Clinical Application of Neuromuscular Techniques, Volume 1: The Upper Body

The new edition of Clinical Application of Neuromuscular Techniques

are described within the context of normal anatomy and physiology

The Upper Body updates and expands on the theories,

of the structures, as well as the common dysfunctions that may arise.

Volume 1

-

validation and techniques for the manual treatment of chronic and

Indications for treatments and guidance on making the appropriate

acute neuromuscular pain and somatic dysfunction. Over 600 pages

treatment choice are given for 'each muscle to be addressed, and

of highly illustrated material from the two leaders in the field of

particular attention is paid to the treatment of trigger points. Clinical

manual therapy ensure the anatomy and techniques involved in the

insights stem from many years of clinical and teaching experience of

application of neuromuscular techniques are easier to follow than

both authors.

ever before.

This new edition of Clinical Application of Neuromuscular Techniques

New to this edition is a CD-ROM containing fully searchable and

Volume 1

referenced book text complete with the illustrations and bonus

information from several sources. The result is a textbook which will

-

The Upper Body continues to combine and integrate key

illustrative material.

do much to ensure the safe and effective application of soft tissue

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

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).

-

The Lower Body,

About the Authors

Key Features •

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 •

All muscles covered from the perspective of assessment and treatment of myofascial pain

•

Describes the normal anatomy and physiology as well as the common dysfunctions

•

Provides indications for treatments and guidance on making the appropriate treatment choice for each patient

of treatment. He is author of over 60 books, including a series on Advanced Soft Tissue Manipulation (Muscle Energy Techniques, Positional Release Techniques, Modern Neuromuscular Techniques) and also Palpation Skills; Cranial Manipulation: Theory and Practice; Fibromyalgio Syndrome: A Practitioner's Guide to Treatment, and many more. He is editor of the peer reviewed Journal of 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 •

Includes location and treatment of trigger points

•

Covers manual and complementary techniques.

New to this edition •

Expanded text includes additions on the 'internal environment' (biochemistry), connective tissue, updated research, and many new illustrations

•

Illustrations demonstrating the bony anatomy under the treating fingers enhance aid to the reader in visualizing what is under palpation

not in Corfu, Greece where he focuses on his writing.

Judith Delany LMT has

spent two decades developing neuromuscular

therapy techniques and course curricula for manual practitioners as well as for massage schools and other educational venues. Her ongoing private trainings with the Tampa Bay Devil Rays athletic trainers (professional 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 -As the massoge profession embraces the knowledge base that is the foundation for the work that we do, there is a need for texts and reference bootes that provide concrete, researched, and integrated information free from the influence of personal sty/e. This text has accomplished the task by expertly weaving the sciences

editor for Journal af Bodywark and Movement Therapies, her professional focus aims to advance education in all healthcare professions to include myofascial therapies for acute and chronic pain syndromes. She resides in St. Petersburg, Florida where she is the director of and primary curriculum developer for NMT Center.

with the skills, and blending methods for physiologic outcomes� Sandy Fritz BS NCTMB "This book mosterfully integrates the biomechanical biopsychosocial and biomechanicol approoches of monogement of the soft tissue dysfunction: Craig Liebenson DC "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

www.elsevierhealth.com

9780443074486

Clinical Application of Neuromuscular .Techniques

For Elsevier: Senior Commissioning Editor: Sarena Wolfaard Associate Editor: Claire Wilson Project Manager: Gail Wright Designer: Eric Drewery Illustration Manager: Bruce Hogarth lIlustrators: Graeme Chambers, Peter Cox, Bruce Hogarth, Paul Richardson, Richard Tibbitts

Clinical Application of Neuromuscular Techniques Volume 1

-

The Upper Body

Second Edition

leon Chaitow ND DO Consultant Naturopath and Osteopath. Honorary Fellow, University of Westminster, London, UK

Judith Delany LMT Lecturer in Neuromuscular Therapy, Director of NMT Center, St Petersburg, Florida, USA

Foreword by

Diane lee

BSR FCAMT CGIMS

Director, Diane Lee Et Associates, Consultants in Physiotherapy, White Rock, BC, Canada

CHURCHILL LIVINGSTONE

ELSEVIER EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2008

CHURCHILL LIVINGSTONE ELSEVlER

© Elsevier Limited 2000. All rights reserved. © Elsevier Ltd,

2008.

All rights reserved.

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

1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103(+ 1) 215 239 3804; fax: (+ 1) 215 239 3805; or, e-mail: healthpennissions@elseviL>r.com.

Sciences Rights Department,

2899,

USA: phone:

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'. First edition

2000 2008

Second edition ISBN

978-0-443-07448-6

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is avaUabJe from the Library of Congress 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.

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I

vii

Contents

Major types of voluntary contraction 33 Terminology 33 Muscle tone and contraction 33 Vulnerable areas 34 Muscle types 34 Cooperative muscle activity 35 Muscle spasm, tension, atrophy 37 Contraction (tension with EMG elevation, voluntary) 38 Spasm (tension with EMG elevation, involuntary) 38 Contracture [tension of muscles without EMG elevation, involuntary) 38 Increased stretch sensitivity 38 Viscoelastic influence 39 Atrophy and chronic back pain 39 What is weakness? 39 Trick patterns 39 Joint implications 40 When should pain and dysfunction be left alone? 40 Beneficially overactive muscles 41 Somatization - mind and muscles 41 But how is one to know? 41

List of boxes xv Foreword xvii Preface to the Second Edition xix Acknowledgments xxi Connective tissue and the fascial system

1

The fascial network 2 Fascia and proprioception 2 Fascia: collagenous continuity 2 Further fascial considerations 2 Elasticity 3 Plastic and elastic features 3 Connective tissue as a 'sponge' 6 Deformation characteristics 6 Hypermobility and connective tissue 7 Trigger points, fascia and the nervous system 8 The importance of Langevin's research 9 Summary of fascial and connective tissue function 13 Fascial dysfunction 16 Restoring gel to sol 17 A different model linking trauma and connective tissue 17 Therapeutic sequencing 1 9 2

Muscles

23

Dynamic forces - the 'structural continuum' 23 Signals 25 Essential information about muscles 25 Types of muscle 25 Energy production in normal tissues 27 Energy production in the deconditioned individual 28 Muscles and blood supply 28 Motor control and respiratory alkalosis 31 Two key definitions 32 The Bohr effect 32 Core stability, transversus abdominis, the diaphragm and BP D 32 Summary 32

3

Reporting stations and the brain

45

Proprioception 45 Fascia and proprioception 46 Reflex mechanisms 47 Local reflexes 50 Central influences 50 Neuromuscular dysfunction following injury 51 Mechanisms that alter proprioception 52 An example of proprioceptive dysfunction 52 Rectus capitis posterior minor (RCPMin) research evidence 52 Neural influences 53 Effect of contradictory proprioceptive information 53 Neural overload, entrapment and crosstalk 57

viii

CONTENTS

Scapulohumeral rhythm test 91 Neck flexion test 92 Push-up test 92 Breathing pattern assessments 92 Seated assessment 92 Supine assessment 93 Sidelying assessment 93 Prone assessment 93 Trigger point chains 94

Manipulating the reporting stations 58 Therapeutic rehabilitation using reflex systems 59 Conclusion 60 4

Causes of m usculoskeletal d ysfunction

63

Adaptation - GAS and LAS 63 Posture, respiratory function and the adaptation phenomenon 64 An example of 'slow' adaptation 66 What of adaptation to trauma? 67 What of adaptation to habits of use? 67 Making sense of the picture 67 Example 68 Postural and emotional influences on musculoskeletal dysfunction 69 Postura I interpretations 69 Contraction patterns 69 Emotional contractions 69 'Middle fist' functions 70 'Upper fist' functions 70 Behavior and personality issues 71 Cautions and questions 72 Postural imbalance and the diaphragm 73 Balance 74 Respiratory influences 75 Effects of respiratory alkalosis in a deconditioned individual 75 Respiratory entrainment and core stability issues 75 Summary of effects of hyperventilation 76 Neural repercussions 77 Tetany 77 Biomechanical changes in response to upper chest breathing 77 Additional emotional factors and musculoskeletal dysfunction 78 Selective motor unit involvement 78 Conclusion 79 5

Patterns of dysfunction

Upper crossed syndrome 82 Lower crossed syndrome 82 Layer (stratification) syndrome 83 Chain reaction leading to facial and jaw pain: an example 84 Patterns from habits of use 84 The big picture and the local event 85 Janda's 'primary and secondary' responses 85 Recognizing dysfunctional patterns 86 Excessive muscular tone 86 Simple functional tests for assessing excess muscular tone 87 Functional screening sequence 88 Prone hip (leg) extension (PLE) test 89 Trunk flexion test 90 Hip abduction test 90

6

Trigger points

97

Ischemia and muscle pain 101 Ischemia and trigger point evolution 102 Trigger point connection 102 Microanalysis of trigger point tissues 103 Ischemia and fibromyalgia syndrome (FMS) 1 03 FMS and myofascial pain 105 Facilitation - segmental and local 105 Trigger points and organ dysfunction 106 How to recognize a facilitated spinal area 108 Local facilitation in muscles 1 08 Lowering the neural threshold 109 Varying viewpoints on trigger points 109 Awad's analysis of trigger points 109 Nimmo's receptor-tonus techniques 109 Improved oxygenation and reduced trigger point pain - an example 110 Pain-spasm-pain cycle 110 Fibrotic scar tissue hypothesis 110 Muscle spindle hypothesis 110 Radiculopathic model for muscular pain 111 Simons' current perspective: an integrated hypothesis 111 Central and attachment trigger points 112 Primary, key and satellite trigger points 112 Active and latent trigger points 113 Essential and spillover target zones 114 Trigger points and joint restriction 1 1 4 Trigger points associated with shoulder restriction 114 Other trigger point sites 114 Testing and measuring trigger points 114 Basic skill requirements 115 Needle electromyography 116 Ultrasound 116 Surface electromyography 116 Algometer use for research and clinical training 117 Thermography and trigger points 117 Clinical features of myofascial trigger points 118 Developing skills for TrP palpation 1 1 9 Which method i s more effective? 121

81

7

The internal environment

Local myofascial inflammatory influences 125 Pain progression 126 Sensitization 126 Mechanisms of chronic pain 126

125

Contents

Glutamate: a contrary view of the cause of tendon pain 127 Acute (lag) phase of the inflammatory response 128 Regeneration (repair) phase 128 Remodeling phase 128 Difference between degenerative and inflammatory processes 129 Antiinflammatory nutrients and herbs 129 What about antiinflammatory medication7 130 Controlled scarring - friction and prolotherapy 130 When inflammation becomes global 131 Hormonal influences 131 Muscles, joints and pain 140 Reflex effects of muscular pain 141 Source of pain 142 Is it reflex or local? 142 Radicular pain 142 Are the reflexes normal? What is the source of the pain? 142 Differentiating between soft tissue and joint pain 143 Neuropathic pain 143 Neurotoxic elements and neuropathic pain 144 Effects of pH changes through breathing 149 Alkalosis and the Bohr effect 149 Deconditioning and unbalanced breathing 149 Caffeine in its various forms 150 When should pain and dysfunction be left alone? 151 Somatization 152 How is one to know? 152 Pain management 154 Gunn's view 154 Questions 154 Pain control 154 8

Assessment, treatment and rehabilitation

161

Numerous influences 162 A biomechanical example 162 'Looseness and tightness' as part of the biomechanical model 163 Lewit (1996) and 'loose-tight' thinking 164 Soft tissue treatment and barriers 164 Pain and the tight-loose concept - and the trigger point controversy 164 Three-dimensional patterns 165 Methods for restoration of 'three-dimensionally patterned functional symmetry' 165 Neuromuscular management of soft tissue dysfunction 166 Manipulating tissues 166 Nutrition and pain: a biochemical perspective 167 Nutritional treatment strategies 167 Specific nutrients and myofascial pain 167 Allergy and intolerance: additional biochemical influences on pain 168 What causes this increase in permeability? 169 Treatment for 'allergic myalgia' 169 Antiinflammatory nutritional (biochemical) strategies 169

Psychosocial factors in pain management: the cognitive dimension 170 Guidelines for pain management 171 Group pain management 171 The litigation factor 171 Other barriers to progress in pain management 171 Stages of change in behavior modification 171 Wellness education 172 Goal setting and pacing 172 Low back pain rehabilitation 172 The biopsychosocial model of rehabilitation 172 Concordance 173 Patient advice and concordance (compliance) issues 173 9

Modern neuromuscular techniques

177

Neuromuscular therapy - American version 177 Biomechanical factors 178 Biochemica I factors 179 Psychosocial factors 180 Biomechanical, biochemical and psychosocial interaction 180 NMT techniques contraindicated in initial stages of acute injury 181 NMT for chronic pain 182 Palpation and treatment 182 Treatment and assessment tools 189 Pain rating tools 190 Treatment tools 190 European (Lief's) neuromuscular technique (NMT) 191 NMT thumb technique 192 Lief's NMT finger technique 193 Use of lubricant 194 Variations 194 Variable ischemic compression 194 A framework for assessment 195 Some limited NMT research 196 Integrated neuromuscular inhibition technique 197 10 Associated therapeutic modalities and techniques 205 Hydrotherapy and cryotherapy 206 How water works on the body 206 Warming compress 206 Alternate heat and cold: constitutional hydrotherapy (home application) 208 Neutral bath 209 Alternate bathing 209 Alternating sitz baths 210 Ice pack 210 Integrated neuromuscular inhibition technique (lNIT) 210 INIT method 1 210 INIT rationale 211 Ruddy's reciprocal antagonist facilitation (RRAF) 212 Lymphatic drainage techniques 212 McKenzie Method® 213 Massage 215

ix

x

CONTENTS

Petrissage 215 Kneading 215 Inhibition 215 Effleurage (stroking) 215 Vibration and friction 216 Transverse friction 216 Effects explained 216 Mobilization and articulation 217 Notes on sustained natural apophyseal glides (SI'JAGs) 217 Muscle energy techniques (MET) and variations 218 l'Jeurological explanation for MET effects 218 Use of breathing cooperation 218 Muscle energy technique variations 219 Myofascial release techniques (MFR) 221 Exercise 1 Longitudinal paraspinal myofascial release 222 Exercise 2 Freeing subscapularis from serratus anterior fascia 223 Myofascial release of scar tissue 223 Neural mobilization of adverse mechanical or neural tension 223 Adverse mechanical tension (AMT) and pain sites are not necessarily the same 224 Types of symptoms 224 Neural tension testing 224 Positional release techniques (PRT) 225 The proprioceptive hypothesis 225 The nociceptive hypothesis 226 Resolving restrictions using PRT 226 Circulatory hypothesis 227 Variations of PRT 227 Rehabilitation 230 Relaxation methods 231 Rhythmic (oscillatory, vibrational, harmonic) methods 231 What's happening? 231 Application exercise for the spine 232 Trager® exercise 233 Spray and stretch for trigger point treatment 233 Additional stretching techniques 235 Facilitated stretching 235 Proprioceptive neuromuscular facilitation (PNF) variations 235 Active isolated stretching (AIS) 236 Yoga stretching (and static stretching) 236 Ballistic stretching 236 Using multiple therapies 236 11 The cervical region The vertebral column: a structural wonder 244 Cervical vertebral structure 246 The upper and lower cervical functional units 248 Movements of the cervical spine 250 Upper cervical (occipitocervical) ligaments 251 Lower cervical ligaments 253 Assessment of the cervical region 253

243

Landmarks 255 Functional features of the cervical spine 255 Muscular and fascial features 256 Neurological features 256 Circulatory features and thoracic outlet syndrome 256 Cervical spinal dysfunction 259 Assessments 259 Assessment becomes treatment 266 Assessment and treatment of occipitoatlantal restriction (CO-C'I) 268 Functional release of atlantooccipital joint 269 Translation assessment for cervical spine (C2-7) 269 Treatment choices 270 Alternative positional release approach 271 SCS cervical flexion restriction method 271 SCS cervical extension restriction method 271 Stiles' (1984) general procedure using MET for cervical restriction 272 Harakal's (1975) cooperative isometric technique (MET) 272 Cervical treatment: sequencing 273 Cervical planes and layers 274 Posterior cervical region 275 NMT for upper trapezius in supine position 277 MET treatment of upper trapezius 278 Positional release of upper trapezius 279 Myofascial release of upper trapezius 280 Variation of myofascial release 280 NMT: cervical lamina gliding techniques - supine 281 Semispinalis capitis 282 Semispinalis cervicis 283 Splenii 283 NMT techniques for splenii tendons 284 Spinalis capitis and cervicis 285 NMT for spinalis muscles 286 Longissimus capitis 286 Longissimus cervi cis 286 Iliocostalis cervicis 286 Multifidi 287 Rotatores longus and brevis 287 Interspinales 287 NMT for interspinales 289 Intertransversarii 289 Levator scapula 289 NMT for levator scapula 290 MET treatment of levator scapula 291 Positional release of levator scapula 291 Suboccipital region 292 Rectus capitis posterior minor 294 Rectus capitis posterior major 295 Obliquus capitis superior 295 Obliquus capitis inferior 295 NMT for suboccipital group - supine 296 Platysma 298 NMT for platysma 299 General anterior neck muscle stretch utilizing MET 299

Contents

Sternocleidomastoid 300 NMT for SCM 301 Treatment of shortened SCM using MET 303 Positional release of sternocleidomastoid 304 Suprahyoid muscles 304 Infrahyoid muscles 304 Sternohyoid 305 Sternothyroid 306 Thyrohyoid 306 Omohyoid 306 NMT for infrahyoid muscles 307 Soft tissue technique derived from osteopathic methodology 308 Longus colli 308 Longus capitis 309 NMT for longus colli and capitis 311 MET stretch of longus capitis 31 2 Rectus capitis anterior 312 Rectus capitis lateralis 313 NMT for rectus capitis lateralis 31 3 Scalenii 314 NMT for scalenii 316 Treatment of short scalenii by MET 318 Positional release of scalenii 319 Cervical lamina - prone 319 NMT for posterior cervical lamina - prone position 320 NMT for posterior cranial attachments 320 12 The cranium Cranial structure 326 Occiput 328 Sphenoid 332 Ethmoid 335 Vomer 336 Mandible 337 Frontal 340 Parietals 343 Temporals 344 Zygomae 347 Maxillae 349 Palatines 350 NMT treatment techniques for the cranium 351 Muscles of expression 351 Mimetic muscles of the epicranium 352 Occipitofrontalis 352 Temporoparietalis and auricular muscles 352 NMT for epicranium 354 Positional release method for occipitofrontalis 355 Mimetic muscles of the circumorbital and palpebral region 355 NMT for palpebral region 355 Mimetic muscles of the nasal region 356 NMT for nasal region 356 Mimetic muscles of the buccolabial region 356 NMT for buccolabial region 357

3 25

Muscles of mastication 358 Neck pain and TMD 359 External palpation and treatment of craniomandibular muscles 365 I'JMT for temporalis 366 NMT for masseter 367 Massage/myofascial stretch treatment of masseter 368 Positional release for masseter 368 NMT for lateral pterygoid 369 NMT for medial pterygoid 369 Stylohyoid 369 External palpation and treatment of styloid and mastoid processes 371 Intraoral palpation and treatment of craniomandibular muscles 372 Intraoral NMT applications 372 Temporalis 372 NMT for intraoral temporalis tendon 373 Masseter 373 NMT for intraoral masseter 375 Lateral pterygoid 375 NMT for intraoral lateral pterygoid 378 Medial pterygoid 379 NMT for intraoral medial pterygoid 380 Musculature of the soft palate 380 NMT for soft palate 382 Muscles of the tongue 382 NMT for muscles of the tongue 383 Suprahyoid muscles - the floor of the mouth 384 NMT for intraoral floor of mouth 385 Cranial treatment and the infant 387 The craniocervical link 388 Sleeping position and cranial deformity 389 What other factors do medical authorities think cause serious cranial distortion in infants? 389 What are the long-term effects of deformational plagiocephaly? 389 Different cranial approaches 390 Ear disease and cranial care 390 Summary 392 13 Shoulder. arm and hand Shoulder 401 Structure 40 1 Key joints affecting the shoulder 401 Pivotal soft tissue structures and the shoulder 404 Assessment 407 Repetitions are important 408 Janda's perspective 41 0 Observation 41 0 Palpation of superficial soft tissues 41 1 Range of motion of shoulder structures 41 1 Active and passive tests for shoulder girdle motion (standing or seated) 41 2 Strength tests for shoulder movements 41 3

3 99

xi

xii

CONTENTS

Muscular relationships 41 3 Spinal and scapular effects of excessive tone 415 Shoulder pain and associated structures 415 Therapeutic choices 416 Specific shoulder dysfunctions 417 Specific muscle evaluations 420 Infraspinatus 420 Levator scapula 420 Latissimus dorsi 420 Pectoralis major and minor 421 Supraspinatus 421 Subscapularis 421 Upper trapezius 421 Is the patient's pain a soft tissue or a joint problem? 422 The Spencer sequence 422 Treatment 429 Trapezius 429 Assessment of upper trapezius for shortness 431 NMT for upper trapezius 432 NMT for middle trapezius 433 NMT for lower trapezius 433 NMT for trapezius attachments 434 Lief's NMT for upper trapezius area 434 MET treatment of upper trapezius 435 Myofascial release of upper trapezius 435 Levator scapula 435 Assessment for shortness of levator scapula 436 NMT for levator scapula 436 MET treatment of levator scapula 438 Rhomboid minor and major 438 Assessment for weakness of rhomboids 439 Assessment for shortness of rhomboids 439 NMT for rhomboids 439 MET for rhomboids 440 Deltoid 441 NMT for deltoid 443 Supraspinatus 443 Assessment for supraspinatus dysfunction 446 Assessment for supraspinatus weakness 446 NMT treatment of supraspinatus 446 MET treatment of supraspinatus 446 MFR for supraspinatus 447 Infraspinatus 447 Assessment for infraspinatus shortness/dysfunction 447 Assessment for infraspinatus weakness 448 NMT for infraspinatus 448 MET treatment of short infraspinatus (and teres minor) 448 MFR treatment of short infraspinatus 449 PRT treatment of infraspinatus (most suitable for acute problems) 449 Triceps and anconeus 449 Assessment for triceps weakness 452 NMT for triceps 452 MET treatment of triceps (to enhance shoulder flexion with elbow flexed) 452

NMT for anconeus 453 Teres minor 453 Assessment for teres minor weakness 453 NMT for teres minor 454 PRT for teres minor (most suitable for acute problems) 455 Teres major 456 NMT for teres major 457 PRT for teres major (most suitable for acute problems) 457 Latissimus dorsi 458 Assessment for latissimus dorsi shortness/dysfunction 458 NMT for latissimus dorsi 459 MET treatment of latissimus dorsi 460 PRT for latissimus dorsi (most suitable for acute problems) 460 Subscapularis 460 Assessment of subscapularis dysfunction/shortness 462 Observation of subscapularis dysfunction/shortness 462 Assessment of weakness in subscapularis 463 NMT for subscapularis 463 MET for subscapularis 463 PRT for subscapularis (most suitable for acute problems) 464 Serratus anterior 464 Assessment for weakness of serratus anterior 465 NMT for serratus anterior 465 Facilitation of tone in serratus anterior using pulsed MET 466 Pectoralis major 467 Assessment for shortness in pectoralis major 470 Assessment for strength of pectoralis major 470 NMT for pectoralis major 471 MET for pectoralis major 472 Alternative MET for pectoralis major 473 MFR for pectoralis major 474 Pectoralis minor 474 NMT for pectoralis minor 476 Direct (bilateral) myofascial stretch of shortened pectoralis minor 477 Subclavius 477 MFR for subclavius 477 Sternalis 479 Coracobrachialis 479 Assessment for strength of coracobrachialis 479 NMT for coracobrachialis 481 MFR for coracobrachialis 481 PRT for coracobrachialis 481 Biceps brachii 482 Assessment for strength of biceps brachii 483 Assessment for shortness and MET treatment of biceps brachii 483 NMT for biceps brachii 483 MET for painful biceps brachii tendon (long head) 484 PRT for biceps brachii 485 Elbow 485

Contents

Introduction to elbow treatment 485 Structure and function 485 Humeroulnar joint 486 Humeroradial joint 486 Radioulnar joint 486 Assessment of bony alignment of the epicondyles 486 The ligaments of the elbow 486 Assessment for ligamentous stability 487 Evaluation 487 Biceps reflex 487 Brachioradialis reflex 487 Triceps reflex 488 Ranges of motion of the elbow 488 Range of motion and strength tests 488 Elbow stress tests 488 Strains or sprains 489 Indications for treatment (dysfunctions/syndromes) 489 Median nerve entrapment 489 Carpal tunnel syndrome 489 Ulnar nerve entrapment 489 Radial nerve entrapment 492 , Tenosynovitis ( tennis elbow' and/or 'golfer's elbow') 492 Assessments for tenosynovitis and epicondylitis 492 Elbow surgery and manual techniques 492 Treatment 493 Brachialis 493 NMT for brachialis 493 Triceps and anconeus 493 NMT for triceps (alternative supine position) 494 NMT for anconeus 494 Brachioradialis 494 Assessment for strength of brachioradialis 494 NMT for brachioradialis 495 MFR for brachioradialis 495 Supinator 495 Assessment for strength of supinator 496 NMT for supinator 496 MET for supinator shortness 496 MFR for supinator 496 Pronator teres 496 Assessment for strength of pronator teres 497 NMT for pronator teres 497 MFR for pronator teres 498 PRT for pronator teres 498 Pronator quadratus 498 NMT for pronator quadratus 498 Forearm, wrist and hand 498 Forearm 499 Wrist and hand 499 Capsule and ligaments of the wrist 501 Ligaments of the hand 502 Key (osteopathic) principles for care of elbow, forearm and wrist dysfunction 503 Active and passive tests for wrist motion 503 Reflex and strength tests 506 Ganglion 506

Carpal tunnel syndrome 507 Phalanges' 508 Carpometacarpal ligaments (2nd, 3rd, 4th, 5th) 509 Metacarpophalangeal ligaments 510 Range of motion 510 Thumb 511 Thumb ligaments 511 Range of motion at the joints of the thumb 511 Testing thumb movement 511 Dysfunction and evaluation 511 Preparing for treatment 511 Terminology 512 Neural entrapment 513 Distant influences 513 Anterior forearm treatment 513 Palmaris longus 513 Flexor carpi radialis 515 Flexor carpi ulnaris 515 Flexor digitorum superficialis 515 Flexor digitorum profundus 51 6 Flexor pollicis longus 516 NMT for anterior forearm 518 Assessment and MET treatment of shortness in the forearm flexors 519 MET for shortness in extensors of the wrist and hand 521 PRT for wrist dysfunction (including carpal tunnel syndrome) 521 MFR for areas of fibrosis or hypertonicity 521 Posterior forearm treatment 522 Superficial layer 522 Extensor carpi radialis longus 523 Extensor carpi radialis brevis 523 Extensor carpi ulnaris 524 Extensor digitorum 524 Extensor digiti minimi 525 NMT for superficial posterior forearm 525 Deep layer 527 Abductor pollicis longus 527 Extensor pollicis brevis 528 Extensor pollicis longus 528 Extensor indicis 528 NMT for deep posterior forearm 528 Intrinsic hand muscle treatment 529 Thenar muscles and adductor pollicis 530 Hypothenar eminence 532 Metacarpal muscles 532 NMT for palmar and dorsal hand 533 14 The thorax

Structure 540 Structural features of the thoracic spine 540 Structural features of the ribs 541 Structural features of the sternum 541 Posterior thorax 541 Identification of spinal levels 542

53 9

xiii

xiv

CONTENTS

The sternosymphyseal syndrome 542 Spinal segments 543 Palpation method for upper thoracic segmental facilitation 544 How accurate are commonly used palpation methods? 544 Red reflex assessment (reactive hyperemia) 545 Biomechanics of rotation in the thoracic spine 546 Coupling test 547 Observation of restriction patterns in thoracic spine (C-curve observation test) 547 Breathing wave assessment 547 Breathing wave - evaluation of spinal motion during inhalation/exhalation 548 Passive motion testing for the thoracic spine 548 Flexion and extension assessment of Tl-4 548 Flexion and extension assessment of T5-12 548 Sideflexion palpation of thoracic spine 549 Rotation palpation of thoracic spine 549 Prone segmental testing for rotation 550 Anterior thorax 550 Respiratory function assessment 550 Palpation for trigger point activity 554 Alternative categorization of muscles 554 Rib palpation 554 Specific 1st rib palpation 554 Test and treatment for elevated and depressed ribs 554 Rib motion 554 Tests for rib motion restrictions 554 Discussion 556

Thoracic treatment techniques 557 Posterior superficial thoracic muscles 557 NMT: posterior thoracic gliding techniques 560 NMT for muscles of the thoracic lamina groove 562 Spinalis thoracis 563 Semispinalis thoracis 563 Multifidi 563 Rotatores longus and brevis 564 NMT for thoracic (and lumbar) lamina groove muscles 565 PR method for paraspinal musculature: induration technique 566 Muscles of respiration 567 Serratus posterior superior 567 Serratus posterior inferior 568 Levatores costarum longus and brevis 568 Intercostals 570 NMT for intercostals 571 Influences of abdominal muscles 571 NMT assessment 571 PR of diaphragm 572 MET release for diaphragm 572 Interior thorax 572 Diaphragm 572 NMT for diaphragm 573 Transversus thoracis 574 Thoracic mobilization with movement - SNAGs method 575 Index

579

xv

List of boxes

1.1 1.2 1.3 1.4 1.5 1.6 1.7

Definitions 1 Biomechanical terms relating to fascia 3 Biomechanical laws 2 Connective tissue 4 Myers' fascial trains 11 Tensegrity 14 Postural (fascial) patterns 18

2.1

Muscle contractile mechanics and the sliding filament theory 26 The lymphatic system 29 Alternative categorization of muscles 36 Muscle strength testing 39 Two-joint muscle testing 39

2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 3.5

Neurotrophic influences 47 Reporting stations 51 Co-contraction and strain 54 Biochemistry, the mind and neurosomatic disorders 55 Centralization mechanisms including wind-up and long-term potentiation [LTP] 58

4.1 4.2

Partial pressure symbols 76 Hyperventilation in context 76

5.1 5.2

Hooke's law 85 Trigger point chains 94

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10

Historical research into chronic referred muscle pain 98 Fibromyalgia and myofascial pain 105 Trigger point activating factors 113 Active and latent features 114 Trigger point incidence and location 11 6 Trigger point and referred inhibition 117 Trigger point perpetuating factors 119 What are taut bands? 1 1 9 Clinical symptoms 120 Lymphatic dysfunction and trigger point activity 120

7.1 7.2

The endocrine system 132 Underactive thyroid 133

7.3

7.5 7.6 7.7 7.8

Leptin and other chemical influences in systemic inflammation 134 Key concepts in the relation between adipose tissue and inflammation 140 Mercury - is there a 'safe' level? 145 Umami 1 47 Health influences of tea, coffee, and other beverages 1 50 Placebo power 153

8.1

Tight-loose palpation exercise 164

9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12

The roots of modern neuromuscular techniques 178 Semantic confusion 178 Summary of rehabilitation sequencing 182 Effects of applied compression 183 Two important rules of hydrotherapy 185 The general principles of hot and cold applications 185 Compression definitions 187 Summary of American NMT assessment protocols 189 Positional release techniques (PRT) 198 Muscle energy techniques 199 Notes on synkinesis 201 Ruddy's pulsed muscle energy technique 201

1 0.1 10.2

Acupuncture and trigger points 207 A summary of soft tissue approaches to FMS and CFS 211

7.4

11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 11.10

Water imbibition by the nucleus 247 Important questions to ask 254 How acute is a problem? 254 Posttrauma fibromyalgia 256 Tests for circulatory dysfunction 257 Tests for cervical spinal dysfunction 257 Whiplash 261 Lief's NMT for upper trapezius area 278 Summary of American NMT assessment protocols 281 Spinal mobilization using mobilization with movement (MWM) 288 11 .11 Cranial base release 296 11.1 2 Lief's NMT for the suboccipital region 297 11.1 3 PRT (strain-counterstrain) for any painful areas located in the posterior cervical musculature 298

xvi

LIST OF BOXES

11.14 Balancing of the head on the cervical column 302 11.15 Sidelying position repose 316 12.1

Cranial terminology and associated motion patterns based on traditional osteopathic methodology 326 12.2 The meaning of 'release' 327 12.3 Cranial bone groupings 328 12.4 Temporomandibular joint structure, function and dysfunction 359 12.5 Temporal arteritis 366 1 2.6 Notes on the ear 370 12.7 How do we maintain equilibrium? 370 12.8 Muscles producing movements of mandible 371 12.9 Latex allergy alert 371 12.10 Tinnitus: the TMD and trigger point connection 374 12.11 Deglutition 386 12.12 Muscles of the eye 392 13.1 13.2 13.3 13.4 13.5 1 3.6 13.7

Ligaments of the shoulder girdle 405 Caution: Scope of practice 409 Reflex tests (always compare both sides) 411 What is normal range of arms? 411 Neutralizers 413 Spencer's assessment sequence 423 Clavicular assessment 425

13.10 13.11 13.12 13.13 1 3.1 4 13.15 13.16 13.17 13.18

Acromioclavicular and sternoclavicular MET approaches 426 Spencer's assessment sequence including MET and PRT treatment 427 MFR 466 Shoulder and arm pain due to neural impingement 475 Modified PNF spiral stretch techniques 478 Sternalis and chest pain 479 Definition of enthesitis 492 Focal hand dystonia (FHd) - 'repetitive strain injury' 503 Nerve entrapment possibilities 507 Mulligan's mobilization techniques 520 Arthritis 529

14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9

Identification of spinal level from spinous process 546 Liefs NMT of the upper thoracic area 549 Respiratory muscles 550 Respiratory mechanics 551 Some effects of hyperventilation 553 Upper ribs and shoulder pain 556 Pressure bars 566 Liefs NMT of the intercostal muscles 569 McConnell and the diaphragm 572

13.8 13.9

xvii

Foreword

Headache, TMJ, neck/shoulder pain and tennis elbow are all common complai nts of patients seeking help from vari­ ous hea lth practitioners. The source of the impairment and/or the pain is often found in the neuromyofascial sys­ tem. As a novice, a cli nician will approach the problem based on the paradigm taught in their formal training such as physiotherapy, osteopathy, massage therapy, Rolfing, acupuncture or chiropractic. Thus we see the advocacy of many different traditional treatments for myofascial pain such as: •

•

•

• • •

Physiotherapy - thermal agents followed by stretching exercises Osteopathy - strain/counterstrain, positional release, functional and muscle energy techniques Massage therapy - deep pressure on tender points, stroking, lymphatic massage techniques Rolfi ng - deep fascial release/stretching tec hniques Acupunc ture - dry needling of 'An Shi' pOints Chiropractic - manipulation (high velocity, low amphtude thrust techni ques) of the spinal segment which correlates to the segmental nerve supply of the affected muscle.

At this point, you may be thinking 'Wait a mi nute! I do more than tha t (or all of that, or some of tha t) for my patients with myofascial pain'. This is true enough, since over time most clinicians gain expertise and are exposed to the paradigms of other disciplines and thus their 'tool box' grows. l11is book is a wonderful representation of all the paradigms of the many discipl ines that ha ve ever consid­ ered how to rela x/release a muscle or a trigger point in a muscle. Yet, this book is way more than this and even more than the title Clinical Application of Neuromuscular Techniques alludes to. While this text relies heavily on the clinical expertise of both the authors and the historical leaders in both their pro­ fessions and others, it also refers and draws on the current scientific evidence where it is available. Some may say that the techniques and suggested protocols in this text are not

evidence-based and I think it is worthwhile defining exactly what evidence-based practice is. According to Sackett et al (2000), Evidence-based practice is the integration of best research evidence, clinical expertise and patient values. External clinical evidence can inform, but can never replace individ­ ual clinical expertise, and it is this expertise that decides whether the external evidence applies to the patient at all, and if so, how it should be integrated into a clinical decision.

W hat is expertise? Expertise has been defined as the ability to do the right thing at the right time (Ericsson & Smith 1991). Indeed, I believe that this monumental text is evi­ dence-based since it includes the best a vailable research evi­ dence and integrates it with the multi-disciplinary clinical expertise that has accumulated over the last 100 years. As mentioned earlier, this text is a bout more than neuro­ muscular techniques. It begins with an o verview of the anatomy and function of connective tissue, fascia, muscles and the nervous systems (peripheral and central). The anatomical illustrations are clear, weU-labeled and perti­ nent. Many of the current hypotheses regarding the ca uses of musculoskeletal dysfunction and the various patterns of presentation are outlined . There is an extensive discussion on the current theories and evidence pertaining to the cause, effect and cli nical presentation of myofascial trigger points. While ultima tely the text turns to the detailed trea t­ ment of every possible muscle you could think of i n the upper half of the body, prior to this the a uthors discuss where, when and how the neuromuscular techniques fit into the entire treatment protocol. This ensures tha t the reader is not left with the impression that neuromuscular release is all that is needed for treating a patient. Once into trea tment, consideration is given to the role of non-manual therapies such as thermal modal ities, spray and stretch and exercise, and then the use of the manual techni ques is explained in great detail. Following this, the upper half of the body is divided and each section begins with a review of

xviii

FOREWORD

the regional anatomy and biomechanics and a Hsting of the muscles in which trigger p oints are commonly found. Each manual tecl mique is illustrated and described in explicit detail. This is easy for the novice to follow and often con­ 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

Neuromuscular Techniques, a text which is applicable to the novice and the expert of any discipline that deals with patients p resenting with i mp airments of the neuromyofas­ ciaI system. White Rock, Be C anada 2007

Diane Lee

References Ericsson KA, Smith

J 1991 Towards a general theory of expertise:

prospects and limits. Cambridge University Press, New York

Sackett DL, Strauss SE, Richardson WS, et al 2000 How to practice

& teach evidence-based medicine. Elsevier Science, New York

xix

Preface to the Second Ed ition

The clinical utilization of soft tissue manipulation has increased dramatically in recent years in all areas of manual health-care provision. A text that integrates the safe and proficient application of some of the most effective soft tis­ sue tedmiques is both timely and necessary. The decision to write this book was therefore based on a growing aware­ ness of the need for a text that describes, in some detail, the clinical applications of neuromuscular techniques in p artic­ ular, and soft tissue manipulation in general, on each and every area of the musculoskeletal system. There are n umerous texts c ommunicating the features of different manual therapy systems (osteopathy, chiropractic, physical therapy, manual medicine, massage the rapy, etc.) and of modalities employed with i. n these health-care deliv­ ery systems (high-velocity thrust techniques, muscle energy tedmiques, myofascial release and many, many more). There are also excellent texts that describe regional p rob­ lems (say of the pelvic region, temporomandibular j oint or the spine) with protocols for assessment and treatment, often presented from a p articular perspective. Increasingly, edited texts incorporate a variety of perspectives when focusing on particular regions, offering the reader a broad view as well as detailed informati on on the topic. And t hen there are wonderfully crafted volumes, such as those p ro­ duced by Travell and Simons, covering the spectrum of 'myofascial pain and dysfu nction' and incorporating a deeply researched and evolving model of care. We adopted Travell and Simons' view of the human b ody, which offers a valuable regional approach model on which to base our own perspectives. To this practical and intellec­ tually satisfying model, we have added detailed anatomical and physiological descripti ons, coupled with clinically prac­ tical 'bodywork' solutions to t he problems located in each region. In this first vol ume of the text, the upper b ody is cov­ ered; in Volume 2, the region from the waist down is sur­ veyed in the same way. As authors, we have attempted to place in context the relative importance and significance of local conditions, pain and/or dysfu nction, which are quite

logically the main focus for the p atient. However, we believe it is vital that loc al problems should be commonly seen by the p ractitioner to form p art of a larger picture of compensa­ tion, adaptation and/or decompensation and that the back­ ground causes (of local myofascial pain, for example) be sought and, where possible, removed or at least m odified. We also take the position t hat it is the p ractitioner's role to take account of biochemical (nutriti onal and hormonal influences, allergy, etc.), biomec hanical (posture, b reathing p atterns, habits of use, etc.) and/or psychosocial (anxiety, depression, stress factors, etc.) influences that might be involved, as far as this is p ossible. If appropriate, suitable advice or treatment c an then be offe red. However, if the p ractitioner is not trained and licensed to do so, profes­ sional referral becomes the obvious choice. In this way, the focus of health care goes beyond treatment of local condi­ tions and moves toward holism, to the benefit of the patient. In this volume, the person applying the techniques i s referred t o as the 'practitioner' so as to include all the ra­ pists, physicians, nurses or others who apply manual tech­ niques. To ease confusion, the practitioner is depicted as male and t he recipient of the treatment modalities (the patient) is depicted as female so that gender references (he, his, she, hers) used within the text are n ot ambiguous. In Volume 2, the roles are reversed with the female p racti­ tioner treating the male p atient. The protocols described in this text fall largely within the biomechanical arena, with the main emphasis being the first comprehensive, detailed description of the clinical applica­ tion of NMT (neuromuscular therapy in the USA, neuro­ muscular technique in Europe). The desc riptions of NMT are mainly of the modern American version, as described by Judith DeLany, whose many years of involvement with NMT, both clinically and academically, make her a leading authority on the subject. Additional therapeutic choices, including nutri tional and hydrotherapeutic, as well as complementary bodywork methods, such as muscle energy, positional release and

xx

PREFACE TO THE SECOND EDITION

variations of myofascial release teclmiques, and the European version of NMT, are largely the contribution of Leon Chaitow, as are, to a large extent, the opening chapters regarding the physiology of pain and dysfunction. In addition to the practical application sections of the book, a nwnber of chapters offer a wide-ranging overview of current think ing and research into the background of the dysfunctional sta tes for which solutions a nd suggestions are provided in la ter chapters. The overview, 'big picture' chapters cover the latest research findings a nd information relevant to understanding fascia, muscles, neurological fac­ tors, pa tterns of dysflmction, pain and inflammation , myofascial trigger points, emotional and nutritional influ­ ences a nd much more. It is our assertion tha t the combina­ tion of the 'big picture', together with the detailed NMT protocols, offers a foundation on which to build the excep­ tional palpation and treatment skills necessary for finding effective, practical solutions to chronic pain conditions. Some chapters, such as Chapters 6 and 7, have evolved substantially since the first edition, based on integration of our diverse viewpoints, with the occasional result being paradigm shifts that altered therapeutic platforms. We 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 cepts to assist in safe application of the methods described,

especially if they have had previous training in soft tissue palpation and treatment. The text of this book is therefore intended as a framework for the clinical application of NMT for those already quali fied (and, where appropriate, licensed to practice), as well as being a learning tool for those in training. It is definitely not meant to be a substitute for hands-on training with skilled in structors. To this volume is married the companion text for the lower body, the layout and style of which is very similar. Its foundational chapters cover posture, gait, balance, influ­ ences of the close environment surrounding the body, adap­ tations from sport and other repetitious use, and other contextual material that influences clinical thinking. Additionally, Clinical Application of Neuromuscular Techniques - Practical Case Study Exercises is now available to support the practitioner in developing a model by which to apply the protocols to clinical cases. The use of the study guide cases is enhanced with the addition of key words printed in red that may be found in the indices of the larger texts. We trust that these tools, together with practitioner's skills and training, will assure that NMT remains a power­ ful tool in the manual therapy fields.

London 2007 Florida 2007

LC JD

xxi

Acknowl ed g m ents

In the first edition of this text and its companion volume for the lower body, a substantial number of people dedica ted many hours of time to assure clarity and accuracy of the final text. Their contribution was not lost in the second edi­ tion. Instead, it served as a solid foundation to be built upon with the contributions of revised and added material. The authors once again express sincere gratitude to the original team who help formulate this project many years ago and to the various authors and illustrators whose work was cited, quoted and borrowed. Addi tionally, contribu­ tions, support and inspiration for this revised edition were given by William Ellio tt, Donald Kelley, Ken Crenshaw, Ron Porterfield, Nathan Shaw, Mary-Beth Wagner, Andrew and Kaila DeLany, and Adam Cunliffe. In the second edition of this book, a new team of talented staff members at Elsevier offered insightful ideas, patient support to achieve deadlines, and a variety of professional services in order for the work to evolve. Among those who made this second edition possible, the a uthors especially acknowledge and appreciate the efforts of Claire Wilson, Gail Wright, Claire Bonnett and the illustration team who gave visual life to the pages of text. To Sarena Wolfaard , we express deep apprecia tion for her steady na ture and for her ability to juggle the assorted deadlines and the many phases of the project so as to keep it close to its production schedule. She has proven herself as capable of filling the extraordinary shoes of Mary Law, who served as the editorial director of the first edition. As to Mary, her contributions will last forever and her presence is continually missed. And, most endearingly, we offer our deepest gratitude to our families for their pa tience, support, and inspiration, all of which fills an ever-present and deep well from which we can draw to sustain and nurture ourselves. Their loving

support is threaded through these pages in remarkable yet indiscernible ways.

