LWW Massage Therapy & Bodywork Educational Series
Jocelyn Granger, NCTMB
Neuromuscular Therapv Manual is the long-awaited text that distills the essential content ofTraveil
&
Simons' Myofascial Pain and Dysfunction needed
by massage therapy students and practitioners into a concise, easy-to-under stand textbook. Part I of this text gives an in-depth overview of the basics of neuromuscular therapy, including its history and physiological basis, client assessment, body mechanics, and more. Part II is organized by body region, with each chapter providing detailed information on each muscle in that region, such as origin, insertion, and action. Students will also learn the trigger points and referral zones, trigger point activation, stressors and perpetuating factors, precautions, and massage considerations for each muscle. Key Features • Classic trigger point and referral zone charts fromTravell and Simons are included for each muscle. • Anatomical illustrations of each muscle are featured. • Case studies apply knowledge of neuromuscular therapy to client scenarios. • Sample routines sections include step-by-step massage procedures for each body region and are illustrated with a wealth of photographs. • Review questions test knowledge of the content covered in each chapter. • Online video clips demonstrate neuromuscular therapy routines for each region of the body.
LWW.com
ISBN-13: 978-1-58255-800-4 ISBN-10: 1-58255-800-0 90000
. Wolters Kluwer Lippincott Health Williams & Wilkins
9 781582 558004
NEUROMUSCULAR TH ERAPY MANUAL Jocelyn Granger, NCTMB Founder and Director Ann Arbor Institute of Massage Therapy Ann Arbor, Michigan
I
. Wolters Kluwer Lippincott Williams Health
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Wilkins
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Library of Congress Cataloging-in-Publication Data Granger,Jocelyn. Neuromuscular therapy manual/Jocelyn Granger. p.; cm. Includes bibliographical references and index. Summary: "Neuromuscular T herapy Manual is a concise "essentials" manual of neuromuscular massage therapy and trigger point therapy. The book is designed specifically for the needs of massage therapy students. Content is presented in a highly easy-to-use format"-Provided by publisher. ISBN 978-1-58255-800-4 (pbk. : alk. paper)
I. Massage therapy. [DNLM:
2. Myofascial pain syndromes.
I. Massage-methods.
3. Soft Tissue Injuries-therapy.
I. Title.
2. Myofascial Pain Syndromes-therapy.
WB 537]
RM72I.G765 2011 615.8'2--dc22 2010026299 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. T his is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the F D A status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at orders to
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o ... en o CJ) o o
To Bob King and]im Hackett, the founders of the Chicago School of Massage T herapy; they mentored me and generously shared their school curriculum information and manuals while helping me start the Ann Arbor Institute of Massage Therapy. Because of their generosity with a certain neuromuscular therapy manual, the idea for this book came about. But if it weren(t for Kathie King who constantly reminded me that I can write and encouraged me to do so, this would never have happened. 1 am sad, though, that she did not have the chance to see the finished product.
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PREFACE This book was created to help massage therapists grow into
illustrations of anatomy showing attachment sites, and illus
effectiv� neuromuscular therapists and be able to specialize
trations of trigger points and their referral areas.
in working with individuals in chronic pain. Although it is
Throughout the book, many pedagogical features are
meant to be a textbook for massage therapists, it may be use
included to facilitate learning. These are described
ful for osteopaths, athletic trainers, physical therapists, and
below:
other health care providers. This text is devoted
to
•
providing a concise manual of
neuromuscular therapy that contains the most relevant con tent from Travel! and Simons' Myofascial Pain and Dysfunction:
and appear in a glossary at the end of the book. •
T he Trigger Point Manual, volumes 1 and 2, in a highly struc tured, regionally organized, accessible, and user-friendly text
Key terms: are listed and defined at the beginning of each chapter, boldfaced on first mention in the text, Chapter introductions provide a brief overview of
each chapter's contents. •
Case studies discuss clients with particular pathologi
for massage students. As so much of the information in
cal conditions and how neuromuscular therapy rou
these volumes is regarding medical treatment and is thus
tines, as presented in the text, can address them. A few
highly detailed and technical, it is often intimidating to
critical thinking questions regarding the scenario pre
massage therapists to read. Thus, this textbook bridges that gap and highlights the information that is most helpful
to
a
massage therapist.
sented are included at the end of each case study. •
procedures for each body region. •
OVERVIEW OF CONTENTS Part I of the book gives an in-depth overview of the basics of neuromuscular therapy, including information about its his tory, the phy iological basis on which neuromuscular ther apy is founded, client assessment, body mechanics, and more. Part II is divided into sections by body region. Each
Sample routines sections include step-by-step massage Chapter summaries briefly review the content covered
in each of the first four chapters. •
Chapter review questions, appearing at the end
of each chapter, allow readers to test their knowledge of the content covered in each chapter and consist of multiple choice questions, short answer questions, true/false, and matching.
chapter gives specific information regarding the muscles in that region, such as origin and insertion. Also included here is further information regarding trigger points and referral zones, perpetuating factors, and massage considerations for each muscle, along with color pictures of the anatomy and trigger points. There is also a step-by-step guide to perform ing the treatment of each muscle, which is coordinated with online videos of the same making it easy to practice this work at home.
PEDAGOGICAL FEATURES
USE OF THIS BOOK It will be imperative for you to read and study the chapters in Part I and gain a comprehensive understanding of the theory of neuromuscular therapy before attempting
to
mas
ter the techniques in Part II. This is very advanced work and it will be important that you also have an excellent grasp on anatomy to be able to master this work. A neu romuscular therapist must work from the heart, wh ich means working with integrity. Integrity means to be mas terful and knowledgeable, in this case. Last of all, it is
This text is easy to read and includes features such as
important that you enjoy challenge. It will be challenging
bulleted lists for easy reference, photos of the technique,
to become masterful with this technique; it will also be
v
vi
PREFACE
challenging when working with clients in chronic pain and
improvement or questions about this book or workshops
dysfunction. Challenging clients are what will keep the
may be addressed to:
work fresh for the neuromuscular therapist: it will never become boring. So, enjoy the work and the sense of fulfill
Jocelyn Granger
ment it will provide and always remember that it is an
Ann Arbor Institute of Massage Therapy
honor to work on an individual who needs your help.
180 Jackson Plaza, # 1 00 Ann Arbor, MI 48 1 03
• FEEDBACK This author appreciates any feedback from students, profes sional therapists, school instructors, etc. Any ideas for
E-mail:
[email protected] ACKNOWLEDGMENTS I first wish to acknowledge Georgine L ynett. As soon as I
information I received from my reviewers was valuable and
was given the "go-ahead" for this project, she informed me
a great help. I truly appreciate all of their patience in read
that she would do as much as she could for me at home, so I
ing the information and taking the time to give me their
would have the time to work on this book. It was only then
critiques and correction suggestions.
that I realized I would actually be able to take on the project.
Thanks to the photographer, Mark Lozier, and the video
Having this support at home kept me on track and bolstered
grapher, Michael Licisyn, those long days went smoothly
me emotionally. My appreciation of this is huge!
and we have some great photo and video shots that add
It is with gratitude that I offer this simple acknowledge
more dimension to the book. Also, a huge thank you to the
ment and thanks to the many people out there who contrib
Cortiva Institute, Pennsylvania School of Muscle Therapy,
uted and supported me through this project. The opportu
and Jeff Mann, its President, for providing us with a nice
nity to work with L ippincott W illiams & W ilkins on this
room to do our photo shoot. They also found the therapists
book was a dream come true for me.
that served as models. All models we used, both the models
In particular I would like to thank David Payne for being
on the table and the professionals serving as models, were
so nice while trying to keep me on track and off the ceiling.
excellent: thank you for your hard work and being part of
David is a great editor and works well with others. His calm
this book.
ness at the photo shoot really helped me to be present and keep my energy at a high level during those very long days.
