, 506 Suprahyoid muscles, 304, 305, 358, 384-385, Tendinopathy, 127
Stress, 3 385 Tend inosis, 127-128
-strain curve, S NMT for, 385, 385, 387 Tendon hood, 530, 530, 532
tests shortness, 364 Tendons, palpation of, 119
elbow, 488-489 Supraspinatus, 402, 415, 443-446, 444, 445 Tennis elbow, 127, 492, 522, 526
wrist, 506 assessment, 446 Tenosynovitis ( tennis elbow), 127, 492, 522,
Stretch, 179, 283 calcification, 419--420 526
active isolated (AIS), 236 MET for, 421, 421, 446 TENS, 154
ballistic, 236 MFR for, 446--447, 447 Tensegrity, 14-16, 245
biceps brachii, 484 NMT for, 195, 446 Tension
brachioradialis, 494, 495 Supraspinatus tendinitis, 417--418 loading, 1 66
facilita ted, 235 Supraspinatus tendon, 402 movement, 37
general cervical, 299-300, 300 Sup raspinous ligament, 253 muscle, 24, 24, 37-39
latissimus dorsi, 460 Surface anesthesia, 233 Tensional integri ty, 14-16, 245
muscle, 375 Surface electromyography (EMG), 1 1 6-11 7 Tensor fascia lata (TFL), 91, 221
palpation and, 188 Su rgery, elbow, 492--493 Tensor veli palatini, 381
pectoralis major, 473 Sustained natural apophyseal glides Ten torium cerebelli, 344, 347
postrnas tectomy, 470 (SNAGs), 217-218, 288, 565-566, 575, Teres major, 413, 415, 456--457, 456
sensitivi ty, 38-39 575 NMT for, 457, 457
spray and, 233-235 self-treatment and, 289 PRT for, 457, 458
supinator, 496 Sutu res, distraction of, 391 Teres minor, 402, 413, 415, 453
techniques, 112, 122, 235-236, 313 Swallowing, 386 assessment, 453--454
upper trapezius, 121 Symphysis pubis, 542 MET for, 448--449, 448
see also Proprioceptive neuromuscular Synchronous temporal rolling exercise, 347 NMT for, 454-455, 454, 455
facilitation (PNF) Synergists, 37, 413 PRT for, 455, 455
Structural continuum, Ingber 's, 23-25 Synkenesis, 201 Tetany, 77
Sty loglossus, 382 'Tethering' of tissues, 163-164
Stylohyoid, 369-371, 383 Tetrahydrofolate enzyme, 167
Styloid process, 313, 313, 369-370, 371, 383 T Theile massage, transvaginal, 107
palpation, 371-372 Thenar eminence, 533
Stylomastoid foramen, 346 Taleisnik, Dupuytren's contracture Thenar muscles, 530-531
Subacromial bursa, 445 characteristics, 514 Therapeutic sequencing, 1 9
Subacromial bursitis, 419, 419 TART (tissue texture, asymmetry, restriction, Therapeutic touch, 231
Subclavian artery compression, 257 tenderness), 254 Therapies, multiple, 236
Subclavius Tau t bands, 119 Thermal a p p lications, 1 1 2
MFR for, 477, 479 Tea, 150-151 Thermoreceptors, 4 6
respiration fWlction, 552 Tectorial membrane, 251 Third cervical plane, 274
Subcostales muscles, 570 Temporal arteritis, 366 Thixotropy, 3, 4-5, 5
Subdeltoid bursitis, 419, 419 Temporal bones, 333, 344-347, 346, 372, 374 Thoracic lamina groove, NMT for, 562-563,
Submandibular salivary glands, 385 Temporalis, 333, 338, 341, 344, 345, 358, 366, 565-566
Suboccipital region, 292-298, 292 370, 372-373 Thoracic nerve, serratus anterior and, 465
Lief's NMT for, 297 NMT for, 366, 366 Thoracic outlet synd rome (TOS), 256, 259,
NMT for, 296-298, 296 trigger points, 354, 373 477
PRT for, 298 Temporalis tendon, 367 pectoralis major and, 469
see also individual muscles NMT for, 373, 373 pectoralis minor and, 474
Subscapularis, 402, 403, 415, 460--462, 461 Temporomandibular intraarticular disc, Thoracic spine
assessment, 421, 422, 462, 462, 463 360 coupling, 542, 546, 547
MET for, 463-464, 463 Temporomandibular joint (TMJ), 358, 374 facet joints, 540, 540
MFR for, 223 assessment, 364, 364-365 flexion, 542
NMT for, 463, 463 associated structu res, 363-364 mobilization with movement (MWM),
PRT for, 464 compression and decompression, 339, 339 757-756
594 I N D EX
testing and measuring, 114-118 Upper trapezius, 103, 275-276, 275, 329/ 359 Walther, strain/counterstrain, 55