AC K N O W L E D G E M E N TS F R O M T H E F I RST E D IT I O N Books are wri tten by the efforts of numerous people, a l though most of the support team is invisible to the reader. We humbly express our appreciation to our friends and col­ leagues who assisted in this project and who enrich our lives simply by being themselves. From the long list of staff members and practitioners who dedicated time and effort to read and comment on this text, we are especially grateful to Jamie Alagna, Paula Bergs, Bruno Chikly, Renee Evers, Jose Fernandez, Gretchen Fiery, Barbara Ingram-Rice, Donald Kelley, Leslie Lynch, Aaron Mattes, Chama Rosenholtz, Cindy Scifres, Alex Spassoff, Bonnie Thompson and Paul Witt for reviewing pages of material, often at a moment's notice. And to those whose work has inspired segments of this text, such as John Hannon, Tom Myers, David Simons, Janet Travell and others, we offer our heartfelt appreciation for their many contributions to myofascial therapies. John and Lois Ermatinger spent many hours as models for the photographs in the book, some of which eventually became line art, while Mary Beth Wagner dedicated her time coordinating each photo session. The enthusiastic attitudes and tremendous pa tience shown by each of them turned what could have been tedious tasks into pleasant events. Many people offered personal support so tha t quality time to write was available, including Lois Allison, Jan Carter, Linda Condon, Andrew DeLany, Valerie Fox, Patricia Guillote, Alissa Miller, and Trish Solito. Special appreciation is given to Mary Beth Wagner and Andrea

xxii

ACKNOWLED G M ENTS

Conley for juggling many, many ongoing tasks which serve to enhance and fortify this work. Jane Shanks, Katrina Mather, and Valerie Dearing each put forth exceptional dedication to find clarity, organization and balance within this text, which was exceeded only by their patience. The illustration team as well as the many authors, artists and publishers who l oaned artwork from other books have added visual impact to help the material come alive. To Mary Law, we express our deepest app reciation for her vision and commitment to complementary medicine

worldwide. Mary's ability to foster organization amidst chaos, to find solutions to enormous challenges and to sim­ ply provide a listening ear when one is needed has endeared her to our hearts. And finally, to each of our families, we offer our deepest gratitude for their inspiration, patience, and ever present understanding. Thei r supporting l ove made this project possible.

Chapter

1

Connective tissue and the fascial system

Connective tissue forms the single largest tissue component of the body. The material we know as fascia is one of the

CHAPTER CONTENTS The fascial network 2 Fascia and proprioception 2 Fascia: collagenous continuity 2 Further fascial considerations 2 Elasticity 3 Plastic and elastic features 3 Connective tissue as a 'sponge' 6 Deformation characteristics 6 Hypermobility and connective tissue 7 Trigger points, fascia and the nervous system 8 The importance of Langevin's research 9 Summary of fascial and connective tissue function Fascial dysfunction 1 6 Restoring gel to sol 17 A different model linking trauma and connective tissue 17 Therapeutic sequencing 19

many forms of connective tissue. In this chapter we will examine some of the key features and functions of fascia in particular, and connective tissue in general, with specific focus on the ways in which: • these tissues influence myofascial pain and dysfunction • their unique characteristics determine how they respond

to therapeutic interventions, as well as to adaptive stresses imposed on them. In order to understand myofascial dysfunction, it is impor­

tant to have a clear picture of this single network that

13

enfolds and embraces all other soft tissues and organs of the body, the fascial web. In the treatment focus in subsequent chapters, a great deal of reductionist thinking will be called for as we identify focal points of dysfunction, local trigger points, individual muscular stresses and attachment prob­ lems, with appropriate local and general treatment descrip­ tions flowing from these identified areas and structures.

Box 1.1 Definitions Stedman's Medical Dictionary

(2004) says fascia is:

A sheet of fibrous tissue that envelops the body beneath the skin; it also encloses muscles and groups of muscles, and separates their several layers or groups

and that con nective tissue is: The supporting or framework tissue of the . . . body. formed of fibraus and graund substance with more or less numerous cells of various kinds; it is derived fram the mesenchyme, and this in turn from the mesoderm; the varieties of connective tissue are: areolar or loose; adipose; dense, regular or irregular, white fibrous; elastic; mucous; and lymphoid tissue; cartilage; and bone; the blood and lymph may be regarded as connective tissues, the ground sub­ stance of which is a liquid.

Fascia, therefore, is one form of con nective tissue.

2

CLI N I CA L A P P L I CATIO N OF N E U 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

The truth, of course, is that no tissue exists in isolation but acts - is bound to and is interwoven - with other structures, to the extent that a fallen arch can directly be shown to influence TMJ dysfunction (Janda 1986). In contrast, loss of occlusal supporting zone can change weight distribution on the feet and alter overall body posture (Yoshino et aI 2003a,b) When we work on a local area, we need to keep a constant aware­ ness of the fact that we are influencing the whole body. Remarkable research (see Box 1.5 in particular) is adding to our understanding of just how important connective tis­ sues are in relation to musculoskeletal function, and to pain management (Chen & Ingber 1999, Langevin et al 2001, 2004, 2005, Schleip et al 2004). As a foundation of under­ standing of connective tissue is built within this chapter, this and other research evidence is presented that alters pre­ vious concepts of this extraordinary matrix. .

THE FASCIAL NETWORK

Fascia comprises one integrated and totally connected net­ work, from the attachments on the inner aspects of the skull to the fascia in the soles of the feet. If any part of this net­ work becomes deformed or distorted, there will be com­ pensating adaptive stresses imposed on other parts of the connective tissue web, as well as on the structures that it divides, envelopes, enmeshes, supports and with which it connects. There is ample evidence that Wolff's law (Wolff 1870) applies, in that fascia accommodates to chronic stress patterns and deforms itself (Cailliet 1996), something which often precedes deformity of osseous and cartilaginous struc­ tures in chronic diseases (see Box 1.3). As fascia, ligaments and tendons deform when accommodating to chronic stress (Dorman 1997, Lederman 1997), this might disrupt the home­ ostasis of the body (Keeffe 1999, Kochno 2001) and certainly interferes with normal function. Visualize a complex, interrelated, symbiotically function­ ing assortment of tissues comprising skin, muscles, ligaments, tendons and bones, as well as the neural structures, blood and lymph channels and vessels which bisect and invest these tissues - all given shape, cohesion and functional abil­ ity by the fascia. Now imagine removing from this all that is not connective tissue. What remains would still demon­ strate the total form of the body, from the shape of the eye­ ball to the hollow voids for organ placement.

FASCIA AND PROPRIOCEPTION

Research has shown that: • •

muscle and fascia are anatomically inseparable fascia and other connective tissues form a mechanical con­ tinuum that extends throughout the body that includes even the innermost parts of each cell - the cytoskeleton (Chen & Ingber 1999, Oschman 2000)

• •

•

•

•

fascia moves in response to complex muscular activities acting on bone, joints, ligaments, tendons and fascia fascia, according to Bonica (1990), is critically involved in proprioception, which is, of course, essential for postural integrity (see Chapter 3) research by Staubesand (using electron microscope stud­ ies) shows that 'numerous myelinated sensory neural structures exist in fascia, relating to both proprioception and pain reception' (Staubesand 1996) after joint and muscle spindle input is taken into account, the majority of remaining proprioception occurs in fas­ cial sheaths (Earl 1965, Wilson 1966) new research by Langevin et al (2001, 2004, 2005), described later in this chapter, suggests that a great deal of commu­ nication occurs by means of fascial cellular structures (integrins).

FASCIA: COLLAGENOUS CONTINUITY

Fascia is one form of connective tissue, formed from colla­ gen, which is ubiquitous. The human framework depends upon fascia to provide form, cohesion, separation and sup­ port and to allow movement between neighboring structures without irritation. Since fascia comprises a single structure, from the soles of the feet (plantar fascia) to the inside of the cranium (dura and meninges), the implications for body­ wide repercussions of distortions in that structure are clear. An example is found in the fascial divisions within the cra­ nium, the tentorium cerebelli and falx cerebri, which are commonly warped during birthing difficulties (too long or too short a time in the birth canal, forceps delivery, etc.). They are noted in craniosacral therapy to affect total body mechanics via their influence on fascia (and therefore the musculature) throughout the body (Brookes 1984, Carreiro 2003, Von Piekartz & Bryden 2001). Dr Leon Page (1952) discusses the cranial continuity of fascia:

The cervical fascia extends from the base of the skull to the mediastinum and forms compartments enclosing the esoph­ agus, trachea and carotid vessels and provides support for the pharynx, larynx and thyroid gland. There is direct con­ tinuity of fascia from the apex of the diaphragm to the base of the skull. Extending through the fibrous pericardium 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 foramina in the base of the skull around the vessels and nerves to join the dura.

FURTHER FASCIAL CONSIDERATIONS

Fascia is colloidal, as is most of the soft tissue of the body (a colloid is defined as comprising particles of solid material

---�-------.. ------------

1 Connective tissue a n d the fascial system

Creep Continued deformation (i ncreasing strai n) of a viscoelastic material with time under constant load (traction, compression, twist) Hysteresis Process of energy loss due to friction when tissues are loaded and unloaded Load The degree of force (stress) applied to an area or an organism as a whole Strain Change in shape as a result of stress (external force) Stress Force (load) normalized over the area on which it acts (all tissues exh ibit stress-stra in responses) Thixotropy A qua lity of colloids in wh ich the more rapidly force is applied ( load), the more rig id the tissue response and to become less viscous when shaken or subjected to shearing forces and to return to the original viscosity upon standing. Viscoelastic The potential to deform elastica lly when load is applied and to return to the original non-deformed state when load is removed Viscoplastic A perma nent deformation resulting from the elastic potential having been exceeded or pressure forces susta i ned for too great a period of time

Mecha nical princi ples i nfluencing the body neurologica l ly and anatom ica l ly are governed by basic laws. •

•

•

•

•

•

Wolffs law states that biological systems (including soft and hard tissues) deform in relation to the l ines of force imposed on them. Hooke's law states that deformation (resulting from strain) imposed on an elastic body is in proportion to the stress (force/load) placed on it. Newton's third law states that when two bodies interact, the force exerted by the first on the second is equa l in magnitude and opposite in di rection to the force exerted by the second on the fi rst. Ardnt-Schultz's law states that weak stimuli excite physiological activity, moderately strong ones favor it, strong ones retard it and very strong ones a rrest it. Hilton's l aw states that the nerve su pplying a joint a lso supplies the muscles that move the joint and the skin covering the a rticular insertion of those muscles. Head's law states that when a painful stimulus is a pplied to a body part of low sensitivity (such as a n organ) that is in close central connection (the same segmenta l supply) with an area of higher sensitivity (such as a part of the soma), pain will be felt at the point of higher sensitivity rather than where the stimulus was appl ied.

suspended in fluid - for example, wallpaper paste or, indeed, much of the human body). Scariati (1991) points out that colloids are not rigid - they conform to the shape of their container and respond to pressure even though they are not compressible. The amount of resistance colloids offer increases proportionally to the velocity of force applied to them. A simple example that gives a sense of colloidal behav­ ior is available when flour and water are stirred together with the resulting colloid being mixed into a paste, using a

stick or spoon. A slowly moving stick or spoon will travel smoothly thlough the paste, whereas any attempt to move it rapidly will be met with a semirigid resistance (known as 'drag'). This makes a gentle touch a fundamental require­ ment if viscous drag and resistance are to be avoided when attempting to produce a change in, or release of, restricted fascial structures, which are all colloidal in their behavior.

ELASTICITY

Soft tissues, and other biological structures, have an innate, variable degree of elasticity, springiness, resilience or 'give', which allows them to withstand deformation when force or pressure is applied. This provides the potential for sub­ sequent recovery of tissue to which force has been applied, so that it returns to its starting shape and size. This quality of elasticity derives from these tissues' (soft or osseous) ability to store some of the mechanical energy applied to them and to utilize this in their movement back to their original sta­ tus. This is a process known as hysteresiS (see below). The stability and movement characteristics of each body part - whether this involves organs, vessels, nerves, mus­ cles or bones - is defined by a fibrin matrix combined with other elements. For example, bone incorporates calcium phosphate to lend rigidity, while muscle contains neurore­ sponsive proteins that enable changes in shape. Each ele­ ment in connective tissue contributes to its strength, resilience and compliance, with elastin allowing controlled, reversible deformation under strain, and fibrin, laid out along the lines of the local axis of motion, serving as a check on the extent of this deformation. Although a certain amount of deformation is physiologi­ cally necessary, trauma may cause deformation beyond the elastic limit of the tissues, thereby causing permanent dam­ age or possibly resulting in a semipermanent distortion of the connective tissue matrix if the damage is not too severe. Return to normal is then sometimes possible, but only with the reintroduction of sufficient energy to allow a reversal of the deformation process - for example, by means of manual therapy ('soft tissue manipulation'). Appropriately applied 'force' (i.e. slowly) can assist in resolving the deformation results of strain. In such processes energy is both absorbed and released. This energy transfer feature, known as hystere­ sis, is described further below (Becker 1997, Comeaux 2002).

PLASTIC AND ELASTIC FEATURES

Greenman (1989) describes how fascia responds to loads and stresses in both a plastic and an elastic manner, its response depending, among other factors, upon the type, duration and amount of the load. When stressful forces (undesirable or therapeutic) are gradually applied to fascia (or other bio­ logical material), there is at first an elastic reaction in which the degree of slack is reduced. If the force persists, this is

J

4

C L I N I CAL APP LICAT I O N O F N E U R O M USCU LAR TECH N I QU ES: T H E UPPER B O DY

Box 1.4 Connective tissue Connective tissue is composed of cells (including fibroblasts and chond rocytes) and an extrace l l ular matrix of collagen and elastic fibers surrounded by a g round substance made primarily of acid glycosam inoglycans (AGAGs) and water (Gray's Anatomy 2005, Lederman 1997). Its patterns of deposition change from location to location, depending upon its role and the stresses applied to it. The collagen component is com posed of three polypeptide cha ins wound around each other to form triple hel ixes. These microfi la ments are arranged in parallel manner and bound together by crossl inking hydrogen bonds, which 'glue' the e lements together to provide strength and stabil ity when mecha nical stress is applied. Movement encourages the col lagen fibers to a l ign themselves a long the l ines of structural stress as well as improving the ba lance of glycosami noglycans and water, therefore lubricating and hydrating the connective tissue (Lederman 1997). While these bonding crossbridges do provide structu ra l support, injury, chronic stress and immobility cause excessive bonding, 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 tissue lengthening potential would then not be due to the volume of collagen but to the random pattern in which it is laid down and the

F i broblast

Procollagen

----�---

\ \

�

/O-TropOCOllagen

abnorma l crossbridges which prevent normal movement. Fol lowing tissue i nju ry, it is important that activity be introduced as soon as the healing process will allow in order to prevent maturation of the sca r tissue and development of adhesive crossl inks (Lederman 1 997). Lederman ( 1 997) tel ls us: The pattern of collagen deposition varies in different types of connective tissue. It is an adaptive process related to the direction of forces imposed on the tissue. In tendon, collagen fibers ore organized in parallel orrangement; th is gives the tendon stiffness and strength under unidirectional loads. In ligaments, the organization of the fibers is looser. groups of fibers lying in different directions. This reflects the multidirectional forces that ligaments are subjected to, for example during complex movements of a joint such as flexion combined with rotation ond shearing . . . Elostin has an arrongement similar to that of collagen in the extracellular matrix, and its deposition is also dependent on the mechanical stresses imposed on the tissue.

Elastin provides an elastic-l ike quality that allows the connective tissue to stretch to the limit of the collagen fiber's length, while 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 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 (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 ). •

•

•

'------Collagen microfibril

L

•

Fibroblasts Fascicle

Tendon

Figure 1.1 Col lagen is p rod uced locally for repa i r of d a maged connective tissue. After Lederm a n 1997.

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 waste, antibodies and white blood cells (Juhan 1998). 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.

The consistency of the connective tissue varies from tissue to tissue. Where fewer fibers and more liquid is found, an ideal environment for metabolic activities abounds. With less fluid and more fibers, a soft, flexible lattice is achieved that can hold skin cel ls, nerve cells or organ tissue in place. With little fluid and many fibers, a tough, stringy material forms for use in muscle sacs, tendons and ligaments. When chondroblasts (ca rtilage-producing cel ls) and their hya l ine secretions are added, a more solid substance occurs, a nd when mineral salts are added to achieve a rock-like hardness, bones a re formed (Juhan 1998). Unless i rreversible fibrotic changes have occurred or other pathologies exist, connective tissue's state ca n be changed from a gelatinous-like substance to a more solute (watery) state by the i ntroduction of energy through muscu lar activity (active or passive movement provided by activity or stretching), soft tissue manipulation (as provided by massage) or heat (as in hydrotherapies). Th is characteristic, cal led thixotropy, is a 'property of certain gels of becoming less viscous when shaken or subjected to shea ring forces box continues

1

Connective tissue and the fascial system

Box 1 .4 (continued)

Elongation

Figure

1.2

Toe

Elastic

region

region

Pre-elastic

Elastic rangel

Initially, molecular

range

physiological

displacement

Slack range

range

leading to microtears

Intramolecular

and complete

crosslinks

rupture Loss of mechanical

Collagen's triple helices are bound together by inter­

and intramolecular crosslinking bonds. After Lederman

properties

(1997).

and returning to the original viscosity upon standing' (Stedman's Medical Dictionary 2004). Without th i x otropic properties, movement would eventually cease due to solid ification of synovium and connective tissue. Oschman states (1997):

Figure

1.3

Schematic represe n tatio n of the stress-strain

After Lederman

cu rve.

(1 997).

If stress, disuse and lack of movement cause the gel to deh ydrate, contract and harden (an idea that is supported both by scientific evidence and by the experiences of many somato therapists) the

con ten t and in its ability to conduct energy and movement. The ground substance becomes more porous, a better medium for the

application of pressure seems to bring about a rapid solation and rehydration. Removal of the pressure allows the system to rapidly re-gel, but in the pracess the tissue is transformed, both in its water

diffusion of nutrien ts, oxygen, waste products of metabolism and the enzymes and building blocks involved in the 'metabolic regenera tion '

followed by what is colloquially referred to as creep a vari­ able degree of resistance (depending upon the state of the tis­ sues). This gradual change in shape is due to the viscoelastic property of corulective tissue. Creep, then, is a term that accurately describes the slow, delayed, yet continuous deformation that occurs in response to a sustained, slowly applied load, as long as this is gentle enough not to provoke the resistance of colloidal 'drag'. During creep, tissues lengthen or distort ('deflect') until a point of balance is achieved. An example often used of creep is that which occurs in intervertebral discs as they gradually compress during periods of upright stance. Stiffness of any tissue relates to its viscoelastic properties and, therefore, to the thixotropic colloidal nature of colla­ gen/ fascia. Thixotropy reIates to the quality of colloids in which the more rapidly force is applied (load), the more rigid the tissue response will be - hence the likelihood of -

process ..

fracture when rapid force meets the resistance of bone. If force is applied gradually, 'energy' is absorbed by and stored in the tissues. The usefulness of this in tendon function is obvious and its implications in therapeutic terms profound (Binkley 1989). Hysteresis is the term used to describe the process of energy loss due to friction and to minute structural damage that occurs when tissues are loaded and unloaded. Heat will be produced during such a sequence, which can be illustrated by the way intervertebral discs absorb force transmitted through them as a person jumps up and down. During treatment (tensing and relaxing of tissues, for example, or on-and-off pressure application), hysteresis induction reduces stiffness and improves the way the tissue responds to sub­ sequent demands. The properties of hysteresis and creep provide much of the rationale for myofascial release tech­ niques, as well as aspects of neuromuscular therapy, and

5

6

CLINICAL A PPLICATION OF NEUROMUSCULAR TECHN IQUES: THE U P PER BODY

L

need to be taken into account during technigue applica­ tions. Especially important are the facts that: • •

rapidly applied force to collagen structures leads to defen­ sive tightening slowly applied load is accepted by collagen structures and allows for lengthening or distortion processes to commence.

When tissues (cartilage, for example) that are behaving vis­ coelastically are loaded for any length of time, they first deform elastically. Subseguently, there is an actual volume change, as water is forced from the tissue as they become less sol-like and more gel-like . Ultimately, when the applied force ceases, there should be a return to the original non­ deformed state. However, if the elastic potential has been exceeded, or pressure forces are sustained, a viscoplastic response develops and deformation can become perma­ nent. When the applied force ceases, the time taken for tis­ sues to return to normal, via elastic recoil, depends upon the uptake of water by the tissues. This relates directly to osmotic pressure, and to whether the viscoelastic potential of the tis­ sues has been exceeded, which can result in a viscoplastic (permanent deformation) response.

Figure

1 .4 Electron photomicroscopy of a typical smooth muscle

cell within the fascia cruris. Above it is the terminal portion of a type IV (unmyelated) sensory neuron. ( Photo reproduced with the kind permission of Springer Verlag, first published in Staubesand

1 996.) Reproduced with permission from Journal of Bodywork and Movement Therapies 2003; 7(2) :104-11 6. CONNECTIVE TISSUE AS A 'SPONGE'

Schleip et al (2004) have shown that when an isometric con­ traction takes place - as in sustained effort, or therapeuti­ cally with methods such as muscle energy technigue (MET), proprioceptive neuromuscular facilitation (PNF) or other similar techin gues simultaneously loses some of its stability, making it easier to stretch. It behaves like a sponge, and if the contraction is long and strong enough, and if no movement occurs after the contraction, the fascia reabsorbs water, becoming stiffer as it 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:

By carefully measuring the wet weight of our fascial strips, at different experimental stages, plus the final dry weight (after later drying the strips in an oven), we found the fol­ lowing pattern: During the isometric stretch period, water is extruded, which is then refilled in the following rest period. Interestingly if the stretch is strong enough, and the following rest period long enough, more water soaks into the ground substance than before. The water content then increases to a higher level than before the stretch. Fascia seems to adapt in very complex and dynamic ways to mechanical stimuli, to the degree that the matrix reacts in smooth-muscle-like con­ traction and relaxation responses of the whole tissue. It seems likely that much of what we do with our hands in Structural Integration and the tissue response we experience, may not be related to cellular or collagen arrangement changes, but

to sponge-like squeezing and refilling effects in the semi-liquid ground substance, with its intricate scrub-like arrangement of water binding glycosaminoglycans and proteoglycans. Schleip et al (2004) have presented evidence that derives from the same German research, showing that the thoracolumbar fascia has the ability to contract, suggesting that the 'fascia may play an active role in joint dynamics and regulation'. Schleip et al also suggest that this research 'offers new insights into understanding low back instability, compartment syn­ drome, and my ofascial release therapies'.

DE FORMATION CHARACTERISTICS

Cantu & Grodin (1992) describe what they see as the 'unigue' feature of connective tissue as its 'deformation characteris­ tics'. This refers to the combined viscous (permanent, plastic) deformation characteristic, as well as an elastic (temporary ) deformation status discussed above. The fact that cOIUlective tissues respond to applied mechanical force by first chang­ ing in length, followed by some of the change being lost while some remains, has implications in the application of stretching technigues to such tissues. It also helps us to understand how and why soft tissues respond as they do to postural and other repetitive insults that exert load on them, often over long periods of time. It is worth emphasizing that although viscoplastic changes are described as 'permanent', this is a relative term. Such

1 Connective tissue a nd

the

fascial system

changes are not necessarily absolutely permanent since col­ lagen (the raw material of fascia/connective tissue) has a limited (300-500 day) half-life and, just as bone adapts to stresses imposed upon it, so will fascia. If negative stresses (e.g. poor posture, use, etc.) are mod­ ified for the better and/or positive (therapeutic) 'stresses' are imposed by means of appropriate manipulation and/or exercise, apparently 'permanent' changes can modify for the better. Dysfunctional connective tissue changes can usually be improved, if not quickly then certainly over time (Brown 2000, Carter & Soper 2000, Neuberger 1 953). However, some connective tissue changes are more permanent. Schleip et al (2004) have observed many examples of tis­ sue contractions caused by connective tissue cells called myofibroblasts (see Box 1 .5): This happens naturally in wound healing, but also in sev­ eral chronic fascial contractures. In the hand, it presents as palmar fibromatosis, also known as Dupuytren's contrac­ ture, or as a pad-like thickening of the knuckles. In the foot the same process is called plantarfibromatosis, while in club foot contraction of the myofibroblasts is focused on the medial side. In frozen shoulder, the contraction occurs in the shoulder capsule . . . considering the existence of pathologi­ cal faSCial contractu res, it seems likely that there may be lesser degrees offascial contractions, which may influence biomechanical behavior.

Important features of the response of tissue to load include: • • • • •

• • • •

the degree of the load the amount of surface area to which force is applied the rate, uniformity and speed at which it is applied how long load is maintained the configuration of the collagen fibers (i.e. are they par­ allel to or differently oriented from the direction of force, offering greater or lesser degrees of resistance?) the permeability of the tissues (to water) the relative degree of hydration or dehydration of the indi­ vidual and of the tissues involved the status and age of the individual, since elastic and plastic qualities diminish with age another factor (apart from the nature of the stress load) that inl1uences the way fascia responds to application of a stress load, and what the individual feels regarding the process, relates to the number of collagen and elastic fibers contained in any given region.

B

HYPERMOBILITY AND CONNECTIVE TISSUE • •

Ligamentous laxity and general increased mobility of the connective tissues creates a background of instability. Hypermobility is usually genetically acquired. Kerr & Grahame (2003) describe the sequence that leads to this as follows: 'Genetic aberrations affecting fibrous proteins give rise to biochemical variations, then in turn to

C Fig u re 1.5

A-C: Examples of hypermobility. Reproduced with (2003).

permission from Kerr Et Grahame

7

CLI N I CA L A P P L I CATI O N O F N E U R O M USCULAR TECH N I QUES: TH E U P P E R B O DY

8

at the cost of stability (Simons 2002, Thompson 2001). Simons (2002) concurs: In this case it is wise to correct the u nderlying cause of ins tability before releasing the MTrP tension. In fact, cor­ recting the underlying instability often results in sponta­ neous resolution of the M TrP. It is important to identify and remove or modify as many etiological and perpetuat­ ing influences as can be found, however, without creating further distress or a requirement for excessive adaptation. It is also important to consider that, at times, apparent symptoms may represent a desirable physiological response (Thompson 2001).

Mechanical failure Figure

1 .6 Pathophysiology of heritable connective tissue disorders. (2003).

Reproduced with permission from Kerr Et Grahame

•

•

•

• •

•

•

•

•

•

impairments of tensile strength, resulting in enhanced mobility but at a cost of increased fragility, ultimately risk­ ing mechanical tissue failure.' A number of disorders derive from connective tissue pathophysiology, including Marfan syndrome, Ehlers­ Danlos syndrome, osteogenesis imperfecta and joint hypermobility syndrome. The commonality of these different syndromes, all result­ ing from variations of connective tissue laxity, is a ten­ dency toward hypermobility, arthralgia, tendency to dislocation (and possible fracture), osteoporosis, thin skin (and stretch marks), varicose veins, prolapse (rectal, uterine, mitral valve), hernia and diverticulae. Hypermobility has been shown to be a major risk factor in the evolution of back pain (Muller et aI2003). Hypermobile individuals often present with chronic pain syndromes and an increased tendency to anxiety and panic attacks (Bulbena et al 1 993, Martin-Santos et al 1998). Hypermobility is more common in people of African, Asian and Arab origin where rates can exceed 30% (as compared with Caucasians ±6%), as well as being more frequently identified in the young compared with the elderly, and in females compared with males (Hakim & Grahame 2003). When joints are vulnerable because of hypermobility, pas­ sive stretches and end-range positions seem to be able to trigger musculoskeletal symptoms (Russek 2000). Patient care requires that patients modify their ergonom­ ics and body mechanics (avoiding overuse and extreme posi tions) to avoid stretching their joints past end-range during activities of daily living (Russek 2000). Trigger point evolution in associated muscles is a com­ mon result of the relative laxity of joints (Kerr & Grahame 2003). The authors of this text hypothesize that these energy efficient (if painful) entities may offer an efficient means of achieving short-term stability in unstable areas (Chaitow 2000, Chaitow & DeLany 2002, DeLany 2000). The implications of this possibility are clear. If myofascial trigger points (MTrPs) are serving functional roles, such as in stabilization of hypermobile joints, deactivation of potentially stabilizing trigger points may ease pain but

A safer alternative is to encourage fitness training, along with the self-use of ice, hydrotherapy and gentle stretching and toning exercises (Goldman 1991). It might also be helpful to selectively deactivate the most painful MTrPs before movement therapies can begin; active movement and, therefore, toning can then be part of the immediate therapy session when the MTrPs are suffi­ ciently reduced.

TRIGGER POINTS. FASCIA AND THE NERVOUS SYSTEM

Changes that occur in connective tissue, and which result in alterations such as thickening, shortening, calcification and erosion, may be a painful result of sudden or sustained ten­ sion or traction. Cathie (1 974) points out that many trigger points (he calls them trigger 'spots') correspond to points where nerves pierce fascial investments. Hence, sustained tension or traction on the fascia may lead to varying degrees of fascial entrapment of neural structures and consequently a wide range of symptoms and dysfunctions. Neural recep­ tors within the fascia report to the central nervous system as part of any adaptation process, with the pacinian corpuscles being particularly important (these inform the CNS about the rate of acceleration of movement taking place in the area) in terms of their involvement in reflex responses. Other neural input into the pool of activity and responses to biomechanical stress involve fascial structures, such as ten­ dons and ligaments which contain highly specialized and sensitive mechanoreceptors, and proprioceptive reporting stations (see reporting stations, Chapter 3). Additionally: •

•

German research has shown that fascia is 'regularly' pen­ etrated (via 'perforations') by a triad of venous, arterial and neural structures (Heine 1995, Staubesand 1996) these seem to correspond with fascial perforations previ­ ously identified by Heine, which have been correlated (82% correlation) with known acupuncture points (Heine 1 995). Further, Bauer & Heine (1998) showed that the triad of pedora ting neurovascular structures was regu­ larly 'strangulated' by an excessive amount of collagen

1 Connective tissue and the fascial system

Fig u re 1 .7 Location of acupuncture points and meridians in serial gross anatomical sections through a human arm. Reproduced from Langevin H

M , Yandow J

A Relationship

of acupuncture points and meridians to connective tissue

269(6):257-265, 2002. 2002, Wiley-Liss, Inc. Reprinted with permission

planes. Anatomical Record Copyright

SJ1

of Wiley-Liss, Inc., a subsidiary of John Wiley Et Sons, Inc. P2

Meridians Yin H= heart p= pencarolum L= lung

•

Yang SJ triple heat"r SI= small intestine

@ •

acupunclure pOint meridian intersection

fibers around these openings in most of the acupoints of the painful region. When those strangulated areas were surgically opened a little, most of the patients experi­ enced significant improvements (i.e. less pain) many of these fascial neural structures are sensory and capable of being involved in pain syndromes.

Staubesand states: The receptors we found in the lower leg fascia in humans could be responsible for several types of myofascial pain sensations . . . Another and more specific aspect is the inner­ vation and direct connection of fascia with the autonomic nervous system. It now appears that the fascial tonus might be influenced and regulated by the state of the autonomic nervous system . . . intervention in the fascial system might have an effect on the autonomic nervous system, in general, and upon the organs which are directly effected from it. (Schleip 1998)

THE IMPORTANCE OF LANGEVIN'S RESEARCH

Ongoing research at the University of Vermont has pro­ duced remarkable new information regarding the function of fascial connective tissue (Langevin et al 2001, 2004, 2005). In evaluating the importance of the research information (below) it is important to recall that approximately 80% of common trigger point sites have been claimed to lie pre­ cisely where traditional acupuncture points are situated on meridian maps (Wall & Melzack 1 990). Indeed, many experts believe that trigger points and acupuncture points are the same phenomenon (Kawakita et al 2002, Melzack et al 1 977, Plummer 1 980). Others, however, take a different view. For example, Birch (2003) and Hong (2000) have revisited the original work of Wall & Melzack (1 990) and have both found this to be flawed, particularly when the acupuncture points referred to as correlating with trigger points are seen to be 'fixed' anatomically, as on myofascial meridian maps. Both

9

10

CLINICAL APPLICATION O F NEUROMUSCULAR TECHNIQUES: THE UPPER BODY

Birch and Hong agree, however, that so-called 'Ah shi' acupW1cture points may well represent the same phenome­ non as trigger points. Ah shi points do not appear on the classical acupW1cture meridian maps, but refer to 'sponta­ neously tender ' points which, when pressed, create a response in the patient of, 'Oh yes' ('Ah shi'). In Chinese medicine Ah shi points are treated as 'honorary acupuncture points' and are needled or receive acupressure in the same way as regular acupW1cture points, if/when they are ten­ der/painful. This would seem to make them, in all but in name, identical to trigger points. It is clearly important therefore, in attempting to under­ stand trigger points more fully, to pay attention to current research into acupuncture points and cOlU1ective tissue in general, as noted in the following research. Langevin & Yandow (2002) have presented evidence that links the network of acupW1cture points and meridians to a network formed by interstitial cOlU1ective tissue. Using a unique dissection and charting method for location of cOlU1ective tissue (fascial) planes, acupW1cture points and acupuncture meridians of the arm, they note that: 'Overall, more than 80% of acupuncture points and 50% of meridian intersections of the arm appeared to coincide with inter­ muscular or intramuscular cOlU1ective tissue planes.' Langevin & Yandow's research further shows microscopic evidence that when an acupuncture needle is inserted and rotated (as is classically performed in acupW1cture treatment), a 'whorl' of cOlU1ective tissue forms around the needle, thereby creating a tight mechanical coupling between the tissue and the needle. The tension placed on the cOlU1ective tissue as a result of further movements of the needle delivers a mechanical stimulus at the cellular level. They note that changes in the extracellular matrix ' . . . may, in turn, influ­ ence the various cell populations sharing this connective

Figure

1 .8

tissue matrix (e.g. fibroblasts, sensory afferents, immune and vascular cells)'. The key elements of Langevin's research can best be sum­ marized as follows: •

•

Acupuncture points, and many of the effects of acupW1c­ ture, seem to relate to the fact that most of these localized 'points' lie directly over areas where there is fascial cleav­ age; where sheets of fascia diverge to separate, surround and support different muscle blmdles (Langevin et al 2001). COlU1ective tissue is a commW1ication system of as yet unknown potential. The tiny projections emerging from each cell are called 'integrins'. Ingber demonstrated (Ingber 1993b, Ingber & Folkman 1 989; see Box 1.6) inte­ grins to be a cellular signaling system that modify their fW1ction depending on the relative normality of the shape of cells. The structural integrity (shape) of cells depends on the overall state of normality (deformed, stretched, etc.) of the fascia as a whole. As Langevin et al (2004) report: 'Loose' connective tissue forms a network extending throughout the body inc/uding subcutaneous and intersti­ tial connective tissues. The existence of a cellular network of fibroblasts within loose connective tissue may have considerable significance as it may support yet unknown body-wide cellular signaling systems . . . Our findings indicate that soft tissue fibroblasts form an extensively interconnected cellular network, suggesting they may have important, and so far unsuspected integrative func­ tions at the level of the whole body.

•

Perhaps the most fascinating research in this remarkable series of discoveries is that cells change their shape and behavior following stretching (and crowding/deforma­ tion) . The observation of these researchers is that: 'The

Formation of a connective tissue 'whorl' when an acupuncture needle was inserted through the tissue and progressively rotated.

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. Reproduced from Langevin H M, Yandow

1 Connective tissue and the fascial system

dynamic, cytoskeleton-dependent responses of fibrob­ lasts to changes in tissue length demonstrated in this study have important implications for our understand­ ing of normal movement and posture, as well as thera­ pies using mechanical stimulation of connective tissue, including physical therapy, massage and acupuncture' (Langevin et aI2005). As will become clear, changes in the shape of cells also alter their ability to function normally, even in regard to how they handle nutrients. Ingber conducted research (Ingber 1993a,b, 2003, Ingber & Folkman 1989), much of it for NASA, into the reasons that astronauts lose bone density after a few months in space. He showed that cells deform

Box 1 . 5

Myers'

fascial tra i n s

(Myers 1 997. 2001 )

Tom Myers, a distinguished teacher of structural i ntegration, has described a number of clinically useful sets of myofascial chai ns. The connections between different structures ('long functional continuities') that these insights a l low will be drawn on and referred to when treatment protocols are discussed in this text. They a re of particu lar importance in helping draw attention to (for example) dysfu nctional patterns in the lower limb which impact d i rectly (via these chains) on structures in the upper body. The five major fascial ch a i ns

The superficial back line (Fig. 1 .9) involves a chain that starts with: •

• •

when gravity is removed or reduced. The behavior of cells changes to the extent that, irrespective of how good the overall nutritional state is, or how much exercise (static cycling in space) is taking place, individual cells cannot process nutrients normally, and problems such as decalcifi­ cation emerge. The importance we give to this information should be tied to the awareness that, as we age, adaptive forces cause changes in the structures of the body, with the occurrence of shortening, crowding and distortion. With this, we are see­ ing in real terms, in our own bodies and those of our patients, the environment in which cells change shape. As they do so they change their potential for normal genetic

the plantar fascia, linking the plantar su rface of the toes to the calcaneus gastrocnem ius, linking calcaneus to the femoral condyles hamstrings, l inking the femoral condyles to the ischial tuberosities

• •

•

subcutaneous ligament, linking the ischial tuberosities to sacrum l u mbosacra l fascia, erector spinae and nuchal ligament, linking the sacrum to the occiput sca lp fascia, linking the occiput to the brow ridge.

The superficial front line (Fig. 1 .1 0) i nvolves a chain that starts with: •

•

•

•

the anterior compartment and the periostium of the tibia, linking the dorsal surface of the toes to the tibial tuberosity rectus femoris, linking the tibial tuberosity to the anterior i nferior iliac spine and pubic tubercle rectus abdominis as well as pectora lis and sternalis fascia, linking the pubic tubercle and the anterior i nferior iliac spine with the manubrium sternocleidomastoid, linking the manubri um with the mastoid process of the tempora l bone.

Figure 1 .9 Myers' superficial fascial back l i n e. Reproduced with permission fro m t h e Journal o f Bodywork and Movement Therapies

1 997; 1 (2):95.

The superficial back line (SBl)

box con tinues

11

12 c::

C LI N I CAL A P P LI 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 ER B O DY

•

•

the sacrotuberous ligament li nks the ischial tuberosity to the sacrum the sacral fascia and the erector spinae link the sacrum to the occipital ridge.

The deep front line describes several a lternative chains i nvolving the structures anterior to the spine (internally, for example) : •

•

•

•

the anterior longitud inal l iga ment. diaph rag m, pericardium, med iastinum, parietal pleura, fascia prevertebra lis and the scalene fascia, which connect the lumbar spine (bodies and transverse processes) to the cervical tra nsverse processes and via longus ca pitis to the basilar portion of the occiput other l inks in this chain might involve a connection between the posterior manubrium and the hyoid bone via the subhyoid muscles a nd the fascia pretrachea lis between the hyoid and the cranium/mandible, involving suprahyoid muscles the muscles of the jaw li nking the mandible to the face and cranium.

Myers includes in his cha in description structures of the lower limbs that connect the tarsum of the foot to the lower l u mbar spine, making the li nkage complete. Additional smaller chains involving the a rms are described as follows. The superficial front line (SFL)

Fig u re 1 . 1 0 Myers' su perficial fascial front l i ne. Reproduced with perm ission from the Journal of Bodywork a n d Movement Therapies 1 997 ; 1 (2) :97.

Back of the a rm l i nes •

•

•

The lateral line involves a cha i n that starts with: •

•

•

•

•

peroneal muscles, linking the 1 st and 5th metatarsal bases with the fibular head ilioti bial tract, tensor fascia latae and g luteus maximus, linking the fibu lar head with the iliac crest external obliques, internal obliques and (deeper) quadratus lum­ borum, linking the iliac crest with the lower ribs externa l i ntercostals and internal intercostals, linking the lower ribs with the remaining ribs splenius cervicis, i liocostal is cervicis, sternocleidomastoid and (deeper) sca lenes, linking the ribs with the mastoid process of the temporal bone.

•

•

•

•

•

The spiral line involves a chain that starts with: •

•

•

•

•

•

splenius capitis, which wraps across from one side to the other, linking the occipital ridge (say, on the rig ht) with the spinous processes of the lower cervical and u pper thoracic spine on the left continuing in this direction, the rhomboids (on the l eft) link via the medial border of the scapula with serratus anterior and the ribs (stil l on the left), wrapping around the tru nk via the external obliques and the abdom inal a poneurosis on the left, to connect with the internal obliques on the right and then to a strong anchor point on the anterior superior i l iac spine (ASIS) (right side) from the ASIS, the tensor fascia latae and the il iotibial tract link to the lateral tibial condyle tibialis anterior links the lateral tibial condyle with the 1 st metatarsal and cuneiform from this a pparent endpoint of the chain ( 1 st metatarsal and cuneiform), peroneus longus rises to link with the fibular head biceps femoris connects the fibu lar head to the isch ial tu berosity

The broad sweep of trapezius links the occipital ridge and the cervical spinous processes to the spine of the scapula and the clavicle. The deltoid, together with the latera l intermuscu lar septum, connects the scapula and clavicle with the lateral epicondyle. The latera l epicondyle is joined to the hand and fi ngers by the com mon extensor tendon. Another track on the back of the arm can arise from the rhomboids, which link the thoracic tra nsverse processes to the medial border of the sca pula. The sca pula in turn is linked to the olecranon of the u l na by infraspinatus and the triceps. The olecranon of the ulna connects to the sma l l fi nger via the periostium of the u l na. A 'stabil ization' feature in the back of the arm i nvolves latissimus dorsi and the thoracolumbar fascia, which connects the a rm with the spinous processes, the contra lateral sacral fascia and gluteus maximus, wh ich in tu rn attaches to the shaft of the femur. Vastus latera lis connects the femur shaft to the tibial tuberosity and (via this) to the periostium of the tibia.

Front of the arm l i nes •

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Latissimus dorsi, teres major and pectoralis major attach to the humerus close to the medial i ntram uscular septum, connecting it to the back of the trunk. The medial i ntramuscu lar septum connects the humerus to the medial epicondyle which con nects with the palmar hand and fi ngers by means of the common flexor tendon. An additional line on the front of the arm involves pectora lis mi nor, the costocoracoid ligament, the brachial neurovascular bundle and the fascia clavi pectoral is, which attach to the coracoid process. The coracoid process also provides the attachment for biceps brachii (and coracobrachialis), linking this to the radius and the thumb via the flexor compartment of the forearm. A 'stabil ization' line on the front of the arm involves pectora lis major attaching to the ribs, as do the external obliques, which box continues

1 Con nective tissue a n d the fascial system

then run to the pubic tubercle, where a con nection is made to the contralateral adductor longus, graci lis, pes anserinus and the tibial periosti um. In the following chapters' discussions of local dysfu nctional patterns i nvolving the cervical, thoracic, shoulder and a rm regions, it will be useful to hold in mind the direct muscular and fascia l connections that Myers highlig hts, so that the possibil ity of d istant infl uences is never forgotten. Di ssection confirm ation of fasci a l conti n u ity (Fig. 1 . 1 1 ) Barker Et Briggs ( 1 999) have shown the lu mbodorsal fascia to extend

from the pelvis to the cervical area and base of the cranium, in a n unbroken sweep: 'Both superficial a n d deep laminae o f the posterior layer are more extensive superiorly than previously thoug ht: There is fibrous continuity throughout the lumbar, thoracic and cervical spine and with the tendons of the splenius muscles superiorly. There is a lso growing i nterest in the possible effects that contractile smooth muscle cells (SMC) may have in the many fascial/connective tissue sites in which their presence has now been identified, including cartilage, ligamen ts, spinal discs and the lu mbodorsal fascia (Ah luwalia et a l 2001 , Hastreiter et a l 200 1 , Meiss 1 993, Murray Et Spector 1 999). For example, Yahia et a l (1 993) have observed that: 'H istologic studies indicate that the posterior layer of the (Iumbodorsal) fascia is able to contract as if it were infiltrated with muscular tissue: Schleip and col leagues (2006) report that: 'Morphological considerations, as well as histological observations in our laboratory, suggest that the perimysium is characterized by a high density of myofibroblasts, a class of fibroblasts with smooth muscle-like contractile kinetics: Analysis of 39 tissue samples from the thoracolumbar fascia of 1 1 human donors (aged 1 9-76 years) by Schleip e t al (2004) demonstrated the widespread presence of myofibroblasts in all samples, with an average density of 79 cells/mm2 i n the longitudi na l sections. Schleip et al (2006) suggest that: 'These fi ndings confirm that fascial tissues can actively contract, and that their contractility appears to be driven by myofibroblasts. The q uestion as to whether or not these active fascial contractions could be strong enough to exert any sig nifican t impact on musculoskeletal dynamics has previously been addressed in this journal (Schleip et al 2005) the fol lowing way: taking the g reatest measu red force of in vitro fascial contractions and extra polating that to an average size of the superficial layer of the thoracolumbar fascia in humans the resulting contraction force can amount to 3 8 N, which may be a force strong enough to infl uence biomechanical behaviour, such as in a contribution to paraspinal compartment syndrome or in the prevention of spinal segmental instability:

expression, as well as their abilities to communicate and to handle nutrients efficiently. Reversing or slowing these undesirable processes is the potential of appropriate bodywork and movement approaches. It is yet to be precisely established to what degree cellular function can be modified by soft tissue tech­ niques, such as those used in neuromuscular therapy. However, the normalizing of structural and functional fea­ tures of connective tissue by means of addressing myofas­ cial trigger points, chronic muscle shortening and fibrosis, as well as perpetuating factors such as habits of use, has clear implications. Well-designed research to assess cellular

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Fig u re 1 . 1 1 AEtB: The cont i n u ity of vertical a n d spira l myofascia l l i n es i m plies a mechanical con nection from head to toe. R eproduced with permission from Myers (2001 ).

changes that follow the application of manual techniques that offer pain relief and improve function is sorely needed.