Finally, I extend my appreciation to Melanie Gibbs, Administrator, and Sara Martens, Academic Coordinator,
Of course, my gratitude also goes out to Jennifer Ajello,
at the Ann Arbor Institute of Massage Therapy. They took
an editor at LWW, and John Goucher, a previous executive
on more of a workload for the last 2 years to give me the
editor at LWW. These two saw the value in this project and
time to work on the book while I was in the office. They also
offered me a chance to write. There were many, many more
helped make my life much easier with their emotional sup
folks involved from LWW that should also be thanked. The
port, and I am greatly appreciative.
vii
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REVIEWERS Rebecca Birch-Blessing, MS, DC
Suzie Goggin, BA, BSRN, LMT
Health Science Department
Massage Therapist
University of Phoenix
Rising Spirit Institute of Natural Health
Sandy Springs, Georgia
Dunwoody, Georgia
Rebecca Buell, BS
Leigh Ann McNair, LMT
Instructor
Mas age Therapist
Massage Therapy Department
Oviedo, Florida
McIntosh College Dover, New Hampshire
Jason Schiller, LMT
Massage Instructor Nancy Cavender, MM, CMT, CNMT
Massage Program
Teaching Faculty
Sun State Academy
RSI
Clearwater, Florida
Atlanta, Georgia Heather Cooperstein, BS, BA
Senior Massage Therapist Out-Patient Therapy Kessler Institute Piscataway, New Jersey
ix
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CONTENTS Preface/v Acknowledgments/vii Reviewers/ix List of Muscles Covered in T his Text/xiii
PART I: Neuromuscular Therapy Basics / 1 1
Introduction to NeuromuscularTherapy /3
2
Neuromuscular Physiology /11
3
Client Assessment /23
4
Basic NeuromuscularTherapyTechniques and Body Mechanics /45
PART II: Muscles and Neuromuscular Therapy Routines by Body Region / 59 5
Head and Neck /61
6
UpperTorso /103
7
Arm, Wrist, and Hand / 163
8
LowerTorso and Abdomen /215
9
Hip,Thigh, and Anterior Knee /245
10
Leg with Posterior Knee, Ankle, and Foot /285
11 Trigger Point and Referral Guide /323 Appendix A: Answers to Chapter Review Questions/331 Glossary/337 Index/341
xi
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LIST OF MUSCLES
COVERED IN THIS TEXT
HEAD AND NECK / 61
Splenius Capitis and Splenius Cervicis: Ache Inside the Skull / 707
Posterior Cervical Muscles / 62
Supraspinatus: Subdeltoid Bursitis / 709
Posterior Suboccipital Muscles / 62
Infraspinatus: Shoulder Joint Pain / 777
Rectus Capitis Posterior Major and Minor, Obliquus
Teres Minor: The Silver Dollar Pain / 773
Capitis Superior and Inferior: The Rock and
Latissimus Dorsi: Pernicious Midthoracic
Tilt Muscles / 62
Backache / 775
Levator Scapula: The Stiff Neck Muscle / 64
Teres Major: Twin to Latissimus Dorsi / 777
Anterior Cervical Muscles / 66 Sternocleidomastoid: Amazingly Complex / 66 Scalenes: Anterior, Medius, and Posterior: The Entrappers/ 68
Anterior Suboccipitals / 70 Rectus Capitis Anterior and Rectus Capitis Lateralis / 70 Longus Capitis and Longus Colli: Military Neck / 77
Suprahyoid Muscles / 72 Mylohyoid / 72 Geniohyoid / 73 Digastric: Pseudo-sternocleidomastoid Pain / 74
Head and Face Muscles / 75 Occipitalis: The Scalp Tensor / 75 Frontalis: The Scalp Tensor / 77 Corrugator Supercilii / 78 Temporalis: Temporal Headache and Maxillary Toothache / 79 Masseter: The Trismus Muscle / 80
The Pterygoid Muscles / 82 Medial Pterygoid: Ache Inside The Mouth / 82 Lateral Pterygoid: TMJ Dysfunction / 83
Serratus Anterior: Stitch in the Side Muscle / 778 Rhomboids, Major and Minor: Superficial Backache and Round Shoulder Muscles / 779 Deltoid: A Dull Actor / 727 Serratus Posterior Superior: Cryptic, Deep, Upper Back Pain / 723
Thoracolumbar Paraspinals: Lumbago / 124 Spinalis / 724 Longissimus / 726 Iliocostalis / 728 Semispinalis / 730 Multifidus / 737 Rotatores / 733
Anterior Shoulder/Chest Area / 135 Sternalis: Anomalous Substernal Ache / 735 Pectoralis Major: The Poor Posture and Heart Attack Muscle / 737 Pectoralis Minor: Neurovascular Entrapper / 740 Subclavius: Poor Posture and Heart Attack / 742 Subscapularis: The Frozen Shoulder Muscle / 744
ARM,WRIST,AND HAND / 163 Upper Arm (Brachium) / 164
UPPER TORSO / 103 Posterior Shoulder/Upper Back Area / 104 Trapezius: The Coat Hanger / 704
Biceps Brachii: A Three-Jointed Motor / 1 64 Coracobrachialis: Hide and Go Seek / 1 66 Brachialis: Workhorse Elbow Flexor / 1 67 Triceps Brachii: Three-Headed Monster / 1 69 xiii
x iv
LIST OF MUSCLES
Forearm / 171 Brachioradialis: Painful Weak Grip / 1 71 Supinator: Tennis Elbow / 1 73
Extensor Group: Painful Weak Grip / 175 Extensor Carpi Radialis Longus / 1 75 Extensor Carpi Radialis Brevis / 1 77 Extensor Digitorum / 1 78 Extensor Carpi Ulnaris / 1 80 Anconeus: The Little Helper / 1 81
HIP, THIGH,AND ANTERIOR KNEE / 245 Posterior Hip / 246 Gluteus Maxim us: The Swimmers Nemesis / 246 Gluteus Medius: Lumbago Muscle / 248 Gluteus Minimus: Pseudo Sciatica / 250 Piriformis: The Double Devil / 252 The Other Five Short Lateral Hip Rotators / 253
Posterior Thigh: Chair-Seat Victims / 255
Flexor Group: Lightening Pain and
Hamstrings: Biceps Femoris, Semimembranosus,
Trigger Finger / 183
and Semitendinosus / 255
Flexor Carpi Radialis / 1 83 Flexor Carpi Ulnaris / 1 85 Flexors Digitorum Superficialis and Profundus / 1 87 Palmaris Longus / 1 89 Pronator Teres / 1 91
Wrist and Hand / 192 Adductor and Opponens Pol/icis: Weeders Thumb / 1 92
Anterior Thigh / 257 Tensor Fascia Latae: Pseudotrochanteric Bursitis / 257 Sartorius: Surreptitious Accomplice / 258 Quadriceps: The Four-Faced Troublemaker / 259
Lateral Thigh / 263 Iliotibial Band / 263
Flexor Pollicis Longus: Lightening Pain / 1 94
Medial Thigh / 264
Extensor Indicis: Stiff Fingers / 1 95
Adductors: Obvious Problem-Makers / 264
Interossei and Lumbricals: Associates of
Gracilis / 264
Heberden's Nodes / 1 96
Pectineus: The Fourth Adductor / 266
Abductor Digiti Minimi / 1 98
Adductor Brevis and Longus / 267 Adductor Magnus / 268
• LOWER TORSO AND ABDOMEN / 215 Quadratus Lumborum: Trochanteric Bursitis / 216
• LEG WITH POSTERIOR KNEE,ANKLE, AND FOOT / 285
Serratus Posterior Inferior: Nuisance Residual Backache / 218
Anterior Leg Area / 286
External and Internal Obliques: Pseudovisceral
Tibialis Anterior: Foot-Drop Muscle / 286
Pain / 21 9
Extensor Longus Group: Muscles of Classic
Transverse Abdominis: Pseudovisceral Pain / 221
Hammer Toes / 288
Rectus Abdominis and Pyramidalis: Pseudovisceral Pain / 223 Iliopsoas: The Hidden Prankster / 226 Intercostals / 228 Diaphragm / 230
Dorsal Foot Area / 290 Extensor Digitorum Brevis, Extensor Hal/ucis Brevis, and the Dorsal Interossei: Sore Foot Muscles / 290
LIST OF MUSCLES
Plantar Foot Area / 292
Posterior leg And Ankle Area / 301
Abductor Hallucis, Abductor Digiti Minimi,
Gastrocnemius: Calf Cramp Muscle / 307
and Flexor Digitorum Brevis: Sore
Soleus: Jogger's Heel / 303
Foot Muscles / 292 Quadratus Plantae, Lumbricals, and Interossei: Vipers' Nest / 294 Adductor Hallucis, Flexor Hallucis Brevis, and Flexor Digiti Minimi Brevis: Vipers' Nest / 296