thermography and, 117-118 assessment for shortness, 431-432 Ward, 'loose-tight' concept, 163
tinnitus, 374 attachments, 277-278, 278 Warming compress, 206-208
tissue microanalysis, 103, 103 flat compression, 432 Wartenberg pendulum test, 87
tongue muscles, 383 gliding teclmiques, 433 Wellness education, 172
trapezius, 430 Lief's NMT for, 278, 434-435 Whiplash, 256, 261-262, 276
treatment, 121-122, 194-195, 196 MET, 278-279, 422, 435 -associated disorders (WAD), 261
triceps, 450, 452 myofascial release, 279, 280-281, 435 White adipose tissue (WAT), 134-135
upper trapezius, 431, 433, 435 NMT for, 277, 432-433, 432 Whole-body approaches, 211
uvulae muscles, 382 pincer compression, 432 Wiederholt, end plate potentials, 116
vertical muscular columns, 559 PRT for, 279-280, 279 Wilson & Best, tendinopathies, 127
whole muscle problems and, 211 respira tion function, 552 Wilson's syndrome, 133
wrist extensors, 523 shortened, 82, 86, 276, 409 Wind-up, 57, 58-59, 126
see also Central trigger points (CTrPs) tissue layers, 280-281 'Winging', serratus anterior, 465
Trigger thumb, 517 trigger points, 431, 433, 435 Wolff's Law, 2, 3, 66
True joint, 401-402 Uvulae muscles, trigger points, 382 Wrap-around patterns, 165
Trunk flexion test, 90, 90 Wright maneuver, 474
Trunk pack (warming compress), 208 Wrist and hand, 498, 499-508, 499
Tumor-necrosis factor-alpha (TNF-a), 137 v bones of, 500
20th century syndrome, 148 bony structures and ligaments, 501
Twisted muscle fibers, 27 Vaccines, mercury derived, 145 deep structures, 532
Two-joint muscle testing, 39, 413 Van Griensven MET for, 521
long-term potentiation, 58 mobilization with movement (MWM),
wind-up, 58 520
u Van Wingerden, sacroiliac joint (SIJ), 41, range of movement, 505
163-- 1 64 Wrists
Ulnar collateral ligament, 502 Vasilyeva & Lewitt, dysfunctional patterns, 86 capsule and ligaments, 501-502, 501
Ulnar nerve entrapment, 489-491, 490, 491, Vasonemoactive substances (VNS), 101 dysfunction, 503
507, 508 Vault bones, 328 extensors, 523, 524
Ulnar tunnel syndrome, 490 Vault hold, 330, 331 motion tests, 503, 505-506
Ulnaris muscles, 513 Verbal rating scale (VRS), 190 reflex and strength tests, 506, 506
Ultrasound, 40, 116, 407 Vertebra prominens (C7), 250 stress tests, 506
upper trapezius, 121 Vertebral artery-related vertigo, 257 tests, 508
Umami, 147 Vertebral colmnn, 244-250, 244
Uncinate process, 250 typical vertebrae, 250, 250
Unidirectional transverse friction, 320 Vertical linguai, 382 x
for semispinalis cervicis, 283 Vertical muscular columns, trigger points,
Unilateral transverse friction, pronator teres, 559 Xiphoid process, 472, 541
497 Vertigo, 257
U nipennate muscle fibers, 27 Vibration, 154, 231-233
United States of America (USA), 166 Viscerocutaneous reflex, 8 y
Unpaired bones, 328 Viscerosomatic reflex, 48, 48
Upledger & Vredevoogd, red reflex Viscerovisceral reflex, 49 Yergason's test, 408, 418, 418
assessment, 546 Viscoelasticity, 3, 6, 39 Yoga stretching, 236
Upper arm Viscoplasticity, 3, 6 Yoshino, occlusal supporting zone, 358
MET for, 426 Viscous drag, 3 Yunus, fibromyalgia and myofascial pain,
restricted horizontal flexion, 425 Visual analogue scale (VAS), 191 105
Upper cervical region Vitamin C, 170
dysfunction, 268, 268 Vitamin D, 139
joint complex, 53 Vlaeyen, wellness education, 172 z
ligaments, 251 Vogt & Banzer, prone hip extension, 88
tissue preference, 264-266 Vomer, 336-337 Zink & Lawson
Upper crossed syndrome, 82, 82, 162, 409 inflammation, 337 postural (fascial) patterns, 18
'Upper fist' functions, 70-71 testing tissue preference, 264-265
Upper limb tension tests (ULIT), 224, 475 Zink tests, 266
Upper rectus abdominis, 293 w
Upper ribs, shoulder pain and, 416-417, 556
Upper thoracic area, 549 WaUden, adaptation sequences, 66