SUMMARY OF FASCIAL AND CONNECTIVE TISSUE FUNCTION

Fascia is involved in numerous complex biochemical activities. •

Connective tissue contains a subtle, bodywide signaling system with as yet unknown potentials.

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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

14 L

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The fascial cleavage planes appear to be sites of unique sensit ivity and of great importance in manual (and acupuncture) therapeutic focus. Connective tissue provides a supporting matrix for more highly organized s tructures and attaches extensively to and invests into muscles. Individual muscle fibers are enveloped by endomysium, which is connec ted to the stronger perimy sium that sur­ rounds the fasciculi. The perimysium's fibers attach to the even stronger epimy sium that surrounds the muscle as a whole and attaches to fascial tissues nearby. Because it contains mesenchymal cells of an embry onic type, connective tissue provides a generalized tissue capable of giving rise, under certain circumstances, to more specialized elements. It provides (by its fascial planes) pathway s for nerves, blood and lymphatic vessels and structures.

Box 1 . 6

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Many of the neural structures in fascia are sensory in nature. Fascia supplies restraining mechanisms by the differenti­ ation of retention bands, fibrous pulley s and check liga­ ments as well as assist ing in the harmonious production and control of movement. Where connective tissue is loose in texture it allows move­ ment between adjacent structures and, by the formation of bursal sacs, i t reduces the effects of pressure and friction . Deep fascia ensheaths and preserves the characteristic contours of the limbs and promotes the circulation in the veins and lymphatic vessels. The superficial fascia, which forms the panniculus adipo­ sis, allows for the storage of fat and also provides a sur­ face covering that aids in the conservation of body heat. By virtue of its fibroblastic activity, connective tissue aids in the repair of injuries by the deposition of collagenous fibers (scar tissue).

Tensegrity

Tensegrity, a term coined by architect/eng ineer Buckmi nster Fuller, represents a system characterized by a discontinuous set of compressional elements (struts) which are held together, u prighted and/or moved by a continuous tensional network (Myers 1 999, 2001 , Oschman 1 997, 2000). Fu l ler, one of the most original thinkers of the 20th centu ry, developed a system of geometry based on tetrahedral (four-sided) shapes found i n nature which maximize strength while occupying minima l space (maxi mum stabil ity with a minimum of materials) (Juhan 1 998). From these concepts he designed the geodesic dome, including the US Pavilion at Expo '67 in Montreal. Tensegrity structures actually become stronger when they are stressed as the load a ppl ied is distributed not only to the area being directly loaded but a lso throughout the structure (Barnes 1 990). They employ both compressional and tensional elements. When applying the principles of tensegrity to the human body, one ca n readily see the bones and i ntervertebral discs as the disconti nuous compressional u n its and the myofascial tissues (muscles, tendons, l igament, fascia and to some degree the discs) as the tensiona l elements. When load is applied (as in lifting) both the osseous and myofascial tissues distribute the stress incu rred. Ingber ( 1 999) concurs with this concept and then adds to it: I n reality. our bodies are composed of 206 compression-resistant bones that are pulled up against the force of gravity and stabilized through interconnection with a continuous series of tensile muscles, tendons, and ligaments . . . cells may sense mechanical stresses, includ­ ing those due to gravity. through changes in the balance of forces that are tronsmitted across transmembrane adhesion receptors that link the cytoskeleton to the extracellular matrix ond to the other cells (e.g. in tegrins, cadherins, selectins). The mechanism by which these mechanical signals are transduced and converted into a biochemical response appears to be based, in part, on the finding that living cells

A

Figure 1 . 1 2 ARB: Tenseg rity-based structures. Reproduced w ith perm ission from the Jaurnal of Bodywork a n d Movement Therapies 1 99 7 ; 1 (5) :300-302.

use a tension-dependent form of architecture, known as tensegrity. to organize and stabilize their cytoske/etons.

Oschman (2000) suggests that bones fit in both the strut and tensile categories, argu ing that: 'Bones contai n both compressive and tensile fibres, and are therefore tensegrity systems unto themselves: Tensegrity a l lows mecha nica l energy to be transmitted away from

the point of impact and to be absorbed throughout the structure. 'The more flexible and balanced the network (the better the tensiona l integ rity), the more readily it absorbs shocks and converts them to information rather than damage: box con tinues

1 Connective tissue a n d the fascial system

Regarding Ingber's work, Oschman (2000) points out that the living tensegrity network is not only a mechanical system, but a lso a vibratory continuum. When a part of a tensegrity structure is plucked, the vibration produced travels throughout the entire structure: Restrictions in one part have both structural and energetic consequences for the en tire organism. Structural integrity, vibratory integrity, and energetic or information integrity go hand in hand. One cannot influence the structural system without influencing the energetic/informational system, and vice versa. Ingber's work shows how these systems also interdigitate with biochemical poth ways.

Of tensegrity, Juhan (1 998) tells us:

Osch man ( 1 997) concurs, adding another element: Robbie (1977) reaches the remarkable conclusion that the soft tissues araund the spine, when under apprapriate tension, can actually lift each vertebra off the one below it. He views the spine as a tensegrity mast. The various ligaments form 'slings ' that are capable of support­ ing the weight of the body without applying compressive forces to the vertebrae and intervertebral discs. In other words, the vertebral col­ umn is not, as it is usually portrayed, a simple stack of blocks, each cushioned b y an intervertebral disc.

These views are also suggested by Myers (200 1 ) in his enlightening book, Anatomy Trains: Myofascial Meridians for Manual and Movemen t Therapists (see a lso Box 1 .4). 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 framework - in conjunction with active muscles - provides another kind of tensional force that is crucial to the upright structure of the skeleton. We are not made up of stacks of building blocks resting securely upon one another, but rather of poles and guy-wires, whose stability relies not upon flat stacked surfaces, but upon praper angles of the poles and balanced tensions on the wires. . . . There is not a single horizontal surface anywhere in the skeleton that pravides a stable base for anything to be stacked upon it. Our design was not conceived by a stone-mason. Weight applied to any bone would

Folkman 1989, Ingber Et Jamieson 1985). Elegant research has docu­ mented how the gravity system connects, via a family of molecules

cause it to slide right off itsjoints if it were not for the tensional balances that hold it in place and contral its pivoting. Like the beams in a simple tensegrity structure, our bones act more as spacers than as compressional members; more weigh t is actually borne by the connective system of cables than by the bony beams.

known as in tegrins, to the cytoskeletons of cells throughout the body. Integrins 'glue' every cell in the body to neighbouring cells and to the surrounding connective tissue matrix. An important study by Wang et al (1 993) documents that integrin molecules carry tension from the extracellular ma trix, across the cell surface, to the cytoskeleton, which behaves as a tensegrity matrix. Ingber (1 993a,b) has shown how cell shape and function are regulated by an interacting tension and compression system within the cytoskeleton.

Levin (1 997) informs us that once spherica l shapes involving tensegrity structures occur (as in the cells of the body), a many-sided framework evolves which has 20 triangular faces. This is the hierarchica lly constructed tensegrity icosahedron ( icosa is 20 in Greek) which a re stacked together to form an infinite n u mber of 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

Fig u re 1 . 1 3 Tensegrity-based structures.

Fig u re 1 . 1 4 Cycle wheel structure a l l ows com pressive load to be distributed to rim t h rough tension network. box con tinues

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CLI N ICAL A P P L I CATI O N O F N E U RO M USCU LA R TECH N I Q U E S : T H E U P P E R B O DY

16

L Box 1 . 6

(tott t{ntled) Fig u re 1 . 1 5 A : Dehydration of g round su bstance may ca use kinking of collagen fibers. B: Sustained pressure may result i n tempora ry solation of g round substance, a l lowing kinked collagen fibers to lengthen, thereby redu cing m uscular stra i n. Reproduced with permission from the Journal of Bodywork and Movemen t Therapies 1 997; 1 (5) :309.

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principle is demonstrated in a wire-spoked bicycle wheel. A minimum of 12 tension spokes rigidly fixes the hub in space (anything more than 12 is a fail safe mechanism).

Levin points out that the tension-loaded spokes transmit compressive loads from the fra me to the ground while the hub remains suspended in its tensegrity network of spokes: 'the load

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The ensheathing lay er of deep fascia, as well as inter­ muscular septa and interosseous membranes, provides vast surface areas used for muscular attachment. The meshes of loose connective tissue contain the 'tissue fluid' and provide an essential medium through which the cellular elements of other tissues are brought into functional relation with blood and ly mph. This occurs partly by diffusion and partly by means of hy drokinetic transportation encouraged by alterations in pressure gradients - for example, between the thorax and the abdominal cavity during inhalation and exhalation. Connective tissue has a nutritive function and houses nearly a quarter of all body fluids. Fascia is a major arena of inflammatory processes (Cathie 1 974) (see Chapter 7). Fluids and infectious processes often travel along fascial planes (Cathie 1 974). Chemical (nutritional) factors influence fascial behavior directly. Pauling (1976) showed that 'Many of the results of deprivation of ascorbic acid [vitamin C] involve a defi­ ciency in connective tissue which is largely responsible for the strength of bones, teeth, and skin of the body and which consists of the fibrous protein collagen'. The histiocytes of connective tissue comprise part of an important defense mechanism against bacterial invasion by their phagocytic activity. They also play a part as scavengers in removing cell debris and foreign material. Connective tissue represents an important 'neutralizer' or detoxicator to both endogenous toxins (those produced under phy siological conditions) and exogenous toxins. The mechanical barrier presented by fascia has important defensive functions in cases of infection and toxemia. Fascia, then, is not just a background structure with little function apart from its obvious supporting role, but is an

distributes evenly around the rim and the bicycle frame and its load hangs from the hubs l i ke a ham mock between trees'. Other examples of tensegrity in common use include a tent and a crane. In the body this architectural principle is seen in many tissues, most specifica lly in the way the sacrum is suspended between the il ia.

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ubiquitous, tenacious, living tissue that is deeply involved in almost all of the fundamental processes of the body 's structure, function and metabolism. In therapeutic terms, there can be little logic in try ing to consider muscle as a separate structure from fascia since they are so intimately related. Remove connective tissue from the scene and any muscle left would be a jelly -like structure without form or func­ tional ability.

FASCIAL DYS FUNCTION

Mark Barnes (1997) states: Fascial restrictions can create abnormal strain patterns that can crowd, or pull the osseous structures out of proper alignment, resulting in compression of joints, producing pain and/or dysfunction. Neural and vascular structures can also become entrapped in these restrictions, causing neurological or ischemic conditions. Shortening of the myofascial fascicle can limit its functional length - reducing its strength, contractile potential and deceleration capacity. Facilitating positive change in this system [by therapeutic intervention] would be a clinically relevant event.

Cantu & Grodin (1992) have stated that 'The response of normal connective tissue [fascia] to immobilization pro­ vides a basis for understanding traumatized conditions'. A sequence of dy sfunction has been demonstrated as follows (Akeson & Amiel 1977, Amiel & Akeson 1983, Evans 1960). •

The longer the immobilization, the greater the amount of infiltrate there will be.

1 Connective tissue and the fascial system

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If immobilization continues beyond about 12 weeks, colla­ gen loss is noted; however, in the early days of any restric­ tion, a significant degree of grolU1d substance loss occurs, particularly glycosarninoglycans and water. Loss of (47% of) muscle strength due to immobilization has been shown to occur in as little as 3 weeks (Hortobagyi et al 2000). Since one of the primary purposes of ground substance is the lubrication of the tissues it separates (collagen fibers), its loss leads inevitably to the distance between these fibers being reduced. Loss of interfiber distance impedes the ability of collagen to glide smoothly, encouraging adhesion development. This allows crosslinkage between collagen fibers and newly formed connective tissue, which reduces the degree of fascial extensibility as adjacent fibers become more and more closely bound. Because of immobility, these new fiber connections will not have a stress load to guide them into a directional for­ mat and they will be laid down randomly. Similar responses are observed in ligamentous as well as periarticular connective tissues. Mobilization of the restricted tissues can reverse the effects of immobilization as long as this has not been for an excessive period. If, due to injury, inflammatory processes occur as well as immobilization, a more serious evolution occurs, as inflammatory exudate triggers the process of contrac­ ture, resulting in shortening of connective tissue. This means that, following injury, two separate processes may be occurring simultaneously: there may be a process of scar tissue development in the traumatized tissues and also fibrosis in the surrolU1ding tissues (as a result of the presence of inflammatory exudate). Cantu & Grodin ( 1992) give an example: 'A shoulder may be frozen due to macroscopic scar adhesion in the folds of the inferior capsule . . . a frozen shoulder may also be caused by capsulitis, where the entire capsule shrinks.' Capsulitis could therefore be the result of fibrosis involv­ ing the entire fabric of the capsule, rather than a localized scar formation at the site of injury.

Noted author Rene Cailliet (2004) points out that the vis­ coelastic properties of collagen are influence by tempera­ ture, 'which, when added to the equation of force and speed of stress, may cause irrecoverable damage'. Prolonged immo­ bilization results in a number of alterations in tissue, includ­ ing failure of collagen fibers to physiologically elongate and loss of collagen strength in as little as 4 weeks. RESTORING GEL TO SOL

Mark Barnes ( 1997) insists that therapeutic methods that try to deal with this sort of fascial, connective tissue change (summarized above in relation to trauma or immobilization) would be to 'elongate and soften the connective tissue, cre­ ating permanent three-dimensional depth and width'.

To achieve this, he says: Most important is the change in the ground substance from a gel to a sol. T his occurs with a state phase realignment of crystals exposed to electromagnetic fields. This may occur as a piezoelectric event (changing a mechanical force to electric energy) which changes the electrical charge of collagen and proteoglycans within the extracellular matrix.

In offering this opinion Barnes is basing his comments on the research evidence relating to connective tissue behavior which takes the properties of fascia into an area of study involving liquid crystal and piezoelectric events (Athenstaedt 1 974, Pischinger 199 1). Appropriately applied manual therapy can, Barnes suggests, often achieve such changes, whether this involves stretching, direct pressure, myofascial release or other approaches. As noted earlier, much that changes can be seen to possibly involve the 'sponge-like' behavior of connective tissues as they extrude and absorb water. All these elements form part of neuro­ muscular therapy interventions. A DIFFERENT MODEL LINKING TRAUMA AND CONNECTIVE TISSUE

Discussion of trauma and connective tissue has focused thus far on the physical changes that evolve, and the adap­ tations and compensations that are often amenable to soft tissue therapeutic interventions. Oschman (2006) offers a different perspective, which may be seen to build on the observations above on the work of Langevin, since both conceive connective tissue as (amongst other things) a communication network. Oschman summarizes this hypothesis as follows: The hypothesis is that the connective tissue matrix and its extensions reaching into every cell and nucleus in the body is a whole-person physical system that senses and a bsorbs the physical and emotional impact in any traumatic experi­ ence. T he matrix is also the physical material that is influ­ enced by virtually all hands-on, energetic and movement therapies. It is suggested that the living [connective tissue] matrix is the physical substrate where traumatic memories are stored and resolved.

Oschman continues: The living matrix is a pervasive system, consisting of both the nerves and the connective tissues and cytoskeletons of every neural and non-neural cell in the body. On the basis of the known biophysical properties of this system, we can visualize this as a high-speed solid-state information proces­ sor with capabilities that far exceed the brightest minds and fastest computers. Intuition can therefore be described as an emergent property of a very sophisticated semiconducting liquid crystalline molecular matrix that is capable of stor­ ing, processing and communicating a vast amount of sub­ liminal information that never reaches the nervous system

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C L I N I CA L A P P LI CAT I O N O F N EU R O M U S C U LA R TECH N I Q U E S : T H E U PPER B ODY

link Et Lawson have described patterns of postural patterning determ ined by fascial compensation and decompensation. •

•

Fascial compensation is seen as a usefu l, beneficia l and, above all, functional adaptation (i.e. no obvious symptoms) on the part of the musculoskeleta l system, for exa mple, in response to anom­ a l ies such as a short leg, or to overuse. Decompensation describes the same phenomenon but only in relation to a situation in which adaptive changes are seen to be dysfunctional, to produce symptoms, evidencing a failure of homeostatic adaptation.

By testing the tissue 'preferences' in different areas it is possible to classify patterns i n clin ically useful ways: • •

•

ideal (minimal ada ptive load transferred to other regions) compensa ted patterns which alternate in direction from area

to area (e.g. atla ntoocci pital, cervicothoracic, thoracolumbar, lum­ bosacral) and which a re commonly adaptive in nature uncompensated patterns which do not a lternate and which are commonly the result of trauma.

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link Et Lawson observed that the 20% of people whose compen­ satory pattern d id not a lternate had poor health h istories. Treatment of either CCP or uncompensated fascial patterns has the objective of trying, as far as is possible, to create a sym metri­ cal degree of rotatory motion at the key crossover sites. The treatment methods used to ach ieve this ra nge from direct muscle energy approaches to indirect positional release techniques.

Assessment of tissue preference

Occipitoatl antal area (Fig. 1 . 1 6) Patient is supine. • Practitioner sits at head, and cradles upper cervical region. • The neck is fu l ly flexed. • The occiput is rotated on the atlas to eva luate tissue preference as the head is slowly rotated left and then right.

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Cervi cothoracic area (Fig. 1 . 1 7) Patient is seated in relaxed posture with practitioner behind, with hands placed to cover medial aspects of upper trapezius so that fingers rest over the clavicles.

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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. •

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There a re fou r crossover sites where fascial tensions can be noted : occipitoatiantal (OA), cervicothoracic (CT), thoracolu mbar (TL) and lumbosacral (LS). 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.

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Fig u re 1 . 1 6 Alternative hand positions for assessment of u pper cervical region tissue d i rection prefe rence.

F i gu re 1 . 1 7 AEtB: Hand positions for assessment of u pper cervicothoracic reg ion tissue di rection preference. box continues

1 Connective tissue and the fascial system

Box 1 . 7 (con�in ued)

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The hands assess the area being palpated for its 'tightness/loose­ ness' preferences as a slight degree of rotation left and then right is introduced at the level of the cervicothoracic junction.

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Patient is supine, practitioner stands at waist level facing cepha­ lad and places hands over lower thoracic structures, fingers a long lower rib shafts lateral ly. 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 axis, one way and then the other.

Lumbosacral a rea •

Patient is supine, practitioner stands below waist level facing cepha lad and places ha nds on anterior pelvic structu res, using the contact as a 'steering wheel' to eval uate tissue preference as the pelvis is rotated around its central axis while seeking information as to its 'tightness/looseness' preferences.

and consciousness directly. A computer, with its software programs and memory and information storage capacities pales to insignificance in comparison with the evolutionar­ ily ancient solid-state system that is expressed within every cell and sinew of the body. Since the primary channels of this informational system are the acupuncture meridians, it is not surprising that there are energy psychology methods that involve tapping on key paints on the meridian system. Such tapping will introduce electrical fields into the meridian system because of the piezoelectric or pressure-electricity effect (e.g. Lapinski 1977, MacGinitie 1995). Such currents, then, will be transduced into signals that will be propagated through the meridian/living matrix system for a certain distance, since the meridians are low resistance pathways to the flow of electricity (e.g. Reichmanis et aI 1975).

NOTE: By holding tissues in their 'loose' or ease positions, by holding tissues in their 'tight' or bind positions and introd ucing an isometric contraction or just by holding tissues at their barrier, waiting for a release, changes ca n be encouraged. The latter a pproach would be i nducing the myofascial release in response to lig ht, sustained load. Questions following assessment exercise: 1 . Was there an 'a lternating' pattern to the tissue preferences? 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? 3 . If the latter was the case, was this in an i ndividual whose health is more compromised than average - in line with Zink & Lawson's suggestion? 4. By means of any of the methods suggested in the 'Note' above, are you able to produce a more balanced degree of tissue preference?

superficial tissues (involving autonomic responses) as well as deeper tissues (influencing the mechanical components of the musculoskeletal system) and that also address the factor of mobility (movement) meet with the requirements of the body when dysfunctional problems are being treated.

NMT,

as presented in this text, adopts this comprehensive approach and achieves at least some of its beneficial effects because of its influence on fascia. In the upcoming chapters we will see how influences from the nervous system, inflarrunatory processes and pat­ terns of use affect (and are affected by) the fascial network.

In the second volume of this text, the principles of tenseg­ rity, thixotropy and postural balance will be seen to form an intricate part of the foundations of whole-body structural integri ty. As will become clear in the next chapter, Ingber

(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

THERAPEUTIC SEQUENCING

pendently enmeshed. The authors of this text believe that an understanding of these different ways of appreciating

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.

Refe r e n ces Ahluwalia S, Fehm M, Murray MM, Martin SD, Spector M 2001 Distribution of smooth muscle actin-containing cells in the human meniscus. Journal of Orthopaedic Research 19(4):659-664 Akeson W, Amiel D 1977 Collagen cross linking alterations in joint contractures. Connective Tissue Research 5: 15-19 Amiel D. Akeson W 1983 Stress deprivation effect on metabolic turnover of medial collateral ligament collagen. Clinical Orthopedics 172:265-270 A thenstaedt H 1974 Pyroelectric and piezoelectric properties of vertebrates. Ann a ls of New York Academy of Sciences 238:68-110

Barker p, Briggs C 1999 Attachments of the posterior layer of lum­ bar fascia. Spine 24(17):1757-1764 Barnes J F 1990 Myofascial release: the search for excellence. Myofascial Release Seminars, Paoli. PA Barnes M 1997 The basic science of myofascial release. Journal of Bodywork and Movement Therapies 1 (4):231-238 Bauer J, Heine H 1998 Akupunkturpunkte und Fibromyalgie ­ Mbglichkeiten chirurgischer Intervention. Biologische Medizin 6(12):257-261 Becker R 1997 Life in motion. Rudra Press, Portland Binkley J 1989 Overview of l igaments and tendon structure and mechanics. Physiotherapy Canada 41(1):24-30

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C L I N ICAL A P P L I CATI O N O F N EU R O M USCULAR TECH N I Q U E S : TH E U P P E R B O DY

Birch S 2003 Trigger pOint-acupuncture point correlations revisited. Journal of Alternative and Complementary Medicine 9(1):91-103 Bonica J 1990 The management of pain, 2nd edn. Lea and Febiger, Philadelphia Brookes 0 1984 Cranial osteopathy. Thorsons, London Brown J S 2000 Faulty posture and chronic pelvic pain. In: Howard F M, Perry C P, Carter J E et al (eds) Pelvic pain d iagnosis and management. Lippincott Williams and Wilkins, Philadelphia, p 363-380 Bulbena A, Duro J C, Porta M et al 1993 Anxiety disorders in the joint hypermobility syndrome. Psychiatry Research 46:59--68 Cailliet R 1996 Soft tissue pain and disability, 3rd edn. F A Davis, Philadelphia Cail liet R 2004 Medical orthopedics: conservative management of musculoskeletal impairments. AMA Press, Chicago Cantu R, Grodin A 1992 Myofascial manipulation. Aspen Publications, Gaithersburg, MD Carreiro J 2003 An osteopathic approach to children. Churchill Livingstone, Edinbmgh Carter J E, Soper 0 E 2000 Diagnosing and treating nongynecologic chronic pelvic pain. Women's Health in Primary Care 3(10):708-725 Cathie A 1974 Selected writings. Academy of Applied Osteopathy Yearbook, Maidstone, England Chaitow L 2000 Multidisciplinary approaches to myofascial pain. JBMT European Conference lecture, Dublin, Ireland Chaitow L, DeLany J 2002 Clinical application of neuromuscular techniques. Volume 2 - The lower body. Churchill Livingston, Edinburgh, p 27 Chen C, Ingber 0 1999 Tensegrity and mechanoregulation: from skeleton to cytoskeleton. Osteoarthritis and Cartilage 7(1):81-94 Coffey 0 1985 See Levine J The man who says YES. Johns Hopkins Magazine February / April:34-44 Comeaux Z 2002 Robert Fulford and the philosopher physician. Eastland Press, Seattle DeLany J 2000 Multidisciplinary approaches to myofascial pain. JBMT European Conference lecture, Dublin, Ireland Dorman T 1997 Pelvic mechanics and prolotherapy. In: Vleeming A, Mooney V, Dorman T et al (eds) Movement, stability and low back pain. Churchill Livingstone, Edinburgh Earl E 1965 The dual sensory role of the muscle spindles. Physical Therapy Journal 45:4 Evans E 1960 Experimental immobilization and mobilization. Journal of Bone and Joint Surgery 42A:737-758 Fuller B 1975 Synergetics. Macmillan, New York Goldman J 1991 Hypermobility and deconditioning. Southern Medical Journal 84:1192-1196 Gray's anatomy 2005 (39th edn) Churchill Livingstone, Edinburgh Greenman P 1989 Principles of manual medicine. Williams and Wilkins, Philadelphia Hakim A, Grahame R 2003 Joint hypermobility. Best Practice &. Research CLinical Rheumatology 17:989-1004 Hastreiter 0, Ozuna R M, Spector M 2001 Regional variations in cellular characteristics in human l u mbar intervertebral discs, including the presence of alpha-smooth m uscle actin. Journal of Orthopaedic Research 19(4):597--604 Heine H 1995 Functional anatomy of traditional Chinese acupuncture pOints. Acta Anatomica 152:293 Hong C-Z 2000 Myofascial trigger points: pathophysiology and correlation with acupuncture points. Acupuncture Medicine 18(1):41-47 Hortobagyi T, Dempsey L, Fraser 0 et al 2000 Changes in muscle strength, muscle fibre size and myofibrillar gene expression after immobilization and retraining in humans. Journal of Physiology 524(1):293-304

Ingber 0 E 1993a Cellular tensegrity: defining new rules of biologi­ cal design that govern the cytoskeleton. Journal of Cell Science 104:613-627 Ingber 0 E 1993b The riddle of morphogenesis: a question of solution chemistry or molecular cell engineering. Cell 75:1249-1252 Ingber 0 E 1999 How cells (might) sense microgravity. Workshop on cell and molecular biology research in space, Leuven, Belgium, June 1998. FASEB Journal 13(Suppl):S3-S15 Ingber 0 2003 Mechanobiology and diseases of mechanotransduc­ tion. Annals of Medicine 35(8):564-577 Ingber 0 E, Folkman J 1989 Tension and compression as basic deter­ minants of cell form and function: utilization of a cellular tenseg­ rity mechanism. In: Stein W, Bronner F (eds) Cel l shape: determinants, regulation and regulatory role. Academic Press, San Diego, p 1-32 Ingber 0 E, Jamieson J 1985 Cells as tensegrity structures. In : Andersson L L, Gahmberg C G, Ekblom P E (eds) Gene expres­ sion d uring normal and malignant differentiation. Academic Press, New York, p 13-32 Jackson 0 W, Scheer M J, Simon T M 2001 Cartilage substitutes: overview of basic science and treatment options. Journal of the American Academy of Orthopedic Surgery 9:37-52 Janda V 1986 Extracranial causes of facial pain. Journal of Prosthetic Dentistry 56(4):484-487 Juhan 0 1998 Job's body: a handbook for bodywork, 2nd edn. Station Hill Press, Barrytown, NY Kawakita K, Itoh K, Okada K 2002 The polymodal receptor hypoth­ esis of acupuncture and moxibustion, and its rational explana­ tion of acupuncture points. International Congress Series: Acupuncture - is there a physiological basis? 1238:63-68 Keeffe E B 1999 Know your body. Times Edition, Ulysses Press, Berkeley, CA Kerr R, Grahame R 2003 Hypermobility syndrome. Butterworth­ Heinemann, Edinburgh, p 15-32 Kochno T V 2001 Connective tissue perspective. Part 2: Active iso­ lated stretching (the Mattes method). Journal of Bodywork and Movement Therapies 6(4):226-227 Kurz I 1986 Textbook of Dr Vodder's manual lymph d rainage, vol 2: Therapy, 2nd edn. Karl F Haug, Heidelberg Langevin H M, Yandow J A 2002 Relationship of acupuncture points and meridians to connective tissue planes. Anatomical Record 269(6):257-265 Langevin H, Churchill 0, Cipolla M 2001 Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. FASEB Journal 15:2275-2280 LangeVin H, Cornbrooks C, Taa�es 0 et al 2004 Fibroblasts form a body-wide cellular network. Histochemistry and Cell Biology 122(1):7-15 Langevin H, Bouffard N, Badger G et al 2005 Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. American Journal of Physiology - Cell Physiology . 288:C747-756 Lapinski B 1977 Biological significance of piezoelectricity in relation to acupwlCture, Hatha yoga, osteopathic medicine and action of air ions. Medical Hypotheses 3(1):9-12 Lederman E 1997 Fundamentals of manual therapy. Physiology, neurology and psychology. Churchill Livingstone, Edinburgh Levin S 1997 Tensegrity. In: Vleeming A, Mooney V, Dorman 1, Snijders C, Stoeckart R (eds) Movement, stability and low back pain. Churchill Livingstone, Edinburgh MacGinitie L A 1995 Streaming and piezoelectric potentials in connective tissues. In: Blank M (ed) Electromagnetic fields: bio­ logical interactions and mechanisms. Advances in Chemistry Series 250. American Chemical Society, Washington DC p 125-142

1

Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro J C 1998 Association between jOlnt hypermobility synd rome and panic disorders. American Journal of Psychiatry 155:1578-1583 Meiss R A 1993 Persistent mechanical effects of decreasing length during isometric contraction of ova rian ligament smooth muscle. Journal of Muscle Research and Cell Motility 14(2):205-218 Melzack R, Stillwell 0 M, Fox E J 1977 Trigger points and acupuncture points for pain: correlations and implications. Pain 3:3-23 Muller K, Kreutzfeld t A, Schwesig R et a l 2003 Hypermobility and chronic back pain. Manuelle Medizin 4 1 (2):105-109 Murray M, Spector M 1999 Fibroblast distribution in the anterome­ dial bundle of the human anterior cruciate ligament: the pres­ ence of a lpha-smooth muscle actin-positive cel ls. Journal of Orthopaedic Research 17(1):18-27 Myers T 1997 Anatomy trains. Journal of Bodywork and Movement Therapies 1 (2):91-101 and 1 (3):134-145 Myers T 1999 Kinesthetic dystonia parts 1 and 2. Journal of Bodywork and Movement Therapies 3(1):36-43 and 3(2):107-117 Myers T 2001 Anatomy trains: myofascial meridians for manual and movement therapists. Churchill Livingstone, Ed inburgh Neuberger A 1953 Metabolism of collagen. Journal of Biochemistry 53:47-52 Oschman J L 1997 What is healing energy? Part 5: Gravity, struc­ ture, and emotions. Journal of Bodywork and Movement Therapies 1(5):307-308 Oschman J L 2000 Energy medicine: the scientific basis. Churchill Livingstone, Edinburgh Oschman J L 2006 Trauma energetics. Journal of Bodywork and Movement Therapies 10(1):21-34 Page L 1952 Academy of Applied Osteopathy Yearbook Pauling L 1976 The common cold and flu. W H Freeman, New York Pischinger A 1991 Matrix and matrix regulation. Haug international, Brussels Plummer J 1980 Anatomical findings at acupuncture loci. American Journal of Chinese Medicine 8:170-180 Reichmanis M, Marino A A, Becker R 0 1975 Electrical correlates of acupuncture points. IEEE Transactions on Biomedical Engineering 22(Nov):533-535 Robbie 0 L 1977 Tensional forces in the human body. OrthopaediC Review 6:45-48 Russek L N 2000 Examination and treatment of a patient with hypermobility syndrome. Physical Therapy 80:386-398 Scariati P 1991 Myofascial release concepts. In: DiGiovanna E (ed) An osteopathic approach to d iagnosis and treabnent. Lippincott, London Schleip R 1998 Interview with Prof. Dr. med. J Staubesand in Rolf Lines. Rolf Institute, Boulder, CO

Connective tissue and the fascial system

Schleip R 2003 Fascial plasticity - a new neurobiological explanatiori, Part 2. Journal of Bodywork and Movement Therapies 7(2):104-116 Schleip R, Klingler W, Lehmann-Horn F 2004 Active contraction of the thoracolumbar fascia. In: Vleeming A, Mooney V, Hodges P et al (eds) Proceedings of the 5th InterdiSciplinary World Congress on Low Back and Pelvic Pain, Melbourne Schleip R, Klingler W, Lehmann-Horn F 2005 Active fascial contrac­ tility: fascia may be able to contract in a smooth muscle-l ike manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 65(2):273-277 Schleip R, Naylor 1, Ursu 0 et a l 2006 Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Medical Hypothesis 66(1):66-71 Simons 0 G 2002 Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies 6(2):81-88 Staubesand J 1996 Zum Feinbau der fascia cruris mit BerucksichtigLmg epi- und intrafaszia lar Nerven. Manuelle Medizin 34: 196-200 Stedman's Electronic Medical Dictionary 2004 version 6.0. Lippincott Williams and Wilkins, Baltimore Thompson B 2001 Sacroiliac joint dysfunction: neuromuscular massage therapy perspective. Journal of Bodywork and Movement Therapies 5(4):229-234 Von Piekartz H, Bryden L (eds) 2001 Craniofacial dysfunction and pain. Butterworth-Heinemann, Oxford Wal l P, Melzack R 1990 Textbook of pain, 2nd edn. Churchill Livingstone Edinburgh Wang J Y, Butler J P, Ingber 0 E 1993 Mechanotransd uction across the cell surface and th.rough the cytoskeleton. Science 260:1124-1127 White A, Panjabi M 1978 Clinical biomechanics of the spine. J B Lippincott, Philadelphia Wilson V 1966 Inhibition in the CNS. Scientific American 5:102-106 Wolff J 1870 Die i.n.nere Architektur der Knochen. Arch Anat Phys 50 Yahia L, Pigeon P, DesRosiers E 1993 Viscoelastic properties of the human lumbodorsal fascia. Journal of Biomedical Engineering 15(5):425-429 Yoshino G, Higashi K, Nakamura T 2003a Changes in head pOSition d ue to occlusal supporting zone loss during clenching. Journal of Craruomandibular Practice 21(2):89-98 Yoshino G, Higashi K, Nakamura T 2003b Changes in weight distribution at the feet due to occlusal supporting zone loss during clenching. Journal of Craniomandibular Practice 21 (4):271-278 Zink G, Lawson W 1979 An osteopathic structural examination and functional interpretation of the soma. Osteopathic Annals 12(7):433-440

21

I 23

Chapter

2

I

Muscles

CHAPTER CONTENTS Dynamic forces - the 'structural continuum' 23 Signals 25 Essential information about muscles 25 Types of muscle 25 Energy production in normal tissues 27 Energy production in the deconditioned individual 28 Muscles and blood supply 28 Motor control and respiratory alkalosis 31 Two key definitions 32 The Bohr effect 32 Core stability, transversus abdominis, the diaphragm and BPD 32 Summary 32 Major types of voluntary contraction 33 Terminology 33 Muscle tone and contraction 33 Vulnerable areas 34 Muscle types 34 Cooperative muscle activity 35 Muscle spasm, tension, atrophy 37 Contraction (tension with EMG elevation, voluntary) 38 Spasm (tension with EMG elevation, involuntary) 38 Contracture (tension of muscles without EMG elevation' involuntary) 38 Increased stretch sensitivity 38 Viscoelastic influence 39 Atrophy and chronic back pain 39 What is weakness? 39 Trick patterns 39 Joint implications 40 When should pain and dysfunction be left alone? 40 Beneficially overactive muscles 41 Somatization - mind and muscles 41 But how is one to know? 41

In this chapter our focus of a ttention is placed on the prime movers and stabilizers of the body, the muscles. It is neces­ sary to understand those aspects of muscle struc ture, func­ tion and dysfunction that can help to make selection and applica tion of therapeutic interventions as suitable and effective as possible. Unless otherwise noted, the general muscle discussions in this chapter refer to skeletal muscles. The skeleton provides the body with an appropria tely semlflgld framework that has facility for movement a t its junctions a � d joints. However, it is the muscular system, given coheslOn by the fascia (see Chapter 1), that both sup­ ports and propels this framework, providing us with the ability to express ourselves through movement, in activities ranging from c �opping wood to brain surgery, climbing . mo untams to glvmg a massage. Almost everything, from . . faCIal expresslOn to the beating of the heart, is dependent on muscular function. Synchronized and coordinated movement depends on structural integra tion, in which the form of the body parts, and how they interrelate spatially, from the smallest to the largest, determines the efficiency of function. It is in this complex setting that muscle function (and dysfunction) should be seen.

DYNAMIC FORCES - THE 'STRUCTURAL CONTINUUM'

It may be useful to qualify the description above, in which a division is suggested between the semirigid skeleton and the attaching elastic soft tissues that propel and move it. In fact, the integrated systems of the body are better described as representing a series of interrelated tensegrity structures . It � as Fuller (1975) who used the term tensegrity to desc� lbe structures whose stability, or tensionaL integrity, reqUired a dynamic balance betvveen discontinuous com­ pression elements (such as bones) connected (and moved) by continuous tension cables (such as the soft tissues of the body, e.g. ligaments, tendons, muscle and fascia). There

I

24

C L I N ICAL A P P LICAT I O N OF N E U RO M U SCULAR T E C H N I QU E S : TH E U P P E R B O DY

�-- Upper trapezius �-- Spine of scapula �----Infraspinatus Site of vertebral malrotation---L--�

'----- Teres minor ----

Thoracolumbar junction

�-----

Piriformis

Iliopsoas-----t---'

TFUITB------1

t------ Biceps femoris

Gastrocnemius and soleus-------t

Figure

2.2

Typical sites of increased muscle/ tendon tension and

tenderness resulting from malalignment. The drawing also indicates the typical lateralization; if the structure is involved bilaterally, the one indicated here is usually affected more severely. TFL/ ITB, tensor

fascia lata/ iliotibial band. Redrawn with permission from Schamberger

Figure 2.1 The miraculous possibilities of human balance. Reproduced with permission from

Gray's Anatomy (1 995).

was, in this construct, the implied balance created between

tension and compression, involving all tissues, from an intra­ and extracellular level, to the gross skeletal and muscular structures of the physical body (Ingber 1993, 2003). Ingber (2003) has, in fact, moved beyond the tensegrity model in his descriptions, having more recently discussed what he terms a 'structural continuum', in which every­ thing from the macro (skeleton, muscles, organs, etc.) to the micro (intra- and extracellular structures) are interdepend­ ently enmeshed. Ingber summarizes this when he states: 'Mechanical deformation of whole tissues [the outcome of the interaction between tensional, shear and compression forces] results in coordinated structural re-arrangements on many different size scales.' He uses the word mechanotransduction to summarize the effects of shear and other forces on cells, which change their shape and function, including gene expression. These processes occur in tissues that have been, or are being, over- or underused, or abused. This implies that functional

(2002).

misuse (poor posture, for example) leads to structural mod­ ifications, and that once such structural rearrangements have occurred, normal (or at least optimal) function may become impossible. The interlocking elements of structure, function and dys­ function are the territory of the manual therapist, as we evaluate in our patients these processes of 'coordinated structural rearrangement' that are capable of affecting all tissues, including neural, fascial and muscular. The end results of such 'rearrangement' will be noted when a muscle is found to be shortened, fibrotic or to contain trigger points. These symptom-producing changes (reduced range of motion, tense, tight and /or indurated muscles that may be housing trigger points) are the manifestation of rearrange­ ment of the structural continuum. An example of a 'rearranged' structure is given by Schamberger (2002) who describes an example of what he terms a 'malalignment syndrome' (Fig. 2.2). In this example rotational and other malalignments are seen to cause increased muscular ten­ sions and corresponding adaptations. Fortunately, 'coordinated structural rearrangement' in a positive direction is also possible, when appropriate thera­ peutic measures are initiated to help restore the 'structural continuum', offering the chance for function to improve, or

2 Muscles

it will be possible to commence explora tion of the many dysfunctiomll patterns that can interfere with the quality of life and create painful leading to degenerative changes. Because the ana tomy and physiology of muscles are ade­ quately covered elsewhere, the information in this chapter will be presented largely in summary form. Some specific topics (muscle type, for example) receive a fuller discussion due to the significance they have in regard to neuromuscu­ lar therapy.

ESSENTIAL IN FORMATION ABOUT MUSCLES (Fritz 1998, Jacob a Falls 1997, Lederman 1997, Liebenson 1996, Macintosh et al 2006, Schafer 1987)

Triad --HIZ disc ----"'I

•

• •

•

Figure 2.3 Details of the intricate organization of skeletal muscle. Reproduced with permission from Gray's Anatomy (2005).

• •

normalize. It is within this context that you should consider our survey of fascia (Chapter 1) and muscles (this chapter) and the dysfunctions that are described and the treatments proposed throughout the book. •

SIGNALS

Healthy, well-coordinated muscles receive and respond to a multitude of signals from the nervous system, providing the opportunity for coherent movement. When, through overuse, misuse, abuse, disuse, disease or trauma, the smooth interaction between the nervous, circulatory and the musculoskeletal systems is disturbed, movement becomes difficult, restricted, commonly painful and, some­ times, impossible. Dysfunctional patterns affecting the musculoskeletal system (see Chapter 5) which emerge from such a background lead to compensatory adaptations and a need for therapeutic, rehabilitation and / or educational interven tions. This chapter will highlight some of the unique qualities of the muscular system. On this founda tion

•

Skeletal muscles are derived embryologically from mes­ enchyme and possess a particular ability to contract when neurologically stimulated. Skeletal muscle fibers comprise a single cell with hun­ dreds of nuclei. The fibers are arranged into bundles (fasciculi) contain­ ing approxima tely 100 fibers, with connective tissue fill­ ing the spaces between the fibers (the endomysium) as well as surrounding the fasciculi (the perimysium). Entire muscles are surrounded by denser connective tis­ sue (fascia, see Chapter 1 ) where it is known as the epimysium. The epimysium is continuous with the connective tissue of surrounding structures. Individual muscle fibers, which are bundles of 1000-2000 myofibrils, can vary in length from a few millimeters to about 12 cm. When a muscle appears to be longer than this, it has fibers a rranged in series, separated into com­ partments by inscriptions. The sartorius, for instance, has three such inscriptions (four compartments), with each compartment having its own nerve supply (Macintosh et aI2006). IndividuC{1 muscle fibers can vary in diameter from 10 to 60�m, with most adult fibers being a round 50�m. Individual myofibrils are composed of a series of sarcom­ eres, the basic contractile units of a skeletal muscle, con­ nected end to end. Actin and myosin filaments overlap within the sarcomere and slide in rela tion to one another to produce shortening of the muscle (see Box 2.1).