lateral leg Area / 298 Peroneal Group: Peroneus Longus, Peroneus Brevis, and Peroneus Tertius-Weak Ankle Muscles / 298
xv
Flexor Longus Group / 305 Flexor Digitorum Longus and Flexor Hallucis Longus: Claw Toe Muscles / 305 Tibialis Posterior: Runner's Nemesis / 308
Posterior Knee Area / 310 Popliteus: Bent-Knee Troublemaker / 370 Plantaris: Jogger's Heel / 372
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PART I Neuromuscular Therapy Basics
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INTRODUCTION TO NEUROMUSCULAR THERAPY Acute� of recent onset
Noxious: harmful or painful
Chromc: of long standing
Postural and biomechanical dysfunction: abnormal function of
Concentric strain: a condition in which a muscle is chronically
the body because of poor posture and poor biomechanics
shortened because of overuse or postural dysfunction; its
Range of motion the amount of movement of a joint
opposing muscle will most likely be eccentrically strained,or
Trigger point: an area of hypersensitivity that when
overstretched
compressed creates referral sensation at a distance from that
Etiology: the cause of disease
area
Hypertonicity: excess muscular tonus
Trigger point referral: the sensation felt at a distance from a
Ischemia: local and temporary deficiency of blood supply
trigger point
Neuromuscular therapy is a comprehensive and advanced system
come injuries and postural dysfunction. If we can balance each
of soft tissue manipulation that specializes in working with chronic
area of the body, we can help people change their posture and
myofascial pain and pain syndromes. On the basis of neurologi
gait. This work may also be used to enhance the function of
cal laws, this therapy works toward bringing the body's central
joints, muscles, and general biomechanics of the body while
nervous system into homeostatic balance with the musculoskeletal
speeding healing by the facilitation of release of endorphins, the
system using various Swedish massage strokes, such as effleur
body's natural painkillers.
age, petrissage, and deep transverse friction, along with trigger point release. Neuromuscular therapy techniques, along with a thorough structural evaluation, are needed to understand and treat the causa
Neuromuscular therapy has many broad applications in today's health care setting. It is used to treat people who suffer from acute or chronic pain stemming from various injuries, such as those related to the following:
tive factors involved in acute, or of rapid onset, and chronic, or
•
Sports injuries, such as strains and sprains
long-lasting, myofascial pain and dysfunction. Specifically, neu
•
Automobile injuries, such as whiplash
romuscular therapy is used to deactivate trigger points in muscle,
•
tendon, and ligaments. It is also used to lengthen chronically short ened muscles and balance muscle groups, especially when working
•
with people suffering from postural dysfunction or distortion, such as internal rotation of a shoulder girdle or scoliosis. Thus, being trained in this therapy will allow a massage thera
Repetitive strain injuries, such as epicondylitis, carpal tun nel syndrome, etc. Accumulative trauma injuries, such as temporomandibular joint dysfunction
•
Skeletal problems, such as spinal disc herniation
pist to specialize in working with chronic myofascial pain and
There are, of course, many more uses for this technique. There
pain syndromes and take an active role in helping people over-
are only a few contraindications, however. The most common
3
4
NEUROMUSCULAR THERAPY BASICS
PART I
include large bruises, phlebitis, varicose veins, o/Jen wounds, and
amount of movement in any given joint, that has been com
skin infections.
promised by pain and discomfort.
In addition to massage therapists, many other health care
By lengthening chronically shortened muscles, this ther
/Jrofessionals use neuromuscular therapy today. T hese include
apy helps clients recover their range of motion. By deacti
chiro/Jractors, /Jhysiatrists, nurses, physical therapists, occupa
vating trigger points, it relieves clients of the pain and other
tional thera/Jists, osteopaths, and dentists.
sensation brought about by the trigger points.
The /Jur/Jose of this chapter is to introduce you to neuromus
Not only does neuromuscular therapy treat pain and sensa
cular therapy and provide you with foundational information you
tion that is local to trigger points, but it also treats pain that is
will need to become an effective /Jracritioner of this modality.
"referred" to parts of the body distant from the actual site of
S/Jecifically, we will consider how neuromuscular therapy works,
the trigger point. This type of pain is known as referred pain.
what the key com/Jonents of a session are, a brief history of the
Skeletal muscle makes up approximately 50% of the
modality, goals and therapeutic intent, knowledge and tools
body's weight and can develop trigger points that produce
required, and how to effectively relate to clients.
sensations such as varying degrees of pain, itching, tickling, and thermal sensation (hot or cold). It is daily activity that
HOW ITWORKS In neuromuscular therapy, therapists first assess the body's
causes the most wear and tear on the muscle tissue in our bodies. If the client is experiencing pain as the sensation of referral from trigger points, it could be extreme pain.
soft tissues to locate chronically shortened muscles and trig ger points, using effleurage, petrissage, and friction. Once
COMPONENTS OF THE TECHNIQUE
the areas in question are identified, more specific techniques
The technique approach in this text is an integration of sev
are used. Lengthening techniques such as myofascial release, deep
eral different approaches that produce optimum therapeutic
effleurage, muscle stripping, and passive stretching are per
impact when working with chronic myofascial pain. The fol
formed to help break the concentric strain, or chronically,
lowing is the list of the components of this approach: Health history intake, evaluation, and assessment skills
pathologicall y shortened muscles. A concentric contraction
•
occurs in a muscle when both ends of the muscle are brought
•
Soft tissue assessment and treatment
closer together, shortening the muscle during the active
•
Trigger point therapy (Fig. 1-2)
phase of muscle contraction. Trigger point pressure or a pin
•
cer technique is used to deactivate the trigger points formed
Myofascial release and other lengthening techniques
•
in the soft tissues (Fig. 1-1). Once a client is able, practi tioners add active stretching to the treatment schedule. This helps the client to increase range of motion, or the
Passive stretches, muscle energy technique, and active stretching
•
Postural stress analysis
•
Identifying and reducing perpetuating factors
•
Client management and follow-up
These components will be discussed in greater detail throughout the book.
HISTORY There have been many people involved with the origins of neuromuscular therapy. Most agree that the first to discover and develop this technique was a European named Stanley Lief, who was trained in osteopathy and naturopathy. Lief established a famous natural healing resort, Champneys, in Hertfordshire, England, in 1925. Along with Boris Chaitow, his cousin, Lief studied with teachers such as Dewanchand Vanna and Bernard MacFadden to become competent with the concepts of assessment and treatment of soft tissue dys •
FIGURE '-1
Horse receiving neuromuscular therapy. Even horses
function. Lief and Chaitow, also trained in osteopathy and
have trigger points that can be effectively deactivated using
naturopathy, began using these methods of assessment and
neuromuscular therapy.
soft tissue manipulation on the patients coming to the
C HAPTER
1
I NTRODUCTION TO NEUROMUSCULAR T HERAPY
5
trigger points on examination of the muscle is the presence of exquisite tenderness at a nodule in a palpable taut band." Over the course of several decades, neuromuscular therapy as a distinct system began to develop, supported by the writ ings of Janet Travell and David Simons. In the late 1970s, a student of Nimmo, Paul St. John, began teaching his system of this technique. He has traveled the United States training massage therapists and challeng ing the massage industry to become competent in the study of anatomy and kinesiology. Judith (Walker) Delany began teaching with St. John in the mid-1980s and has gone on to develop her own version of this modality, teaching it across the United States. St. John has recently upgraded his teaching program and renamed it as "Neurosomatics." Specifically, his program applies Travell and Simons' information about radiography to determine core body asymmetry and shoe reconstruction to help correctly realign posture. European and American versions of neuromuscular therapy are very similar in theory but different in the hands-on tech niques. Both versions agree on the need to incorporate a home-care program encouraging clients' commitment and participation in their healing process. A primary focus for both •
FIGURE 1-2
Pressure to a trigger paint.
versions is to understand the formation, the cause of disease, or etiology, and treatment of trigger points, locating the source of
healing resort. They spent the years between the late 1930s
referral, any perpetuating factors, and reducing and or elimi
and early 1940s testing and developing these theories and
nating them. One of the goals of this method of soft tissue
techniques. The techniques they used then very closely
manipulation is to promote the person to independence.
resemble the techniques we use today. Lief's idea of neu
Janet Travell and David Simons published a two-volume
romuscular therapy (called "neuromuscular techniques" in
set of textbooks for the medical professions, called Myofascial
Europe) incorporated a holistic approach to healing by using
Pain and Dysfunction: The Trigger Point Manual, that has
nutrition, psychology, hydrotherapy, and soft tissue manipu
impacted the medical, dental, and massage communities.
lation.1 Lief's methods eventually became incorporated into
This is the first definitive exposition on myofascial trigger
the training system at the British College of Naturopathy
points, making these coauthors true pioneers in the under
and Osteopathy.
standing of trigger points and myofascial pain.
Since then, several other osteopaths and naturopaths,
Before treating pain, Dr. Travell taught clinical phar
such as Peter Lief, Brian Youngs, Terry Moule, and leon
macology at Cornell University and was a heart specialist
Chaitow, have further developed this work. Osteopaths and
in New York in the mid-1950s. Interestingly, her father,
chiropractors have included the use of some of the tech
Dr. Willard Travell of New York City, had specialized in
niques used with neuromuscular therapy to manipulate soft
the study of pain, and particularly the pain of muscle
tissue. It has been this use of techniques that has helped to
spasms. later, she served as President John F. Kennedy's
develop this work. Neuromuscular therapy is consequently
personal physician, treating his chronic back problems.
now being taught in osteopathic and sports massage institu
She became a specialist in treating muscle pain and, in
tions in Great Britain.
general, pain management.
Within a few years of neuromuscular therapy emerging in
Janet Travell published more than 40 papers on myofas
Europe, Americans Raymond Nimmo and James Vannerson
cial trigger points between the years 1942 and 1990. David
published a newsletter called the Receptor Tonus Techniques.
Simons has long experience as a research scientist and
In this publication, they described their experiences with
worked as an aerospace physician. After hearing a lecture by
noxious nodules. These noxious nodules are what we now
Janet Travell, he was intrigued by her work. When he retired
call trigger points. According to Travell and Simons, "It
from the Air Force, he began an apprenticeship with her.
now appears that the most reliable diagnostic criterion of
They worked together for 20 years before producing The
6
PART I
NEUROMUSCULAR THERAPY BASICS
Trigger Point Manual. The first volume of The Trigger Point
neuromuscular therapy techniques. When using neuromus
Manual was published in 1983.
cular therapy techniques, the therapist works directly on muscle bellies, origins, and insertions. It is important to
GOALS AND THERAPEUTIC INTENT As with any type or style of bodywork, the therapist's intent is important. With the proper intent, the therapist's energy may actually help make the work more dynamic. This, along with choosing the correct approach for the area of the body being worked, should be given serious consideration. Historically, neuromuscular therapy involves a thorough and systematic examination of the muscles and other soft
know this information along with fiber direction of each muscle in both theory and practice. That is, the therapist should not only be able to cite attachments but should also find them on the body and palpate them. The therapist must also have an understanding of nerve reflexes and nerve physiology to be effective when using neuromuscu lar therapy, as the nervous system plays a central role in producing and perpetuating chronic pain.
tissues to isolate and identify "noxious" (harmful or painful)
"If you really want to utilize your intuition, know your
points and then treat these tissues with various methods. An
-Paul St.John
essential theoretical component to the approach is that the practitioner is working directly and therapeutically with the neuromuscular system, function of which is adversely affected in the establishment of chronic myofascial pain. The goals and therapeutic intent of neuromuscular ther apy are as follows: •
Identify and isolate tissue irregularities related to chronic myofascial pain, perhaps mapping these on a body chart for future reference
•
Restore local tissue circulation and reduce ischemia local and temporary deficiency of blood supply-so that the tissues there will begin to heal
•
Reduce hype r tonicity-excess muscular tonus-and spasm to regain integrity
•
Reduce soft tissue pain
•
Reduce and eliminate noxious or excessive nerve stim ulation and normalize reflex activity of the neuromus cular system
•
Reduce and eliminate trigger points
•
Restore normal range of motion to affected muscles
•
Release related adhesions or fascial binding and lengthen chronically shortened muscles, fascia, and other soft tissue
•
Identify and reduce or eliminate the perpetuating fac tors that continue to aggravate the trigger points and chronic pain patterns
KNOWLEDGE AND TO O LSREQUIRED
anatomy!"
Along with anatomic precision comes a much more com prehensive style of bodywork that invites one's intuition to come into play. To be able to use intuition, there must be a core body of knowledge to draw on. A neuromuscular thera pist armed with precise anatomical and kinesiological knowledge, along with an understanding of the theory and practice of neuromuscular therapy, will be able to use any intuitional responses he comes across when reading over a client's health history form and assessment information and/ or when actually working with the client's soft tissues. Without the core body of knowledge, the intuition has no way of producing information. This is a faSCinating subject that takes interest or passion, study, practical use, and time to master. You are encouraged to continue to study anatomy through all available means. Being able to palpate and work at an exact attachment site of any muscle is crucial to the success of this work.
Analysis and Kinesiology The therapist also needs to develop an overall orientation to stress and trigger points with respect to the interrelatedness of the body's structure and position. An understanding of struc tural kinesiology is a must here. Body reading, postural stress analysis, and an examination of the client's everyday use of his or her body must become a part of a therapist's repertoire to reduce and eliminate structurally based soft tissue problems.
Tools
Neuromuscular therapy is an advanced form of soft tissue
Besides being armed with knowledge, you also must have the
therapy that requires skills and integration of several tech
proper tools with which to practice neuromuscular therapy.
niques. The following principles are essential to your success of this work.
Anatomy
As with many forms of massage, an effective lubricant is needed. Small amounts of lubrication-using gel, oil, lotion, or cream-are required at certain times during each session' to mildly reduce friction to the skin. It is important, however, to
A precise and thorough knowledge of musculoskeletal
use only as much lubrication as necessary to be able to prop
anatomy is necessary to confidently and effectively use
erly engage the tissues, such as when performing effleurage, as
C HAPTER
1
I NTRODUCTION TO NEUROMUSCULAR T HERAPY
7
Dependency, Participation, and Support As a massage therapist, you should feel privileged to serve each client and be a part of his or her support system in life. However, you should be careful to not become part of
a
dependency system. A dependant client is not a healthy client, as he is look ing for a therapist, nurse, doctor, physical therapist, and so forth, to "fix" his problem. This is a client who feels "less than" the person he is dependant on. This places the thera pist, in this situation, in a "greater than" position in the client's mind. The client then has expectations that the therapist will fix his problem, and his own responsibility ends there. We want the client to feel responsible for his •
FIGURE 1-3
T-Bar pressure bar. Pressure bars are wooden tools
with rubber or plastic tips that can be used to apply pressure into the tissues.
recovery rather than expecting us to do it all for him. For a client to recover and stay healthy, he must take on some responsibility and understand that the therapist is only one of the tools he is choosing to use to recover. Now the
a small amount of drag against the skin is required for this.
responsibility of recovery is his.