TYPES OF MUSCLE

Muscle fibers can be broadly grouped into those that are: •

longitudinal (or strap or parallel or fusiform), which have lengthy fascicles, largely oriented with the longitudinal axis of the body or its parts. These fascicles favor speedy action and are usually involved in range of movement (sartorius, for example, or biceps brachii)

25

26

CL I N I CAL A P P L I CAT I O N OF N E U R O M U SC ULAR TECH N I Q U E S : T H E U P P E R B O DY

Striated (skeletal) muscles are com posed of fasciculi, the nu mber of which is dependent upon the size of the muscle. Each fascicle is made up of bundles of (approximately) 1 00 fibers with each fiber containing up to around 2000 myofibrils (Macintosh et al 2006, Simons et a l 1 999). Each myofibri l is composed of a series of sarcomeres laid end to end; these conta in two primary types of protein filament, actin a nd myosin, as well as a stabi lizing filament (titin) a nd other proteins, such as troponin, tropomyosin and nebulin. In most a natomy books the reader can easily find illustrations and d iscussions regarding the distinct bands and shadings, such as the Z-line, H-zone and M-region, which are created by the myofibri l components. The sliding fi lament theory, first proposed by biophysicist Jea n Hanson and physiologist H ugh Esmor H uxley in 1 954, offers a n explanation of how m uscles shorten during contraction. Although scientists have fa iled to fu l ly explain the biomechanics of movement, the sl iding fila ment theory remains today as the foundational platform. The fol lowing i l l u strates the basis of this theory. Figure 2.4 i l l u strates the relationsh ip of acti n, myosin and other components of the m u scle cell during contraction. As ATP binds to the myosin heads (which form the crossbridges between the two

Tropinin Thin filament

Thick (myosin) filament

Actin

filaments). it partially hydrolyzes them to produce an energized (pre­ cocked) myosin head. This preloaded thick filament has a high affinity for the thinner actin component. When a muscle is at rest, binding of the two filaments m ust be blocked or else continual contraction will resu lt, such as seen in rigor mortis. The tropomyosin filament overlies the myosin binding sites on the actin molecule, thereby preventing coupling of the two fi la ments. As an action potential spreads across the muscle fiber, signaling contraction, it travels down the transverse tubu les, which lie close to the term inal cisternae (lateral sacs), the storage site for Ca2+. As the action potential progresses, it causes a depolarization of the membrane, an opening of the calcium cha n nels and the release of Ca2+ from the sarcoplasmic reticu lum. The release of Ca2+ cata lyzes tropon in to cha nge its sha pe, thereby moving tropomyosin aside. This process exposes the binding sites on the actin molecule and allows myosin to attach itself to the actin fi la ments. This occurs to many filaments sim u l taneously, not just the one described here. The myosin heads (and possibly shafts) flex, causing nu merous myosin and actin fi la ments to slide past each other, resulting in muscle contraction.

Z band

Tropomyosin

---i��M�88J��ii;is1l�iiiij����ePSi�;,iIi1��

-r=�I!�=�I=I" i;!��i�

At rest, ATP binds to myosin head

I

groups and is partially hydrolyzed to

I produce a high-affinity binding site

II

I

for actin on the myosin head group. However, the head group cannot bind because of the blocking of the

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.

I

the myosin head, causing it to 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,

, the crossbridge will quickly ,, reform, causing further sliding of I the actin and myosin filaments

a8������;i;l������������ga�t� r

Ca2+ released from sarcoplasmic

, reticulum in response to action

I

I

potential binds to troponin, causing tropomyosin to move and expose

I�

the myosin binding site on the actin molecule, The crossbridge is

past each other. If Ca2+ is no

ormed.

I longer elevated, the muscle relaxes.

�

ATP

f

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 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

Box 2.1 (continued) 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

elements. Reproduced

•

• • •

pennate, which have fascicles running at an angle to the muscle's central tendon (its longitudinal axis). These fasci­ cles favor strong movement and are divided into unipennate (flexor pollicis longus), bipennate, which has a feather-like appearance (rectus femoris, peroneus longus) and multi­ pennate (deltoid) forms, depending on the configuration of their fibers in relation to their tendinous attadunents circular, as in the sphincters triangular or convergent, where a broad origin ends with a narrow attachment, as in pectoralis major spiral or twisted, as in latissimus dorsi or levator scapulae.

Muscles are the body's force generators. In order to achieve this function, they require a source of power, which they derive from their ability to produce mechanical

energy from chemically bound energy (in the form of adenosine triphosphate ATP). This process of energy production depends on an ade­ quate supply of oxygen, something that will be normal in aerobically fit tissues, but not in the tissues of the decon­ ditioned individual (see below). Some of the energy so produced is stored in contractile tissues for subsequent use when activity occurs. The force that skeletal muscles generate is used to produce or pre­ vent movement, to induce motion or to ensure stability. 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, to a full-strength contraction, which can be sustained for very short periods. When a contraction involves more than 70% of available strength, blood flow is reduced and oxygen availability diminishes. -

•

•

•

ENERGY PRO DUCTION IN NORMAL TISSUES •

the sarcomere's actin and myosin with pe rm i ss ion from Gray's Anatomy (2005).

From whole muscle to

•

27

28

CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY

Strap

Strap with tendinous intersections

Tricipital

Triangular

Quadrilateral

Bipennate

Figure

Radial

2.6 Types of muscle fiber arrangement. Reproduced with permission from Gray's Anatomy (2005).

ENERGY PRO DUCTION IN THE DECONDITIONE D INDIVI DUAL •

•

• •

Multipennate

When anaerobic energy (ATP) pathways are activated in the tissues of deconditioned individuals, the result is accumulation of incompletely oxidized metabolic prod­ ucts, such as lactic acid and pyruvic acid (Fried 1987, Nixon & Andrews 1996). The effects of this are described by Nixon & Andrews (1996) as leading to: 'Muscular aching at low levels of effort; restlessness and heightened sympathetic activity; increased neuronal sensitivity; constriction of smooth­ muscle tubes [e.g. vascular, respiratory and gastrointesti­ nal], accompanying the basic symptom of inability to make and sustain normal levels of effort.' Aerobic activity, if at all possible, is the solution to such problems. As outlined later in this chapter, another feature that can result in anaerobic glycolysis is a disturbed breathing pattern, where excessive levels of CO2 are exhaled (as in h yperven tila hon).

MUSCLES AND BLOOD SUPPLY

Gray's Anatomy (2005, p. 118) explains the intricacy of blood supply to skeletal muscle as follows: In most muscles the major source artery enters on the deep surface, frequently in close association with the principal vein and nerve, which together form a neurovascular hilum. The vessels course and branch within the connective tissue framework of the muscle. The smaller arteries and arterioles ramify in the perimysial septa and give off capillaries which run in the endomysium. Although the smaller vessels lie mainly parallel to the muscle fibres, the1j also branch and anastomose around the fibres, forming an elongated mesh. Gray's also tells us that the capillary bed of predominantly red muscle (type I postural, see below) is far denser than that of white (type II phasic) muscle. Research has shown tha t there are two distinct circula­ tions in skeletal muscle (Grant & Payling Wright 1968). Nutritive circulation

derives from arteriolar branches of arteries entering by way of the neurovascular hilus. These

2 M uscles

penetrate to the endomysium where all the blood passes through to the capillary bed before collection into venules and veins to leave again through the hilus. Alternatively, some of the blood passes into the arterioles of the epi- and perimysium in which few capillaries are present. Arteriove­ nous anastomosis [a coupling of blood vessels] are abundant here, and most of the blood returns to the veins without passing through the capillaries; this circuit therefore consti­ tutes a non-nutritive [collateral} pathway through which blood may pass when the flow in the endomysia I capillary bed is impeded, e.g. during contraction. In this way blood would keep moving but would not be nourishing the tissues it was destined for, if access to the capillary bed was blocked for any reason. This includes when ischemia is present in the tissues due to overuse, pro­ longed shortening due to postural positioning, and tight clothing, such as an elastic waistband in pants applying pressure to the lower back tissues. This is also particularly relevant to deep pressure tech­ niques, designed to create 'ischemic compression' - for example, when treating myofascial trigger points. When ischemic compression is applied, the blood destined for the tissues being obstructed by this pressure ( the trigger point

site) will diffuse elsewhere until pressure is released, at which time a· 'flushing' of the previously ischemic tissues will occur. A blanching/ flushing combination repeated sev­ eral times can act as a local 'irrigation pump' to significantly increase blood flow to localized ischemia. As explained below, when a situation of increased alka­ linity (respiratory a lkalosis) leads to the smooth muscles around blood vessels constricting, blood supply w ill be diminished. In addition, oxygen release to the tissues will also be reduced in such a setting due to the Bohr effect (Pryor & Prasad 2002). Some a reas of the body have relatively inefficient anasto­ moses and are termed hypovascular. These are particularly prone to injury and dysfunction. Examples include the supraspinatus tendon, which corresponds with 'the most common site of rotator cuff tendinitis, calcification and spontaneous rupture' (Cailliet 1991, Tulos & Bennett 1984). Other hypovascular sites include the insertion of the infra­ spinatus tendon and the intrascapular aspect of the biceps tendon (Brewer 1979). The lymphatic drainage of muscles occurs via lymphatic capillaries that lie in the epi- and perimysial sheaths. They converge into larger lymphatic vessels that travel close to the veins as they leave the muscle.

Box 2.2 The lymphatic system Coming in contact with lymph is to connect with the liquid dimension of the organ ism. (Ch ikly 1 996) The lymphatic system serves as a collecting and filtering system for the body's interstitial fluids, while removing the body's cellular debris. It is able to process the waste materials from cel l u lar metabolism and provide a strong line of defense agai nst foreign invaders while reca pturing the protein elements and water content for recycling by the body. Through 'immunolog ica l memory', lymphocyte cells, which reside in the lymph and blood a n d are part of the general immune system , recognize invaders (antigens) a nd rapidly act to neutra l ize these. This system of defending during invasion and then clea ning up the battleground makes the lymphatic system essential to the health of the organism.

Organization of the lymph system The lymphatic system comprises an extensive network of lymphatic capilla ries, a series of collecting vessels and lymph nodes. It is associated with the lymphoid system (lymph nodes, spleen, thymus, tonsi ls, appendix, mucosal-associated lym phoid tissue such as Peyer's patches and bone ma rrow), which is pri marily responsible for the immune response (Braem 1 994, Chikly 1 996, 2001 ). The lym phatic system is: • •

•

an essential defensive component of the immune system a carrier of (especially heavy and large) debris on behalf of the circulatory system a transporter of fat-soluble nutrients (and fat itself) from the digestive tract to the bloodstream .

Chikly (2001) notes: The lymphatic system is therefore a second pathway back to the heart, parollel to the blood system. The interstitial fluid is a very important fluid. It is the real 'interior milieu' (Claude Bernard,

1813-1878) in which the cells are immersed, receive their nutritive substances and reject damaging by-products. Lymph is a fluid which originates in the connective tissue spaces of the body. Once it has entered the first lymph capillaries ... this fluid is called lymph.

Col lection beg ins in the interstitial spaces as a portion of the circu lating blood is picked up by the lymphatic system. This fl uid is comprised primarily of large waste particles, debris and other material from which protein might need to be recovered or that may need to be disposed. Foreign particulate matter and pathogenic bacteria are screened out by the lymph nodes, which a re interposed a long the course of the vessels. Nodes a lso produce lymphocytes, which makes their location at various points a long the transportation pathway convenient should infectious material be encountered. Lym ph nodes (Chikly 200 1 ): • • •

•

filter and purify capture and destroy toxins reabsorb a bout 40 0/0 of the lymphatic liq uids, so concentrating the lymph while recycling the removed water produce mature lymphocytes - white blood cells that destroy bacteria, virus-infected cel ls, foreign matter and waste materia ls.

Production of lymphocytes increases (in nodes) when lym phatic flow is increased (e.g. with lymphatic d ra i nage techniques). A lymphatic ca pillary network made of vessels slightly larger than 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 closed system, whereas the lymphatic system is an open-end system, beginning blind in the interstitial spaces. The moment the fluid enters a lymph capillary, a fla p valve prevents it from returning into the interstitia l spaces. The fluids, now cal led 'lymph', continue box continues

29

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

Box 2.2 (continued) coursing th rough these 'precollector' vessels which empty into lymph col lectors. The collectors have valves every 6-20 mm that occur directly between two to th ree layers of spira l muscles, the unit being ca lled a Iymphangian (Fig. 2.7). The alternation of valves and muscles gives a characteristic 'monil iform' shape to these vessels, like pearls on a string. The Iymphangions contract in a peristaltic man ner that assists in pressing the fluids through the va lved system. When stimulated, the muscles can substantially increase (up to 20-30 ti mes) the capacity of the whole lymphatic system (Chikly 2001). The la rgest of the lymphatic vessels is the thoracic duct, wh ich begins at the cisterna chyli, a large sac-like structure withi n the abdominal cavity located at approximately the level of the 2nd lumbar vertebra. The thoracic duct, containing lymph fluids from both of the lower extremities and a l l abdominal viscera except part of the liver, runs posterior to the stomach a n d intestines. Lymph fluids from the left upper extremity, left thorax and the left side of cranium and neck may join it just before it empties into the left subclavian vein or may empty nearby into the internal jugular vein, brachiocepha l ic junction or directly into the subclavian vein. The right lymphatic duct d rains the right upper extrem ity, right side of

the head and neck and right side of the thorax and empties in a similar manner to that of the l eft side. Stimulation of Iymphangions (and therefore lymph movement) occurs as a result of automotoricity of the Iymphangions (electrical potentials from the autonomic nervous system) (Kurz 1 986). As the spiral muscles of the vessels contract, they force the lymph through the flap valve, which prevents its return. Additionally, stretching of the muscle fibers of the next Iymphangion (by increased fluid volume of the segment) leads to reflex muscle contraction (internally stimulated), thereby producing peristaltic waves along the lymphatic vessel. There are a lso external stretch receptors that may be activated by manual methods of lymph drainage which create a similar peristalsis. Lymph movement is also augmented by respiration as the altering intrathoracic pressure produces a suction on the thoracic duct and cisterna chyli and thereby increases lymph movement in the duct and presses it toward the venous arch (Kurz 1 986, 1 987). Skeletal muscle contractions, movement of l imbs, peristalsis of smooth muscles, the speed of blood movement in the veins into which the ducts empty and the pulsing of nearby arteries a l l contribute to lymph movement (Wittl inger & Wittl inger 1 982). Exposure to cold, tight cloth ing, lack of exercise and excess protein consumption can hinder lymphatic flow (Kurz 1 986, Wittlinger & Wittlinger 1 982).

White pulp

Spleen

Afferent lymphatic vessels

Lymphatic

via

efferent

drainage

lymphatic vessels marrow tissue: including: connective tissue, epithelia, non-encapsulated lymphoid tissue of gut, elc.

Figure 2.7 Lymph pathway (a Iymphangion is shown in insert). box continues

2 M uscles

Box 2.2 (continued) Contraction of neighboring muscles compresses lymph vessels, mov­ ing lymph in the directions determined by their valves; extremely little lymph flows in an immobilized limb, whereas flow is increased by either active or passive movements. This fact has been used clinically to diminish dissemination of toxins from infected tissues by immobi­ lization of the relevant regions. Conversely, massage aids the flow of

lymph from oedematous regions. (Gray's Anatomy 1995)

By recovering up to 20% of the interstitial fluids, the lymphatic system rel ieves the venous system (and therefore the heart) of the responsibility of transporting the large molecules of protein and debris back to the general circulation. Additional ly, the lymphocytes remove particulate matter by means of phagocytosis, that is, the process of ingestion and digestion by cel ls of solid substances (other cells, bacteria, bits of necrosed tissue, foreign particles). By the time the fluid has been returned to the veins, it is ultrafiltered, condensed and hig hly concentrated. In effect, if the lymphatic system did not regain the 2-20% of the protein-rich liquid that escaped in the interstitium (a large part of which the venous system cannot recover), the body would probably

develop major edemas and autointoxication and die within 24-48 hours. (Chikly 2001, Guyton

1986)

Conversely, when applying lymph d rainage techniques, care must be taken to avoid excessive increases in the volume of lymph flow in people who have heart conditions as the venous system must accom modate the load once the fluid has been delivered to the subclavian veins. Significantly increasing the load could place excessive strain on the heart. Lymphatic circulation is separated i n to two layers. The superficial circulation, which constitutes approxi mately 70% of all lymph flow (Chikly 2001 1. is located just under the dermoepidermic junction. The deep muscular and visceral circulation, below the fascia, is activated by muscular contraction; however, the superficial circulation is not directly sti mulated by exercise. Additional ly, lymph capi l l aries (Iacteals) in the jejunum and i l eum of the digestive tract absorb fat and fat-soluble nutrients that ultimately reach the liver through the blood ci rculation (Braem 1 994). Manual or mechanical lymphatic d rainage tech niques are effective ways to increase lymph removal from stag nant or edemic tissue. The manual techn iques use extremely light pressure, which

MOTOR CONTROL AND RESPIRATORY ALKALOSIS

Motor control is a key component in injury prevention. Loss of motor control involves failure to con trol joints, com­ monly because of incoordination of agonist-antagonist muscle coactivation. According to Panjabi (1992), three sub­ systems work together to maintain joint and spinal stability: 1.

The central nervous subsystem (control) The muscle subsystem (active) 3. The osteoligamentous subsystem (passive).

2.

Anything that interferes with any aspect of these features of normal motor control may contribute to dysfunction and pain. This includes a condition in which the bloodstream increases in alkalinity because of overbreathing (for exam­ ple hyperventilation, the extreme of overbreathing, see

significantly increases lymph movement by crosswise and lengthwise stretching of the anchoring filaments that open the lymph capillaries, thus allowing the i n terstitial fluid to enter the lymphatic system. However, shearing forces (like those created by deep pressure gliding techniques) can lead to temporary i n hibition of lymph flow by inducing spasms of lymphatic muscles (Kurz 1 986). Unless the vessels are d amaged, lymphatic movement can then be reactivated by use of manual tech niques that sti mulate the Iymphangions. While each case has to be considered individual ly, numerous conditions, ranging from postoperative edema to premenstrual fluid retention, may benefit from lymphatic d rainage. There are, however, conditions for which lymphatic d rainage would be contrai ndicated or precautions exercised. Some of the more serious of these conditions include: • • • • • • • •

acute infections and acute inflammation (generalized and local) thrombosis circulatory problems cardiac conditions hemorrhage malignant cancers thyroid problems acute phlebitis.

Conditions that might benefit from lymphatic d rainage but for which precautions are indicated include: •

• • • • • • • • • • •

certain edemas, depending upon their cause, such as cardiac insufficiency carotid stenosis bronchial asthma burns, scars, bruises, moles abdom i nal surgery, radiation or undetermined bleeding or pain removed spleen major kidney problems or insufficiency menstruation (drain prior to menses) gynecological infections, fibromas or cysts some pregnancies (especially in the first 3 months) chronic infections or inflammation low blood pressure.

below), which interferes with the first tvvo of those three ele­ ments - the CNS as well as muscle function. People who 'overbreathe', or who have marked upper chest breathing patterns ('brea thing pattern disorders' or BPD), automatically exhale more carbon dioxide (C02) than is appropriate for their current metabolic needs. Exhaled CO2 derives from carbonic acid in the bloodstream, and an excessive reduction of this leads to a situation known as res­ piratory alkalosis, where the pH of the blood becomes more alkaline than its normal of ::'::7 .4 (Lum 1987, Pryor & Prasad 2002). There are a number of major consequences of increased alkalinity, one of which is a contrac tion of smooth muscle cells (SMC) . This reduces the diameter of all struc tures sur­ rounded by smooth muscles, such as the blood vessels and intestinal structures. Reduced diameter of blood vessels limits blood supply to the tissues and the brain, thereby

31

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

32

resulting in a variety of symptoms (see below), one of which is increased fatigability. It is postulated that SMC contrac­ tion may also influence fascial tone (Schleip et aI 2004). (See Chapter 1 for information regarding smooth muscle cells and their location and behavior in connective tissues.)

motor discharges, muscular tension and spasm, speeding of spinal reflexes, heightened perception (pain, photophobia, hyperacusis) and other sensory disturbances. ' Muscles affected in this way inevitably become prone to fatigue, 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

•

resul ting from hyperventilation, leading to respiratory alkalosis. Hypoxia: Reduction of O2 supply to tissue, below physio­ logical levels despite adequate perfusion of the tissue by blood.

Lum (1987) reports that research indica tes that not less than 10% of patients attending general internal medicine practice in the US have such breathing pattern disorders as their pri­ mary diagnosis. Newton (2001) agrees with this assessment. The authors of this text suggest that there exists a large patient population with BPDs who do not meet the criteria for hyperventilation, but whose breathing patterns may contribute markedly to their symptom picture, and whose mo tor control is likely to be negatively affected as a result (Chaitow 2004). • • •

• •

Breathing pattern disorders are female dominated, rang­ ing from a ratio of 2:1 to 7:1 (Lum 1994). Women are more at risk, possibly because progesterone is a respiratory accelerator (Damas-Mora et aI 1980). Progesterone is known to cause hyperventilation and hypercapnia in the luteal phase of a normal menstrual cycle (Brown 1998, Rajesh et a l 2000, Stahl et aI 1985). During post ovulation phase, CO2 levels drop ::+::25% (Lum 1994) . Additional stress then, 'increases ventilation when CO2 levels are already low' (Lum 1994).

THE BOHR EFFECT

Prasad 2002)

CORE STABILITY, TRANSVERSUS ABDOMINIS, THE DIAPHRAGM AND BPD

It is well established that the tone of both the diaphragm and transversus abdominis hold the key to maintenance of core stability (Panjabi 1992) . McGill et al (1995) have observed a reduction in spinal support if there is both a load challenge to the low back, combined with a demand for increased breathing (imagine shoveling snow!). 'Modulation of muscle activity needed to facilitate breathing may compromise the margin of safety of tissues that depend on constant muscle activity for support.' Hodges & Gandevia (2000) reported that after approxi­ mately 60 seconds of overbreathing, the postural (tonic) and phasic functions of both the diaphragm and transversus abdominis are reduced or absent. SUMMARY • • •

• •

(Fried 1987, Pryor Et

The Bohr effect states that a rise in alkalinity (due to a decrease in CO2) increases the affinity of hemoglobin (Hb) for oxygen (02). This means that when tissues, and the bloodstream, increase in alkalinity the Hb molecule binds more firmly to the oxygen it is carrying, releasing it less effi­ ciently, which leads to hypoxia. Increased OrHb affinity also leads to changes in serum calcium and red cell phos­ phate levels which both reduce. Additionally, there is a loss of intracellular Mg2+ as part of the renal compensation mechanism for correcting alkalo­ sis. The function of motor and sensory axons will be signif­ icantly affected by lower levels of calcium ions and these sensi tive neural structures will tend toward hyperirritabil­ ity, negatively affecting motor control (Seyal et a11998). Lum (1994) explains: 'Loss of CO2 ions from neurons stimulates neuronal activity, causing increased sensory and

•

•

•

BPDs alter blood pH, thereby creating respiratory alkalosis. This induces increased sympathetic arousal, which affects neuronal function (including motor control). There will be an increased sense of apprehension and anxiety. As a result, the person's balance may be compro­ mised (Winters & Crago 2000). Depletion of Ca and Mg ions enhances neural sensitiza­ tion, encouraging spasm and reducing pain thresholds. As pH rises, smooth muscle cells constrict, leading to vasoconstriction that reduces blood supply to the brain and tissues (particularly the muscles) and possibly alters fascial tone. Reduced oxygen release to cells, tissues and brain (Bohr effect) leads to ischemia, fatigue and pain, and the evolu­ tion of myofascial trigger points. If the individual is deconditioned, not involved in aero­ bic activity, this sequence will trigger release of acid wastes when tissues a ttempt to produce ATP in a rela­ tively anaerobic environment (as discussed earlier in this chapter). Biomechanical overuse stresses emerge along with compromised core stability and postural decay.

What this (overbreathing) scenario illustrates is that when pain and dysfunction involving neuromuscular imbalance are evident in a patient, any therapeutic intervention that fails to pay attention to breathing patterns is less likely to be successful than if this receives appropriate clinical evalua­ tion and rehabilitation, if necessary (see Chapter 4).

2 M uscles

MAJOR TYPES OF VOLUNTARY CONTRACTION

Muscle contractions can be: • •

•

isometric (with no movement resulting) isotonic concentric (where shortening of the muscle pro­ duces approximation of its attachments and the struc­ tures to which the muscle attaches) or isotonic eccentric (in which the muscle lengthens during its contraction, therefore the attachments separate during contraction of the muscle) .

Epimysium w-;_-- Perimysium

TERMINOLOGY •

•

The terms origin and insertion are somewhat inaccurate, with attachments being more appropriate. Attachments can be further classified as proximal or distal (in the extremities) or by location, such as sternal, clavicular, costal or humeral attachments of pectoralis major. In many instances, muscular attachments can adaptively reverse their roles, depending on what action is involved and therefore which attachment is fixed. As an example, psoas can flex the hip when its lumbar attachment is 'the origin' (fixed point) or it can flex the spine when the femoral attachment becomes 'the origin', i.e. the pOint toward which motion is taking place.

Basement Thin filament Thick filament Crossbridge Cross-sections show relationships of myofilaments within myofibril at levels indicated

,,"""VI'VO'

�H

11\.I/1\L'!�V111

Muscles display excitability - the ability to respond to stimuli 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 ceases. Lederman (1997) suggests that muscle tone in a resting muscle relates to biomechanical elements - a mix of fascial and connective tissue tension together with intramuscular fluid pressure, with no neurological input (therefore, not measurable by EMG). If a muscle has altered morphologi­ cally, due to chronic shortening, for example, or to compart­ ment syndrome, then muscle tone, even at rest, will be altered and palpable. He differentiates this from motor tone, which is measura­ ble by means of EMG and which is present in a resting mus­ cle only under abnormal circumstances - for example, when psychological stress or protective activity is involved . Motor tone is either phasic or tonic, depending upon the nature of the activity being demanded of the muscle - to move something (phasic) or to stabilize it (tonic). In normal muscles, both activities vanish when gravitational and activity demands are absent. Contraction occurs in response to a motor nerve impulse acting on muscle fibers.

A

u

ro

(/)

z

MUSCLE TONE AND CONTRACTION

�

Q) E 0 -,

----- - - -

/

Myofilaments _

Organization of skeletal muscle. Redrawn after Hansen Koeppen (2002).

Figure 2.8

&

A motor nerve fiber will always activate more than one muscle fiber and the collection of fibers it innervates i s called a motor unit. The greater the degree o f fine control a muscle is required to produce, the fewer muscle fibers a nerve fiber will innervate in that muscle. This can range from 10 muscle fibers being innervated by a single motor neuron in the extrinsic eye muscles to one motor neuron innervating several hundred fibers in major limb muscles (Gray's Anatomy 2005, p. 121). Because there is a diffuse spread of influence from a sin­ gle motor neuron throughout a muscle (i.e. neural influence does not necessarily correspond to fascicular divisions) only a few need to be active to influence the entire muscle. The functional contractile unit of a muscle fiber is its sar­ comere, which contains filaments of actin and myosin. These myofilaments (actin and myosin) interact in order to shorten the muscle fiber. Gray's Anatomy (2005) describes the process as follows:

At higher power, sarcomeres are seen to consist of two types of filament, thick and thin, organized into regular arrays.

33

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

34

The thick filaments, which are c. 15 nm in diameter, are composed mainly of myosin. The thin filaments, which are 8 nm in diameter, are composed mainly of actin. The arrays of thick and thin filaments form a partially overlapping structure . . . The A-band consists of the thick filaments, together with links of thin filaments that interdigitate with, and thus overlap, the thick filaments at either end . . . The I-band consists of the adjacent portions of two neighbouring sarcomeres in which the thin filaments are not overlapped by thickfilaments. It is bisected by the Z-disc, into which the thin filaments of the adjacent sarcomeres are anchored. In addition to the thick and thin filaments, there is a third type of filament composed of the elastic protein, titin . . . The banded appearance of the individual myofibrils is thus attributable to the regular alteration of the thick and thin fil­ aments arrays.

VULNERABLE AREAS •

•

•

•

In order to transfer force to its attachment site, contractile units merge with the collagen fibers of the tendon which attaches the muscle to bone. At the transition area, between muscle and tendon, these structures virtually 'fold' together, increasing strength while reducing the elastic quality. This increased ability to handle shear forces is achieved at the expense of the tissue's capacity to handle tensile forces. The chance of injury increases at those locations where elastic muscle tissue transitions to less elastic tendon and finally to non-elastic bone - the attachment sites of the body.

MUSCLE TYPES

Muscle fibers exist in various motor unit types - basically type I slow red tonic and type II fast white phasic (see below). Type I are fatigue resistant while type II are more easily fatigued. All m uscles have a mixture of fiber types (both I and II), although in most there is a predominance of one or the other, depending on the primary tasks of the muscle (pos­ tural stabilizer or phasic mover). Those which contract slowly (slow-twitch fibers) are clas­ sified as type I (Engel 1986, Woo 1987) . These have very low stores of energy-supplying glycogen, but carry high con­ centrations of myoglobulin and mitochondria. These fibers fatigue slowly and a re mainly involved in postural and sta­ bilizing tasks. The effect of overuse, misuse, abuse or disuse on postural muscles (see Chapters 4 and 5) is that, over time, they will shorten. This tendency to shorten is a clini­ cally important distinction between the response to 'stress' of type I and type II muscle fibers (see below).

There are also several phasiC (type II) fiber forms, notably: •

•

•

type IIa (fast-twitch fibers) which contract more speedily than type I and are moderately resistant to fatigue with relatively high concentrations of mitochondria and myo­ globulin type IIb (fast-twitch glycolytic fibers) which are less fatigue resistant and depend more on glycolytic sources of energy, with low levels of mitochondria and myoglobulin type lIm (superfast fibers) which depend upon a unique myosin structure that, along with a high glycogen con­ tent, differentia tes them from the other type II fibers (Rowlerson 1981). These are found mainly in the jaw muscles.

As mentioned above, long-term stress involving type I mus­ 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 ger points evolve without shortening the muscle overall). Shortness/ tightness of a postural muscle does not neces­ sarily imply strength. Such muscles may test as strong or weak. However, a weak phasic muscle will not shorten overall and will always test as weak. Fiber type is not totally fixed, in that evidence exists as to the potential for adaptability of muscles, so that committed muscle fibers can be transformed from slow twitch to fast twitch, and vice versa (Lin 1994). An example of this potential, which has profound clinical significance, involves the scalene muscles. Lewit (1985) con­ firms that they can be classified as either a postural or a pha­ sic muscle. The scalenes, which are largely phasic (type II) and dedicated to movement, can have postural functions 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 tural demands are prolonged, more postural (type I) fibers may develop to meet the situation. If overuse continues (as in upper chest breathing involving the upper ribs being reg­ ularly elevated during inhalation), these now postural mus­ cles will shorten, as would any type I muscle when chronically stressed (Janda 1982, Liebenson 2006). The following findings, relating to the scalene muscles, were reported in a study that evaluated the link between these and inappropriate breathing patterns, in this instance, mainly asthma.

The incidence of scalene muscle pathology was assessed in 46 consecutively hospitalized patients with bronchial asthma and irritable cough diagnoses. Three tests described by Travell & Simons were used in patient evaluation, including palpation for scalene trigger points and the use of Adson's test. Breathing patterns were also evaluated in all patients for the presence of paradoxical breathing patterns. Scalene muscle pathologtj [dysfunction] was identified in 20 of the 38 bronchial asthma patients (52%), and in 5 of the

2 M uscles

Sternocleidomastoid -----e.\ Pectoralis major

Levator scapula ----�".

l'+------ Upper trapezius

----- Deltoid

--+.......

-

Sacrospinalis ---+--It-----111 External oblique ---h Flexors -----r.J Tensor fascia lata -----;;f-J'III'--IH

-\--- Latissimus dorsi

B..":++-+-Quadratus lumborum ..�\----\- Quadratus lumborum +--+---+-+--- Iliopsoas

Piriformis ---+--f--j�" lY----l---\-i*\-- Add uctor long us Adductor magnus ----t-_III

:+-/'----- Biceps femoris Semimembranosus ---1-jIJF--J'c---�;II........ .. ..

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 nature, isometric contractions as the patient attempts to move against the resistance offered by the practitioner. Lewit (1985) points out that such tests may induce pain that is likely to be of muscular origin. Although these tests are designed to evaluate muscular strength, if pain is induced, implicating particular muscles, this too should have diagnostic value. If muscles test as weak, the reason for this is often excessive tone in their antagonists that recip­ rocally inhibit them Qanda 1988). See upper and lower crossed syndromes in Chapter 5 for a full discussion of the implications of the chain reaction of influences as some muscles become excessively hypertonic and their antago­ nists are almost constantly inhibited. In the absence of atrophy, weakness of a muscle may be due to:

•

•

•

compensatory hypotonicity relative to increased tone in antagonistic muscles

• • •

palpable trigger points in affected (weak) muscles, notably those close to the attachments trigger points in remote muscles for which the tested muscle lies in the target referral zone trigger points in synergists or antagonists to the tested muscle.

Muscle strength is most usually graded as follows.

• • •

•

Grade 5 is normal, demonstrating a complete (100%) range of movement against gravity, with firm resistance offered by the practitioner. Grade 4 is 75% efficiency in achieving range of motion against gravity with slight resistance. Grade 3 is 50% efficiency in achieving range of motion against gravity without resistance. Grade 2 is 25% efficiency in achieving range of motion with gravity eliminated. Grade 1 shows slight contractility without joint motion . Grade 0 shows no evidence of contractility.

1 1 The cervical reg i o n

Box 1 1 .7 Whiplash The term 'whiplash' was first coined by Dr Harold Crowe ( 1 928). Thirty-six years later, he commented in a fol low-up article (1 964) that: This expression was intended to be a description of motion, but it has been accepted by physicians, patients and attorneys as the name of a disease; and the misunderstanding has led to its misappl ication by many physicians and others over the years: 'Whip' impl ies two forces in different directions, opposing each other in a differential motion. When applied to the experience of trauma, there may a l so be a jerk, jolt, stress or stra in and those may include a shear or torque force that affects the load deformation. The soft tissues, including the l igaments and joint capsules of a l l affected joints, may exceed their elastic limits, resulting in plastic deformation that incl udes tissue tears, ruptures and loss of mechan ical properties. Although discussions of 'whiplash synd rome' (acceleration­ deceleration injury) usually revolve around motor veh icle accidents (MVAsl. a whiplash effect on the spine (particu la rly the cervical region) ca n also occu r as a result of 'sl i p and fall', bicycle accidents, horse riding injuries, sport inju ries and recreational occurrences. The fol lowing discussions pri marily involve MVAs since these a re com mon and a lso because of the substantial forces that resu lt from them. True whiplash injuries are norma lly thought of as relating to 'non-impact' trauma. However, Taylor & Taylor (1 996) state that: A large proportion of cervical spinal injuries are secondary to head impact. A comparison of the nature and distribution of cervical spine injuries in those subjects with primary head impact, and those with­ out head injury but with primary acceleration of the torso (i.e. whiplash), fails to reveal significant differences in the nature and dis­ tribution of injuries.

Whiplash-associated disorders (WAD) account for upwards of 20% of compensated traffic injury claims in some regions (Cassidy 1 996). Cassidy states that when over 3000 whiplash claims were analyzed by the Quebec Task Force they found that 'The vast majority of WAD victims recovered q uickly, but that 1 2.5% of claimants still [being] compensated 6 months after the collision accounted for 460/0 of the total cost to the insurance system'. The Quebec Task Force has classified whiplash-related d isorders as fol lows (Spitzer et al 1 995). •

•

• •

Category I: neck complaint without musculoskeletal signs such as loss of mobility Category I I : neck complaint with m uscu loskeletal signs such as loss of mobility Category I I I : neck com plaint with neurological signs Category IV: cervical fracture or d islocation

Research suggests that 75% of persons with sign ificant whiplash injury recover in approximately 6 months and over 90% by the end of the first year following the accident, irrespective of age or gender, as demonstrated in Ca nadian, Swiss and Japa nese studies (Cassidy 1 996, Radanov 1 994).

Variations in response to WAD Why do some of these traumatic soft tissue sprains not heal when most do? The answer for some researchers suggests tearing of the end plates of discs and damage to facet joints (Taylor 1 994). A study involving over 1 00 patients with traumatic neck injury as well as approximately 60 patients with leg trauma eva luated the presence of severe pa in (fibromya lgia syndrome) an average of 1 2 months posttrauma (Buskila & Neumann 1 997). The fi ndings were that 'Almost all symptoms were significa ntly more prevalent or severe in the patients with neck inj u ry ... The fibromya lgia

preva lence rate in the neck inj u ry group was 1 3 times greater than the leg fracture group'. Pa in threshold levels were significantly lower, tender point cou n ts were higher and qual ity of life was worse in the neck injury patients as compared with leg inj u ry subjects. Over 2 1 % o f the patients with neck inj u ry (none o f whom had chronic pain problems prior to the inju ry) developed fibromyalgia within 3.2 months of tra u ma as agai nst only 1 .7% of the leg fracture patients (not sign ifica ntly different from the genera l population). The researchers make a particu lar point of noting that, 'In spite of the injury or the presence of fibromya lgia, all patients were employed at the time of examination a n d that i nsurance claims were not associated with increased fibromyalgia symptoms or i m paired functioning'. Why should whiplash-type injury provoke fibromya lgia more effectively than other forms of tra u ma? One answer may l ie in the role of rectus capitis posterior mi nor, part of the suboccipital g roup, details of which are found on pp. 52 and 294 (Hallgren et a l 1 993, 1 994). Dommerholt (2005) notes: There is no question that people with persistent pain following whiplash suffer from widespread cen tral hyperexcitability, which can cause seemingly exaggerated pain responses, even with low-intensity nociceptive input (Banic et 01 2004, Curatola et a1 2001, 2004, Munglani 2000). Persistent pain following whiplash may start with the so-called 'wind-up' of dorsal ham neurans and activation of N-methyl-O-aspartate receptors. These phenamena can lead to central sensitization and its hallmark characteristics of allodynia and hyper­ sensitivity, which, in animal models, can persist even after peripheral noxious input has been elimina ted. Persisten t pain following whiplash thus can be considered a dysfunctional pain disorder (Lindbeck 2002).

Treatment choices for whiplash? With common whiplash symptoms ranging from radiating neck and arm pain to chronic headache and virtually incapacitating d izziness and imbalance, WAD has attracted a wide range of (apparently mostly useless) treatment strategi es. Collars are probably con traindicated for whiplash ... they irritate jaws, fosterjoint adhesions, and lead to tissue atrophy. Physicians can be blamed for prescribing too many drugs . . . most of which are probably an ugly approach to whiplash. Physiotherapists are chided for exces­ sive passive modalities which not only do no good, but by their repeated failure can help convince the poor suffering patien ts that all is lost. Among the chiroproctors repeated manipulations can also fos­ ter illness behavior. but short-term manipulation and mobilization may be helpful. (Allen 1996)

Dr Allen, whose opinion is quoted above, is a world authority on whiplash and his views are based on both experience and research and a re therefore deserving of respect. Contrary viewpoi n ts (Schafer 1 987) and clinical experience suggest that short-term use of cervical collars and NSAID medication d u ring the acute phase, postwhiplash, may be helpful. However, it is our opinion that illness behavior and retardation of healing can certainly be promoted by a nything other than a brief use of such approaches.

What happens in a collision? Ea rly studies suggested that in rear-end a utomobile accidents the trauma occu rring in the cervical spine related to hyperextension a nd/or hyperflexion of the neck. Cu rrent seat and head su pport design tend to prevent hyperextension and yet whiplash injuries do not appea r to have lessened and research has tried to assess the reasons for this apparent anomaly. box continues

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T ,

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Cervical damage resulting from rear-end accidents seems to relate d irectly to the position i n itially adopted by the injured individual d u ring the incident, with those leaning forward experiencing compressive stresses as well as hyperflexion inju ries and those seated u pright or reclining experiencing initial extension, with no compressive cervical damage. The speed of im pact, the weight of the target car in relation to that of the bullet ca r, road viscosity and skid marks, as well as different directions of impact and car design features, all add obvious va riations to these basic fi ndings (Delany 2006, Gough 1 996). Of substa ntial im portance is the change in velocity measured as d istance over time (feet per second, m iles per hour) ; sim ply put, this is the amount of time it takes for the accident to occur from beginning to end. If the overall time of the col l ision is increased, the acceleration factors are reduced, resu lting in less force tra nsference to the occupant cage.

All in the m i nd? lewit ( 1 999) places whiplash i n context w h e n he says: The high incidence of traumatic neurosis [following whiplash-type injuries] must be put down to mismanogement; in the vast mojority of cases without gross neurological findings doctors not troined in the manual diagnosis of movement restriction and segmental reflex change come to the disastrous conclusion that there ore no 'organic findings', and hence dismiss the trouble as 'functional', i.e. 0 psycho­ logical disturbance.

In treating patients with whiplash and concussion (the sym ptoms of wh ich differ only in minor ways, accord ing to lew itl. he found that out of a series of 65 patients, he achieved results that

• • •

the patient builds force slowly after engaging the barrier of resistance offered by the practitioner the patient uses maximum controlled effort to move in the prescribed direction the practitioner ensures that the point of muscle origin is efficiently stabilized care is taken to avoid use of 'tricks' by the patient, in which synergists are recruited.

Strength tests for the cervical region • Assessment of flexion strength (Fig. 1l. 19A) evaluates sternocleidomastoid, longus colli and capitis, rectus capi­ tis anterior and lateralis (and to a secondary degree the scalenii and hyoid muscles). If a group of muscles tests as weak this could involve inhibitory influences from their antagonists. • The practitioner places a hand on the forehead of the supine patient and the other hand on the sternum (to pre­ vent thoracic flexion) as the patient slowly attempts to flex the neck against this resistance. • Assessment of extension strength (Fig. 1l.19B) evaluates upper trapezius, splenius capitis and cervicis, semi­ spinalis capitis and cervicis, erector spinae (longissimus capitis and cervicis) and, to a secondary degree, levator scapulae and the transversospinalis group. The practitioner

;��

. ��

could be classified as 'excel lent' in 37, 'fai r' i n 1 8, with 1 0 fai l u res. 'Fa i l ure was most freq uently d u e t o ligament pain and anteflexion [Le. flexion) headache; the most frequent site of blockage was between atlas and axis: lewit's methods in these cases involved 'manipulation', which incorporates, in his defin ition, soft tissue approaches such as MET and trigger point deactivation. Dommerholt (2005) em phasizes a central viewpoint: There are importan t consequences when central pain mechanisms and MTrPs are included in the differential diagnosis and in the man­ agement ofpatients with persistent pain following whiplash. Once structural lesians have been ruled out with magnetic resonance imag­ ing, computed tomography scans, and radiography. clinicians should consider that MTrPs can contribute to and maintain central sensitiza­ tion phenomena. Eliminating the painful peripheral input is likely to break the pain cycle, discontinue dysfunctional pain patterns, and facilitate the return to a productive and pain-free life. Adding the iden tificotion and treatment of MTrPs to the clinical toolbox can pro­ vide patients with hope and optimism.

We bel ieve that the methods outlined in this text, in which a comprehensive soft tissue approach is recommended, involving NMT, MET, PRT, MFR and massage, as well as rehabilitation methods, offer the best opportunity for successfu l ly treating the majority of patients suffering the seq uels of whiplash, as long as fu l l and accurate assessments are undertaken before and during treatment. In some cases active manipu lation (mobil ization or high-velocity thrust) may a lso be required but it is strongly suggested that soft tissue approaches be a ttempted initially.

For efficient muscle strength testing, it is necessary to ensure that: •

"

•

•

places a stabilizing hand on the upper posterior thoracic region and the palm of the other hand on the occiput as the prone patient slowly extends the neck against this resistance. The suboccipital muscles are tested if this extension movement concludes with a 'tipping' back­ wards and caudad of the occiput. Assessment of rotational strength (Fig. 11.19C) evaluates sternocleidomastoid, upper trapeZius, obliquus capitis inferior, levator scapula, splenius capitis and cervicis (and to a secondary degree the scalenii and transversospinalis group). The practitioner stands in front of the seated patient and places a stabilizing hand on the posterior aspect of the shoulder with the other hand on the patient's cheek on the same side, as the patient slowly turns the head ipsilaterally to meet the resistance offered by the hand. Assessment of sidebending (lateral flexion) strength (Fig. 1l. 19D) involves the scalenii and levator scapula (and to a secondary degree rectus capitis lateralis and the transver­ sospinalis group). The practitioner places a stabilizing hand on the top of the shoulder to prevent movement and the other hand on the head above the ear as the seated patient attempts to flex the head laterally against this resistance.