Most nerve endings are at the level of skin. If you do not use
To avoid this dependency system, encourage your clients
a small amount of friction against the skin when treating an
from the very first session to participate in the therapy and
area, you will miss the opportunity to treat tissue and bone
assist you in understanding their conditions.
directly below that area. Certain techniques, however, are performed on dry skin to increase effectiveness. For example, when using any myofascial release techniques during a ses sion, begin with them so they can be done before lubricating . for best effectiveness. In addition, pressure bars can be an invaluable asset in performing this modality. Pressure bars are wooden tools with rubber or plastic tips that can be used to apply pressure into the tissues. One such tool, a TBar with a beveled rub ber tip, is used in routines presented in this book (Fig. 1-3). Pressure bars are particularly useful to reduce strain on the thumbs in doing extensive amounts of therapy, such as six to eight sessions per day. When using a pressure bar, be sure to hold it in a stable manner. With enough practice, the pres sure bar will become a natural extension of the hand. Another tool, called "Thumby," may be used to apply effleurage, friction, and trigger point pressure. It is also an excellent tool for a client to use at home for trigger point work. This is a device made of silicone and, like a pressure bar, can help reduce the strain on hands and thumbs, in particular.
RElATING TO THE CLIENT
Client-Therapist Communication To succeed in this vital work and to encourage participation from the client, you must establish effective, two-way com munication with the client. Specifically, during the first ses sion, communicate with the client to determine the extent of ischemia in tissues, find the location and referred zones of trig ger points, and determine the ability of the tissues to release spasms and respond to the therapy. This communication can be accomplished by asking the client the following three ques tions and listening carefully to his or her responses.
1. Where is it tender or sensitive to my touch? Tlssues that are in a hypercontracted state are more tender than that of healthy, flexible tissues. In questioning the client about this, be careful not to use words that may have a negative connotation, such as "painful" or "hurt ing." Use more positive terms when referring to tissues, such as "tender" or "sensitive," so that the client does not associate your work with causing pain. Furthermore, many therapists ask their clients to rate their discom fort on a scale from 1 to 10, with 10 being the greatest discomfort. Having this information will not only let you know what your client is experiencing at the
Another critical consideration when performing neuromus
moment but also how effective the treatment is later,
cular therapy is how you relate to the client. Discussed below
when you again ask them to rate their discomfort.
are how to avoid fostering dependency in your client and
2. Do you feel any referred sensations to other parts of
how to promote his or her participation and provide sup
your body? Explain to the client what "referred"
port. Also discussed is how to effectively communicate with
means and that these sensations might include tin
the client during therapy.
gling, burning, numbness, pain, or thermal sensations.
8
PART I
NEUROMUSCULAR T HERAPY BASICS
It is important for the client to know that a referral sensation may be something other than pain. Without that knowledge, a client might not relate to the thera pist certain sensations that may be coming from trig ger points and the work you are doing with them. Often when discussing trigger points, therapists, teachers, and authors call the referral sensation a referral pain only. When this is the case, some may not understand that pain is only one of several sensa tions that can occur because of trigger points.
3. Do you feel a release or decrease in discomfort as
I
press on this area? Ask this question as you are pressing and holding a trigger point for 10 or more seconds. If you are using the numbered scale, as described above, have the client rate the level of discomfort from moment to moment to indicate any changes. Some therapists, how ever, find this method distracting to clients-possibly causing them to focus more on the discomfort itself than on the release-and simply ask clients to let them know when the discomfort changes or lessens. Try both systems to see which works best for you.
PRECAUTIONS Precautions must always be taken when working with a cli ent. This helps us keep our work safe for the client to receive. Some precautions are very general and are used with any massage work, whereas others are quite specific to an area. These precautions include, but are not limited to, things such as being sure the client does not have an unstable heart condition, untreated high blood pressure, brittle diabetes (especially when working on legs), varicosities, bruises, phle bitis, broken bones, inflammation, and sunburn. Fears of being injured during bodywork need to be considered, along with restricted range of motion, very recent surgery, an upcoming sports event within the next 5 days, or degenera tive arthritis, pregnancy, and disc herniation. Precautions regarding the performance of this work include being sure that the referral patterns, pain, and trigger points you are treating actually lend themselves to neuromus cular therapy. A client demonstrating signs of swelling, discoloration, or neurological symptoms should be referred to the appropriate health care provider.
C H APT E R S UMM ARY In this chapter, we have looked a t some of the basics of neu
how to relate effectively with clients. However, it is important
romuscular therapy, including a brief explanation of how it
to note that you need more than this information to adminis
works, its components, and its history. We have also consid
ter a neuromuscular therapy session; you need to use critical
ered the goals of this modality and the importance of thera
thinking in applying this information. You may then ensure a
peutic intent when performing it. Finally, we have learned the
treatment session that will produce the most effective results
essential knowledge and tools required for this therapy and
possible in the shortest amount of time necessary.
CHAPTER
1
I NTRODUCTION TO NEUROMUSCULAR THERAPY
9
REVIEW QUESTIONS
Short Answer Questions 1. Describe neuromuscular therapy.
2. List at least three of the goals and therapeutic intents of neuromuscular therapy. 3. Regarding the approach for neuromuscular therapy, list
C. Good jokes, problems with coworkers, and family issues D. All of the above
10. Which types of injuries may be treated using neuromus cular therapy? A. Acute trauma and infections
at least three of the components of performing this
B. Repetitive strain and automobile accident injuries
modality.
C. Organ failure and accumulative trauma
4. Name three techniques that are used to help locate chronically shortened muscles and trigger points.
5. Neuromuscular therapy is a specialized technique. Which systems of the body does it tend to balance? Multiple Choice Questions 6. What is necessary to apply neuromuscular therapy
effectively and with confidence? A. Palpatory artistry and good luck B. Preci e and thorough knowledge of anatomy C. A medical degree D. Really strong hands
7. Who are known as the pioneers of trigger point therapy and myofascial pain? A. Raymond Nimmo and James Vannerson B. Stanley Lief and Boris Chaitow C. Peter Lief and Leon Chaitow D. Janet Travell and David Simons
8. In communicating with clients, many therapists like to use which of the following to evaluate the client's dis comfort level and the effectiveness of trigger point release? A. A verbal discomfort scale from 1 to 10 B. A stethoscope C. A medical reflex hammer D. Needles
9. When establishing communication with the client, what three areas are important to discuss with the client? A. Codependency, delinquency, and stress levels B. The extent of ischemia, location of trigger points and referrals, and whether the tissues are releasing/ responding to the work
D. Inflammation and open wounds True/False 11. The techniques we use to assess and locate chronically
shortened muscles and trigger points arc effleurage, petrissage, and friction.
12. Paul St. John was the first person to discover and develop neuromuscular therapy in Europe.
13. The term acute usually refers to an injury of recent onset.
14. We u e very small amounts of lubrication when treat ing with neuromuscular therapy so that we can use friction to more effectively stimulate the nerve endings in skin.
15. It is not necessary to have an understanding of struc tural kinesiology when using neuromuscular therapy. Matching a. Pressure bars
d. Range of motion
b. Postural dysfunction
e. Referral sensation
c. Concentric contraction
f. Eccentric contraction
16. What one feels at a distance from an active trigger
point?
17. Internal rotation of a shoulder girdle and scoliosis are examples of what?
18. Name a wooden tool with various rubber or plastic tips. 19. A type of contraction in which the muscle shortens in response to tension.
20. Name the term used for the available movement at a given joint?
10
PART
I
/
NEUROMUSCULAR THERAPY BASICS
R EF E R E N C E 1. Chaitow L. Modem Neuromuscular Techniques. Philadelphia: Elsevier, 1996.