Palpation of sym m etry of m ovem ent - general

As is so often the case when comparing anatomy texts, there exists disagreement as to the normal ranges of motion of the

1 1 The cervical region

A

B

o c 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 approximate ranges below which are intended to guide the practitioner in assessing joint motion (Fig. 11 .20). Lewit (1985) suggests the patient be seated with the shoulder girdle stabilized with one hand as the other hand guides the head into flexion. •

The chin (mouth closed) should easily touch the sternum and any shortness in the posterior cervical musculature will prevent this.

•

The normal range of flexion is approximatel y 500 (Mayer et al 1994). If pain is noted when full, unforced flexion has been achieved (and if meningitis and radicular pain have been ruled out), Lewit maintains that this probably indicates restriction of the occiput on the atlas. If, how­ ever, there is pain after the head has been in flexion for 15-20 seconds (see McKenzie notes, p. 213), it is probably ligamentous pain. This is especially corrunon in individu­ als who display hypermobility tendencies. Headaches will be a likely presenting symptom with extreme sensitivity

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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).

•

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•

noted on palpation of the lateral tip of the transverse process of the axis. Normal range of extension is approximately 70° (Mayer et 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 distressed intervertebral discs may occur, along with a folding of the dura and anteriorly directed pressure on the ligamentum flavum, any of which could produce a degree of increased symptomatology, including pain. The normal range of lateral flexion is 45° (Mayer et al 1994). When testing sidebending (lateral flexion) of the cervical spine, the side toward which lateral flexion is tak­ ing place is stabilized. If the shoulder on the side from which lateral flexion is taking place is stabilized, upper trapezius is being evaluated. The normal range of rotation is approximately 85° (Mayer et aI 1994). 1. With the patient seated, gentle rotation around a verti­ cal axis is carefully performed as symmetry and qual­ ity of movement are evaluated. 2. Full flexion rotation is then performed to assess sym­ metry of rotational movement of the occiput and C2. 3. The practitioner is standing behind the seated patient. With the neck upright, the patient's chin is actively drawn toward the neck (without flexion of the remain­ der of the cervical spine) while the practitioner's other hand cradles the occiput in order to direct subsequent rotational movement of the head. Rotational restric­ tion with the head in this position indicates dysfunc­ tion localized to C2 and C3. 4. With the head and neck in extension, rotation increas­ ingly focuses on the lower cervicals (the greater the extension, the lower the segment involved). It is

important in this assessment to avoid chin poking (which would induce anterior translation of the mid­ cervicals), but to maintain the chin relatively fixed. Functional evaluation of fascia l postural patterns

Zink & Lawson ( 1979) have described methods for testing tissue preference. •

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There are four crossover sites where fascial tensions can most easily be noted: occipitoatlantal (OA), cervicotho­ racic (CT), thoracolumbar (TL) and lumbosacral (LS). These sites are tested for rotation and side flexion prefer­ ence. Zink's research showed that (assessing the occipitoat­ lantal pattern first) most people display alternating pat­ terns of rotatory preference, with about 80% of people showing a common pattern of left-right-left-right (L-R-L-R, termed the 'common compensatory pattern' or CCP). Zink observed that the 20% of people whose compensa­ tory pattern did not alternate had poor health histories and low levels of 'wellness' and coped poorly with stress. Treatment of either CCP or uncompensated fascial pat­ terns has the objective of trying as far as possible to cre­ ate a symmetrical degree of rotatory motion at the key crossover sites. The methods used to achieve this range from direct mus­ cle energy approaches to indirect positional release tech­ niques and high-velocity thrusts.

Assessment of tissue preference. This basic Zink & Lawson assessment (as described in Box 1.7, Chapter 1) has been elaborated on by clinicians who suggest that the assessment described above (and in Box 1.7, Chapter 1)

11 The cervical region

265

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should also be conducted with the patient standing. The reasoning for this is ou tlined below (Liem 2004, Pope 2003). •

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Tissue preference is the sense of preferred direction(s) of movement the palpa ting hands derive from the tissues as they are moved. Evalua tions of this sort are discussed under the heading 'Functional technique' in Chapter 10. The process of evaluation can be conceived as a series of 'questions' that are asked as tissues are moved. 'Are you more comfortable moving in this direction, or that?' The terms 'comfort position', 'ease' and 'tissue prefer­ ence' are synonymous. Positions of ease, comfort, preference are directly oppo­ site to directions which engage barriers or move toward 'bind'.

1. Occipitoatlantal area • • •

• •

• •

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The patient is supine. The practi tioner is a t the head of the table, facing the pa tient's head. One hand (caudal hand) cradles the occiput so that it is supported by the hypothenar eminence and the mid­ dle, ring and small finger. The index finger and thumb are free to control either side of the atlas. The other hand is placed on the patient's forehead or crown of head to assist in moving this during the pro­ cedure. The neck is flexed to its fullest easy degree, locking the rotational potential of the cervical segments below C2. The contact hand on the occipitoatlantal joint evalu­ ates the tissue preference, as the area is slowly rotated left and right. Alternatively, with the patient standing, the head / neck is placed in full flexion, and rota tion left and right, of the head on the neck, are evalua ted for the preferred direction (range) of movemen t. By holding tissues in their 'loose' or ease positions or by holding tissues in their ' tight' or bind posi tions and introducing isometric contractions or by just waiting for a release, changes can be encouraged.

2. Cervicothoracic area (Fig. 11.21) • The patient is seated in a relaxed posture; the practi­ tioner stands behind with hands placed to cover the medial aspects of upper trapezius so that the fingers rest over the clavicles. • Each hand independently assesses the area being pal­ pa ted for its 'tightness/ looseness' (see above) prefer­ ences, in rotation. • Alternatively, the patient is standing in a relaxed pos­ ture with the practitioner behind, with hands placed to cover the medial aspects of the upper trapezius so that the fingers rest over the clavicles and thumbs rest on the transverse processes of the T1 /T2 area. The hands

Fig u re 1 1 .2 1 Assessment of tissue rotation preference in cervicothoracic reg ion.

•

assess the area being palpated for its ' tightness / loose­ ness' preferences as a slight degree of rotation left and then right is introduced at the level of the cervi co tho­ racic junction. By holding tissues in their 'loose' or ease posi tions or by holding tissues in their ' tight' or bind positions and introducing isometric contractions or by just waiting for a release, changes can be encouraged.

Variation •

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With the patient supine, the cervicothoracic j unction is assessed by the practitioner sliding the treating fingers under the transverse processes. An anterior compressive force is applied, first to one side then the other, assessing the response of the trans­ verse process to an anterior, compressive, springing force. A sense should easily be achieved of one side having a tendency to move further anteriorly (and therefore more easily into rotation) compared with the other.

3. Thoracolumbar area (Fig. 11 .22) • The patient is supine; the practitioner stands facing caudally and places the hands over the lower thoracic structures, fingers along the lower rib shafts la terally. • Treating the structure being palpated as a cylinder, the hands test i ts preference for rotating around its central axis, one way and then the other. • Once this has been established, the preference to sidebend one way or the other is evaluated, so that combined ('stacked') positions of ease or bind can be established. • Alternatively, the pa tient is standing with the practi­ tioner behind, with hands placed over the lower tho­ racic structures, fingers along lower rib shafts laterally, palpating the preference for the lower thorax to rotate around i ts central axis, one way and then the other.

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2. Alternatively, was there a tendency for the tissue prefer­ ence to be in the same direction in all, or most of, the four areas assessed? 3. If the latter was the case, was this in an individual whose health is more compromised than average (in line with Zink & Lawson's observations)? 4. What therapeutic methods would produce a more bal­ anced degree of tissue preference? Differential assessm ent, based on findings of su pine and standing Zink tests (Li e m 2004) •

•

F i g u re 11.22 Assessment of tissue rotation preference i n thoraco l u m ba r (diaphragm) region.

•

Defeo & Hicks (1993) have described the observed signs of CCP as follows:

In the common compensatonJ pattern (CCP), an examiner will note the following observations in the supine patient. The left leg will appear longer than the right. The left iliac crest will appear higher or more cephalad than the right. The pelvis will roll passively easier to the right than to the left because the lumbar spine is sidebent left and rotated right. The sternum is displaced to the left as it courses inferiorly. The left infraclavicular parasternal area is more prominent anteriorly because the thoracic inlet is sidebent right and rotated right. The upper neck rotates easier to the left. The right arm appears longer than the left, when fully extended.

By holding tissues in their 'loose' or ease positions or by holding tissues in their 'tight' or bind positions and introducing isometric contractions or by holding at the barrier (bind position) without a contraction and just waiting for a release, changes can be encouraged.

4. Lumbosacral area • The patient is supine; the practitioner stands below waist level facing cephalad and places the hands on the anterior pelvic structures, using the contact as a 'steering wheel' to evaluate tissue preference as the pelvis is rotated around its central axis, seeking information as to its 'tightness/looseness' (see above) preferences. Once this has been established, the preference to sidebend one way or the other is evaluated, so that combined (,stacked') positions of ease or bind can be established. • Alternatively, the patient is standing with the practi­ tioner behind, with hands placed on the pelvic crest and rotating the pelvis around its central axis to iden­ tify its rotational preference. • By holding tissues in their 'loose' or ease positions or by holding tissues in their ' tight' or bind positions and introducing isometric contractions or by holding at the barrier (bind position) without a contraction and just waiting for a release, changes can be encouraged.

ASSESS M EN T BEC O M ES TREATM ENT The series of range of motion (and tissue preference) assess­ ments outlined above offers a general impression. Specific localized evaluations should then also be performed which offer information directly linking the assessment procedure to a range of treatment options. •

•

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Qu estions the practitioner sho u ld as k himself fo l l owing the assessm ent exercise

1. Was there an 'alternating' pattern to the tissue preferences, and was this the same when supine and when standing?

If the rotational preferences alternate when supine, and display a greater tendency not to alternate (i.e. they rotate in the same directions) when standing, a dysfunc­ tional adaptation pattern that is ascending is most likely, i.e. the major dysfunctional patterns lie in the lower body, pelvis or lower extremi ties. If the rotational pattern remains the same when supine and standing this suggests that the adaptation pattern is primarily descending, i.e. the major dysfunctional pat­ terns lie in the upper body, cranium or jaw.

If a movement in one direction is more restricted than the same movement in the opposite direction, a barrier will have been identified. This might be by means of a sense of bind, locking or restriction as compared with a sense of ease, comfort or freedom in the opposite direction . The palpated information might take the form of a differ­ ence in end-feel, or a contrast in the feel of tissue texture ('bind').

Once a barrier of resistance is identified, several treatment options are open to the practitioner.

11 The cervical region

267

j 1. If a shortened soft tissue structure is identified during

2.

3.

4.

assessment, holding tissues at their barrier of resistance and then waiting allows a slow passive myofascial release to occur (as in holding a yoga posture for several minutes and then being able to move further in that direction). If a shortened soft tissue structure is identified during assessment, holding tissues at their barrier of resistance and having the patient attempt to push further in that direction, using no more thiw 20% of strength for 7 sec­ onds, against the practitioner's resistance, produces an isometric conh'action of the antagonists to the tissues restricting movement (the agorusts) which would produce a reciprocal inhibition effect (MET) and allow movement to a new barrier - or through it if stretching was being used. If a shortened soft tissue structure is identified during assessment, holding the tissues at their barrier of resist­ ance and having the patient attempt to push away from that barrier, using no more than 20% of strength for 7 seconds, against the practitioner's resistance, produces an isometric contraction of the agonists which would produce a postisometric relaxation effect (MET) and allow movement to a new barrier - or through it if stretching was being used. In examples 2 and 3, an alternative is to introduce a series of very small rhythmic contractions (20 contrac­ tions in 10 seconds, rather than a 7-second sustained one) toward or away from the resistance barrier pulsed MET (Ruddy's approach) - in order to achieve an increase in range of movement. If the pulsa ting contrac­ tions are toward the restriction barrier, this wiH effec­ tively be activating the antagonists to the shortened soft tissues that are restricting movement. This action would therefore induce a series of minute reciprocal inhibition influences into the shortened tissues. Note: Ruddy's method should not be confused with ballistic stretching. Ruddy specifically warns against 'bounce' occurring during the pulsations, which because they 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 as reeducate proprioceptive function. If a barrier of resistance was noted when (as an example) flexion of the neck was being tested, the cause might lie in a restriction (shortening of the muscles) which would move the area in the opposite direction, in this example the extensors. If the principles of strain--cou nterstrain (SCS) are being used as part of positional release methodology (PRT), an area of localized tenderness or pain should be sought in the shortened m usculature (extensors) and this point should be used as a monitor (press and score '10') as the area is positioned to take the pain down to a score of '3' or less. This position of ease is then held for 90 seconds (see guidelines for SCS, including Goodheart's approach, in Chap ter 10). An alternative positional release method (PRT) might involve functional technique, in which the practitioner

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uses a series of movements involving all the variables available (flexion, ex tension, sideflex ion both ways, rota tion both ways, translation, compression, traction), seeking in each the most easy, relaxed, comfortable response from the tense, distressed tissues under palpa­ tion. Each tested direction of movement commences from the combined positions of ease previously identi­ fied, so that the final position represents a 'stack' of positions of ease. This is held for 90 seconds before a slow release and retesting occurs. Changes of a dysfunctional nature (fibrotic, contracted, etc.) might be palpated in the shortened soft tissues and after the tissues had been placed in a shortened state, the area of restriction could be localized by a flat compression (thumb, finger, heel of hand). The patient then initiates a slow stretching movement that would take the muscle to its full length while compression is maintained, before returning it to a shortened state and then repeating the exercise. This is a form of active myofascial release (MFR). The soft tissues of the area could be mobilized by means of massage techniques, including neuromuscular nor­ maliza tion of areas of dysfunction and reflexogenic activity discovered during palpation (NMT). The joints and soft tissues of the area can be mobilized by careful articulation movements, which take the tissues through their normal ranges of motion in a rhythmic painless sequence, so encouraging greater range of motion. This approach actively releases and stretches the soft tissues associated with the joint, often effectively mobilizing the joint without recourse to manipulation. A suitably trained and licensed individual could engage the restriction barrier identified during motion palpa­ tion and u tilize a high-velocity thrust (HVT) to overcome the barrier.

All these examples indicate different ways in which assess­ ment becomes treatment, as a seamless process of discovery leads to therapeutic action. Caution

When MET is used in relation to joint restriction, no stretch­ ing should be introduced after an isometric contraction, only a movement to the new barrier. This is also true of MET trea tment of acute soft tissue dysfunction. Therefore, for acute m uscular problems and all joint restrictions: • • •

identify the barrier introduce MET move to the new barrier after release of the contraction.

Any sense that force is needed to move a joint, or that tis­ sues are 'binding' as movement is performed, should inform the hands of the practitioner that the barrier has been passed or reached. Only in chronic soft tissue conditions is stretching beyond the restriction barrier introduced, never in joint restrictions.

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[

F i g u re 1 1 .24 Ease of m ovement as well as cha nges in tissue texture and ton e may be assessed using tra nslation side to side ( without i m posing sidebending o r rotation ) .

F i g u re 1 1 .2 3 To assess dysfu nction of the u pper cervica l u n it, the head is first placed i n flexio n , which l ocks the area below C2 and isolates rotational movement to the u pper u n i t. This step is o m i tted when posterior d isc damage is present in the cervical reg ion.

The following examples offer a means of exploring the therapeutic possibilities that emerge from assessment meth­ ods that uncover restrictions. The clinical language used derives from osteopathic medicine. U p per cervical dysfunction assessm ent ( F i g . • • •

•

•

•

•

1 1.23)

To test for dysfunction i n the upper cervical region, the patient lies supine. The practi tioner passively flexes the head on the neck fully, with one hand, while the other cradles the neck. Since flexion locks the cervical area below C2, evaluation is isolated to a tlantoaxial rotation where half the gross rota tion of the neck occurs. With the neck flexed (effectively 'locking' everything below C2), the head is then passively rotated to both left and right. If the range is greater on one side, this is indicative of a probable restriction which may be amenable to soft tissue manipulation trea tment or HVT. If rotation toward the right is restricted compared with rotation toward the left, the indication is of a 'left rotated atlas' or, in osteopa thic terminology, an atlas which is 'posterior left' (as the transverse process on the left has moved posteriorly). Treatment options discussed above can then be utilized by means of engaging the barrier and introducing MET

variations (reciprocal inhibition, postisometric relax­ ation, pulsed MET) or considering PRT methods (in more acute settings, ideally).

ASSES S M E N T A N D TR EATM E N T O F O C C I P I TO ATLA N TA L R ESTR I CTI O N (CO- C 1 ) ( F I G . 1 1 . 2 4) • •

•

• •

•

•

The patient is supine while the practitioner sits or stands at the head of the table. The patient's head is supported in both the practitioner 's hands with middle and/or index fingers immediately inferior to the occiput, b ilaterally. The fingers assess tissue change as the hands take the head into lateral translation one way and then the other (a 'shunt' movement along an axis; simple translation side to side, without rotation or deliberate sideflexion). Translation assessment is performed with the head in a neutral position, as well as in flexion and also in extension. As translation occurs in a given direction (say, toward the right), a sideflexion is taking place to the left and there­ fore, in the case of the occiput/atlas, rotation is occurring to the right (refer to notes on spinal coupling earlier in this section, p. 255). It is far safer (and much simpler) to use translation in order to evaluate sideflexion and rota tion than it would be to perform these movements at each articulation. Two sets of information are being received from the hands as the translation movement takes place. 1. The relative ease of movement left and right as trans­ lation is performed. 2. The changes in the tissue tone and texture as transla­ tion takes place. There may also be reported discom­ fort, either in response to the movement or to the palpation of suboccipital tissues.

1 1 The cervical region

Because spinal biomechanics decree that sidebending and rotation take place in opposite directions at the occipitoat­ lantal j unction, the following findings would relate to any sense of restriction (' bind') noted (using the same example) during flexion and translation toward the right. 1. The occiput is extended and rotated left and sideflexed right (this describes the positional situation of the struc­ ture involved - the occiput in relation to the a tlas). 2. This same restriction pattern can be described differently, by saying that there is a flexion, right rotation, left side­ flexion restriction (this describes the dysfunctional pattern, i .e. the directions toward which movement is restricted).

•

Treatment choices might include the following. •

•

•

•

NMT. Application of soft tissue manipulation methods, deep massage and neuromuscular techniques to the soft tissues of the area which display altered tone or tissue texture, followed by reassessment of range of motion. MET. Takes the occiput/atlas to its restriction barrier, either using simple translation (as in the assessment) or into full flexion, right rotation, left sideflexion, in order to engage the restriction barrier before introducing a light isometric contraction toward or away from the barrier for 7 seconds, and then reassesses the range of motion. PRT. Takes the occiput/atlas away from its restriction barrier, either into translation to the left, in the direction opposite that in which restriction was noted, or into extension, left rotation, right sideflexion to disengage from the restriction barrier, and waits for 30-90 seconds for a positional release change to occur. Range of motion is then reassessed . HVT. A high-velocity thrust could be performed (by a suitably l icensed individual) by taking the structures to their restriction barrier and then rapidly forcing them through the restriction barrier.

All these methods would be successful in certain circum­ stances. The MET and PRT choices, as well as the applica­ tion of NMT, would be the least invasive. HVT may be the only choice if the less invasive measures fail.

F U N CT I O N A L R E LEASE OF ATLANTO O CC I PITA L J O I NT • • • • •

•

The patient is supine. The practitioner sits at the comer of the head of the table, facing the patient's head from that corner. The caudal hand cradles the occip ut with opposed index finger and thumb controlling the atlas. The other hand is placed on the patient's forehead. The caudal hand (,listening hand') searches for feelings of 'ease', 'comfort' or 'release' in the tissues surrounding the atlas as the hand on the forehead directs the head into a compound series of motions. As each motion is ' tested', a point is found where the tis­ sues being palpated feel at their most relaxed or easy. This

•

is used as the start point for the next sequence of assess­ ment. In no particular order, the following ranges and directions of motion are tested, seeking always the easi­ est position to 'stack' onto the previously identified posi­ tions of ease as evaluated by the 'listening hand'. 1. Flexion/extension 2. Sidebending left and right 3. Rotation left and right 4. Anteroposterior translation 5. Side-to-side translation 6. Compression / traction Once ' three-dimensional equilibrium' has been ascer­ tained (known as dynamic neutral), the patient is asked to inhale and exhale fully, to identify which stage of the cycle increases 'ease', and then asked to hold the breath in tha t phase for 10 seconds or so. The combined position of ease is held for 90 seconds before slowly returning to neutral.

Note that the sequence of movements is not relevant, pro­ vided that as many variables as possible are employed in seeking a combined position of ease. The effect of this held position of ease is to allow neural resetting to occur, reduc­ ing muscular tension, and also to encourage dramatically better circulation through previously tense and possibly ischemic tissues. Following this sequence, a direct inhibitory method (such as cranial base release - see Box 11.11) is used to further release the suboccipital musculature.

,� TRA N S LAT I O N ASS E SS M E NT F O R C E RV I CA L " S P I N E (C2-7) The following assessment sequence is based on the work of Philip Greenman DO ( 1989). In performing this exercise, it is important to recall that normal physiology dictates that sidebending and rotation in the cervical area below the axis are type 2, i.e. segments that are sidebending will automati­ cal ly rotate toward the same side. Most cervical restrictions are compensations and will involve several segments, all of which will adopt this type 2 pattern. Exceptions occur if a restriction is traumatically induced by a direct blow to the joint, in which case there might be sidebending to one side and rotation to the o ther - type 1 - which is the physiologi­ cal pattern for the rest of the spine. •

•

•

•

To easily palpate for sidebending and rotation, a side-to­ side translation movement is used, with the neck in slight flexion or slight extension. When the neck is absolutely neutral (no flexion or exten­ sion, an unusual state in the neck) true translation side to side is pOSSible. As a segment is translated to one side, it is au tomatically sidebending to the opposite side and because of the bio­ mechanical rules which govern i t, it will be rotating to the same side. The practitioner is seated or standing at the head of the supine patient.

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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

270

•

•

A

•

•

• •

•

•

Figure 1 1 .2 5 A : Finger positions in re lation to a rtic u l a r p i l l a rs a n d s p i n o u s process. B : I n d ividual seg ments of cervical s p i n e (below C3) a re ta ken i nto left a n d right translation, in order to eva l u a te ease of movement, in neu tra l , slight flexion a n d slight extension.

TREAT M E NT C H O I CES •

•

• •

•

• •

The index finger pads rest on the articular pillars of C6, medial and superior to the transverse processes of C7 (which can be palpated just anterior to the upper trapez­ ius) (Fig. 11 .25). The middle finger pads will be on C6 and the ring finger on C5 with the little finger pads on C3. With these contacts, it is possible to examine for sensitiv­ ity, fibrosis and hypertonicity as well as being able to apply lateral translation to cervical segments with the head in flexion or extension. In order to do this effectively, it is necessary to stabilize the superior segment to the one about to be examined with the finger pads. The heel of the hand controls movement of the head. With the head/neck in relative neutral (no flexion and no extension), translation to one side and then the other is introduced by a combination of contact forces involving the finger pads on the articular pillars of the segment being assessed, as well as the supporting hands supporting the

head, to assess freedom of translation movement (and, by implication, sidebending and rotation) in each direction. For example, C5 is being stabilized with the finger pads, as translation to the left is introduced. The ability of C5 to freely sidebend and rotate to the right on C6 is being evaluated with the neck in neutral. If the joint is normal this translation will cause a gapping of the left facet and a closing of the right facet as left transla­ tion is performed and vice versa. There will be a soft end­ feel to the movement, without harsh or sudden breaking. If, say, translation of the segment toward the left from the right produces a sense of resistance or bind, then the seg­ ment is restricted in its ability to sidebend right and (by implication) also to rotate right. If such a restriction is noted, the translation should be repeated but this time with the head in extension instead of neutral. This is achieved by lifting the contact fingers on C5 (in this example) slightly toward the ceiling, before reassessing the side-to-side translation. The head and neck are then taken into flexion and right­ to-left translation is again assessed. The objective is to ascertain which position creates the greatest degree of bind as the barrier is engaged. Is trans­ lation more restricted in neutral, extension or flexion? If this restriction is greater with the head extended, the diagnosis is of a joint locked in flexion, sidebent left and rotated left (meaning that there is difficulty in the joint extending, sidebending and rotating to the right). If this (C5 on C6 translation right to left) restriction is greater with the head flexed, then the joint is locked in extension and sidebent left and rotated left (meaning that there is difficulty in the joint flexing, sidebending and rotating to the right).

• •

• •

•

•

•

Using MET and using the same example (C5 on C 6 as above, with greatest restriction in extension). The hands palpate the articular pillars of the inferior seg­ ment of the pair which is dysfunctional. One hand stabilizes the C6 articular pillars, holding the inferior vertebra so that the superior segment can be moved on it. The other hand controls the head and neck above the restricted vertebra. The articular pillars of C6 should be eased toward the ceiling, introducing extension, while the other hand introduces rotation and sidebending until the restriction barrier is reached. A slight isometric contraction is introduced by the patient using sidebending, rotation or flexion (or all of these) either toward or away from the barrier. After 5-7 seconds the patient relaxes and extension, sidebending and rotation left are increased to the new resistance barrier. Repeat 2-3 times.

11 The cervical region

•

•

•

Fig u re 1 1 .2 6 Fo r cerv ica l flexion stra i n using SCS, a tender poi n t is monitored (right thumb) as the head is flexed and fi ne-tu ned (usua l ly turning towa rd side of pain) to remove pain from the poi nt.

ALTERNATIVE POSIT I O N A L R E L EASE APPROACH •

• •

As a n alternative, the directions o f ease o f translation of the dysfunctional segmen t can be assessed in neutral, slight flexion and slight extension. Whichever position produces the greatest sense of pal­ pated 'ease' is held for 90 seconds. Following this reassessment, the area should show a degree of 'release' and increased range of motion.

• •

•

SCS CERV I CAL F L EX I O N R E STR I CTI O N M ET H O D ( F I G . 1 1 . 2 6) Note that strain and counters train is an ideal approach for self-treatment of 'tender ' points and can safely be taught to pa tients for home use. •

•

•

An area of local dysfunction is sought, using an appro­ priate form of palpation on the skin areas overlying the tips of the transverse processes of the cervical spine (Lewit 1992). Light compression is introduced to identify and establish a point of sensitivity (a 'tender point') that in this area represents (based on Jones' findings) an anterior (for­ ward-bending) strain site. The patient is instructed in the method for reporting a reduction in pain during the positioning sequence which follows. 1. Say to the patient, 'I want you to score the pain caused by my pressure, before we start moving your head

•

into diff�rent positions, a s a '10'. Please don't say any­ thing apart from giving me the present score (out of 10) whenever I ask for it'. 2. The aim is to achieve a reported score of '3' or less before ceasing the positioning process and to avoid conversation which would distract from the practi­ tioner's focus on palpating tissue change and reposi­ tioning the tissues. The head / neck should then be passively taken lightly into flexion until some degree of 'ease' is reported in the tender point (based on the score reported by the pa tient) which is being constantly compressed at this stage (Chaitow 1991). When a reduction of pain of around 50% is achieved, a degree of fine-tuning is commenced in which very small degrees of additional positioning are introduced in order to find the position of maximum ease, at which time the reported 'score' should be reduced by at least 70%. At this time the patient may be asked to inhale fully and exhale fully while personally observing for changes in the palpated pain point, in order to evaluate which phase of the cycle reduces the pain score still more. That phase of the breathing cycle in which the patient senses the great­ est reduction in sensitivity is maintained for a period which is tolerable to the patient (holding the breath in or out or at some point between the two extremes, for as long as is comfortable) while the overall position of ease continues to be maintained and the tender/ tense area monitored. This position of ease is held for 90 seconds in Jones' methodology. During the holding of the position of ease the direct com­ pression can be reduced to a mere touching of the point along with a periodic probing to establish that the posi­ tion of ease has been maintained. After 90 seconds the neck/head is very slowly returned to the neutral starting position. This slow return to neu­ tral is a vital component of SCS since the neural receptors (muscle spindles) may be provoked into a return to their previously dysfunctional state if a rapid movement is made at the end of the procedure. The tender point/area, and any functional restriction, may be retested at this time and should be found to be improved.

SCS C ERVI CAL EXTE N S I O N R EST R I CT I O N M ET H O D ( F I G . 1 1 . 2 7) •

•

With the patient in a supine position and the head clear of the end of the table and fully supported by the practi­ tioner, areas of localized tenderness are sought by light palpation alongside the tips of the spinous processes of the cervical spine. Having located a tender point, compression is applied to elicit a degree of sensitivity or pain which the patient notes as representing a score of '10'.

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STI LES' ( 1 9 8 4) G E N E RAL PROC E D U R E U S I N G M ET F O R C E RVICAL R ESTR I CTI O N • •

• • •

•

Figure 11.27 For cervica l extension stra i n using SCS, a tender point is mon i tored (right finger) as the head is extended and fine-tuned (usu a l ly turning away from the side of pain) to remove pain from the point.

Stiles suggests a general maneuver, in which the patient is sitting upright. The practi tioner stands behind and holds the head in the mid-line, with both hands stabilizing it and possibly employing the chest to prevent neck extension. The pa tient is told to try (gently) to flex, extend, rotate and sidebend the neck alternately in all directions. No particular sequence is necessary, as long as all direc­ tions are engaged, a number of times. Each muscle group should undergo slight contraction for 5-7 seconds, against unyielding force offered by the prac­ titioner 's hands (either toward or away from the direc­ tion of the barrier) once the barrier in any particular direction is engaged. This relaxes the tissues in a general manner. Traumatized muscles will relax without much pain via this method. After each contraction the patient eases the area to its new position (barrier) without stretching or force.

HARA KA L'S ( 1 9 7 5) C O O P E RATIVE I S O M ETRIC TE C H N I Q U E ( M ET) [ F I G . 1 1 . 2 8 ) •

• •

•

•

•

The head/neck is then taken into light extension along with sidebending and rotation (usually away from the side of the pain if it is not on the mid-line) until a reduc­ tion of at least 50% is achieved in the reported sensitivi ty. The pressure on the tender point is constant a t this stage. With fine-tuning of posi tion, a reduction in sensitivity should be achieved of at least 70%, at which time inhala­ tion and exhalation are monitored by the patient to see which reduces sensitivity even more and this phase of the cycle is held for as long as is comfortable, during which the overall position of ease is maintained. Intermittent pressure on the poin t is applied periodically d uring the holding period in order to ensure that the posi tion of ease has been maintained. After 90 seconds a very slow and deliberate return to neutral is performed and the pa tient is allowed to rest for several minutes. The tender point should be repalpated for sensitivi ty, or functional restriction retested, to assess for improve­ ments.

The following technique is used when there is a specific or general restriction in a spinal articulation. • • •

•

•

•

Mobi lizati o n of the cervical spine

General, non-specific cervical mobiliza tion as well as pre­ cise segmental releases, as appropria te, considerably enhance cranial function by reducing undue myofascial and mechanical stress in the region. The following methods, based on the work of Drs Greenman, Harakal and Stiles, incorporate safe non-invasive approaches that can be easily learned. Practitioners are again strongly advised to practice w i thin the scope of their license.

• •

The area should be placed in neutral (patient seated). The permitted range of motion should be determined by noting the patient's resistance to further motion. The patient should be rested for some seconds at a point j ust short of the resistance barrier, termed the 'point of balanced tension', in order to 'permit anatomic and phys­ iologic response' to occur. The patient is asked to reverse the movement toward the barrier by ' turning back toward where we started' (thus contracting any agonists which may be influencing the restriction) and this movement is resisted by the practi tioner. The degree of patient participation at this stage can be at various levels, ranging from 'j ust think abou t turning' to ' turn as hard as you would like' or by giving specific instructions ('use only about 20% of your strength'). Following a holding of this isometric effort for a few sec­ onds (5-7) and then relaxing completely, the patient is assisted to move further in the direction of the previous barrier to a new point of restriction determined by their resistance to further motion as well as tissue response (feel for 'bind'). The procedure is repeated until no further gain is being achieved. It wou l d also be appropriate to use the opposite direction of rotation - for example, asking the patient to ' turn fur­ ther toward the direction you are moving', so utilizing the antagonists to the muscles which may be restricting free movement.

11

•

•

•

•

•

A

B Fig u re 1 1 .28 A: Harakal's approach requ i res the restricted seg ment to be taken to a position just short of the assessed restriction barrier before isometric contraction is introduced as the patient attem pts to return to neu tra l , after which slack is removed and the new barrier engaged. B: Sidebend i n g a n d rotation restriction of the cervica l reg ion is treated by hold i ng the neck just short of the restriction barrier and having the patient attempt to return to n eutral, a fter which slack is removed and the new ba rrier engaged.

What if it h urts? Evjenth & Hamburg (1984) have a prac­ tical solution to the problem of pain being produced when an isometric contraction is employed. •

They suggest that the degree of effort be markedly reduced and the duration of the contraction increased, from 10 to up to 30 seconds.

The cervical region

If this fails to allow a painless contraction, then use of the antagonist muscle(s) for the isometric contraction is another alterna tive. Following the contraction, if a joint is being moved to a new resistance barrier and this produces pain, wha t vari­ ations are possible? If following an isometric contraction and movement toward the direction of restriction there is pain, or if the patient fears pain, Evjenth & Hamburg suggest, 'Then the therapist may be more passive and let the patient actively move the joint'. Pain experienced may often be lessened considerably if the practitioner applies gentle traction while the patient actively moves the joint. Sometimes pain may be fur ther reduced if, in addition to applying gentle traction, the practitioner simultaneously either aids the patient's movement at the joint or pro­ vides gentle resistance while the patient moves the jOint.

C E RVI CA L T R EATM E N T : S E Q U E N C I N G

In the assessment section o f this chap ter, we have seen how it is possible to move from the gathering of information into treatment almost seamlessly. This is a characteristic of NMT. As the practitioner searches for information, the appropri­ ate degree of pressure modification from the contact digit or hand can turn 'finding' into 'fixing'. This will become clearer as the methods and objectives of NMT and i ts asso­ cia ted modalities become more familiar. The authors feel it useful to suggest that where the tissues being assessed and treated are particularly tense, restricted and indurated, the prior use of basic muscle energy or positional release meth­ ods can reduce superficial hypertonicity sufficiently to allow better access for exploring, assessing and ultimately treating the dysfunctional tissues. Sequencing is an important element in bodywork, as the d iscussion immedia tely below reinforces. What should be treated first? Where should treatment begin? To some extent this is a ma tter of experience but in many instances protocols and prescriptions based on clinical experience and sometimes research - can be offered . Several concepts relating to sequencing may usefully be kept in m ind when addressing upper body (and other) dysfunctions from an NMT perspective. Most of these thoughts are based on the clinical experience of the a uthors and those with whom they have worked and studied. • •

•

Superficial muscles are addressed before deeper layers (see cervical planes below). The proximal portions of the body are released before the distal portions; therefore, the cervical region is trea ted before craniomandibular or other cranial myofascial teclmiques a re used . The portion of the spinal column from which innervation to an extremity emerges is addressed with the extremity

273

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CLI N I CA L A P P L I CATI O N O F N E U R O M USCU LAR TEC H N I Q U ES : T H E U P PER B O DY

Infrahyoid muscles

T hyroid

�

-

Pretracheal layer

2"iif;�������

------.,

-

r------ Internal jungular vein

Sternocleidomastoid muscle ------,Ifff�_lf'"----- Zygomaticus major ��------ Masseter '----- Zygomaticus minor

B

�----

Zygomaticofacial foramina

Articulation with maxilla c

Masseter

F i g u re 1 2 .22 A: Left zyg omatic bone and associated structu res. B: Lateral aspect show ing m uscu l a r attachments a nd a rticu lations. C: Medial aspect. Reproduced with permission from Cha itow (2005).

1 2 The cranium

Range a n d d i rection of m ot i o n

Dysfu n cti o n a l pattern s

The orbital border is said to 'roll antero-Iaterally, and the tuberosi ty rolls inferior' in the classic osteopathic descrip­ tion of flexion motion (Brookes 1981 ) .

Sinus problems can often benefit from increased freedom of the zygomae. They should always receive attention after dental trauma, especially upper tooth extractions, as well as trauma to the face of any sort, as they are likely to have absorbed the effects of the forces involved. Habits such as supporting the face/ cheekbone on a hand when writing (for example) should be discouraged as the persistent pressure modifies the position of not just the maxillae but all associa ted bones and s tructures. They should be assessed and treated in relation to problems involving the temporals, maxillae and sphenoid.

Other a ssoci ati o n s a n d i nfl u ences

The zygomae offer protection to the temporal region and the eye and are, as with the etlunoid and vomer, shock absorbers which spread the shock of blows to the face. Milne (1995) suggests that ' they act as speed reducers between the markedly eccentric movements of the tempo­ rills and the relative inertia of the maxillae'. The zygomati­ cofacial and the zygomaticotemporal foramina offer passage to branches of the 5th cranial nerve (maxillary branch of trigeminal).

MAXILLAE

See Figure 1 2.23.

Articulates with frontal bone Medial palpebral ligament Frontal process

Nasolacrimal groove

----

___

11+-1-.,..-- Orbicularis oculi ---- Articulates with ethmoid

___

Levator labii superioris alaeque nasi --------+--\

--"...------ Orbital surface ,...�'t----- Infraorbital groove

Levator labii superioris -------\,---i' Infraorbital foramen -------+-� Nasal notch -------1

Nasalis

{

Anterior nasal spine

�;----+---- Zygomatic process. with zygomatic bone

-----���1_()

o-t---==� Openings of alveolar canals

transverse part alar part ------..-'

----=1--- Tuberosity

Depressor septi ----/ Canine eminence -----.../

Levator anguli oris

A

Buccinator

Articulates with frontal bone Nasolacrimal groove

�.----- Ethmoidal crest -+----- Middle meatus Maxillary hiatus -------+ft:;.:.;.:.-

"---;-1---- Conchal crest

For perpendicular plate of palatine bone --------\\-....v!

---+---- Inferior meatus

Greater palatine bone ----­ For perpendicular plate of palatine bone ----'

�i\'i:;:;::;��---- Anterior nasal spine

������

Palatine process Incisive canal

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).

349

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

350

Articu l ations

Articu la ti o ns

As described above, the maxillae articulate at nwnerolls complex sutures, with each other and with the teeth they house, as well as with the ethmoid and vomer, the pala tines and the zygomae, the inferior conchae and the nasal bones, the frontal bone and the mandible (by tooth contact) and sometimes with the sphenoid. There are no direct reciprocal tension membrane rela­ tionships.

• • • • •

Muscu l a r attachm ents

(not described h ere) • • • • • • • • •

(see Fig. 12.23)

Medial pterygoid Masseter Risorius Orbicularis oculi Levator labii sllperioris Nasalis Depressor septi Levator anguli oris Buccinator

Range a n d d i rection of motion

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 terior, the tuberosity moves lateral and slightly posterior, the frontal process posterior border moves la teral and the alveolar arch widens posteriorly' (Brookes 1981) .

•

•

The conchal crest for articulation with the inferior nasal concha. The ethmoidal crest for articulation with the middle nasal concha. The maxillary surface has a roughened and irregular sur­ face for articulation with the maxillae. The anterior border has an articula tion with the inferior nasal concha. The posterior border is serrated for articulation with the medial pterygoid plate of the sphenoid. The superior border has an anterior orbital process (which articulates with the maxilla and the sphenoid concha) and a sphenoidal process posteriorly (which articulates with the sphenoidal concha and the medial pterygoid plate, as well as the vomer). The median pala tine suture joins the two palatines.

There are no direct reciprocal tension attachments.

Muscu l a r attachm ents

The medial pterygoid is the only important muscular attachment. It attaches to the la teral pterygoid plate and palatine bones, running to the medial ramus and angle of the mandible.

R a n ge a nd d i rection of moti o n

The palatines move, during flexion, to follow the p terygoid 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

Because of the involvement of both the teeth and the air sinuses, the cause of pain in this region is not easy to diag­ nose. These connections (teeth and sinuses) as well as the neural structures tha t pass through the bone plus its multi­ ple associations with other bones and its vulnerability to trauma make it one of the key areas for cranial therapeutic attention.

Dysfu nctiona l patterns

Headaches, facial pain and sinus problems plus a host of mouth and throat connections with emotion (especially 'unspoken' ones) mean that purely structural and largely mind-body problems meet here, j ust as they do in dysfunc­ tional breathing patterns.

Other associations a nd i nfl u ences

These delicate shock-absorbing structures, with their multi­ ple sutural articulations, spread force in many directions when any is exerted on them. They are capable of deforma­ tion and stress transmission and their imbalances and deformities usually reflect what has happened to the struc­ tures with which they are articulating. Great care needs to be exercised in any direct contact on the palatines (especially cephalad pressure) because of their extreme fragility and proximity to the sphenoid in particu­ lar, as well as to the nerves and b lood vessels which pass through them. CAUTION: In a report on iatrogenic effects arising from inappropriately applied cranial treatment, Professor John McPartland (1996) presented nine i l l ustrative cases, two of which involved i ntraoral treatment. All cases seemed to

PALATINES

involve excessive force being used, which strongly high­ lights the need for care, especially when working inside

See Figure 1 2.24.

the mouth.

1 2 The cranium

Maxillary hiatus -------, Orbilal process ------, Sphenopalatine notch

->r------ Frontal process

Sphenoidal process --------..

1.----- Nasolacrimal groove Ethmoidal crest ---------___

,---#--- Conchal crest

Perpendicular plale of palatine bone --------+-Conchal crest -------Jt.=� Rough area for medial pterygoid plate

-------4.�����-

For opposite maxilla

Pyramidal process --------/

A

Palatomaxillary suture

Greater palatine foramen

�-----

Spenoidal process ------4:;__./

Orbital process

�e------ Ethmoidal crest _____

-

Concha I crest

-t----- Maxillary process

Pyramidal process

-------(;jj,-�:§:::t:,;;.�:::;;;

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).

NMT TREATMENT TECHNIQUES F O R T HE CRAN I U M MUSCLES O F EXPRESSION

Mimetic muscles attach skin to skin, skin to underlying fas­ cia or skin to bone and contribute to a wide variety of facial expressions. Youthful skin is highly elastic while aging skin does not recoil as well . Hence, wrinkles and folds of the skin commonly expressed by the contraction of these underlying muscles may remain etched on the aged face or on a younger face when the muscles are overused, such as a ver­ tical furrow between the brows associated with eyestrain or frowning.

Mimetic muscles are easily divided into four regions (Platzer 2004), those being the scalp (epicranial), orbital region and eyelids (circumorbital and palpebral), nose (nasal) and mouth (buccola bial). These regions work together in endless combina tions to produce vast and often unconscious muscular movements that represent a physical expression of the wide variety of emotions experienced in daily life. These muscles, like those of postures tha t express general moods and feelings, are often used unconsciously by the person and frequently at chronic levels. Gray's Anatomy (2005) offers another perspective, by divid­ ing the muscles of the head into craniofacial and mastica tory groups. Craniofacial muscles relate mainly to orbital margins, eyelids, nose, lips, checks, mouth, pinna, scalp and cervical

351

3 52

CLI N I CAL 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 QU ES : T H E U PP E R B O DY

Frontalis -+-+-If:---''--':-:'c':.

Palpebral ligament

Procerus ----¥iHry..--

OCCIPITOFR O N TALIS

(FIG. 1 2.27)

Attachments: Occipitalis portion: highest nuchal line of O rbicularis oculi

B

c

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 connected to each other when tom or surgically reflected. The deeper subaponeurotic areolar tissue allows the scalp to glide readily on the deepest layer, the pericranium. Epicranial muscles express surprise, astonishment, atten­ tion, horror and fright and are used when glancing upwards. When p ulling from below, the fron talis can draw the scalp forward as in worry, grief or profound sadness, especially in combination with other brow muscles.