NEUROMUSCULAR PHYSIOLOGY Active trigger point: a trigger point that causes clinical pain
that body part; it includes a large group of conditions that
complaints; it is always tender, prevents the musCle from
result from using the body in a repetitious way causing
fully lengthening, causes muscular weakness, refers
injury;it is also known as repetitive strain injury
sensation that is obvious to the client, and causes
Radiculopathy. any diseased condition of roots of spinal
sensation to the reference zone
nerves;the sensation caused by such disease
Biomechanics' the study of the forces exerted by soft tissue
Reciprocal inhibition: inhibition to muscles antagonistic to
(muscle) and gravity on the skeletal system
those being facilitated; this is essential for coordinated
Hypertrophy: increase in a muscle's size without an increase
movement
in the number of cells
Reference or referral zone: sensory and motor phenomena such
Key trigger point: a trigger point responsible for activating
as pain, itching, and thermal sensation caused by a trigger
one or more satellite trigger points
point while occurring at a distance from the trigger point
latent trigger pOint: an inactive trigger point;it will be tender
Sarcomere: the portion of striated muscle fibrils between two
and refer sensation only upon palpation
Z-disks
Medulla oblongata: an enlarged portion of the spinal cord
Sarcoplasmic reticulum: a network of fine tubules filled with
above the foramen magnum;the lower portion of the
fluid present in muscle tissue
brainstem
Satellite trigger point: a central trigger point induced by the
Motor endplate' a plate ending where a branch of the axon
activity of a key trigger point
or a motor neuron makes synaptic contact with a striated
Stress factor. any stress-inducing condition that aggravates
muscle fiber
a trigger point and its referral pattern, leading to pain/
Neuropathy: disease of the nerves
sensation
Overuse syndrome: a condition in which a part of the body is
Z-disk: a thin, dark disk that transversely crosses through and
injured by repeated overuse or exerting too much strain on
bisects the clear zone of a striated muscle fiber
To be able to effectively use neuromuscular therapy, you must first have an understanding of the underlying physiology of the neuromuscular system. That is, you need to know on a physio logical level what causes pain and trigger points and how they may be effectively treated. Specifically, this chapter introduces stress factors, along with the physiology involved with trigger points and referrals. It then presents rehabilitation and, finally, a discussion of the laws of physiology.
TRIGGER POINTS Daily activity, along with its corresponding stress to muscle tissue, is our primary source of postural dysfunction and, hence, trigger points. Trigger poihts can develop in any of our 200 pairs of skeletal muscles, which are responsible for almost 50% of body weight. In this section, we will briefly consider the history of trigger point research, trigger point 11
12
P A RTI
N E U R O M U S C U L A R THE R A P Y B A SIC S
anatomy and biochemistry, muscle structure and pain, the interaction of trigger points with the nervous system, and trigger point activation.
A
Trigger Point Complex Nodule
Brief History of Trigger Point Research
Our understanding of trigger points has evolved over time. Many people have "discovered" them and given them differ ent names. In 1900, Adler first came upon trigger points, referring to them as "muscular rheumatism, " whereas a text book from 1904 by Gowers described them as "fibrositis. " In G ermany, a paper was written by Schade, in 1919, about trigger points calling them "myogelosis. " Our understanding began to grow from there, and we now have the definitive exposition written by Janet Travell and David Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual.1 The first edition of Volume I (Upper Half of Body) was pub lished in 1983, and Volume II (The Lower Extremities) was published in 1992. Before writing the Trigger Point Manual, Travell wrote more than 40 papers on the subject. One writ ten in 1942 described trigger points as "idiopathic myalgia. " She then published a paper in 195 2 referring to trigger points as "myofascial trigger points, " a term that has with stood the test of time. Anatomy of a Trigger Point
A trigger point is a relatively small hard lump typically found within a taut band of muscle fiber that is quite sensi tive or tender to the touch. It may take some practice on the part of the therapist to be able to locate the epicenter of the muscular nodule, or the trigger point. When there is a trig ger point present, there is intense contractile activity in the absence of nerve excitation. This is similar to a muscle cramp but will be a small, circumscribed area within the muscle rather than the entire muscle. There is usually not any inflammation present, yet Travell and Simons cite stud ies that seem to indicate there may be ischemia present. See Figure 2-1 for further information. In Figure 2-1, we see a trigger point complex. This is show ing contraction knots that most likely make trigger points feel nodular and cause a taut band within a muscle. This figure presents an explanation of the palpable nodules and the taut bands associated with trigger points. P art B illustrates three single contraction knots within normal muscle fibers, show ing that beyond the thickened segment of contractured mus cle fiber at the knot, the muscle fiber becomes quite thinned, consisting of stretched sarcomeres in compensation for the contractured ones in the knot. The upper right portion of part B shows contraction knots separated by empty sarcolemma. According to Travell and Simons, this may represent one of the first irreversible complications that result from the con tinued presence of the contraction knot.
B
• FIGURE 2-1 A trigger point. ( Reprinted with permission from Simons D G, Travell J G, Simons L S. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Trovel! & Simons' Myofascial Pain ond Dysfunction: The Trigger Point Manual; vol 1. p. 70, Fig. 2.25).
These muscle fibers containing contraction knots are clearly under increased tension at the knot itself and beyond. Part A of Figure 2-1 indicates that this sustained tension could produce local mechanical overload of the connective tissue attachment structures in the vicinity where the taut band fibers attach. This type of distress to soft tissue would most likely induce the release of sensitizing agents to local nociceptors, producing local tenderness and the characteris tics of a trigger point. Characteristics of Trigger Points
A trigger point in a muscle prevents the muscle from being able to stretch to its full range because of a sensation, usually pain. It also restricts the muscle's strength and endurance. This restriction of stretch range along with a palpable increase in the muscle's tension is usually more severe in more active trigger points. An active trigger point, accord ing to Travell and Simons, is identified when a client can recognize the pain or other sensation that is induced by . applying pressure to the trigger point. The therapist can gently apply transverse friction across a superficial muscle to feel the nodule at the trigger point as well as the tautness in the attachments of the muscle. If the
C H APT E R 2
N E U RO M U S C U L A R PH Y S IO LO G Y
13
work done by the therapist is appropriate and effective, the palpable signs will become less and, at times, disappear. This nodule within the muscle will be extremely sensi tive when palpated. A therapist using the correct pressure to this nodule can markedly reduce this pain response. Most likely there will be limited range of motion when an active trigger point is present. If a therapist attempts a passive stretch beyond this limit, there will be severe pain present due to muscle fibers that are under substantial increase of tension at its resting length. This limitation will not be so great during active movement due to reciprocal inhibition. Range of motion will return to normal upon inactivation of the trigger point and normalization of the taut band. According to Travell and Simons, some muscles demonstrate a more marked limitation due to trigger points than do others. For example, subscapularis is likely to be far more limited by trigger points than would latissimus dorsi. Travell and Simons state that when a client takes an affected muscle into a strong isometric contraction, he will feel pain, and the pain felt will be more marked when the contraction is done when the muscle is in a shortened position. Regarding weakness in an affected muscle, Travell and Simons discuss electromyographic (EMG) studies that indi cate that muscles with active trigger points start out being fatigued. These muscles will fatigue more rapidly and become exhausted sooner than unaffected muscles.
The myosin filament heads are actually a form of the enzyme adenosine triphosphatase (ATP) that contacts and interacts with actin to be able to produce a contractile force. H observed under a microscope, these appear as cross bridges between the actin and myosin filaments. It takes ionized calcium to trigger the interaction between the filaments, and the ATP provides the energy. With each cycle, the ATP releases a myosin head from the actin and then immediately gets ready for another cycle. The presence of calcium is what triggers another cycle. It takes many of these cycles to produce what Travel! and Simons call a "rowing motion, " which is required of many myosin heads o f many filaments to accomplish one smooth twitch contraction. In the presence of both free calcium and ATP, the actin and myosin continue to interact, using energy and force to shorten the sarcomere. This interaction cannot happen if the sarcomeres are lengthened until no overlapping remains between the actin and myosin heads, in other words, when the muscle is being stretched. This is what is beginning to happen in the lower portion of Figure 2-2. Each sarcomere of a given muscle can generate maximum force only in the midrange of its length, but it can expend energy in a fully shortened position trying to shorten further. It is the absence of free calcium that stops the contracti Ie activity of the sarcomeres. 1n the absence of ATP, the myosin heads remain firmly attached and the muscle becomes stiff.
Muscle Structure and Contractile Mechanism
According to Travell and Simons, motor units are the final common pathway through which the central nervous sys tem controls voluntary muscular activity. Figure 2-3 illus trates a motor unit consisting of a cell body of a motor neuron in the anterior horn of the spinal cord, its axon that is passing through the motor nerve to enter the mus cle at its branching into fibers, and the motor end plates where each nerve branch terminates on one muscle fiber or cell. The motor unit contains all of those muscle fibers innervated by one motor neuron. So, we could say that a motor unit includes one motor neuron and all of the mus cle fibers that it supplies. One muscle fiber normally receives its nerve supply from only one motor endplate and therefore only one motor neuron. The motor neuron deter mines the fiber type of all of the muscle fibers that it sup plies. In postural as well as in extremity muscles, one motor unit supplies between 3 00 and 1 500 muscle fibers. The smaller the number of fibers that are controlled by an incli vidual motor neuron, the finer the muscle control in that muscle will be. When the cell body of a motor neuron initiates an action potential, the potential propagates along the nerve fiber or axon to the specialized nerve terminal that helps to form the
To understand trigger points, it is important to understand various points of basic muscle structure and function. Often this information is not emphasized in detail during an initial massage therapy training program. Striated, or skeletal, muscle is a grouping of fascicles with each being a bundle of many muscle fibers. The upper por tion of Figure 2-2 shows the muscle bundle broken down. Each fiber, or muscle cell, is a grouping of thousands of myofibrils in most skeletal muscles. A myofibril is made up of a chain of sarcomeres connected continuously, end to end. The basic contractile portion of skeletal muscle is the sarcomere. The sarcomeres are connected to each other by Z lines, which are like links of a chain. Each sarcomere has many filaments, which consist of actin and myosin mole cules interacting ro produce a contractile force. The middle portion of Figure 2-2 shows a sarcomere in rest length with complete overlap of actin and myosin filaments during max imum contractile force. When in maximum contraction, the myosin molecules push against the Z line to block fur ther contraction. The lowest portion of Figure 2-2 shows an almost fully stretched sarcomere with incomplete overlap of actin and myosin molecules.
Motor Units
14
P A R TI
N E U R O M U S C U L A R TH E R A P Y B A SI C S
Muscle
Muscle shortened
Cross bridges Muscle stretched I
Ca+
Sarcomere
+-,
I
Zline_ ----,
"
/ / / ""-
"
��� / /
I
_I band-----l
�;; "
/
A band
"
"-
�
I
1.--1 band--
• FIGURE 2-2 Structure and contractile mechanism of normal skeletal muscle. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams
& Wilkins, 1999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual;
vol 1. p.46, Fig. 2.5).
neuromuscular junction, motor endplate, on each muscle fiber. On arrival at the nerve terminus, the electrical action potential is relayed chemically across the synaptic cleft of the neuromuscular junction to the postjunctional membrane of the muscle fiber. This message is now an action potential again that propagates in both directions to the ends of the muscle fiber, causing the fiber to contract. It is the firing of all the muscle fibers innervated by one neuron at the same time that produces a motor unit action potential. Interestingly, the diameter of one motor unit in the biceps brachii muscle can vary from 2 to 15 mm. This gives space for the intermingling of the fibers of approximately 15 to 30 motor units. According to Travell and Simons, both EMG and glycogen depletion studies show that the density of muscle fibers supplied by one neuron is greater in the center of the motor unit than toward its periphery.
The Motor Endplate
In terms of what actually causes trigger points on a physio logical level, it seems that the motor endplate is central. Research done by Travell and Simons indicates that spikes in electrical activity, along with spontaneous electrical activity, found in trigger points arise from motor endplates, which are plates ending where a branch of the axon or a motor neuron makes synaptic contact with a striated muscle fiber. To summarize, to contract a muscle fiber must be stimu lated by nerve impulses. These nerve impulses are carried from the brain or the spinal cord to a muscle fiber by axons. Axons are part of a motor neuron. Motor neurons are action causing neurons; that is, their impulses produce action in target cells. Each muscle fiber is innervated and controlled by a motor neuron. This is considered to be neuromuscular interaction.
C H A P TER 2
---f---:i--
Anterior horn
Cell body of motor neuron
Muscle nerve
N E UR O M U S C UL AR P H Y S I OL O G Y
15
pioneers in the study of motor endplates, indicates that regardless of fiber arrangement of a muscle, the principle of the trigger points presenting within a muscle belly applies most of the time. Furthermore, owing to the research by Gunn,} it has been found that trigger points may be caused by neuropathy of the nerve serving the affected muscle. He was able to dem onstrate by way of EMG studies that neuropathic changes are significantly related to trigger points in the paraspinal musculature. This evidence shows that compression of motor nerves can activate and perpetuate a primary trigger point dysfunction at the motor endplate. It has also been found that if endplate dysfunction per sists for extended periods of time, it may eventually lead to chronic fibrotic changes. This research, according to Travell and Simons, has not gone far enough to determine how quickly or under what circumstances this might occur. Neuromuscular Junction
• FIGURE 2-3 Schematic of a motor unit. (Reprinted with permission from Simons DG, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1. p. 48,
Fig. 2.7).
A motor neuron along with the muscle fibers to which it is attached form a motor unit. A muscle fiber is attached to only one motor neuron; a single motor neu ron can innervate from 3 to 2,000 muscle fibers. A motor endplate is where each axon attaches to and innervates muscle fiber. The part of a motor neuron that leads to a muscle fiber is an axon. The connection between terminal branches of an axon and the sarcolemma of muscle fiber is called a "neu romuscular junction." There are many secretory vesicles in the axon tip containing neurotransmitters. These neuro transmitters attach to the receptors, triggering a series of reactions to cause the muscle fiber to contract. Understanding the location of motor endplates is very important when it comes to management of trigger points, according to Travell and Simons. They claim that it appears that the pathophysiology of trigger points is closely associ ated with endplates, and, therefore, we can expect to find trigger points only where there are motor endplates. Endplates in almost all skeletal muscles are located near the middle of each fiber, midway between its attachments, or within muscle bellies. A study done by Coers and Woole
The neuromuscular junction is a synapse that depends on acetylcholine (ACh) as a neurotransmitter (Fig. 2-4). The nerve terminal produces ACh. By doing so, the nerve termi nal consumes energy that is supplied mainly by mitochon dria found in the nerve terminal. The nerve terminal responds by opening calcium chan nels, which allow ionized calcium to move from the synaptic cleft into the nerve terminal. The channels are located on both sides of the specialized portion of the nerve membrane. When many packages of ACh are released, this quickly overwhelms the chemical barrier in the synaptic cleft. Quite a bit of the ACh then crosses the synaptic cleft, reaching the postjunctional membrane of the muscle fiber, where the ACh receptors are located. The chemical barrier decomposes any remaining ACh, limiting its time of action. The synapse can now respond quickly to another action potential.
.���"""""!'!"I-P'!"!"'!Il�-.-J. / Synaptic cleft •
(cholinesterase) Acetylcholine receptors
•
FIGURE 2-4 Cross section of a neuromuscular junction. (Reprinted with permission from Simons D G, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams
& Wilkins, 1999. Travell &
Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.
p. 55, Fig. 2.13).