D E F Effects of muscles on facial expression (from RouillE l )

Fig u re 1 2.25 A: M uscles of expression. B: Orbita l m uscles of the eye. C-F: Effects of m uscles on facial expression. Drawn a fter Platzer (2004).

skin while the mastica tory group primarily move the TM joint. Gray's points out: 'Although the muscles can cause movement of the facial skin that reflects emotions, because they are grouped m�inJy arOlmd the orifices of the face, is often argued that their primary function is to act as sphincters and dilators of the facial orifices and that the function of facial expression has developed secondarily.' Gray's subdivides the muscles of facial expression into epicranial, circumorbital and palpebral, nasal and buccolabial groups. While not all of these muscles are discussed in detail within this text, most are offered in the following overview of the region. Those that are the most involved in head and facial pain are covered within this chapter. Orthodontic and cranial influences of the muscles of expression have yet to be fully established . Consider, for example, the influences which a tight, closed-lips smile of someone self-consciously covering the teeth could have on positioning of the anterior teeth and mandible. One has simply to produce that type of smile to feel the potential effect on the mandible and on the teeth. Consider

occipital and temporal bones to the cranial aponeurosis (galea a poneuro tica) 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 wrinkling the forehead Synergists: None Antagonists: Procerus, corrugator supercilii, orbicularis oculi I n d i cati o n s fo r treatment • • • •

Deep aching occipital pain Intense deep pain in the orbit and eye Frontal headaches Frontal sinus pain

TEMPOROPAR I ETALIS AND AURICULAR M USCLES Attachments: Epicranial aponeurosis to the an terior, supe-

rior or posterior ear Innervation: Facial nerve Muscle type: Not established Function: To move the ear in various directions Synergists: Occipitofrontalis, indirectly Antagonists: None

I n d i cati o n s for treatment •

Tenderness anterior, superior and posterior to the attach­ ment of the ear

1 2 The cranium

B

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). Anterior auricular

Superior auricular

Fronlal belly of occipitofrontalis -----+-H'f-+ Orbicularis oculi -----..J Procerus ------, Nasalis -----,

OCcipital belly of occipitofrontalis

Levator labii superioris alaeque nasi ---____ Levator labii superioris -----ft----,= Zygomaticus minor

...,

_ _ _

Zygomaticus major ----,-..�

'----- Posterior auricular

Orbicularis oris ---_... Depressor labii inferioris -------+Mentalis ---

. -+-+___, -/"......1.-

-

Depressor anguli oris

-.J

_ _ _ _ _

Risorius --------'

Buccinator -------' Platysma -------'

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 53

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

The occipitofrontalis is a broad, thin, muscu lofibrous layer that completely envelops the parietal suture. It additionally spans the lambdoidal and coronal sutures, attaching vi a . direct or indirect linkages with the frontal, temporal, pan­ etal and occipital bones, with the potential to significantly influence mobility and function of cranial structures. Restrictions and tension in either the frontalis or occipitalis muscles will produce a ' tightening' of the scalp, which can be diagnostic. Lewit (1996) states: 'The scalp should move easily in aU directions in relation to the skull. Examination of scalp mobility is warranted for patients with headache and/or vertigo.' Tension in the occipitofrontalis, or the epicranial aponeurosis, can also be seen to potentially interfere wl �h the . minute degree of mobility that exists between the OCCipital, parietal and frontal bones. . . . Flat palpation is used to locate and treat tngger pomts m the occipitofrontalis. Trigger points from the frontalis belly of this structure refer to the forehead while trigger points in the occipital fibers refer to the back of the cranium and to the area behind the eyes. Kellgren notes referral pa tterns of occipitalis giving rise to earache (KeUgren 1938, Simons et aI 1999). Temporoparietalis and auricular muscles lie superficial to the temporalis muscle and may be tender associated with trigger points in the underlying tempora lis. While these muscles have significant use in most animals, they have very little obvious influence in most humans. However, Gray's Anatomy (2005) notes that a uditory stimuli evoke pat­ terned responses in these muscles. They may be irrita ted by ill-fitting glasses or by telephone headsets. The following techniques may be applied to assess the epicranial tissues. Frictional or hair tract�on techniqu �s should be avoided where hair loss is occurrmg, where hair transplants have been embedded or if segmenta l neurop� ­ 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

superficial fascia and to begin therapy of the muscles of the cranium. Brisk frictional scalp massage will create heat, which may allow the external cOimective tissue to soften. Any tender areas found may be treated with combination friction or static pressure. Special attention should be given to cranial suture lines, which may be more tender than other areas and may indicate a need for further cranial attention. Light to moderate hair traction may now be applied at palm-width intervals over the entire cranium, one handful at a time, if the hair is long enough to be grasped. The hair is gently lifted away from the scalp by the non-treating hand and the fingers of the treating hand slide into place close to the scalp with segments of hair lying between 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 scalp (Fig. 1 2.28) . The non-treating hand stabilizes the cra­ nium while the grasping hand gently pulls the hair away from the cranium until slack is taken ou t and tension pro­ duced . The hair traction is sustained for 30 seconds to 2 minutes. If brisk friction has been applied immedia tely before hair traction, the fascial tissues will usually quickly loosen and soften. When friction is not applied first, the release of the tissues is delayed a minute or two. The entire procedure may be repeated, although single applications are often adequate. If craniosacral therapy is to be applied, the cranial techniques may precede or follow hair traction or frictional massage. The auricularis muscles may sometimes be manually stretched by pulling the ear into various positions by grasp­ ing the ear cartilage at i ts attachment to the head and trac­ tioning it posteriorly, inferiorly and an teriorly. This technique may also have effects on the posi tion of the tem­ poral plate and should not be applied without concern for the cranial system. The practitioner who is unfamiliar with cranial therapy but uses ear traction for these tissues should

NMT F OR EPICRANIUM

The practi tioner is seated cephalad to the supine patient. A pillow or bolster is placed under the patient's knees and, in the case of an extreme forward head position, may also need to be placed under the head. Otherwise, the head rests on the table in neutral position. Rotation of the head will be necessary to reach the posterior aspect. Transverse friction and small, circular massage techniques may be applied to the entire cranial surface to soften the

Figure 1 2.28 The fingers wrap a round the h a i r shafts as they a re gently p u l led a way from the cra n i u m w h i l e stretching and re leaSing the cra n i a l fascia.

1 2 The cranium

end the treatment by p ulling the ear gently directly laterally and holding for 30-60 seconds. Direct manual release of the fascial restrictions in occipitofron talis are rec­ ommended. Tension in the scalp interferes with cranial motion, just as gross restriction in the thoracolumbar fascia can drag on the sacrum . The methods which will achieve release of such struc­ tures can involve NMT, massage methods, myofascial release and positional release approaches. If NMT is employed, as outlined above, this can be assisted by an isometric contrac­ tion of the muscle prior to NMT. A strongly held frown, for 7-10 seconds, will reduce hypertonicity and allow easier manual applications to the soft tissues.

Manual treatment of occipitofrontalis.

I. POSITIO N A L RELEASE METHOD FOR , OCCIPITOFRONTA L I S •

• •

• •

• • •

•

•

With the pads of two or three fingers the practitioner applies light compression, less than half an ounce, onto the skin overlying those parts of the muscle tha t appear most tightly adherent to the skull, identified by light to-and-fro gliding assessments of skin on the underlying fascia. The point of initial contact is the starting, 'neutral' point. From this contact, assess the rela tive freedom of move­ ment of the skin on underlying fascia in two opposite directions, say moving laterally one way, then back to neutral and then in the opposite direction. Decide which direction of movement is 'easiest' and glide the skin on the fascia toward that direction. Next, from this first posi tion of ease, assess the relative freedom of glide in another pair of directions, say mov­ ing anteriorly and posteriorly. Which of these offers least resistance? 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.

Orbicularis oculi is divided into three parts: orbital, palpe­ bral and lacrimal. The orbital portion of orbicu laris oculi encircles the eye and lies on the body orbit while the palpebral portion lies directly on the upper and lower eyelids. The short, small fibers of the lacrimal portion cross the lacrimal sac and attach to the lacrimal crest. Its trigger points may refer to the nose or create 'jumpy prin t' when reading. As a sphincter muscle, orbicularis oculi is responSible for closing the eye voluntarily or reflexively, as in blinking. I t also aids i n reducing the amount o f light entering the eye and hence is involved w ith squinting. Levator palpebrae superi­ oris antagonizes eye closure by elevating the upper eyelid. Corrugator supercilii" blends with the frontalis muscle and the orbicularis oculi and radiates into the skin of the eye­ brows. It draws the brows toward the mid-line. These tvvo muscles are responsible for bunching the brows to shield the eye from intense light or when eyestrain pro­ duces a similar 'squinting' movemen t. They create vertical furrows between the brows that, over time, may become deeply entrenched lines. Additionally, orbicularis oculi pro­ duces radia ting lateral lines commonly called 'crov,r's feet' and expresses worry or concern while corrugator supercilii is called the muscle of pathetic pain and also produces the expression associated with thinking hard.

It

N MT FOR PA LPEBRA L REGION

The eye region contains the most delicate tissues of the face, which are treated w ith the most gentle touch. Ex treme care must be exercised to avoid stretching the skin of the eye region. Spray and stretch techniques are not recommended near the eyes while injections into the eye region may result in ecchymosis, 'a black eye' (Simons e t al 1999) . Flat palpa tion is used to press fingertip portions of the orbicularis oculi against the underlying bony orbit (Fig. 12.29).

MIMETIC MUSCLES OF THE CIRCUMORBITA L A N D PALPEBR A L REGION

Orbicularis oculi and corrugator supercilii comprise the mimetic muscles of the eye region (palpebral fissure). These two muscles are important not only for facial expression but also in ocular reflexes. Like all mimetic muscles, they are innervated by the facial nerve.

Figure 1 2.29 Any tech n iques a pplied to the eye reg ion should be g entle and ca refu lly placed as the con n ective tissue of t h i s reg ion is extre mely del icate.

355

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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 LA R TECH N I Q U E S : TH E U P P E R B O DY

Levator labii superioris alaeque nasi attaches the skin of the upper lip and nasal wing to the infraorbital margin. vVhen it contracts, it enlarges the nostrils and elevates the nasal wing, producing transverse folds in the skin on each side of the nose and a look of displeasure and discontent, espe­ cially noted when sniffing an unpleasant odor.

1

Fig u re 1 2.30 Compression a n d precise myofascia l release may soften deep vertical furrows between t h e brows.

Gentle static pressure or an extremely gentle transverse movement may help assess the tmderJying muscle. However, frictional movements, gliding techniques or skin rolling, which is usually effective in locating trigger points, may also be too aggressive for this delicate tissue. Use of 'skin drag' palpation (as described in Chapter 6, p. 1 20) is, how­ ever, gentle, safe and effective in localizing underlying trig­ ger pOint activity. The corrugator supercilii is easily picked up near the mid-line between the brows and compressed between the thumb and side of the index finger (Fig. 1 2.30) . It can also be rolled gently between the palpating digits. This compres­ sion and rolling technique is applied at thumb-width inter­ vals the width of the brow and may also include fibers of the procerus, frontalis and orbicularis oculi as well as corru­ gator supercilii.

Procerus is easily grasped between the fingers and thumb at the bridge of the nose. Since this is an action people often per­ form when experiencing a headache or eyestrain, its associa­ tion with those patterns of dyshmction may be implied. Flat palpation and light friction may be used along the sides of the nose and spreading slightly laterally onto the cheeks to treat the remaining nasal muscles. The two index fingers, very lightly placed, may provide precise myofascial release but the practitioner is reminded that the facial tis­ sues are very delicate and anything other than exception­ ally light pressure is contraindicated. Strong tension of the tissues is also not recommended. Trigger point locations and patterns of referral in this region have not yet been established but we suggest that these muscles be assessed when nose, lips and eye problems are encotmtered or facial pain or sensations are experienced near or into these tissues. Wrinkled skin may suggest tmder­ lying muscular tensions, possibly involving chronic overuse.

MIMETIC MUSCLES OF THE BUCCOLABIAL REGION

The movements of the lips are derived from a complex three-dimensional system that postures the lips and con­ trols the shape of the orifice. Structure of the lips and their limits of motion are comprehensively discussed in Gray's Anatomy (2005), as are details of the muscles listed below. •

MIMETIC MUSCLES OF THE NASAL REGION

Procerus arises from the facial aponeurosis over the lower nasal bone and nasal cartilage and attaches into the skin of the forehead between the eyebrows. It reduces glare from excess light and produces transverse w rinkles at the bridge of the nose. Expressions associated with procerus include menacing looks, frowns and deep concentration. Nasalis consists of a transverse (compressor naris) por­ tion which attaches the maxilla to the bridge of the nose and an alar (dilator naris) portion which attaches the maxilla to the skin on the nasal wing. The transverse portion com­ presses the nasal aperture while the alar portion widens it, reducing the size of the nostril and producing a look of desiring, demanding and sensuousness. Depressor septi attaches the mobile portion of. the nasal sep­ tum to the maxilla above the central incisor tooth. It depresses the septum during constriction and movement of the nostrils.

N MT F OR N A SAL REGION

• • •

Elevators, retractors and evertors of the upper lip: levator labii superioris alaeque nasi, levator labii superioris, zygo­ maticus major and minor, levator anguli oris and risorius Depressors, retractors and evertors of the lower lip: depressor labii inferioris, depressor anguli oris and mentalis Compound sphincter: orbicularis oris, incisivus superior and inferior Buccinator

The muscles of the buccolabial region function in eating, drinking and speech as well as emotional expression. A multitude of expressions, including reserve, laughing, cry­ ing, satisfaction, pleasure, self-confidence, sadness, perse­ verance, seriousness, doubt, indecision, disdain, irony and a variety of other feelings, are displayed in the lower face by the action and combined actions of these muscles. The movements as well as individual expressions are covered in detail in both Gray's Anatomy (2005) and Color Atlas/Text of Human Anatomy, Vol l , Locomotor System (Platzer 2004).

1 2 The cranium

Levator tabii superioris alaeque nasi -----, Levator labii superioris ------..

,----- Levator anguli oris

Zygomaticus minor _+,...-\-\----li��---'�'--_,#'-- . -

-

-

�

­

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).

445

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 in Shoulder Pain (Cailliet 1991). Simons et al (1999) report that, with inactivation of trigger points in supraspinatus, early calcific deposits at the insertion site may resolve. Supraspinatus is the most frequently ruptured element of the musculotendinous cuff (Gray's Anatomy 2005), although portions of the conjoined tendon (infraspinatus and teres minor), subscapularis or the joint capsule and supporting ligaments may also be damaged. If a partial or complete tear is suspected, range of motion tests or stretch­ ing procedures should be delayed until the extent of tearing is known (Simons et a1 1999) as these steps could lead to fur­ ther tearing of the structures. The supraspinatus fibers lie deep to the trapezius and its tendon attachment lies deep to the deltoid. Therefore, supraspinatus is not directly palpable except in some cases where displacement of the upper trapezius allows a small amount of access to the proximal end. However, tenderness and trigger points within this muscle may be addressed through the overlying trapezius if the trapezius fibers are not too tender to be pressed and are not too thick.

A S S E SS M E NT F O R S U P R A S P I N AT U S DYS F U N CT I O N •

• •

The practitioner stands behind the seated patient, stabi­ lizing the shoulder on the side to be assessed with one hand while the other hand reaches in front of the patient to support the flexed elbow and forearm. The patient's upper arm is adducted to its easy barrier and the patient then attempts to abduct the arm. If pain is noted in the posterior shoulder region, supraspinatus dysfunction is suspected and because it is a postural muscle, shortness is implied.

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 • •

•

•

The patient sits o r stands with arm abducted 1 5°, elbow 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. The patient a ttempts to resist this and the degree of effort required to overcome the patient's resistance is graded as weak or strong (see grading scale, pp. 39 and 413) . See also 'drop-arm test' on p. 418.

� N MT T R E ATM E N T O F S U PRAS PI NAT U S The patient is prone with the arm resting on the table or sidelying with the arm resting on the lateral surface of the body and the practitioner stands cephalad to the shoulder. •

The top of the shoulder is lubricated from the acromio­ clavicular join t to the upper angle of the scapula.

•

• •

Gliding strokes may be applied in both la teral and medial directions 7-8 times in the region of the supraspinous fossa to reveal thickened or tender areas; however, if inflammation of the tendon or tendon tear is suspected, gliding only in a lateral direction is suggested to reduce potential stress on the tendon. Deeper pressure through the overlying trapezius, if appropriate, will treat the supraspinatus muscle belly. Often the trapezius will need extensive treatment to reduce upper and middle trapezius tension and associ­ a ted trigger points before deeper pressure can be used.

The trapezius, when softened and its fiber ends approxi­ mated, may sometimes be displaced posteriorly to allow access to a small portion of supraspinatus which lies deep to it. This displacement procedure will usually only allow a small portion of the medial aspect of supraspinatus to be compressed directly. However, this procedure is worth­ while in those cases where displacement is possible. If trigger points are found in supraspinatus, gliding mas­ sage techniques may be applied from the center of its fibers 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. Since this muscle underlies the thick trapezius, which effec­ tively obscures palpa tion, it may be a candidate for trigger point injections when manual methods of release fail to be effective. A fingertip or the tip of the beveled pressure bar may be pressed (caudally) straight into the tissues directly medial to the acromioclavicular joint to treat the tendon of supraspina­ tus through the trapezius fibers. Static pressure is held for 1 0-12 seconds. This procedure is avoided if a supraspinatus tear, subacromial (or subdeltoid) bursitis or bicipital or supraspinatus tendinitis is suspected. The tendon attachment of supraspina tus is addressed with the SITS tendons (in a sidelying position) after the infraspinatus and teres minor muscles have been treated. See description in the teres minor section of this text on pp. 448 and 453.

,� 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 practitioner stands behind the seated patient, stabi­ lizing the shoulder on the side to be treated with one hand while the other hand reaches in front of the patient to support the flexed elbow and forearm. The patient's upper arm is adducted to its easy barrier and the patient then attempts to abduct the arm using 20% of strength against practitioner resistance. After a 1 0-second isometric contraction the arm is taken gently toward i ts new resistance barrier into greater adduction with the patient's assistance. Repeat several times, holding each painless stretch for not less than 20 seconds.

1 3 Shoulder, arm and hand

Lateral rotation: teres minor, posterior deltoid Humeral head stabilization: supraspinatus, teres minor, sub­

Synergists:

scapularis (while serratus anterior stabilizes the scapula) To lateral rotation: pectoralis major, la tissimus dorsi, anterior deltoid

Antagonists:

I n d i cations for treatment • •

/

• •

Pain sleeping on side Difficulty hooking bra behind back or pu tting hand into back pocket Scapulohumeral rhythm test positive (see p. 410) Identification of shortness (see tests below).

Specia l notes

Fig u re 1 3.37 Myofascial release of su praspina tus.

f M F R F O R S U PRASPI NAT U S (FIG. 1 3.37) • This procedure is avoided if partial tear or inflamma­

tion of the supraspinatus tendon is suspected. • • •

•

•

•

The practitioner palpates the dysfunctional muscle, seek­ ing an area of local restriction, fibrosis, ' thickening'. This may lie above the spine of the scapula or on the greater tuberosity of the humerus. Having located an area of al tered tissue texture which is 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. The patient is then asked to slowly but deliberately adduct the arm as far as possible, while the thumb con­ tact (reinforced by the other hand, if necessary) is main­ tained. This process takes the myofascial tissue from a shortened position to its longest and modifies the tissue's status under the thumb. This process should be repeated 3-5 times.

I N F R AS P I N AT U S

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 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 der of the scapula, an area of common complaint. Trigger points in infraspina tus respond favorably to massage appli­ ca tions and manual release methods (Simons et aI 1999). The humeral attachment of infraspinatus is addressed with the SITS tendons (in a sidelying position) after the remaining rotator cuff muscles have been treated. However, as with supraspinatus, if a partial or complete tear is sus­ pected, range of motion tests and stretching procedures should be delayed until the extent of the injury is known.

A S S E SS M E N T F O R I N F RAS P I N AT U S S H O RT N E SS/DYS F U N CT I O N •

• •

•

Attachments: Medial two-thirds o f the infraspinous fossa of

the scapula to the middle facet of the greater tubercle of the humerus Innervation: Suprascapular nerve (C5-6) Muscle type: Postural (type I), shortens when stressed Function: Laterally rotates the humerus, stabilizes the head of the humerus in the glenoid cavity during arm movements

•

•

The patient is asked to touch the upper border o f the opposite scapula by reaching with the forearm behind the head. If this effort is painful, infraspinatus shortness should be suspected. Visual evidence of shortness is obtained by having the 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. This brings the arm into internal rotation and places infraspinatus at stretch (see p. 420, Fig. 13. 10). The practitioner ensures that the shoulder remains in contact with the table during this assessment by apply­ ing light compression onto the anterior shoulder. If infraspinatus is short the forearm will not be capable of resting parallel with the floor, obliging it to point some­ what toward the ceiling.

447

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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 ble. Force should always be built slowly and not suddenly.

Fig u re 1 3.38 Pa lpation of the most latera l fibers of i nfraspina tus.

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 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 matches the tension found within them. Attachment trigger points often form under the inferior aspect of the spine of the scapula. The beveled pressure bar tip is placed parallel to the spine of the scapula and angled at 450 underneath the inferior aspect of the scapula's spine which often has an overhanging ledge. Gentle friction is used to assess the a ttaching fibers for taut bands and tender spots. Static pressure is used to commence treatment of any trigger points found there. If extreme tenderness is found, ice massage may be applied to reduce inflamma tion, which often exists at a ttachment si tes.

!

\ \

\

\ Fig u re 1 3.39 M ET treatment of i nfraspinatus.

'� M ET T R EATM E NT OF S H ORT I N FRAS P I N ATUS , (AN D T E R ES M I N O R) (FIG. 1 3.39) •

• •

The patient is supine, upper arm at right angles to the trunk, elbow flexed so that the forearm is parallel with the trunk, pointing caudad with the palm downwards. This brings the arm into internal rotation and places infraspinatus at stretch. The practitioner applies light compression to the anterior shoulder to ensure that it does not rise from the table as rotation is introduced since this would give a false appearance of stretch in the muscle.

1 3 Shoulder, arm and hand

I. PRT T R EAT M E N T O F I N F RA S P I NAT U S ( M O ST " S U ITA B L E F O R A C U T E P R O B L E M S) •

• •

•

•

The patient is supine and the practi tioner, while standing or seated at waist level and facing the pa tient's head, uses the tableside hand to locate an area of marked ten­ derness in infraspinatus. The patient is asked to grade the applied pressure to this dysfunctional region of the muscle as a '10'. The practitioner's other hand holds the forearm and slowly positions the patient's flexed arm in such a way as to reduce the score to a '3' or less. This will almost always involve the practitioner passively taking the muscle into an increased degree of shortness, involving external rotation together with either abduction or adduction (whichever reduces the 'score' more effi­ ciently), as well as some degree of shoulder extension. When the score is reduced to '3' or less, the position of ease is held for 90 seconds before a slow return to neutral.

Figu re 1 3.40 Myofascial release of infraspinatus.

T R I C E PS A N D A N CO N E U S (FIG. 1 3.41 ) Long head: infraglenoid tubercle of scapula Medial head: posterior surface of humerus (medial and

Attachments: •

•

The practitioner applies mild resistance j ust proximal to the dorsum of the wrist for 1 0-12 seconds as the patient attempts to lift it toward the ceiling, so introducing exter­ nal rotation of the humerus at the shoulder. On relaxation, the forearm is taken toward the floor (combined patient and practitioner action), which increases internal rotation at the shoulder and stretches infraspinatus (mainly at its humeral attachment).

I. M FR TREATM E NT O F S H O RT I N F RASPI NAT U S " (FIG. 1 3.40) •

•

•

•

•

•

The patient is prone and the practitioner palpa tes and locates areas within the muscle with pronounced tension, contraction or fibrosis. The patient lies with the arm on the affected side flexed at the elbow and close to the side of the body in order to bring the muscle into a shortened state. The practi tioner applies a firm, flat compression contact (thenar eminence or thumb) to an area of the muscle just superior and lateral to the dysfunctional area. The patient initiates a slow abduction of the shoulder, extension of the elbow followed by flexion of the shoul­ der to its fullest limit, which will bring the distressed soft tissues under the practitioner's pressure contact. As the movement is performed, a degree of internal rota­ tion should be included so that at the end of the range, the patient's upper arm should be alongside the head, thumb downwards. The arm is then slowly returned to the starting position and the process is repeated (3-5 times).

distal to the radial nerve) and intermuscular septum Lateral head: posterior surface of humerus (lateral and prox­ imal to the radial nerve) and lateral intermuscular septum All three heads: join together to form a common tendon, which attaches to the olecranon process of the ulna Anconeus: dorsal surface of the lateral epicondyle to the 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 stressed (Janda 1983, 1988). Triceps may nevertheless require stretching in order to help normalize trigger points located in its fibers Function: All three heads: extension of the elbow Long head: humeral adduction and extension, counteracts downward pull on head of humerus Anconeus: extension of the elbow, may stabilize ulna dur­ ing prona tion of the forearm Synergists: Extension of the elbow: anconeus Humeral adduction and extension: teres major and minor, latissimus dorsi, pectoralis major (adduction) Antagonists: To extension of the elbow: biceps, brachialis To humeral adduction and extension: pectoralis major, biceps brachii, anterior deltoid Counteracts downward pull on head of humerus by pec­ toralis major and latissimus dorsi

I n d ications for treatment • •

Vague shoulder and arm pain Epicondylitis

449

Triceps brachii lateral head ---If-

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

Suprascapular notch (foramen) Supraspinatus

r------ Cut edge of deltoid

Cut edge of trapezius ---f---:ff

--=:-�__-

-

..

. Infraspinatus -------1--

Teres minor

w>---- Surgical neck of humerus

_ _

Triangula r space

I --:I�

t-

-,.1� ---, -

-

-It---- Medial lip of intertubercular sulcus

Quadrangular space

Triangular interval Teres major Long head of triceps brachii ------1"

Cut edge of lateral head of triceps brachii

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) .

• •

Olecranon bursitis 'Tennis elbow' or 'golfer 's elbow'

Specia I notes The triceps fills the extensor compartment of the upper arm with the long and la teral head superficial to the medial head in the upper two-thirds of the a rm. The medial head is directly available on both the medial and lateral aspects of the posterior arm just above the elbow. The radial nerve lies deep to the la tera l head of triceps and is vulnerable to

entrapment by taut fibers or scar tissue. Care should be taken during deep or frictional massage to avoid irrita tion of the radial nerve. Dellon (1986) noted a significant relationship between the presence of the medial head of the triceps in the cubital tunnel and ulnar nerve subluxa tion. O'Hara & Stone (1996) 'present a case of clearcut compression of the ulnar nerve a t two levels just at and posterior t o the epicondyle by a tightly applied prominent head of the triceps, and at a more distal level beneath an anconeus epitrochlearis muscle'. More information on the cubital tunnel is found on p. 489.

451

452

CLI N I CA L A P P LICAT I O N OF N EU R O M U SCU LAR TECH N I Q U E S : T H E U PP E R BODY

The anconeus, a small, triangular muscle positioned on the posterolateral elbow, is easily addressed when treating the olecranon a ttachment of triceps. It is associated with the triceps through their common action of extension of the elbow and may serve to stabilize the elbow j oint during pronation of the forearm by securing the ulna. The articu­ laris cubiti (subanconeus muscle) is a small slip of the medial head of the triceps and, when present, may insert into the capsule of the elbow joint.

T rieeps long head

Teres minor---t-<e::s::,�f:-/#-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 the floor. 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.

Fig u re 1 3.43 Pa l pation of triceps attachment to sca pula is ach ieved by placing the thumb between teres major and teres m i nor.

f N MT F O R T R I C E PS (see a lso p. 494) The patient is prone with the arm hanging off the side of the table so that the upper arm is supported by the table sur­ face. The posterior aspect of the upper arm is lubricated and proximal gliding strokes are applied in thumb-width rows to cover the entire surface of the posterior upper arm to assess the (superficially positioned) lateral and long heads. The radial nerve lies deep to the lateral head and is vulner­ able to compression with deep pressure. If an electric-like sensation is felt down the arm, the hands are repositioned or lighter pressure used to avoid compression of the nerve. The medial head of triceps lies deep to the other two heads except for just above the elbow, where it lies superfi­ cial on both the medial and lateral sides. The practitioner increases the pressure, if appropriate, and repeats the prox­ imal gliding process to address the medial head through the lateral and long heads. A double-thumb gliding technique may also be used by simultaneously gliding up both medial and lateral aspects of the medial head (deep to the other two heads) wi th pressure from each thumb directed toward the mid-line of the posterior humerus. The a ttachment of the long head of triceps is isolated on the infraglenoid tuberosity of the scapula and treated with sta tic pressure or mild friction (Fig. 13.43) . The practitioner applies resistance to elbow extension while simultaneously palpating the tendon a ttachment to assure its loca tion. I t may b e advantageous t o muscle test and isolate the two teres muscles as well, since the triceps passes between the

Figure 1 3.44 Finger friction of triceps te ndon at the olecranon process. Avoid pressi n g on the u l nar nerve.

teres major and minor before a ttaching onto the scapula (Fig. 13.47) . The olecranon attachment of the triceps is treated w ith finger friction or friction which is carefully applied with the beveled pressure bar (Fig. 13.44) . Pressure should be applied directly on the tendon to . avoid com­ pressing neural structures on each side of this tendon.

M ET T R EAT M E NT O F T R I C E PS (TO E N HA N C E

,� S H O U LD E R FLEXI O N W IT H E LB O W F LE X E D )

" (FIG. 1 3.45) • •

Patient is 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 ipSilateral scapula as possible wi th the arm placed close to the side of the head.

13

Shoulder. arm and hand

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)

/ f

I

I nd i cations for treatme nt • •

Rotator cuff dysfunction Teres minor should always be considered as a possible contributor to upper arm or elbow pain

Figure 1 3.45 M ET treatment position of triceps.

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 to the joint and asks the patient to push the elbow toward the floor for 10 seconds, using no more than 20% of strength as resistance to movement is offered. Following this isometric contraction, the patient is asked to stretch the hand further down the scapula, assisted by the practitioner. The stretch should be held for not less than 20 seconds.

It N M T F O R A N C O N E U S (see a lso p. 449) The anconeus lies just lateral and distal to the olecranon process. It is easily isolated by placing an index finger on the olecranon process and the middle finger on the lateral epicondyle while the practitioner 's hand lies flat against the patient's forearm. The anconeus lies between the two fin­ gers. Short gliding strokes are applied between the ulna and radius (in the space between what the fingers have out­ lined) to assess this small muscle which is often involved in elbow pain. NOTE: The following muscles are addressed with the per­

son placed in a sidelying position (see Repose in cervical region, p. 316). The patient's uppermost arm is often

ommended u n til a full diagnosis discloses the extent and exact location of the tear. Only the most gentle assessment and technique steps may be used until diagnosis is clear.

Teres minor is the third posterior rotator cuff muscle. Along with infraspinatus and posterior deltoid, it antagonizes medial rotation as well as providing stability of the humeral head during most arm movements. Teres minor and infra­ spinatus also act together to counteract the upward pull of the deltoid during abduction of the humerus to prevent upslip of the humeral head. With their downward tension, the humeral head may then rotate into abduction rather than slide superiorly, which might result in capsular damage but will most certainly result in mechanical dysfunction. The long head of triceps passes between teres minor and teres major and is palpated by placing a thumb between these two muscles to contact the infraglenoid tubercle of the scapula. Muscle testing of teres minor and teres major with resisted lateral and medial rotation of the humerus, respec­ tively, helps to identify these two muscles precisely.

ASS E SS M E N T F O R T E R E S M I N O R W E A K N ESS •

placed in a supported position so that the practitioner has both hands free. Alterations can be made in this position, including supporting the arm on the practitioner's shoul­ der, in many cases.

•

Patient is seated, elbow flexed t o 900 with the arm touching the side of the body and the humerus internally rotated. The practitioner cups and stabilizes the elbow with one hand while the palm of the other hand holds just proximal to the wrist to maintain the humerus in internal rotation.

453

454

CLI N I CAL A P PL I CAT I O N OF N E U RO M USCU LA R TEC H N I Q U E S : T H E U P P E R B O DY

A

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.

•

•

The patient is asked to externally rotate the humerus (,Twist your upper arm against my resistance' or 'I a m going t o try t o turn your a r m inward and y o u should resist, against my hand on your wrist, as strongly as you can') and the practi tioner grades the relative strength of the action and compares one side with the other. 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.

f N MT FO R T E R E S M I N O R The patient is placed in a sidelying position with the arm to be treated lying uppermost. The arm is placed in passive flexion at 90° and is supported there by the pa tient. This position is hereafter referred to as the supported arm posi­ tion (see sidelying supported arm position, p. 316). The practitioner stands, kneels or sits caudad to the extended arm and uses both hands (or the caudad hand) to grasp the posterior aspect of the axilla with a pincer compres­ sion as close to the head of the humerus as possible. The fin­ gers are placed on the posterior surface of teres minor while the thwnbs rest on the anterior (axillary) surface (Fig. 13.46). The practitioner 's grasp encompasses the teres major and la tissimus dorsi fibers but does not compress them as the thwnb and fingers are placed precisely on and capture the teres minor. Muscle testing with mildly resisted lateral rotation will produce contraction of teres minor to assure direct palpa­ tion (similar technique shown in Fig. 13.47 with patient prone). The muscle is relaxed before treating it. Pressure is applied with precision and local twitch responses monitored from both sides of the muscle. As the

--

--------... B

Figure 1 3.47 The pa l pating thumb feels fi bers of teres m i nor (A) contract with resisted latera l rotation w h i l e teres major (B) con tracts w ith m edial rotation. Shown here in prone position ; similar steps can be perfo rmed in sidelyi n g position.

tissue releases and softens, a light stretch may be applied until ta ut fibers are again distinctive. A firm nodule (or nest of them) wi thin a ta ut band is often present near the center of the fibers. Pressure that matches the tension in the tissue and reproduces the patient's pain pa ttern confirms the pres­ ence of a trigger point, which often can be effectively released with trigger point pressure release. Compression, friction or snapping palpa tion is used on the full length of teres minor and its scapular attachments wuess a tear is suspected, which would warrant more cau­ tion. It a ttaches to the third facet of the greater tubercle of the humerus, which is often tender to palpation. The patient's arm is draped forward to lie passively across the chest. The practitioner assesses the scapular attachment

1 3 Shou lder, arm a nd hand

Fig u re 1 3.48 Teres major and teres minor attachments of the lateral (axillary) border of the sca p u l a are often 'su rprising ly' tender.

of teres minor by sliding a thumb along the upper two-thirds of the lateral (axillary) border of the scapula (Fig. 13.48). If appropriate, static pressure or light friction is applied to any tender points or trigger points in the a ttachment site or, if inflammation is suspected, ice therapy is applied. The teres major attachment is located on the remaining lower one-third of this border and may be ad dressed in a similar manner. To trea t the SITS tendons, the arm remains draped across the patient's chest. When the humerus is so positioned, the humeral head is in flexion combined with extreme horizon­ tal adduction and can be further laterally rotated. This posi­ tion rotates the greater tubercle of the humerus posterior to the acromioclavicular joint and makes the facet attachment of supraspinatus available to palpation (through the del­ toid). The attachment of supraspinatus faces directly toward the practitioner along with the second and third facet attachments of infraspinatus and teres minor, respec­ tively (Fig. 13.49). Unless contraindicated by extreme tenderness or suspi­ cion of rotator cuff tear, the practitioner cautiously applies friction or static compression directly to the insertion of each of the SITS tendons. The tendon attachment of the fourth rotator cuff muscle, subscapularis, is treated with the anterior su rface of the joint capsule (see Fig. 13.85). MET for teres minor is the same as for infraspinatus described above.

Fig u re 1 3.49 The SIT tendons are easily accessed posterior to the acrom ion when the patient is side lying and the arm is d ra ped across the chest.

) (

Fig u re 1 3.50 Stra i n -cou nterstra in (PRT) for teres m i n o r.

• •

•

'6 PRT F O R T E R E S M I N O R ( M OST SU ITA B L E F O R " ACUTE P R O B L E M S ) (FIG. 1 3.50) •

The patient is supine and the practitioner (standing or sitting at waist level and facing the patient's head) uses

------ ----

•

the tableside hand to locate an area of marked tenderness in teres minor on the lateral border of the scapula close to the axilla. The patient is asked to grade the applied pressure to this dysfunctional region of the muscle as a '10'. The practitioner 's other hand holds the forearm and slowly posi tions the patient's flexed arm in such a way as to reduce the score to a '3' or less. This will almost always involve the practitioner pas­ sively taking the muscle into an increased degree of shortness, involving a degree of shoulder flexion, abduc­ tion and external rotation. When the score is reduced to '3' or less, the position of ease is held for 90 seconds before a slow return to neutral.

455

456

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 : THE U PP E R BODY

Figu re 1 3.51 Com posite trigger point target zones for medial rotators, Drawn after Simons et al (1 999),

) -f/jf---'f----'l.-- Latissi mus dorsi

T E R E S M AJ O R (FIG, 1 3,51 ) Attachments: Oval area on the dorsal surface of the scap ula

(near the inferior angle) to the medial lip of the intertu­ bercular sulcus of the humerus Innervation: Lower subscapular nerve (C5-7) Muscle type: Phasic (type II), weakens when stressed Function: Assists medial rotation and extension of the humerus against resistance, adducts the humerus, partic­ ularly across the back Synergists: Medial rotation: la tissimus dorsi, long head of triceps, pectoralis major, subscapularis

Extension of humerus: latissimus dorsi, posterior deltoid and long head of triceps Antagonists: To medial rotation: teres minor, infraspinatus, posterior deltoid To extension of humerus: pectoralis major, biceps brachii, an terior deltoid, coracobrachialis

I n d ications for treatme nt • •

Pain upon motion Pain at full overhead stretch,

1 3 Shoulder, a rm and hand

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 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 (2006) provide a similar report on the use of latissimus dorsi for a comparable procedure, which they report as successful W1less subscapularis function is deficient. Jost et al (2003) report use of pectoralis major transfer for patients with an irreparable subscapularis tear.

f N MT F O R T E R ES M AJ O R The patient remains in a sidelying supported arm position (see p. 316). The practitioner stands caudad to the extended arm and uses one or both hands to grasp the posterior aspect of the axilla with a pincer palpation similar to that used for teres minor. The palpating fingers are positioned 1-2 inches (2.5-5 cm) toward the free border of the posterior axillary fold and directly contact teres major (Fig. 13.52) . Muscle test­ ing with resisted medial rotation will help distinguish teres major fibers from those of teres minor, which are relaxed (inhibited) during medial rotation. Latissimus dorsi will also activate during medial rotation along with teres major and should be distinguishable from it (see Fig. 13.47B). The practitioner applies p incer compression, friction or snapping palpation onto the en tire length of teres major. If appropriate, the teres major fibers may be slightly stretched by moving the humerus into further flexion. The fibers of latissimus dorsi are usual ly distinguished from those of teres major since they continue past the scapula and into the lower back (see Fig. 13.51). The patient's arm is draped forward to lie passively across the chest. The practitioner stands in front of the patient and assesses the scapular attachment of teres major by slid­ ing a thumb along the lower third of the lateral (axillary)

Fig u re 1 3.52 Compression of be l ly of teres m ajor.

border of the scapula. The scapular attachment is often ten­ der; therefore a l ighter pressure is used before increased pressure is applied. Trigger points in the attachment sites require that the associated central trigger points are deacti­ va ted . If inflammation is suspected, ice therapy is applied . The teres minor a ttachment is located on the remain ing upper two-thirds of this border and may be addressed in a similar manner (Fig. 1 3.48).

,� PRT F O R T E R ES M AJ O R ( M OST S U I TA B L E F O R , A C U T E P R O B L E M S) (FIG. 1 3.53) •

• •

• •

•

•

The patient is seated and the practitioner, while standing behind, locates an area of marked tenderness in teres major close to its attachment on the lower lateral surface of the scapula. The patient is instructed to grade the applied pressure to this dysfunctional region of the muscle as a '10'. The practitioner's other hand holds the forearm, bring­ ing the arm backwards, internally rotating the humerus and slowly positioning the patient's extended arm in such a way as to reduce the 'score' markedly. The position is a virtual 'hammerlock' position. This will almost always involve the practitioner pas­ sively taking the muscle into an increased degree of shortness which involves shoulder extension, adduction and internal rotation. Long-axis compression toward the shoulder, through the humerus, may provide additional ease to the painful ten­ der point. vVhen the score is reduced to '3' or less, the position of ease is held for 90 seconds before a slow return to neutral.

458

CLI N I CAL A P PLICAT I O N OF N EU RO M USCU LAR TECH N I Q U E S : TH E U P P E R B O DY

Specia l notes

Fig u re 1 3.53 Stra i n-co u n terstra in (PRTj position for teres major.

LAT I SS I M U S D O RS I Attachments: Spinous processes of T7-12, thoracolumbar

fascia (anchoring it to all lumbar vertebrae and sacrum), posterior third of the iliac crest, 9th-12th ribs and (some­ times) inferior angle of scapula to the intertubercular groove of the humerus Innervation: Thoracodorsal (long subscapular) nerve (C6-8) Muscle type: Postural (type I), shortens when stressed Function: Medial rotation when arm is abducted, ex tension of the humerus, adducts the humerus, particularly across the back, humeral depression; influences neck, thoracic and pelvic postures and (perhaps) forced exhalation, such as to cough (Platzer 2004) Synergists: Medial rotation: teres major, pectoralis major, subscapularis, biceps brachii Extension of humerus: teres major and long head of triceps Adduction of humerus: most anterior and posterior fibers of deltoid, triceps long head, teres major, pectoralis major Depression of shoulder girdle: lower pectoralis major, lower trapezius Antagonists: To medial rotation: teres minor, infraspinatus, posterior deltoid To extension of humerus: pectoralis major, biceps brachii, anterior deltoid To humeral head distraction: stabilized by long head of tri­ ceps, coracobrachialis To depression of shoulder girdle: scalenes ( thorax elevation), upper trapezius

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 when the latissimus contractures and myofascial restric­ tions are released, especially if they were 'tying down' the shoulder girdle. Latissimus dorsi has been successfu lly harvested to replace subscapularis in rotator cuff ruptures (Gerber et al 2006), used in postmastectomy flap reconstruction (Sweetland 2006) and has even been the host site for the growing of a replace­ ment mandible for a cancer patient (Fricker 2004). While the impact on the latissimus dorsi tissues that results from the invasive na ture of these surgeries certainly presents a unique set of challenges, the almost certain improvement in the quality of life would likely be worth the consequences.

A S S E SS M E N T F O R LATI S S I M U S D O R S I S H O RT N ESS/ DYS F U N CT I O N •

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or •

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I n d i cations for treatment • •

Mid-back pain in referred pa ttern not aggravated by movement Identification of shortness (see tests below).

The patient lies supine, knees flexed, with the head 1 .5 feet (45 cm) from the top edge of the table, and ex tends the arms above the head, resting them on the treatment surface with the palms facing upward. If la tissimus is normal, the arms should be able to easily lie flat on the table above the shoulder. If the arms are held laterally, elbow(s) pulled away from the body, then latissimus dorsi is probably short on that side.

•

The standing patient is asked to flex the torso and allow the arms to hang freely from the shoulders while holding a half-bent position, trunk parallel with the floor. If the arms are hanging other than perpendicular to the 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 ward of such a position, then trapezius or deltoid short­ ening is possible). To assess latissimus in this position (one side at a time), 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.

•

•

remains in this half-bent position). While stabilizing the scapula with one hand, the practitioner grasps the arm just proximal to the elbow and gently draws the (straight) arm forward. If there is not excessive 'bind' in the tissue being tested, the arm should easily reach a level higher than the back of the head . If this is not possible, then la tissimus is shortened.

� N MT F O R LATI SSI M U S D O R S I (FIG. 1 3.54) The patient remains in a sidelying position with the arm supported as in the treatment of teres major. Myofascial release may be easily applied before or immediately follow­ ing these techniques (Fig. 13.55). The practitioner sits (or stands) caudal to the supported arm and grasps the latissimus dorsi, which is the remaining muscular tissue in the free border of the posterior axillary fold. Pincer compression is used in a similar manner to that used for teres major. Beginning near the humerus, the prac­ titioner assesses the la tissimus dorsi's long fibers at hand­ width intervals until the rib attachments are reached. These upper fibers ' tie' the humerus to the lower ribs. Ischemic bands are often found in this portion of the muscle and cen­ tral trigger points are found at mid-fiber region of this most lateral portion of the muscle, which is approxima tely halfway between the humerus and the lower ribs. The practitioner stands with the (sidelying) pa tient's arm placed over the practitioner's upper shoulder to elevate the latissimus dorsi and lift i ts lower fibers (somewhat) away

Fig u re 1 3.55 A broad appl ication of myofascial release to the axil lary reg ion.

from the thorax, which makes them easier to grasp. In this position, control of the arm is easily maintained while mov­ ing it into varying positions to stretch the fibers and define taut bands for loca tion and palpation. Sometimes the fibers are more defined and respond more quickly in a stretched position but less pressure is usually needed when the tissue is treated in a stretched position. Once located, the fibers may be more easily lifted away from the torso (and manu­ ally stretched) if tension on them is red uced. Hence, varying the position of the humerus will assist the practi tioner in discovering the best position for accessing and also for treating the la tissimus fibers. The attachments onto the spinous processes, sacrum and iliac crest may be addressed with friction, glides or static pressure, depending on tenderness level. The beveled pres­ sure bar can be used to apply friction or static pressure tech­ niques throughout the lamina groove and sacrum while thumbs are best used along the top of the iliac crest. These portions of the latissimus dorsi are discussed more thor­ oughly in Volume 2 of this text (lower body) as this muscle is very often associated with pelvic distortions.

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1M M ET T R EAT M E N T O F LAT I SS I M U S D O RS I " (FI G . 1 3.56) • • • • •

•

•

•

• •

The patient lies supine with one leg crossed over the other one at the ankle. The practitioner stands on the side opposite the side to be trea ted at waist level and faces the table. The patient slightly sidebends the torso contralaterally (bending toward the practitioner). With the legs straight, the patient's feet are placed j ust off the side of the table to help anchor the lower extremities. The patient places the ipsilateral arm behind the neck as the practitioner's cephalad hand slides under the pa tient's shoulders to grasp the axilla on the treated side, while the patient grasps the practitioner 's arm at the elbow. The practitioner 's caudad hand is placed lightly on the anterior superior iliac spine on the side to be treated, in order to offer stability to the pelvis during the subse­ quent contraction and stretching phases. The patient is instructed to very lightly take the point of that elbow toward the sacrum while lightly trying to bend backwards and toward the treated side. The practi­ 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 simus dorsi. After 7 seconds the patient is asked to relax completely as the practitioner, utilizing body weight, sidebends the 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 latissimus dorsi.

1M PRT FOR LATI S S I M U S D O R S I ( M OST S U ITA B L E " FO R ACUTE P R O B L E M S ) (FIG. 1 3.57) •

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• •

•

•

The patient is supine and lies close to the edge of the table. The practitioner is tableside, at waist level, facing cephalad. Using the tableside hand, the practitioner searches for and locates an area of marked localized tenderness on the upper medial aspect of the humerus, where latissimus attaches. The patient is instructed to grade the applied pressure to this dysfunctional region of the muscle as a '10'. The practitioner 's non-tableside hand holds the patient's forearm close to the elbow and eases the humerus into slight extension or compression, ensuring (by 'fine­ tuning' the degree of extension) before the next move­ ment that the 'score' has reduced somewhat. The practitioner then internally rotates the humerus while also applying light traction or compression in such a way as to reduce the pain 'score' more. When the score is reduced to '3' or less, the position of ease is held for 90 seconds before a slow return to neutral.

S U B S CA P U LA R I S (FIGS 1 3.58, 1 3.59) Attachments: Subscapular fossa (costal surface of scapula) to the lesser tubercle of the humerus and the articular capsule

Fig u re 1 3.57 Stra in-cou nterstra in posi tion for treatment of l atissimus dorsi.

1 3 Shoulder, a rm and hand

Innervation: Superior and inferior subscapular nerves

Synergists:

(CS-6)

Medial rotation: latissimus dorsi, pectoralis

major, teres major

Adduction of humerus: most an terior and posterior fibers

Muscle type: Postural (type I), shortens when stressed Function: Medial rotation and adduction of humerus, stabi­

lization of humeral head

of deltoid, triceps long head, teres major, pectoralis major Humeral head stabilization: supraspinatus, infraspinatus, teres minor Antagonists: To medial rotation: infraspinatus, teres minor To adduction: deltoid, supraspinatus

Transverse humeral ligament Long head of biceps brachii

I nd i cations for treatment

Short head of biceps brachii --f-+f--+-

•

Coracobrachialis

• •

Loss of lateral rotation and abduction of the humerus, 'frozen shoulder' syndrome Difficulty in reaching as if to throw a ball overarm Identification of shortness (see test below).

Specia l notes

-ir�jb!f-- Tendon of biceps brachii

Figure 1 3.58 The muscles of the anterior shoulder. Reproduced with permission from Gray's Anatomy for Studen ts (2005).

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 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 subscapularis dysfunction may result in adhesive capsulitis

Figure 1 3.59 Su bsca p u l a ris referral patterns to the posterior shoulder and i n to the a nterior and posterior wrist. Drawn after Simons et al ( 1 999).

Subscapularis

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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

(Cailliet 1991). Additionally, the subscapularis lies in direct relationship with serratus anterior within the scapulotho­ racie joint space. Myofascial adhesions of these tissues to each other may contribute to full or partial loss of scapular mobili ty. The tendon of subscapularis passes over the anterior joint capsule and lies horizontally between the two a lmost vertical tendons of biceps brachii. It may be injured or torn when the person falls backwards and throws the hands back to bear the body's weight. This impact will force the head of the humerus anteriorly against the joint capsule and the tendon of subscapularis, which overlies the anterior joint capsule (Cailliet 1991). The subscapular bursa lies between the tendon and the joint capsule and commW1i­ cates with the capsule between the superior and middle glenohumeral ligaments while the subcoracoid bursa lies between the subscapularis and the coracoid process. Both bursae communicate with the shoulder joint cavity and therefore may play a role in true frozen shoulder syndrome if they become inflamed (Cailliet 1991, McNab & McCulloch 1994, Simons et al 1999). Ice may be applied if inflammation of the tendon or bursa is suspected or if the region is fOW1d to be excessively tender.

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 •

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•

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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 rests on the medial edge of the contralateral shoulder. The practitioner places the fingers of the caudad (treat­ 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 facing the ribs. The hand will (eventually) slide deeper into the subscapular space (Fig. 13.60A) . Once the fingers are 'prepositioned', the patient is asked to slowly reach toward the anterior or lateral surface of the contralateral shoulder. While the patient slowly moves the hand, the practitioner gently releases the humerus and slides the cephalad hand under the torso to 'hook' the fingers onto the vertebral border of the scapula. The scapula is tractioned laterally by the cephalad hand as the caudal hand slides further medially on the ventral surface of the scapula and presses onto the subscapularis (Fig. 13.60B). There may be a marked reaction from the patient when this muscle is touched, indicating acute sensitivity.

Figu re 1 3.60 ARB: Access to su bsca pularis is significantly i ncreased as the scapula tra nslates latera l ly (with assistance) with proper arm posi tioning.

O B S E RVAT I O N OF S U B S CAPU LAR I S DYS F U N CT I O N/S H O RTN ESS (see p . 422) •

• •

•

The pa tien t is supine with the arm abducted to 90°, the elbow flexed to 90° and the forearm in external rotation, palm upwards. The whole arm is resting at the restriction barrier, with gravity as i ts coun terweight. If subscapularis is short the forearm will be unable to rest easily, parallel with the floor, but will be somewhat ele­ vated, with the hand pointing toward the ceiling. This position might also implicate pectoralis minor. Care is needed to prevent the shoulder lifting from the table, so giving a false-nega tive result (i.e. allowing the forearm to achieve parallel status with the floor by means of the shoulder lifting) .

13

Shoulder, arm and hand

Figure 1 3.61 A small portion of subsca pularis may be reached i n the sidelying position.

ASS ESSM E N T OF W EA K N E S S I N SU BSCAPU LAR I S •

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The patient i s prone with humerus abducted to 90°, the elbow flexed to 90° and the humerus internally rotated so that the forearm is parallel with the torso and the palm faces toward ceiling. The practitioner stabilizes the scapula with one hand and with the other applies pressure (toward the floor) to the pa tient's distal forearm to externally rotate the humerus against the patient's resistance. The strength of the two sides should be compared.

f N M T F O R S U B SCAPU LAR I S The patient is placed in a sidelying position (see p . 316) with the arm supported by the patient or placed on top of the practitioner 's shoulder when the practitioner is seated in front of the patient at the level of the pa tient's chest. The pa tient's arm is tractioned directly forward as far as possible to translate the scapula la terally and allow maximum palpa­ ble space on the ventral (anterior) surface of the scapula. The practitioner 's cephalad hand lies on the posterolat­ eral portion of the shoulder and can be used to support the shoulder 's position. The bellies of teres major and latissimus dorsi comprise the posterior axjJjary fold. Subscapularis resides medial to both of these muscles and fills the sub­ scapular fossa on the ventral surface of the scapula. The practitioner locates the lateral edge of the scapula (medial to teres major and la tissimus dorsi) with the thumb of the cau­ dal hand and slides the thumb medially onto the anterior surface of the scapula where subscapularis resides. The elbow of the practitioner 's treating arm must remain low to assure the proper angle of the thumb (Fig. 13.61).

Figu re 1 3 .62 M ET treatment of su bsca pula ris.

Since this muscle is often ex tremely tender, mild pressure is initially used and increased only if appropriate. The practitioner applies static pressure for 1 0-12 seconds a t thumb-wid th intervals onto a l l accessible portions o f sub­ scapularis. If not too tender, repea t the process while increasing the static pressure or by applying a snapping (unidirectional) transverse friction. Repeat the entire process 3-4 times during the session while allowing short breaks in between applications of pressure. The humeral attachment and a portion of the tendon of subscapularis may be treated between the two bicipital ten­ dons on the anterior surface of the humeral head; this is dis­ cussed with biceps brachii (p. 482). Recurrent bicipital tendinitis and frozen shoulder may both improve consider­ ably after the (horizontal) subscapularis tendon is treated between the two (vertical) biceps tendons. Note: The palpation exercise described previously as 'Assessment of subscapularis dysfunction / shortness' is also an excellent position for treatment of this muscle as i t allows for substantially greater access to the fibers o f this 'hidden' muscle.

It M ET F O R S U BSCAPU LA R I S (FIG. 1 3.62) •

•

The pa tient is supine with the arm abducted to 90°, the elbow flexed to 90° and the forearm in external rotation, palm upward. The whole arm is resting a t the restriction barrier, wi th gravity as i ts counterweight.

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C L I N ICAL A P P LI CATI O N OF N E U RO M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY

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•

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Care is needed to prevent the anterior shoulder from becoming elevated in this position (moving toward the ceiling) and so giving a false-normal picture. The patient raises the forearm slightly, rotating the shoul­ der internally, pivoting at the elbow against light resist­ ance offered by the practitioner on the lower forearm, and holds the resistance for 7-1 0 seconds. Following relaxation, gravity or slight assistance from the practitioner takes the arm into external rotation and through the soft tissue resistance barrier, where it is held for at least 20 seconds.

I. PRT F O R S U B S CA P U LA R I S ( M OST S U ITA B L E " F O R A C U TE P R O B L E M S) • •

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•

The patient is supine and lying so that the arm being treated is close to the edge of the table. The practitioner locates a n area of marked tenderness on the anterior border of the scapula, using the procedure outlined above for direct palpa tion assessment. The patient is instructed to grade the applied pressure to this dysfunctional region of the muscle as a '10'. The practitioner's other hand holds the arm above the elbow and eases it into slight extension and asks the patient for a score. If no reduction is reported, 'fine-tuning' of the degree of extension is carried out to achieve this. Once a reduction in the score is reported, the practitioner then internally rotates the humerus in such a way as to reduce the 'score' further. When the score is reduced to '3' or less, the position of ease is held for 90 seconds before the arm is slowly returned to neu tra!'

S E R RATU S A N TE R I O R (FIG. 1 3.63) Superior part: outer and superior surface of ribs 1 and 2 and intercostal fascia to the costal and dorsal surfaces of the superior angle of the scapula Intermediate part: outer and superior surface of ribs 2, 3 and (perhaps) 4 and intercostal fascia to the costal surface along almost the entire medial border of the scapula Inferior part: outer and superior surface of ribs 4 or 5 through 8 or 9 and intercostal fascia to the costal and dor­ sal surfaces of the inferior angle of the scapula Innervation: Long thoracic nerve (CS-7), which lies on the external surface of the muscle Muscle type: Phasic (type II), weakens when stressed Function: Stabilization of the scapula during flexion and abduction of the arm; rotates the scapula laterally to make the glenOid fossa face upward; abducts the scapula and therefore protracts the shoulder girdle; assists in ele­ vating the scapula; presses the scapula to the thorax, counteracting 'winging' of the scapula; may be an acces­ sory muscle of inspiration during abnormal or demand­ ing breathing patterns Synergists: Protraction of scapula: pectoralis minor and upper fibers of pectoralis major Upward rotation of the glenoid fossa: trapezius Elevation of scapula: levator scapula, upper trapezius, rhomboids Fixation of scapula during arm movements: rhomboids, mid­ dle trapezius Antagonists: To protraction: rhomboids, latissimus dorsi, middle trapezius To upward rotation of the glenoidfossa: la tissimus dorsi, pec­ toral muscles, levator scapula, rhomboids

Attachments:

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

Ind ications for treatment • • • • • •

Shortness of breath due to trigger points 'Winging' of the scapula (reflexive, inhibited weakness) Scapula fixation flat to the thorax (tense fibers) Loss of expansion of rib cage during inhalation Disrupted scapulohumeral rhythm Restriction of adduction of the scapula

Shoulder. a rm and hand

perpetuate myofascial trigger points as well (Simons et al 1999). CAUTION: Caution m ust b e exercised in the deep axil­ lary regions as lymph nodes are present and should be avoided, especially if enlarged. If enlarged lymph nodes or other masses are found, the patient should immedi­ ately be referred to the proper healthcare professional to confirm or rule out breast cancer, thoracic or systemic infection or other serious pathology.

Speci a l notes Serra tus anterior is synergistic with pectoralis minor to pro­ tract the scapula in practically all reaching and pushing movements. It serves to stabilize the scapula (pressing in onto the thorax to counteract 'winging'), rotate and abduct it, and assists in elevating it. Without the stabilization that serratus anterior offers, the function of many other muscles that pull on the scapula will be affected. Serratus anterior is also an accessory breathing muscle, recruited during demanding situations rather than normal breathing patterns. Y\'hether its fibers are activated and how much they are activated will vary depending upon the con­ ditions. When it is inhibited, unusual demand may be placed on other respiratory muscles, such as the scalenes and sternocleidomastoid, when the serratus would nor­ mally be used. This overload may lead to associated trigger point formation in these and other respiratory muscles, although it is not always clear which comes first - the abnormal respiratory pattern or the trigger points (Simons et aI 1999). The long thoracic nerve, which innervates serratus ante­ rior, lies vertically on the surface of the muscle in the line of the axillary fold and is therefore vulnerable during palpa­ tion. Additionally, portions of this nerve supply may pass 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 rax. However, since 'winging' can sometimes be relieved when trigger points in this muscle are inactivated (Simons et aI 1999), the condition may be a result of a combination of activation of antagonists (reflex facilitation) and weakness induced within the serratus since it is a phasic muscle and weakens when stressed (Janda 1996, Simons et al 1999). Weakness in the serratus anterior would affect the patient's ability to raise the arm as well as push away with the arm. Herpes zoster lesions often run the course of intercostals nerves, forming on the skin surface superficial to the serra­ tus anterior. These lesions are extremely painful, have a long recovery process and often recur. Care should be taken to avoid stimulating them through examination of tills mus­ cle, particularly during the early stages of this condition when they are the most tender and prone to spread into fur­ ther eruptions. During the early stages of eruption, herpes zoster pain may mimic that of serratus or intercostal trigger points and herpes viruses are likely to aggravate and

Trigger points in serratus anterior, as well as the diaphragm and external oblique, may produce a 'stitch in the side' com­ plaint, especially when a high demand is placed on it for excessive breathing. The pain may be accompanied by the inability to take a full breath as serratus anterior and sur­ rounding tissues restrict movement of the ribs. Injection of these trigger points should only be attempted when manual methods of release have failed and then only by the most highly skilled practitioner, due to the risk of thoracic punc­ ture (Simons et aI 1999).

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 A N TE R I O R • •

•

The patient adopts a position on all fours with weight placed mainly onto the arms rather than knees. On slightly flexing the elbows, the scapulae are observed to see whether they wing or deviate laterally, which indi­ cates weakness of serratus anterior (there is some influ­ ence from lower trapezius in this assessment but it focuses mainly on serra tus) . The implication, according to Lewit (1985) and Janda (1996), is that excessive tone in the upper fixators of the shoulder and accessory breathing muscles is probably inhibiting these lower fixators.

� N MT F O R S E R RATU S A NT E R I O R The patient remains in a sidelying position with the arm rest­ ing in the supported arm position without forward pull on the arm. The practitioner stands caudad to the extended arm and uses the thwnb of the most caudal hand to perform the ther­ apy. The patient's arm may be placed on the practitioner 's shoulder for support and elevation, which will also allow bet­ ter access to portions of the serratus anterior that lie deep to the scapula, or can be supported by the patient (Fig. 13.64). The practitioner palpates the fibers of serratus anterior on the lateral chest wall to determine the level of tenderness and whether friction or gliding strokes are appropriate to apply. Treatment begins illgh in the axilla and progresses down the lateral surface of the thorax. Each palpable segment of serratus anterior is wider than the one before, forming a triangular treatment area with the vertex of the triangle in the axilla. As the treatment pro­ gresses down the lateral thorax, the vertical (often extremely tender) fibers of the pectoralis minor are encountered on the

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Box 1 3. 1 0 M FR MFR stands for myofascial release. A number of different approaches a re clustered u nder this heading. John Barnes ( 1 996) describes MFR as the appl ication of pas­ sive (practitioner active, patient passive) gentle pressure to restricted myofascial structures, in the direction that will stretch the tissues as far as 'their col lagenous barrier'. Sustained pressure resu lts in the 'creep' phenomenon (see Cha pter 1 ) , a g radual elongation and ultimately 'freedom from restriction'. 2. Mark Barnes ( 1 997) states: 'Myofascial release is a ha nds-on soft tissue technique that facilitates a stretch into the restricted fascia. A sustained pressure is applied into the restricted tissue barrier; after 90- 1 20 seconds the tissue will undergo h istological l ength changes a l lowing the first release to be felt. The therapist follows the release into a new tissue barrier and holds. After a few releases the tissue will become softer and more pliable'. 3. Mock (1 997) offers a different, more active (both practitioner and patient) form of myofascial release methodology. 'Ad hesions' (described as 'ropy', 'leathery', 'fibrous', 'nodular', etc.) are identified in soft tissues by means of pa l pation. Various release methods are described, the most active involv­ ing compression of the dysfu nctional tissue as the muscle in which it is found is taken, four or five times at one treatment session, either passively or actively, through a ra nge of move­ ment from its shortest to its longest length. This effectively 'drags' the 'adhesion' u nder the compressive contact and ' releases' it. 1.

Fig u re 1 3.64 When serratus a n terior is exqu isitely tender, gentle l u b ricated g l iding strokes may be substituted for frictional techniques, w hich (u n l ike the g l iding strokes) can be performed t h rough a cover sheet.

most anterior aspect. The scapula forms the posterior bor­ der of the palpable region and may be lifted away from the thorax so as to reach as much of the muscle as possible by sliding the treating thumb under the lateral aspect of the scapula to apply friction or gliding strokes onto the rib cage. If the muscle fibers are not excessively tender, light fric­ tion is applied in between and on the ribs to assess and treat the serratus anterior. If extremely tender, light-pressure gliding strokes (anterior to posterior) are applied to an area tha t begins at the top of the lateral chest (in the axilla) and ends at the bottom of the rib cage. The more tender the mus­ cle, the lighter the pressure should be. If the lightest pres­ sure is still too much, cryotherapy (ice applications) may be substituted and the treatment a ttempted again at a future session. Progressively more pressure may be applied as the tenderness subsides with treatment, unless osteoporosis or recent rib fractures contraindicate pressure techniques. The friction or gliding techniques may be repeated a t thumb-width intervals, from the pectoralis minor t o as far posteriorly as possible and from the axilla to the 9 th rib. Allowing the tissue to rest between applications of gliding strokes or friction will often produce dramatic reduction of tenderness. Myofascial release techniques may also be used on the lateral surface of the body. Note: MET applied to the upper fixators of the shoulder (if they test as short), notably upper trapezius, to release hypertonicity would automatically increase tone in serra tus an terior.

I. FACI LITATI O N O F TO N E I N S E R RAT U S , ANTE R I O R U S I N G PU L S E D M ET (Ruddy 1 962) This technique is used for rehabilitation and proprioceptive reed uca tion of a weak serratus anterior. •

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The patient is seated or standing and the practi tioner places a single-digit contact very lightly against the lower medial scapula border, on the side of the upper trapezius being treated. The patient is asked to a ttemp t to ease the scapula (at the point of d igital contact) toward the spine. The request is made, 'Press against my finger with your shoulder blade, toward your spine, just as hard (i.e. very lightly) as I am pressing against your shoulder blade, for less than a second'. Once the pa tient has managed to establish control over the particular muscular action required to achieve this subtle movement (wruch can take a significant number of a ttempts) and can do so for 1 second at a time, repeti­ tively, the sequence based on Ruddy'S methodology (see Chapter 10) can be commenced. The patient is instructed, 'Now that you know how to activate the muscles which push your shoulder blade lightly against my finger, I want you to do this 20 times in 10 seconds, starting and stopping, so that no actual movement takes place, just a contraction and a stopping, repetitively'.

1 3 Shoulder, arm and hand

Cephalic vein

Subclavius

Pectoral branch of thoracoacromial artery

Lateral pectoral nerve ----f---�_+----­ Pectoralis minor -----t--+-''f'---..r,.,--Clavi pectoral fascia -----t---fTf--:''d---:­ Pectoralis major -------;r---::� 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, middle and lower trapezii and serratus an terior, all of which are probably inhibited if upper trapezius is hyper­ tonic. The repetitive contractions also produce an a uto­ matic reciprocal inhibition of upper trapezius. The patient should be taught to place a light finger or thumb contact against the medial scapula (opposite arm behind back) so tha t home application of this method can be performed several times daily.

P E CTO RALIS M AJ O R (FIGS 1 3.65, 1 3.66) Attachments:

Clavicular portion: sternal half of the anterior

surface of the clavicle Sternal portion: sternum

Costal portion: costal cartilage of ribs 2-6 (or 7) Abdominal portion: superficial fascia of external obligue and (sometimes) upper part of rectus abdominis; all portions converge into a tendon a ttaching to the lateral lip of the intertubercular sulcus of the humerus at its greater tubercle In nervation: Medial and lateral pectoral nerves (C5-Tl) Muscle type: Postural (type 1), shortens when stressed Function: Adduction (and horizontal adduction), medial 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 is fixed (such as in pull-ups), lowers the raised arm (ster­ nal, costal, abdominal), p ulls the shoulder girdle down and forward (sternaL costal) or up and forward (clavicu­ lar), accessory in deep (forced) respiration

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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

Synergists: Adduction: teres major (and perhaps minor), anterior and posterior deltoid, subscapularis, triceps (long head), latissimus dorsi Medial rotation: latissimus dorsi, teres major, subscapularis Flexion of humerus: supraspina tus, an terior deltoid, biceps brachii, coracobrachialis Protraction of shoulder: subscapularis, pectoralis minor, serratus anterior, subclavius Depression of shoulder: la tissimus dorsi, lower trapezius, serratus anterior Assist clavicular section: anterior deltoid, coracobrachialis, subclavius, scalenus anterior, sternocleidomastoid Assist lower fibers: subclavius, pectoralis minor Antagonists: To sternal section: rhomboidii, middle trapezius To adduction: supraspinatus, deltoid To medial rotation: teres minor, infraspinatus, posterior deltoid; the clavicular and costal fibers antagonize each other in raising and lowering the arm to horizontal

Indications for treatment • • • • •

Back pain between the scapulae Pain in front of the shoulder, in the chest and / or down the arm Intense chest pain Breast pain Symptoms of vascular thoracic outlet syndrome

Special notes The pectoralis major is one of the most complex muscles of the shoulder region, having four sections, a spiraling twist to its lamina ted layers and crossing three joints (sternoclav­ icular, acromioclavicular, glenohumeral) to influence sev­ eral movements of the upper extremity. The complex arrangement of its layers of laminae is best viewed from behind (as shown exquisitely by Simons et al (1999) in Figure 42.5) as an anterior view primarily encompasses only the superficial layers. To form the anterior axillary fold, the dorsal layers fold under the ventral layers in a spi­ ral so that the lowest fibers attach highest on the humerus. Pectoralis major is one of many muscles whose trigger points can refer pain that mimics true cardiac pain. While it is important to rule out these trigger points as the source of false angina, it is even more important to rule out ischemic heart disease as the source of viscerosomatic chest pain. If trigger points are a source of a mimicking angina pattern and the pattern is abolished, an underlying true cardiac condition may still exist even though the external pain pat­ tern has been eliminated. Similarly, once a cardiac condition is stabilized and chest pain still exists, trigger points may be found to be the source of the long-lasting (and fear­ provoking) pain (Simons et al 1999), long after the source of the pain has been removed. Pectoralis major or underlying intercostal fibers may contain trigger pOints associated with cardiac arrhythmias,

a somatovisceral referral that causes irregular heart beats. The associated trigger points are found between the 5th and 6th ribs on the right side while trigger points in a similar position on the left side mimic ischemic heart disease. In the condition of thoracic outlet syndrome, pectoralis major and subclavius should be trea ted due to their down­ ward pull on the clavicle. This tension, coupled with upward pull of the 1st and 2nd ribs by the scalene muscles, can close the subclavicular space, leading to impingement of the neurovascular and /or lymphatic structures serving the upper extremity, which by definition is thoracic outlet syn­ drome (Simons et al 1999). Additionally, pectoralis minor may produce a similar result a few inches further inferolat­ erally along the neurovascular course and the scalene mus­ cles may entrap the cervical nerves as they exit the vertebral column (especially when brea thing patterns are abnorma l). Chronic shortening of pectoralis major and minor pro­ 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 other muscles that influence this dysfunctional posture is important in an effort to regain proper aligrunent. Further, the rhomboids and lower trapezius are often inhibited and weak, which allows the forward slumping. A postural retraining program should be implemented which incorporates length­ ening, strengthening and awareness exercises to avoid recur­ ring dysfunctional postural patterns which are often induced by chronic work positions and recreational habits. Overlying the pectoralis major are mammary tissues and the nipple of the breast. In both genders, but significantly in a higher percentage of females, breast cancer is a condition for which surgical removal, various types of reconstruction and significant tissue damage may be presented; 99% of breast cancer cases occur in women. Fifty years ago a woman's chance of developing breast cancer was 1 in 20 while today's chances are 1 in 8 (DeLany 1999, Fitzgerald 1998, National Cancer Institute 2006). It is the second leading cause of cancer dea ths in women and is the leading cause of all death in women aged 40-55. Poshnastectomy care is a condition often presented to the manual practitioner for rehabilitation of the upper extremity and chest muscles. Since breast cancer is a life-threa tening condition, it is criti­ cally important that a comprehensive treatment plan with a qualified healthcare professional be initiated as soon as a breast cancer diagnosis has been made. Traditional treatments include surgery, radiation, chemotherapy and hormonal drugs (DeLany 1999, Fitzgerald 1998, National Cancer Institute 2006). Each of these treatments has its own posttreat­ ment side effects and special precautions must be taken in each case. Consulta tion with the patient's physician(s) and a clear understanding of her particular condition and trea tment plan is recommended before beginning myofascial therapy. Great care must be used when addressing poshnastec­ tomy tissues, especially w i th reconstruction efforts or lymph node removal (Chikly 1999). The myofascial tissues of the area may be extremely tender and the site of incision

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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

Figure 1 3.67 Test for strength of pectora lis major. A : I ncorrect procedu re. B : Correct procedure (beca use shoulder is stabil ized).

may not have healed completely. In the case of radiation therapy, extreme cau tion must be taken with any tissue that was irradiated as i ts capillaries are often more fragile. Aggressive therapies, such as friction, skin rolling or even myofascial release, may result in permanent injury to the capillary vessels. This would include all muscles of the region tha t was irradiated and potentially those that lie on the posterior surface of the body through which the radia­ tion would also pass. Special care is advised with postmastectomy cases to avoid increasing lymph congestion within the extremity (Chikly 1999), to avoid stretching the incision tissue until well healed and to avoid working with certain techniques when edema or inflammation already exists. Unless otherwise contraindi­ cated, lymph drainage and antiinflamm a tory techniques (e.g. cryotherapy) may be applied to these tissues until the tissue conditions change to allow massage applications. Special training may be needed to safely apply lymphatic drainage and other techniques in cancer recovery therapy. Other less aggressive techniques, such as myofascial release or mild stretching techniques, may be applied to associated muscles until the questionable tissues can be safely treated with NMT. Ex treme tenderness to even mild touch, redness, swelling and heat within the tissues all indi­ cate an inflammatory response, which could be in tensified or spread with NMT applica tions. Consultation with the patient's phYSician is strongly advised and special training in postmastectomy care is suggested, especially if the prac­ titioner 's experience is limited in this area .

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 M AJ O R •

The patient lies supine with the head several feet from the top edge of the table and is asked to ex tend the a rms above the head and rest them on the trea tment surface with palms facing up.

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If pectoralis major is normal the arms should be able to easily reach horizontal (parallel with the floor) while being directly in contact with the surface of the table for the entire length of the upper arms. There should be no arching of the back or twisting of the thorax. If an arm cannot rest with the dorsum of the upper arm in contact with the table surface, withou t effort, then pec­ toral fibers (major and /or minor) are almost certainly short. Assessment of the sternal portion of pectoralis major involves abduction of the arm to 90° (Lewit 1985). In this position the tendon of pectoralis major at the sternum should not be found to be unduly tense even with maxi­ mum abduction of the arm, unless the muscle is short. For assessment of costal and abdominal attachments the arm is brought into elevation and abduction as the mus­ cle as well as the tendon on the greater tubercle of the humerus is palpated. Tautness will be visible and tenderness of the tissues under palpa tion will be reported, if the sternal fibers have shortened.

ASS ES S M E NT F O R STR E N GTH O F P E CTO R A L I S MAJ O R [FIG. 1 3.67) •

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Patient is supine with arm in abduction a t the shoulder joint and medially rotated (palm is facing down) with the elbow extended. 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 other hand. The patient a ttempts to lift the arm and to bring it across the chest, against resistance, as strength is assessed in the sternal fibers. Different arm positions can be used to assess clavicular and costal fibers.

1 3 Shoulder, arm and hand

!\

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).

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For example, with an angle of abduction with elevation 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.

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 portions.

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 the pectoralis major 'pulls away' from the chest wall. The 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. 13.68) . Although the practitioner could be standing to per­ form this technique, a seated posi tion is recommended to decrease wrist stress and avoid bending at the waist (which may produce low back strain). If the wrist does feel strained, the practitioner should change position in such a way that the wrist rests in a neutral position, which usually involves moving toward the pa tient's feet. Pincer pa lpation is used to isolate and assess each section of the muscle (in small portions) while avoiding intrusion onto breast tissues. If not too tender and unless otherwise contraindicated, each of the three sections of pectoralis major is manipulated by rolling the fibers between the thumb and fingers of the examining hand . Taut bands tha t are adhered t o one another m a y separate and can then be addressed more independently. The practitioner continues to examine the fibers i n thumb-width segments while moving toward the hwneral insertion (Fig. 13.69) . Repeat the process for all divisions of

Figure 1 3.70 The arm is tractioned forward to pull the clavicle away from the underlyi n g neu rovascular structu res.

pectoralis major. Thickness usually associa ted with trigger points is often found in the mid-fiber region. When nodules, exquisitely tender spots or taut fibers are found, the practi­ tioner locates and isolates the trigger points and applies static compression for 8-1 2 seconds which may provoke classic referral pa tterns into the breast tissues, onto the chest and down the arm. Addi tionally, a ligh t stretch placed on the fibers may make the ta ut fibers more palpable and may also augment the release. To treat the clavicular a ttachment of pectoralis major and subclavius (see p. 477) which lies deep to i t, the patient remains in a sidelying position and the practitioner stands cephalad to the pa tient's head. The patient's supported arm is pulled as far forward as possible to distract the clavicle from the chest. The fingers of the 'face-side' (treating) hand are 'curled' onto the inferior surface of the clavicle and fric­ tion is applied to the entire length of the inferior aspect of the clavicle to treat the clavicular a ttachment of pectoralis major and subclavius (Fig. 13.70). The supraclavicular fossa

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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

is avoided as the brachial plexus and blood vessels lie here and may be damaged by excessive pressure. Pectoralis major is usually thick and pressure may need to be increased to influence subclavius, which lies deep to it. However, the pressure should be d irected onto the inferior surface of the clavicle and not deeply into the torso as the neurovascular bundle serving the upper extremity a lso courses through the subclavicular area. When addressing subclavius in this position, the arm should be pulled so far forward that the patient almost rolls forward, which will pull the clavicle even further away from the chest wall and help to protect the neurovascular structures. Following the trea tment of pectoralis minor in the sidely­ ing posi tion (see pp. 316 and 476), the patient moves to a s upine position. The sternal and costal attachments of pec­ toralis major and sternalis are assessed by the practitioner who stands at the level of the chest on the side being treated. Lubrica ted gliding strokes, friction or myofascial release may be applied to the remaining portions of pec­ toralis major while care is taken not to intrude on breast tis­ sue. The pa tient's hand may be used to displace and protect the breast while the practitioner examines the a ttachments along the sternum and the portion of the muscle that lies caudal to the breast. Slow, transverse friction is applied to the sternum to examine for a sternalis muscle or trigger points within the fascia covering the sternal area. These trigger points may refer a deep ache to the chest and pain down the upper arm (details regarding sternalis are found on p. 479). The practitioner locates the top of the xiphoid process or where the two sides of the ribs meet if the xiphoid is not pal­ pable. The practitioner's palpating finger moves laterally onto the right side (approximately 2 inches (S cm), depend­ ing upon body size) and into the rib space between the 5th and 6th ribs. The practitioner palpates on the ribs and in between the ribs on pectoralis major and intercostal muscle fibers for tenderness and trigger points. These 'cardiac arrhythmia' trigger points may refer into the heart and cause disturbances in i ts normal rhythm (Simons et a1 1999) (Fig. 13.71). Though the trigger point is located on the right side, the corresponding points on the left side should a lso be treated to eliminate contralateral referrals, which may perpetuate these vola tile trigger points.

It M ET F O R P E CTO R A L I S M AJ O R •

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The pa tient lies supine with the arm abducted in a direc­ tion which produces the most marked evidence of pec­ toral shortness (assessed by palpation and visual evidence of the particu lar fibers involved). The more elevated the a rm (i.e. the closer to the head), the more focus there will be on costal and abdominal fibers. With a lesser degree of abduction, to around 45°, the focus is more on the clavicular fibers.

------- -

- \... ' /1

\ Figure 1 3.71 The stern a l i s has a frighten i n g 'cardiac-type' pa i n pattern i ndependent o f m ovement while the 'cardiac a rrhythmia' trigger point (see fingerti p) contributes to distu rbances i n normal hea rt rhyth m without pa i n referra l . Drawn after Simons et al ( 1 999). • •

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Between these two extremes lies the position which influ­ ences the sternal fibers most directly. The patient lies as close to the side of the table as possible so tha t the abd ucted arm can be brought below the hori­ zontal level in order to apply gravitational pull and pas­ sive s tretch to the fibers, as appropria te. The practi tioner stands on the side to be treated and grasps the humerus while the other hand contacts the insertion of the shortened fibers (on a rib or near the ster­ num or clavicle, depending upon which fibers are being treated and which arm position has been adopted). The thenar and hypothenar eminence of the contact hand stabilizes the area during the contraction and stretch, preventing movement of it but not exerting any pressure to stretch it. The patient's hand should be placed on the contact area so tha t the practitioner's hand can be placed over i t, allowing i t to act as a 'cushion'. This hand placement is for physical comfort and also prevents physical contact with emotionally sensitive areas, such as breast tissue. All stretch is achieved via the positioning and leverage of the arm; the contact hand on the thorax (whether directly or 'through' the patient's hand) acts as a stabilizing con­ tact only. As a rule, the long axis of the pa tient's upper arm should be in a straight line with the fibers being trea ted. A useful hold, which depends upon the relative sizes of the patient and the practitioner, involves the practitioner grasping the anterior aspect of the patient's flexed upper arm just above the elbow, while the patient cups the

1 3 Shou lder, arm and hand

,---�---

Figure 1 3.72 M ET trea tment of pectora l i s major, supine position. Figu re 1 3.73 M ET treatment of pectora l i s m ajor, prone position.

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practitioner's elbow and holds this contact throughout the procedure (Fig. 13.72). Starting with the patient's a rm in a position which takes the affected fibers to just short of their restriction barrier, the patient introduces a light contraction (20% of strength) involving adduction against resistance from the practitioner, for 7-1 0 seconds. If a trigger point has previously been identified in pec­ toralis major, the practitioner should ensure, by means of palpation if necessary or by observation, that the fibers housing the triggers are involved in the contraction. As the patient exhales following complete relaxation of the area, a stretch through the new barrier is activated by the patient and maintained by the practitioner. The stretch needs to be one in which the arm is first pulled away (distracted) from the thorax before the stretch is introduced which involves the humerus being taken below the horizontal. During the stretching phase i t is important for the entire thorax to be stabilized . No rolling or twisting of the tho­ rax in the direction of the stretch should be permitted. The stretching procedure should be thought of as having two phases: 1. the slack being removed by distracting the arm away from the contact/ stabilizing hand on the thorax 2. movement of the arm toward the floor, initiated by the practitioner bending the knees. Stretching should be repeated 2-3 times in each position. All a ttachments should be treated, which calls for the use of different arm positions, as discussed above, as well as different stabilizing ('cushion') contacts as the various fiber directions and attachments are stretched.

�� A LT E R N ATIVE M ET F O R P E CTO R A L I S M AJ O R , (FIG. 1 3.73) • •

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Patient is prone with face in a face hole or cradle. The patient's right arm is abducted to 90° and the elbow flexed to 90°, palm toward the floor, with upper arm sup­ ported by the table. The practitioner stands at waist level facing cephalad and places the non-tableside hand palm to palm with the patient's so that the patient's forearm is in contact with the ventral surface of the practi tioner 's forearm. The practitioner's tableside hand rests on the patient's right scapula area, ensuring that no trunk rotation occurs. The practitioner eases the patient's arm into extension a t the shoulder until the first sign of resistance from pec­ toralis is sensed. It is important when extending the arm in this way to ensure that no trunk rotation occurs and that the anterior surface of the shoulder remains in con­ tact with the table throughout. The patient is asked, using no more than 20% of strength, to bring the arm toward the floor and across the chest, with the elbow taking the lead in this attempted move­ ment, which is completely resisted by the practitioner. The practitioner ensures that the patient's arm remains par­ allel with the floor throughout the isometric contraction. Following release of the contraction effort and on an exhalation, the arm is taken into greater extension, with the patient's assistance, and held at stretch for not less than 20 seconds. This procedure is repeated 2-3 times, slackening the muscle slightly from i ts end-range before each subse­ quent contraction, to reduce discomfort and for ease of application of the contraction.

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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

Muscle type: Not determined Function: Draws the shoulder down and forward, rotates

the scapula (depressing the glenoid), accessory in deep (forced) respiration, lifts the inferior angle and medial border of the scapula away from the ribs Synergists: Deep respiration: diaphragm, scalenes, inter­ costa Is, levator scapula, sternocleidomastoid, upper trapezius Shoulder depression: pectoralis major, latissimus dorsi, lower trapezius Forward pull and rotation of scapula: pectoralis major Downward rotation: rhomboids, levator scapula Antagonists: To protraction and rotation of scapula: lower trapezius To shoulder depression: upper trapezius, levator scapula Figure 1 3 .74 Pa l pation of pectora lis major fo r M FR appl ication.

I n d i cations for treatment •

Varia tions in pectoralis fiber involvement can be achieved by altering the angle of abduction: with a more superior angle (around 140°), the lower sternal and costal fibers; with a lesser angle (around 45°), the clavicular fibers will be committed.

" M FR •

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F O R P E CTORA L I S M AJ O R (FIG. 1 3.74)

Patient is supine with arm in abduction at the shoulder joint and medially rotated so that the palm is facing down and the elbow is extended. The practitioner palpates and assesses pectoralis major until areas of restriction, congestion or fibrosis are discovered. The arm is then brought into adduction to slacken the muscle fibers. The slackening process is further encouraged by means of light compression from the upper humerus toward the lower sternum. A broad flat (finger pads or thumb) digital contact is then made just d istal to the dysfunctional tissues. The patient is then asked to move the arm to its fullest abduction and then back into adduction, lengthening and shortening the m uscle, and so intermittently drag­ ging the dysfunctional tissues under the compressive force of the practi tioner 's fingers or thumb. 3-5 repetitions are normally adequate for each contact area. Different arm positions can be used to trea t the various pectoral fibers in the same manner.

P E CTORA L I S M I N O R Attachments: O uter and upper surfaces of 3rd through 5th

ribs (sometimes 2nd through 4th) and fascia of a djoining in tercostals to the medial aspect of the coracoid process Innervation: Medial and lateral pectoral nerves (C5-T1)

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Chest pain similar to cardiac pain Restricted humeral movements (particularly in reaching overhead) Constriction of nerve or blood flow when reaching over­ head or sleeping with the arms resting overhead (neu­ rovascular entrapment syndrome)

Specia l notes Postural implications of pectoralis minor have been dis­ cussed previously with the overlying pectoralis major. Widely prevailing slumping postures created by tightness in pectoralis minor are readily noticeable (along with forward head position) when viewing the body from the side (coro­ nal plane). Kyphosis often accompanies the 'depressed' look of this postural position, as do repressed breathing patterns. Impingement of neurovascular structures that course deep to pectoralis minor may create duplication of symp­ toms of thoracic outlet syndrome. In such a case, the patient will report loss of feeling in the hand or a tendency to drop objects, particularly when reaching up to a shelf to retrieve them. Additionally, the radial pulse (which is being simul­ taneously palpated) will d isappear as the axillary artery becomes occluded when the practitioner administers the Wright maneuver, a positioning which places the arm in hyperabduction or, in some cases, by merely abducting the humerus to 90° with lateral rotation (see Simons et al 1999, p. 350, Fig. 43.4). Trigger points in pectoralis minor can refer into the breast, creating pain and hypersensitivity of the breast and nipple, into the chest and anterior shoulder, down the ulnar side of the arm and into the last three fingers and palmar hand. Whereas scalenus anticus is more likely to produce hand edema and finger stiffness by entrapment of the subclavian vein, the authors' cl inical experience indica tes that fascial restrictions and scar tissue, due to surgery or other traumas, near the coracoid process may also occlude lymph drainage of the upper extremi ty. This consideration is especially

1 3 Shoulder, arm and hand

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•

Tissues which su rround neura l structu res, and which move independently of the nervous system, are cal led the mechanical interface (MI) (e.g. supinator muscle is the MI to the radial nerve, as it passes through the radial tunnel). Any pathology in the MI may produce tension on the neura l structure, with unpredictable results (e.g. disc protrusion, osteophyte contact, carpal tun nel constriction). Symptoms are more easily provoked in active movement rather than passive tests. Pathophysiolog ical changes resu lting from i nflammation or from chemi ca l damage (i.e. toxic) a re noted as commonly leading on to internal mechanical restrictions of neural structures in a different man ner from mechanical causes, such as those imposed by a disc lesion, for example. Adverse mechanical tension (AMT) changes do not necessarily affect nerve conduction (Butler Et Gifford 1 989) but Korr's ( 1 981) research shows it to be likely that axonal transport wou ld be affected. Maitland (1 986) suggests that treatment (placing the neura l structures at tension, i n t h e test positions) involves 'mobil ization' of the neural structures, rather than sim ply stretching them, and recommends that these tests be reserved for conditions which fa il to respond adequately to normal mobil ization of soft and osseous structures (muscles, joints and so on), for example by use of tech niq ues such as NMT or MET.

Notes 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 ' sensitizing' additions) it only indicates that AMT exists some­ where in the nervous system. 2. The restriction is not, however, necessa rily at the site of reported pain. 3. When tissues housing myofascial trigger poi nts a re stretched, pain and other sensations may result. This can add a deg ree of confusion when evidence derived from use of the tension tests is being eva luated. GEN ERAL PRECAUTIONS AND CONTRAINDICATIONS Care shou ld be taken when introducing sideflexion of the neck d u ring the u pper limb tension test. • If any a rea is sensitive, care should be taken not to aggravate existing cond itions d uring the performance of tests. • If obvious neurological problems exist special care shou l d be taken not to exacerbate the condition by vigorous or strong stretching. • Similar precautions apply to d iabetic, MS or recent surgica l patients or where t h e area being tested i s much affected by circulatory deficit. • The tests should not be used if there has been recent onset or worsening of neu rological signs or if there is any cauda equina or cord lesion.

•

General advice regard ing use of these methods • Usua lly treatment positions that encourage release of mechan ical restrictions impinging on neura l structures involve rep lication of the test positions. • Butler ( 1 99 1 ) suggests that initial stretching should commence well away from the site of pain in sensitive individuals and conditions. • Retesting regu larly during treatment is usefu l, in order to see whether there are gains in range of motion or lessening of pain provoked during testing. • Any sensitivity provoked by treatment should subside im mediately fol lowing application of a test position/stretch. If it does not, the technique/test should be stopped to avoid i rritation of the neura l tissues involved.

•

Additional tests to assess for shortened muscle structures and joint restrictions wou ld a lso be appropriate, as these may be the cause of adverse tension i n the nervous system.

Upper limb tension tests (ULTI) Both versions of the ULT test described below should be used in cases i nvolving thoracic, cervical and u pper limb symptoms, even if this i nvolves only local finger pai n . U LTI 1 1 . Patient is supine and the practitioner places the tested a rm into abduction, extension and lateral rotation of the glenohumeral joint. 2. Once these positions a re establ ished, supination of the forearm is introduced together with el bow extension. 3 . This is followed by addition of passive wrist and finger extension. If pa in or sensations of tingling or n u mbness are experienced at a ny stage during the positioning into the test position or during addition of sensitization maneuvers (below), particularly reproduction of neck, shoulder or arm symptoms previously reported, the test is positive; this confirms a deg ree of mechanical in terference affecting neural structu res. Additional sensitization is performed by: • • • •

adding cervical lateral flexion away from the side being tested, or 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 introduction of pronation rather than supi nation of the wrist.

ULTI 2 Butler maintains that ULTI 2 replicates the working posture i nvolved in many instances of u pper limb repetition disorders. 1 , To perform right-side ULTI 2, the patient l ies close to right side of the table, i.e. sca pula is free of the su rface. 2. Tru n k and legs are a ngled toward the left foot of the table. 3, The practitioner stands to right side of the patient's head facing the 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 and wrist. 5. Variations in the degree and angle of shou l der depression ('l ifted' toward cei l i ng, held toward floor) may be used. 6. Holding the shoulder depressed, the practitioner's right hand grasps the patient's right wrist while the el bow is held by the practitioner's left hand.

Sensitization options include: • • •

shoulder internal or external rota tion elbow flexion or extension forearm su pi nation or pronation.

A com bi nation of shou lder internal rotation, el bow extension and forearm pronation is the most sensi tive. The practitioner then sl ides the right hand down onto the patient's open hand, with the thumb between the patient's thumb and i ndex fi nger and i ntroduces supi nation or pronation, ulnar or radial deviations or stretching of fi ngers/th umb. Further sensitization may involve: • •

neck movement (e.g. side bend away from tested side) or altered shoulder position, such as increased a bduction or extension.

Notes Butler ( 1 99 1 ) reports that where mechan ical interface restrictions are present, cervical lateral flexion away from the tested side increases arm symptoms in 93% of people a nd cervical lateral flex­ ion towards the tested side increases symptoms in 70% of cases. • ULTI mobil izes the cervical dural theca in a tra nsverse d i rection.

•

47 5

476

C LI N I CA L A P P L I CATI O N OF N E U R O M USCU LA R TEC H N I Q U ES : T H E U P P E R BODY

important if lymph node removal was necessary, particu­ larly from the subclavicular area. (See additional informa­ tion regarding the lymphatic system on pp. 29-31.) Simons et al ( 1999) note that pectoralis major can occlude lymphatic drainage of the breast and that trigger points which form in posttraumatic scar tissue in the regions of pectoralis minor's coracoid a ttachment are relieved by trigger point injection. However, extreme caution is advised when injecting tho­ racic muscles to avoid penetration into the thoracic cavity. Additional slips of the muscle are sometimes noted, vary­ ing in number and level (Gray's Anatomy 2005, Platzer 2004, Simons et al 1999), including fibers extending to the greater tuberosity of the humerus (Simons et al 1999). More rare variations include pectoralis minimus (coracoid process to the first rib) (Gray's Anatomy 2005) and pectoralis inter­ medius (from rib cartilages to the fascia covering biceps brachii and coracobrachialis) (Simons et al 1999). Though rarely absent, pectoralis minor may be present or absent when pectoralis major is missing (Gray's Anatomy 2005).

Fig u re 1 3.75 When pectora lis m i nor is extremely tender, m i l d static pressure is substituted for frictional tech niques.

� 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 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 (Fig. 13.75). This m uscle may become significantly wider at 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 too tender, these steps are repeated (gently) 2-3 times. Often, static compression will release the fibers more readily, espe­ cially after the light friction has been applied at least once. With the patient in the supine position, pectoralis minor may be further addressed through pectoralis major. With the elbow flexed to 90°, the arm is placed in an abducted, exter­ nally rotated ('Hi') position (Fig. 13.76). Myofascial release may be used superficial to pectoralis minor (through pec­ toralis major). The pressure should be toward the clavicle rather than toward the breast to avoid stretching the fascia and ligaments that support the breast tissue. This step may also help to bring the shoulders back into coronal alignment.

t �

-

'/�'l) ),

- ---' '--' ----

Figure 1 3.76 Trigger point ta rget zones for pectora l is m i nor. Draw n after Si mons et al ( 1 999).

Gentle friction may also be applied through pectoralis major while transversing the fibers of pectoralis minor, coracobrachialis and short head tendon attachment of biceps brachii as long as the supporting structures of the breast mentioned above and neurovascular structures deep to the coracoid are respected. Biceps tendon and coraco­ brachialis l ie laterally and perpendicularly oriented to pec­ toralis minor in this arm position. The muscle fibers are all stretched when the arm is in this position of extreme lateral rotation and less pressure is used to avoid tearing the fibers or provoking a reflexive spasm. MET and MFR treatments of pectoralis major (pp. 472-474) would a lso involve (to an extent) pectoralis minor.

1 3 Shoulder, arm and hand

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

I n d ication for treatment •

Figu re 1 3.77 Di rect myofascial stretch for pectora lis m i nor.

D I R ECT ( B I LAT E RAL) MYO FAS C I A L STRETCH

�� O F S H O RT E N E D P E CTO R A L I S M I N O R

, (FIG. 1 3.77) • •

• •

•

•

•

•

•

The patient is supine with the arms comfortably at the side. The practitioner, while standing at the head of the table, internally rotates the arms and places the palms of the hands (having ensured nails are well clipped) into the axilla, palms touching the medial humerus, thumb side of index fingers touching the axilla . At this stage the dorsum of the finger pads are located under the lateral border of each pectoralis minor. The practitioner now slowly externally rotates the arms and, using gentle pressure, insinuates the fingertips (index, middle and ring - the small finger and thumb play no part in this method) under the lateral border of the muscle. The hands, the palms of which are now facing medially, are then drawn lightly toward each other (medially) until all the slack in pectoralis minor has been removed. The practitioner 's hands then slowly, deliberately and painlessly lift the tissues toward the ceiling, easing the muscle away from its attachments until a ll slack has been removed (i.e. no actual s tretching is taking place at this stage, merely a removal of all slack). The practitioner should then transfer body weight back­ wards to introduce a lean which removes the slack further, by tractioning in a superior direction (toward the head). The muscle fibers will now have been eased medially, anteriorly and superiorly and should be held at these combined barriers as they slowly release over the next few minutes. If correctly applied, this should not be painful or prove invasive to breast tissue. The procedure is normally both well accepted and effective in releasing tensions at the lower end of the thoracic inlet.

Pain under clavicle and down the arm

Specia l notes This muscle has a short, thick tendon and is difficult to pal­ pate or access for electromyography. It may be absent but that would be difficult to determine manually since it underlies the thick clavicular head of pectoralis major. Some of its fibers may be influenced through pectoralis major if care is taken to avoid intruding on the neurovascu­ lar complex that lies deep to a portion of it. The pain pattern for subclavius is significant as it is one of numerous muscles referring a pattern that mimics ischemic cardiac disease. As discussed in other areas of this book, referral to a phYSician is advised to rule out cardiac involvement. Sanders & Hammond (2005) report potential occlusion of the subclavian vein by subclavius and surrounding tissues.

Unilateral arm sweLLing without thrombosis, when not caused by lymphatic obstruction, may be due to subclavian vein compression at the costoclavicular Ligament because of compression either by that ligament or the subclavius tendon most often because of congenital close proximity of the vein to the Ligament. Arm symptoms of neurogenic TOS [thoracic outlet syndrome), pain, and paresthesia often accompany venous TOS while neck pain and headache, other common symptoms of neurogenic TOS, are infrequent. NMT techniques for subclavius are presented with pec­ toralis major (p. 471).

It M FR FOR S U B C LAVI US • • •

The muscle lies deep to pectoralis major, between the 1st rib and the clavicle. The patient abducts and internally rotates the arm. The practitioner makes digital contact with the muscle by applying broad flat finger pad pressure as far under the clavicle as possible, without causing undue discomfort.

477

478

C L I N ICAL A P P LI CAT I O N OF N EU RO M USCU LAR TECH N I Q U E S : TH E U PP E R BODY

Proprioceptive neuromuscular fac i litation (PNF) methods have been incorporated into useful assessment and treatment seq uences (McAtee Et Charland 1 999). These ideas have been modified to take account of MET principles (Chai tow 2003).

•

•

On complete relaxation, the practitioner, with the patient's assistance, takes the arm further into flexion, adduction and external rotation, stretching these m uscles to a new barrier. The sa me procedure is repeated 2-3 ti mes.

1 Stretch i nto extension • To i ncrease the ra nge of motion i n flexion, adduction and external rotation. • The patient l ies supine with the head turned to the left and ensures that the shoulders remai n i n contact with the table throughout the procedure. • The patient flexes, adducts and externally rotates the (right) a rm ful ly, maintaining the elbow in extension (pa l m facing the ceili ng). • The practitioner sta nds a t the head of the table and supports the patient's a rm a t proximal forearm and hand. • The patient is asked to beg i n the process of returning the arm to the side, in stages, against resistance offered by the practitioner. • The amount of force used by the patient should not exceed 250/0 of available strength. • The first instruction is to pronate and i nternally rotate the a rm ('Turn you r arm inwardly so that your pa l m faces the other way'), followed by abduction and then extension ('Bring your arm back outwards and to your side'). • All these efforts are combined by the patient into a sustained effort wh ich is resisted by the practitioner so that a 'compound' isometric contraction occurs involvi ng i nfraspina tus, m iddle trapezius, rhomboids, teres m inor, posterior deltoid and pronator teres.

2 Stretch i nto flexion • To i ncrease the ra nge of motion in extension, abduction and internal rotation. • The patient l ies supine and ensu res that the shoulders remain in contact with the table throughout the procedure. • The patient extends, abducts and internally rotates the (right) arm fu l ly, maintaining the elbow in extension (wrist pronated). • The practitioner stands at the head of the table and supports the patient's arm at d istal forearm and elbow. • The patient is asked to begin the process of retu rning the arm to the side, in stages, against resistance. • The amount of force used by the patient should not exceed 25% of available strength. • The first instruction is to supinate and externally rotate the arm ('Turn your arm outwardly so that your palm faces the other way'), followed by adduction and then flexion ('Bring your arm back toward the table and then u p to your side'). • All these efforts are combined by the patient into a sustained effort which is resisted by the practitioner, so that a 'compound' isometric contraction occurs i nvolving the clavicular head of pectora lis major, anterior deltoid, coracobrachial is, biceps brachii, infraspinatus a nd supinator. • On complete relaxation, the practitioner with the patient's assistance takes the arm further into extension, abduction and i nternal rotation, stretching these m uscles to a new barrier. • The sa me procedure is repeated 2-3 times.

Fig u re 1 3.78 Spira l M ET a pp lication to increase range of flexion, add uction a n d externa l rotation of shoulder.

Fig u re 1 3.79 Spiral M ET a p p l ication to increase ra nge of extension, a b d u ction and i nternal rotation of shou lder.

1 3 Shoulder, arm a nd hand

of a ventraL longitudinaL coLumn muscle Layer arising at the ventral tip of the hypomeres (Sadler, 1995). Sadler claimed that this muscle is represented by rectus abdominis in the abdominaL region and by the injrahyoid muscuLature in the 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 pectoralis major accompanied by an enormous sternalis. BarLow (1934), on the other ha.nd, claimed that sternaLis represents the remains of a panniculus carnosus.

Box 1 3. 1 3 Sterna lis ",d chest pam Chest pain referred from this muscle [sternal is) has a terrifying quality that is remarkably i ndependent of body movement. (Simons et a 1 1 999)

•

•

The patient is then asked to adduct and externally rotate the shoulder slowly and delibera tely while firm digital pressure is maintained. This should be repeated 3-5 times.

STE R N A L I S Attachments: A vertical slip ascending from the sheath of rectus abdominis, fascia of the chest or costal cartilages of the lower ribs to merge with the fascia of upper chest, attach to the sternum or blend with sternocleidomastoid Innervation: Varies considerably, but usually intercostal nerves or the medial pectoral nerve Muscle type: Not determined Function: Unknown Syn ergis ts : Not applicable Antagoni sts : Not applicable

Ind ications for treatment • •

Soreness on surface of the sternum Deep, intense pain internally deep to the sternum

NMT techniques for sternalis are presented with pectoralis major (pp. 471-472).

C O RAC O B RAC H IA L I S (FIG. 1 3.80) Attachments: From the coracoid process to mid-way a long the medial border of the humera l shaft (between the tri­ ceps and brachialis muscle) Innervation: Musculocu taneous nerve (C6-7) Muscle type: Postural (type I), shortens when stressed Function: Flexes the arm forward and a dducts it, seats the humeral head into the glenOid fossa d uring abduction, may assist in returning the arm to neutral position Sy nergi s ts : FLexion of humerus: anterior deltoid, biceps brachii (short head), pectoraliS major Antagonists: To flexion: latissimus dorsi, posterior deltoid, teres major, triceps (long head)

I nd i catio ns for treatment Special notes Sternalis remains one of the great mysteries of modern anatomy. Since function is unknown and no apparent movement has been determined, the evolu tion of this mus­ cle continues to intrigue those who study the locomotor sys­ tem. To add to the mysterious nature of this anomalous muscle, i ts presence is highly variable: it may be unilateral or, if bilateral, may not be symmetrical in length or size and its attachments as well as innervation are unpredictable. It is present on average 4.4% of the time but cadaver stud­ ies range from 1.7 to 14.3% (Simons et al 1999). It is half as likely to be bilateral as unilateral; however, when present, it is likely to develop trigger points following acute myocardial infarction or angina pectoralis and needlessly prolong the fear associated with the pain of heart a ttack (Simons et aI 1999). Trastour et al (2006) note that sternalis is present in 5-8% of people. They note that since physicians are usually not familiar with it this might lead to misdiagnosis as it 'may be misinterpreted as a breast mass on mammogram'. In a published correspondence, Jeng & Su (1998) offer a few more ideas regarding sternalis.

Although the importance of this muscle is still a mystery, various different interpretations have been made. CLemente (1985) considered sternaLis to be a mispLaced pectoraLis major, although some embryoLogists have viewed it as part

• •

Pain in front of shoulder and down the posterior arm Pain when reaching across the lower back

Speci a l notes This muscle's position allows it to be stretched with both medial and lateral rotation of the humerus. It assists in adduction and may (uniquely) also assist in hyperabduc­ tion by pulling the arm toward the mi d-line in both of these vertical positions. Approximately half of i ts belly can be touched directly beneath the skin before it courses deep to pectoralis major on its way to the coracoid process. The practitioner 's thumb may slide under pectoralis major to touch an additional small portion of this muscle. The practitioner must exercise caution on the inner surface of the upper humerus to avoid pressing on the neurovascular bundle which courses poste­ rior to (musculocu taneous nerve usually pierces) coraco­ brachialis by palpating for the arterial pulse and remaining anterior to the pulse.

A S S E S S M E N T F O R ST R E N GT H O F C O RAC O B RAC H I A LI S (Ja nda 1 983) •

Patient is seated, arm alongside trunk, in ternally rotated, elbow flexed.

479

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

Fig u re 1 3.82 Myofascial release of coracobrachial is. Fig u re 1 3.81 The neurovascular structures located nea rby a re avoided by muscle testing for loca tion of coraco brachia l is.

• •

•

The practitioner offers a stabilizing contact to the shoul­ der from above, hand resting directly over the joint. The practitioner 's o ther hand is placed on the distal aspect of the humerus, just above the elbow, offering counterforce/resistance as the patient attempts to flex the upper arm to 90°. Both sides should be tested and compared for relative strength. This procedure also tests the anterior fibers of deltoid.

It N MT F O R CO RACO BRAC H I A L I S With the patient resting supine, the arm i s abducted to 90° with the forearm supinated and the upper arm supported by the table. This position will allow access to the medial aspect of the upper portion of the arm and allow room for the practitioner's hands to glide proximally when they are correctly positioned. To assess coracobrachialis, the thumbs are placed on the medial surface of the upper arm at mid-level and posterior to the biceps brachii while avoiding the neurovascular bun­ dle mentioned previously (Fig. 13.81 ). A muscle test of hor­ izontal adduction (resisted above the elbow as the arm is raised toward the ceiling) will help define the lower fibers of coracobrachialis for palpation. The practitioner applies proximal gliding strokes 7-8 times directly on the portion of coracobrachialis that is available. As pectoralis major is encountered, the thumbs slide deep to it to continue gliding as high as possible on coracobrachialis. Trigger point pressure release methods may be used by pressing the muscle against the humeral shaft. However, care must be taken to avoid the artery and nerves coursing

posterior to the muscle. Palpation of the pulse and then positioning the hands to avoid the pulse is required to safely trea t this muscle. The coracoid attachment of coracobrachialis has been discussed with pectoralis minor in the supine position (p. 476). In that procedure, friction is applied through pec­ toralis major while transversing the fibers of pectoralis minor, coracobrachialis and short head tendon attachment of biceps brachii while avoiding the neurovascular struc­ tures deep to these tissues.

f M F R F O R CO RACO B RAC H I A L I S (FIG. 1 3.82) area of restriction or fibrotic change is palpated for and identified in the accessible part of the muscle, i.e. in its dis­ tal third mid-way along the medial border of the humeral shaft (between the triceps and brachialis muscles). A flat thumb contact is made by the practitioner slightly distal to the dysfunctional tissues. The patient lies close to the edge of the table with the elbow flexed and the shoulder externa lly rotated. The practitioner's thumb introduces slight but firm com­ pression, as the pa tient slowly and deliberately extends both the elbow and the humerus at the shoulder, before returning to the commencement position. The lengthening of the muscle during the extension aspect of this movement will draw the dysfunctional tis­ sue under the compressive thumb contact. The procedure is repeated 3-5 times.

• An

• • •

•

•

It PRT F O R CO RACO B RAC H IA L I S • •

Patient is seated with the practitioner standing behind. The practitioner identifies a point of tenderness on the anteromedial aspect of the coracoid process.

48 1

482

CLI N I CA L A P PLICA T I O N O F N E U R O M US C U L A R TEC H N I Q U E S : TH E UPPER B O DY

•

•

•

•

•

•

The palpa ting hand cups the shoulder while a finger of tha t hand makes contac t on the tender point and applies pressure to i t, sufficient to have the pa tient ascribe a value of '10' to the discomfort. With the other hand the practi tioner eases the ipsilateral arm into extension and introduces internal rotation at the shoulder, with the dorsum of the patient's hand being placed fla t against the back. The pa tient is asked to report the pain score and fine­ tuning of the a rm position is carried out to achieve a reduction in the pain score of at least 50%. Fine-tuning is then increased; for example the pa tient's flexed elbow may be eased anteriorly, increasing internal rotation at the shoulder, to further reduce the reported score. Add itional fine-tuning methods to reduce pain scores further might include: 1. the hand on the shoulder applying light (l Ib (0.5 kg) maximum) inferomedial 'crowding' of the shoulder contact towards the painful point, or 2. crowding of the acromioclavicular joint by long-axis compression of the humerus in a cephalad direction (l Ib (0.5 kg) force at most). Once pain is reduced by 70%, the position is held for not less than 90 seconds, before a slow return of the arm to a neu tral position and a reassessment of function and ten­ derness is performed .

B I C E PS B RACH I I Attachments:

Short head: Apex of the coracoid process

scapula at the apex of the glenoid cavity to a common tendon merging the two heads and attaching to the posterior surface of

Long head: supraglenoid tubercle of the

the ra d i a l tuberosi ty w i t h a d d itional expansions (bicipi­

tal aponeurosis) blending into the deep fascia of the fore­ arm on the ulnar side Innervation: Musculocuta neous nerve (C5-6) Muscle type: Postural (type I), shortens when stressed Function: Supina tion of the forearm (when elbow is at least slightly flexed), elbow flexion (strongest with the fore­ arm supinated), assists flexion of the shoulder j oint (when medially rotated), stabilizes the h umeral head against upward translation when deltoid contracts and against downward translation when the dependent arm is weigh ted, assists abduction of the arm (when laterally rotated), horizontal adduction of the arm, eccentric (lengthening) contractions when ex tending the weighted forearm, brings the humerus toward the forearm when the forearm is fixed (such as in pull-ups) Synergists: Supination: supina tor Elbow flexion: brachialis and brachioradialis Flexion of shoulder: anterior deltoid, pectoralis major Abduction of the arm: middle deltoid, supraspina tus Adduction of the arm: pectoralis major (clavicular portion), coracobrachia I is

To supination: pronator teres, prona tor quadratus To elbow flexion: triceps brachii To flexion of shoulder: posterior del toid, triceps brachii

Antagonists:

(long head)

To adduction of the arm: middle deltoid, supraspinatus To abduction of the arm: pectoralis major (clavicular por­ tion), coracobrachialis

I n d i cations for treatment • • • •

Shoulder pain (superficial anterior) Pain when supina ting or when forearm flexion is overloaded Snapping or crackling sounds as the arm is abducted Pain or weakness when eleva ting the hand higher than the head

Speci a l notes The biceps brachii is discussed here with the shoulder and is followed by a full discussion of the elbow joint since it crosses both of these joints. Additionally, note that the tri­ ceps also crosses both joints and is discussed briefly with the elbow (supine position). The reader is referred to p. 449 for a full discussion of the triceps brach ii. The biceps brachii is a complex shoulder muscle as it 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 anomaly is noted by some authors as present in 1-10% of cases (Gray's Anatomy 2005, Platzer 2004, Simons et aI 1999) . "The long, narrow tendon of the l a teral head lies in the intertubercular groove and courses through the joint cap­ sule enclosed in a double tubular sheath, which is continu­ ous with the joint capsule. It is held in the groove by the transverse humeral ligament. When this ligament is torn free, the long head tendon may 'pop' as it dislocates from the groove during lateral and medial rotation. When the tendon ruptures completely, the humeral head rises con­ spicuously and the muscle belly bulks on the anterior sur­ face of the arm. Research by Warner & McMahon (1995) confirms biceps brachii long head as a stabilizer of the humeral head in the glenoid d u ring abduc tion of the shoul­ der in the scapular plane. The short head tendon is thick and f1a ttened. It does not a ttach to or pierce the jOint capsule but instead runs slightly d iagonally (anterior to the subscapularis tendon) to a ttach at the coracoid process with the coracobrachialis and pec­ toralis minor. It lies deep to the deltoid and pectoralis major's usually thick mass. Passive supination of the forearm and slight lateral rota­ tion of the humerus places biceps brachii in the most ideal position for palpation. The long head tendon may be more easily felt with full lateral rotation of the humerus. Additionally, strumming laterally across the medial tendon (short head) and medially across the lateral tendon (long

1 3 Shoulder, arm and hand

head) will help the practitioner to more consistently feel them through the often thick mass of overlying deltoid muscle. A portion of the tendon of subscapularis may be addressed between the two proximal bicipital tendons and can be a source of pain when recurren t bicipital tendinitis has been diagnosed. A bursa lies horizontally between the tendon and t he joint capsule and communicates with the capsule between the superior and middle glenohumeral ligaments. Ice applications may be needed on the anterior shoulder if inflammation of the subscapular or bicipital tendons is sus­ pected . Subscapularis is further discussed on p. 421 .

ASS ESS M E NT F O R ST R E N GTH O F B I C E PS B R A C H I I •

Janda (1983) reports:

It must be remembered that biceps brachii is the most impor­ tant [elbow} flexor. Diffe rentiation . . . is a means of deciding on future treatment and the arm should therefore be posi­ tioned so that biceps brachii can act as the principal flexor . . A slight weakness of biceps brachii only shows on testing if the movement starts from maximal extension. ·

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Patient is supine with elbow extended, arm abducted and externally rotated from the shoulder to 90°, palm facing upward. The practitioner places one hand, palm upward, on the posterior surface of the distal upper arm, above the elbow so that the hand supports the patient's arm. The other hand is placed palm downward on the distal forearm, above the wrist. The practitioner introduces light hyperextension of the patient's elbow, utilizing the contact on the lower arm for leverage. The patient is asked to introduce flexion at the elbow against this resistance. Relative strength of biceps brachii is compared on each side.

ASS ES S M E N T F O R S H O RT N E S S A N D M ET T R EAT M E N T O F B I C E PS B RAC H I I •

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The patient sits on the treatment table with legs hanging off the side, with the practitioner seated alongside, on the side of the dysfunctional arm. The practitioner supports the elbow with the hand near­ est the patient while the other hand holds the patient's proximal wrist area (patient's forearm supinated), intro­ ducing slight elbow extension (the slack is removed; this is not a forced extension). If there is biceps brachii shortness, elbow extension will be limited and possibly painful. To treat this shortness using MET, the patient is asked to attempt to flex the elbow for 7-1 0 seconds, using mini­ mal effort, resisted by the practitioner. Following the contraction the degree of extension is increased with patient assistance and the stretch held for not less than 20 seconds. The process is repeated 2-3 times more.

F i g u re 1 3.83 The biceps and brac h i a l is may be grasped i ndivi d u a l l y and compressed between the t h u m b a n d fi ngers.

f N M T F O R B I C E PS B RA C H I I The patient is lying supine with the arm resting on the table for support and the forearm passively supinated. The ante­ rior humerus is lightly lubricated and the thumbs are used to glide proximally, in thumb-width segments, from the crease of the elbow to the head of the humerus to address the entire belly of the biceps brachii. Medially placed glid­ ing strokes address the short head while la terally placed s trokes assess long head fibers and are repeated 7-8 times on each segment while evidence of tenderness, thickness or taut fibers is assessed within the bellies of the biceps brachii. If ischemia is found, these gliding steps are repeated several times with a short break in between, possibly incorporating hot packs to encourage additional blood flow. Gently applied transverse friction can be used on both bicipital bellies to assess for muscular nodules and taut bands, both characteristic of trigger points. When thickness, taut fibers or trigger point nodules are located, pincer compression can be used to lift and differentiate the biceps brachii from the brachialis, which lies deep to it (Fig. 13.83). Trigger points found within its bellies may be treated with compression techniques, either by lifting and compressing the fibers or by pressing them against the deeper belly of brachialis. With the forearm passively supinated, the groove between the ulna and radius is located and the patient is asked to mildly flex the elbow against resistance while the practitioner contacts the tendon area with a thumb or finger (Fig. 13.84) . Contraction of the radial attachment of the biceps brachii and the ulnar attachment of brachialis will make their location obvious. The patient should relax the arm before the tendon is treated with static pressure or mild

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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.

the tissue is not inflamed . Additionally, gliding strokes are applied proximally to soothe the tissues following the fric­ tional techniques. Short gliding strokes are applied (through the deltoid) between the bicipital tendons to address the subscapularis tendon, which lies between the two bicipital tendons and deep to the deltoid. Biceps brachii and triceps brachii cross both the shoulder and the elbow j oints. Triceps brachii is discussed on p. 449 and an additional supine approach is given (see p . 494) after the discussion of the elbow joint.

�. 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) 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 between the two.

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friction. A bicipitoradiai bursa protects the tendon from the radial tuberosity (see discussion of the elbow joints next). To address the proximal tendons of the biceps brachii (through the deltoid), the short head tendon on the anterior upper humerus and the long head tendon on the lateral upper humerus are both located (Fig. 13.85). These tendons feel very tubular and are slightly larger in diameter than the shaft of a pencil. The strumming techniques ]..l sed to locate the tendons (mentioned above) may also be used as a treat­ ment step or transverse (snapping) friction may be used if

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Patient is seated with practitioner behind. The patient is asked to take the hand behind the back and 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 slack. The patient is asked to a ttempt to lightly turn the hand into a supina ted position against resistance offered by the practi tioner. After 7-1 0 seconds the patient ceases the effort and the practitioner (assisted by the patient) increases the degree of pronation at the same time as extending the elbow and further adducting the arm. This stretch is held for a t least 20 seconds. The process is repeated 2-3 times.

1 3 Shoulder. arm and hand

It PRT F O R B I C E PS B RAC H I I There are two tender points associated with biceps brachii: in the bicipital groove (long head) and on the inferola teral surface of the coracoid process (short head).

Long head •

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The practi tioner loca tes an area of tenderness in the bicipital groove and applies sufficient pressure to have the patient ascribe a value of '10' to the discomfort. The practi tioner eases the patient's arm into a posi tion in which it rests, elbow flexed, with the dorsum of the lower arm against the patient's forehead. The practitioner fine tunes this position until the reported tenderness score is reduced by at least 70%. A greater degree of 'score' reduction is usually possible by the addition of a small degree of pressure (l Ib (0.5 kg) maximum) appl ied from the elbow through the long axis of the humerus to 'crowd' the shoulder joint.

Short head •

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The practitioner loca tes an area of tenderness on the inferola teral surface of the coracoid process and applies sufficient pressure to have the patient ascribe a value of ' 10' to the discomfort. The position of ease which reduces the pain score in this tender point is found by the practitioner taking the patient's interna lly rotated arm, flexed at the elbow, into adduction. Once pain is reduced by 70% in either of these pOSi tions, 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.

E LB O W The mechanical advantages that the shoulder joint offers include the ability to achieve an amazing range of positions. The elbow has a more limited ability but its use is absolutely critical to normal daily functioning. Its bending action allows food to be brought to the mouth, the upper body to be scratched and many other daily activi ties which are per­ formed literally withou t thought. This joint's design also permits the hand and forearm to be rota ted, which allows us to turn doorknobs, use screwdrivers and open jar lids. The two distinct functions of the elbow joint - flexion/ extension and supination/pronation - are discussed indi­ vidually though they are often used in combina tion during real movement. For instance, for food to be placed in the mouth, the arm begins in ex tension with pronation and ends in flexion with supination. Eating would indeed look different if either of these actions were not possible.

I NTRO D U CT I O N TO E L B O W T R EATM E NT Before beginning treatment of the elbow, postural distor­ tions of the body's framework should be observed and a 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 ences and vertical plane devia tions of the torso all suggest biomechanical challenges for which the elbow (and other joints) may be compensating. For instance, when shoulder motion is restricted, compensations might involve more distal portions of the extremity, placing undue stress on the elbow, wrist or hand. The patient should be asked to demonstrate to the practi­ tioner the sort(s) of work activities and positions, seated and standing, which are performed on a daily basis. Long hours without breaks are often spent at office and home office desks with little a ttention given to ergonomic (postural) design of the workspace. The postural and use ca uses of repetitive stress disorders involving the forearm muscles and strains of the arm, wrist, shoulder, neck and torso need to be addressed if long-lasting relief is to be achieved. Frequent breaks, cou­ pled with stretches and movement therapy, should be part of both recovery and preventive programs. When addressing pain in the elbow, forearm and hand, it is important to treat trigger points in the torso and shoulder girdle muscles as well as nerve compression possibilities at the spinal level and potential entrapment sites along the nerve's pa th. The cervical region should be assessed in a ll hand, arm or shoulder pain patterns, including the thoracic ou tlet and subclavicular area (such as pectoralis minor, which should be tested for potential encroachment upon neurovascular space).

STR U CTU R E A N D F U N CT I O N The elbow joint is the intermediate joint o f the arm, which links the forearm to the upper arm and allows the upper extremity to bend and the forearm to rotate. The proximal radioulnar joint, the humeroradial joint and the humeroul­ nar joint together form the compound jOint usually referred to as the elbow. These three joints work in combina tion together to provide: • •

flexion / extension - by the humeroradial and humeroul­ nar joints prona tion/supination - by the humeroradial and radioul­ nar joints.

Stability of these joints is provided by bony support of the apposition of the trochlea of the humerus and the trochlear notch of the ulna, together with the ligamentous support of the annular and colla teral ligaments. Additionctlly, a joint capsule encloses the structure, housing all three joints within the capsule.

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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 ding lateral and medial excursions of the head of the radius. By stabilizing the ulna and radius together, the annular lig­ ament ensures tha t these two j oints act as one during flexion and ex tension.

RADIOU LNAR J O I NT This pivotal joint is formed where the rounded circumfer­ ence of the radial head fits against the radial notch of the ulna. While the proximal ulna remains stable during prona­ tion and sup ination, the radius spins inside the annular lig­ ament against the ulna and against the ball-shaped distal surface of the capitulum of the humerus. During this spin­ ning action, the shaft of the radius rota tes around the ulna, which flips the forearm and hand over. Pronation and supination can occur at any point during flexion and exten­ sion if these radial joints are functional. The interosseous membrane provides a continuing fibrous joint between the radius and ulna for the full length of the two bones. This membrane prevents upslip or dis­ placement of the two bones and also acts to transmit pres­ sure stresses from one bone to the other. It is an extremely strong fibrous network, which provides a place for muscu­ lar a ttachment as well as tremendous structura l support for the forearm. In fact, d uring structural distress, the radius and ulna are prone to fracture before the fibers of the mem­ brane are torn (Pia tzer 2004).

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 TH E E P I CO N DYLES (FIG. 1 3.87) • •

Patient's arm is hanging at the side. Practitioner, standing behind, places thumb on medial epicondyle, index finger on olecranon, middle finger on lateral epicondyle.

Figure 1 3 .87 1 . Medial epicondyle. 2. O lecranon. 3. Lateral e picondyle. Horizo n ta l bony a lignment becom es equilatera l tria ngle d u ring e l bow fl exion. • • •

When elbow is fully extended the three contacts should form a straight line. When the elbow is flexed to 90° they should form an inverted triangle. Traumatic insults, for example to radioulnar articulation, may alter these alignments.

T H E L I G A M E N TS O F T H E E LB O W •

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The joint capsule i s thin and lax and i s continuous with the annular ligament, a strong band which encircles the head of the radius. The medial ligament (ulnar collateral ligament) is a thick trian­ gular band, comprising an anterior and a posterior band which unite a t a thin intermediate portion (Fig. 13.88). The anterior part attaches superiorly, via its apex, to the medial epicondyle of the humerus and inferiorly, via its base, to the medial margin of the coronoid process. The posterior part is also triangular which attaches supe­ riorly to the posterior aspect of the medial epicondyle and inferiorly to the medial margin of the olecranon. The intermediate fibers run from the medial epicondyle to an oblique band which joins the olecranon and the coro­ noid processes. The lateral ligament (radial collateral ligament) is attached superiorly to the distal aspect of the lateral epicondyle of the humerus and inferiorly to the annular ligament.

Ruch et al (2006) implicate synovial plicae of the elbow as a possible cause of lateral elbow pain in pa tients with vague clinical symptoms. Although these pa tients failed to

1 3 Shoulder. arm and hand

respond to conservative treatment, Ruch et al suggest tha t arthroscopic management m a y provide a successful treat­ ment option in such cases.

A S S E S S M E NT F O R L I GA M E N TO U S STA B I L I TY

Fat pads ---1+-....--+-'"

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---,\-- Synovial Annular ligament of radius ---f�--=:::;

membrane

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Sacciform recess of synovial membrane •

Patient is seated or supine. Practi tioner holds patient's forearm proximal to the wrist to avoid undue stress on the joints (this is the practi­ tioner 's 'motive hand') while the other hand (the 'stabi­ lizing hand') cups the distal humerus. The patient is asked to slightly flex the elbow (i.e. the pro­ cedure is not performed in hyperextension), arm supinated, and the practitioner introduces a translation action at the elbow by means of a medial push with the motive hand and a simultaneous lateral push with the stabilizing hand, followed by a reversal of these two directions of push. As these side-shift (translation) movements are gently and repetitively carried out, the stabilizing hand notes whether a normal degree of slight gapping is taking place as the valgus and varus stresses are applied .

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 from Gray's Anatomy for Students (2005).

CAUTION: Avoid testing (active or passive) for range of 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 • •

Radial collateral ligament ----\,\- \ Annular ligament of radius ----t�

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Ulnar collateral ligament

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Sacciform recess of synovial membrane -_-...../

This evaluates the integrity o f nerve supply from CS level. The seated pa tient's forearm is placed so that it rests on the practitioner 's forearm. The practitioner cups the medial aspect of the patient's elbow so that his thumb can be placed in the cubital fossa. The p atient's arm must be relaxed. The practi tioner taps his own thumbnail with a neuro­ logic hammer and the biceps should jerk slightly to the extent that it is both visible and palpable.

B RAC H I O RA D I A L I S R E F L E X • • •

Fig u re 1 3.89 Joint capsule a n d l igaments of the el bow. Reproduced with perm ission from Gray's Anatomy for Studen ts (2005).

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 thumbnail) with the neurologic hammer and a palpable and visible jump should occur in brachioradiaIis.

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T R I C E PS R E F L E X • • •

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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 The neutral position o f reference for the elbow joint occurs when the forearm and upper arm are in a straight line (Fig. 13.90). Hence, the range of motion for true extension of the elbow is actually 0°, since the forearm does not extend beyond neutral, except in a few subjects with hyperexten­ sion conditions due to ligamentous laxity. However, the term 'relative extension' is used when the forearm is returned toward a neu tra l position from any point of flexion. The forearm is flexed when it is brought toward the ante­ rior aspect of the upper arm. Active flexion produces a range of 135-145° (Hoppenfeld 1976, Kapandji 1 982) with an additional 15° availab le wi th passive assistance. During active flexion, various m uscles will contract, depending upon the rotational position of the forearm. Both active and passive range of motion tests may be used to assess limits of movement of the elbow joint. Bilateral comparison is possible by both sides performing action simultaneously. If active testing shows normal range without pain or discomfort, passive tests are usually not necessary; however, with elbow flexion an additional 15° of flexion may be achieved with assistance. Restrictions tha t have a hard end-feel during passive range of motion assessment are usually joint related. Restrictions that have a softer end-feel, with slight springi­ ness still available at the end of range, a re usually due to extraarticular soft tissue dysfunction.

F i g u re 1 3.90 From neutra l to fu l l ra nge of flexion of the elbow joint. Relative extension returns the forearm back to neutra l w h i l e t r u e extension o f t h e elbow (beyon d neutral) is termed hyperextension .

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RAN G E O F M OT I O N AN D STR E N GTH T E STS •

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Range of motion tests a re performed both actively and passively involving flexion (135-145°), extension (0°), forearm pronation and supination (90° each). Strength i s tested with the practitioner (standing in front of the patient) cupping the flexed (to 90°) elbow with one hand ('stabilizing hand') while the other hand holds the patient proximal to the wrist.

As the patient attempts t o extend the elbow, the relative strength of triceps and anconeus is being evaluated. Neural supply to these muscles is from C7 and C8. The patient begins with the forearm pronated and the practitioner restricts this position as the patient attempts to supinate against resistance. This evaluates relative strength of biceps, supinator and possibly brachioradi­ alis. Neural supply is from C5 and C6. The patient begins with the forearm supinated and the practitioner restricts this position as the patient a ttempts to pronate against resistance. This evalua tes the relative strength of pronator teres, pronator quadratus and flexor carpi radialis. Neural supply is from C6-8 and TI.

E L B O W S T R E S S TE STS • •

Patient is seated or supine. Practi tioner holds pa tien t's arm proximal to the wrist to avoid undue stress on the wrist joints (this is the

1 3 Shoulder, arm a nd hand

489 J

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practitioner's 'motive hand') while the other hand (the 'stabilizing hand') cups the distal humerus. With the arm relaxed, normal range of motion is assessed involving flexion, extension, pronation and supination. Any pain or restriction of motion should be noted. These symptoms could involve tendinitis, joint pa thol­ ogy or contractures. If these tests are negative (i.e. if no pain or restriction is noted), the same movements are then carried out against resistance. The practitioner notes which soft tissues are being lengthened (stretched) if pain or restriction is noted. And these tissues are investigated further by means of active pa tient movements and/ or by pal­ pation. The same movements are also observed with the patient actively and slowly performing them (more than once to gain insight into normal behavior). The practitioner notes which soft tissues are reported as being painful and these structures are subsequently palpated for dysfunc­ tion or assessed for shortness.

STRA I N S O R S P RA I N S •

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Bicipital attachment to the radius may be trauma tized on hyperextension injuries. Palpation of the tendon will reveal extreme tenderness. Rest (in a sling) for a few days, plus appropriate sprain therapy (ice, etc.), is advised. Hyperpronation or hypersupination inj uries may result in limita tion to rotation and pain. The radial head may actually dislocate. If forced abduction or adduction occurs, rupture of the capsular apparatus, including ligamentous attachments to humerus, radius or ulna, is possible. If a fall occurs in which the outstretched arm absorbs the compression injury, damage to the dorsiflexed wrist (stretching the ventral soft tissues), the extended elbow or the shoulder is possible. The age of the individual and therefore tissue elasticity - will usually influence where damage occurs (e.g. wrist fracture in elderly, distal humerus in younger individuals). With hyperextension strain of the elbow, the following could all be swollen and tender on palpation: posterior capsule, bicipital tendon, olecranon fossa, medial and lateral collateral ligaments, flexor a ttachments a t med­ ial epicondyle. Pain will usually be eased by moving the tissues in a direction which would reproduce the strain (see p. 225). With hyperabduction strain, tenderness of the ulnar col­ lateral ligament, below the lateral epicondyle, is usual. Pain is usually eased by taking the joint in a direction that reproduces the strain. With hyperadduction strain, tenderness of the radial col­ lateral ligament, below the medial epicondyle, is usual. Pain is usually eased by taking the joint in a direction that reproduces the strain.

I N D I CATI O N S FO R T R EATM E NT ( DYS FU N CT I O N S/SYN D R O M ES) M E D IA N N E RV E E NTRAP M E NT This may be produced by the pronator teres, flexor digito­ rum superficialis or the anomalous flexor digitorum super­ ficialis indicis. Impingement of the nerve within the carpal tunnel results in an all-too-common syndrome tha t affects the hand and wrist.

CA R PA L TU N N E L SYN D R O M E The carpal tunnel is a narrow passageway a t the wrist that allows passage of nine tendons, the median nerve and blood vessels that serve the hand. The median nerve can become compressed within the carpal tunnel by a bone, enlarged ten­ don, scar tissue, excessive fluid or abnormal tissue, resulting in a number of symptoms that are associated with 'carpal tunnel syndrome'. Non-surgical treatment of carpal tunnel syndrome requires assessment of biomechanics to determine if poor habits of use in work and recreation are factors as well as examination of the shoulder, neck and forearm muscles for trigger points that frequently refer into the wrist and hand. Additionally, tests to rule out median nerve impingement by other muscles along its course may be required. If true impingement within the cana l is diagnosed, surgi­ cal intervention may be suggested. This might include: •

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Open release, which involves an incision (up to 2 inches) being made at the wrist and the carpal ligament cut to enlarge the tunnel. Endoscopic surgery, which involves two smaller inci­ sions (at the wrist and palm) through which a camera is inserted to help guide a more precise cutting of the carpal ligament. This procedure minimizes scarring and scar tenderness.

Although symptoms may be relieved immediately following surgery, it is not uncommon for it to take months for a full recovery to occur. Wrist joints may lose strength and pa tients may need to undergo physical and occupa tional therapy as well as make adjustments in the workplace and home. Additional discussion of causes, symptoms and treat­ ment options is found on p. 507.

U LN A R N E RVE E N TRAP M E NT The cubital tunnel, positioned on the posterior aspect of the medial epicondyle, is formed by the cubital groove (floor of the tunnel) and an aponeurotic band (roof of the tunnel) which stabilizes the nerve during movement (Fig. 13.91). During flexion, the retinacular band becomes more tau t and closes in on the tunnel's space. This may irritate or com­ press the ulnar nerve as it passes through the tunnel. Addi tionally, if the wrist is extended and the shoulder is

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Triangular Interval

Profunda brachii artery

\ +1�\---,C-+---- Radial nerve (in radial groove)

C:;:::;;