16
PAR T I
NE UR O M U S C UL AR THER A P Y B A S I C S
Muscle Pain
Interaction with the Nervous System
The subject of muscle pain is vast and, according to Travell and Simons, requires a separate book to adequately cover it. What follows, then, is a brief summary. There are several substances that can sensitize muscle noci ceptors. These would be bradykinin, E-type prostaglandin , and 5-hydroxytryptamine. The combination of these has the potential to sensitize. The release of prostaglandins by noradrenalin may influence the trigger point mechanism at the endplate. Peripheral sensitization of nociceptors would be responsible for local tenderness to pressure, and most likely for referred pain. It is unknown which of these is responsible for this sensitizing of nociceptors at this time. Travel! and Simons state that this offers a fertile field of research investigation that may involve drugs. According to Travell and Simons, much of the suffering from chronic pain is preventable if the acute pain is con trolled promptly and effectively. They go on to claim that clinical examples of the importance of this principle are increasing rapidly. Specifically with regard to trigger points, they refer to Hong and Simons' study4 showing that the length of treatment required for patients who had devel oped a trigger point in a pectoralis muscle because of whip lash injury was directly related to the length of time between the accident and the beginning of trigger point therapy. With longer initial delay, more treatments were required and the likelihood of complete symptom relief decreased. Travell and Simons discuss that there are more recent stud ies that show that different areas of the brain become activated in response to an experimentally induced acute pain as com pared with chronic neuropathic pain. Neuropathic pain shows by positron emission tomography a striking preferential acti vation of the right anterior cingulated cortex regardless of the side of the painful mononeuropathy. Activation of this region of the brain is associated with emotional distress and suffering. Acute pain activates both motor and sensory portions of the cortex, producing a cognitive and motor behavioral experi ence rather than an emotional experience. Travel! and Simons state that these findings emphasize the importance of the affective-motivational dimension in chronic ongoing neuropathic pain that is not involved in acute pain. Chronic pain causes suffering that is processed differently in the brain than is the experience of acute pain. These neurophysiological facts emphasize the importance to the patient and to the health care delivery system of pre venting chronic pain and properly interpreting patients' descriptions and behavior. Newly activated trigger points that are poorly identified and poorly managed can become a major unnecessary cause of expensive, misery-producing chronic pain.
Sensation from an active trigger point can cause a person to be aware of the dysfunction it causes. On the other hand, sensation and/or dysfunction from latent trigger points may be overlooked by a person experiencing them. This person will connect this sensation to a trigger point only if the trig ger point is pressed upon. We must also look at key and satellite trigger points. A key trigger point is responsible for the activity of satellite trigger points. One key trigger point may actually control more than one satellite trigger point. When inactivating a key trigger point, one or more satellite trigger points may also become inactive without any direct treatment. Table 2-1 shows key and satellite trigger points mostly based on a report by HongS about keys in the upper trapezius and sternocleidomastoid muscles and their satellite trigger
•
TABLE 2-1
Muscles That Exhibit Corresponding Key Trigger Points and Satellite Trigger Points
MUjch s.wltb�e'yJrigg�poil1t�
�i!tellite Tngg.PfJlojnt�
Sternocleidomastoid
Temporalis Masseter Lateral pterygoid Digastric Orbicularis oculi Frontalis Masseter
Upper trapezius
Splenius capitis and cervicis Semispinalis capitis Levator scapulae Rhomboid minor Occipitalis
Lower trapezius
Upper trapezius
Scalenes
Serratus posterior superior Pectoralis major and minor Deltoid Extensor digitorum communis Extensor carpi radialis and ulnaris Triceps brachii: long head
Infraspinatus
Anterior deltoid Biceps brachii
Latissimus dorsi
Triceps brachii: long head Flexor carpi ulnaris
Reprinted with permission from Hong Cl. Considerations and recommendations regarding myofascial trigger paint injection. J Musculoskel Pain 7994;2(1):29-59.
C H A P TE R 2
Direct stimuli
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NEU RO M U S C UL A R P HY SIO LO GY
17
-----
-Acute overload -Overwork fatigue -Radiculopathy -Gross trauma
visceral disease -Joint dysfunction -Emotional Spinal
reference zone
•
distress
cord
FIGURE 2-5 Schematic of the central nervous system interactions with a trigger point. ( Reprinted with permission from Simons D G, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol
1. p. 20, Fig. 2. 1).
points that show up in the digastric, masseter, and tempo ralis muscles. Key trigger points and satellite trigger points are always related, and there is usually a hierarchy. This hierarchy may not be clear when it comes to which came first. What is clear is that certain trigger points in certain muscles are related to those in certain other muscles and that inactivating one of these related trigger points may inactivate others. It may be easy to overlook a key trigger point when the client is com plaining of the sensation caused by a satellite trigger point. Travell and Simons cited a case study done by J. Whiteside (personal communication, 1995). This is an interesting exam ple of a three-step satellite trigger point system that had set into a fourth-year college student. The student complained of a toothache in her right upper jaw, along with an ache in her right upper trapezius, when she studied for long periods of time. She had undergone extensive dental work, includ ing a root canal, without getting any relief. When pressure was applied to a trigger point in her right lower trapezius, she felt the dull ache in the upper trapezius, just as when she studied. Then, in response to pressure on the trigger point in the upper trapezius, she experienced a pain she had not pre viously felt in the right temporal region. Then, in response to pressure on the right temporalis, she felt the pain in the tooth that had been bothering her when studying. The inten ity and extent of the referred sensation depends on the degree of irritability of the trigger point, not on the size of the muscle. Trigger Point Activation
Trigger points are activated directly by acute overload, over work, fatigue, direct impact trauma, and radiculopathy, according to Travell and Simons. Trigger points can be acti vated indirectly, as well, by other existing trigger points, visceral disease, arthritic joints, joint dysfunctions, and emotional distress (Fig. 2-5).
Satellite trigger points are prone to develop in muscles that are within the reference zone of key trigger points, or within the referral zone from a diseased visceral organ. Examples of this would be the area of referred pain from a heart attack, peptic ulcer, or renal colic. Perpetuating fac tors will increase overload stress that converts latent trigger points to active trigger points. With enough rest, along with the absence of perpetuat ing factors, an active trigger point may become latent on its own. Pain and other sensations disappear but can reactivate with new stress. This, according to Travell and Simons, may explain recurrent episodes of the same symptoms over a period of time.
SOURCES OFTRIGGER POINTS AND REFERRALS Although trigger points usually set up within somatic tis sue, they are actually capable of setting up within any of the body's soft tissues and visceral organs. Also, most trig ger points refer from the trigger point in somatic tissue into a referral area also within somatic tissue in a specific pat tern. However, it is possible that a trigger point may refer into any area of soft tissue or visceral organ in the body. There are four distinct patterns of trigger points to referral areas: 1. From somatic tissue into somatic tissue 2. From somatic tissue into a visceral organ
3 . From a visceral organ into somatic tissue 4. From a visceral organ into a visceral organ
LAWS OF PHYSIOLOGY As a massage therapist, and especially as a neuromuscular therapist, it will be important to develop a deep understanding
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of what you are doing when working with others who are in pain. The laws of physiology will be an important tool to help explain what it is we do. It is necessary to learn these laws to be able to properly grasp the physiological principles on which neuromuscular therapy is based. Taber's Cyclopedic Medical Dictionary defines a law of physiology as a scientific principle that is uniformly true for a whole class of natural physiological occurrences. A law is defined as a uniform or constant fact or principle. The fol lowing is a list of laws of physiology that correspond to what we work with as a neuromuscular therapist. Law of Facilitation
When an impulse has passed through a certain set of neu rons to the exclusion of others, it will tend to take the same course on future occasions, and each time it traverses this path, the resistance will be less. The nervous system tends to train itself to find the path of least resistance. When a neural pathway is activated, this is a habitual pattern produced by the body. This law explains why pain often occurs in the same place. It does not take much to aggravate an old injury again. The patterns of pain will usually become a set pattern in the body. With an area that was previously injured or compromised in some way, it is likely that it will take far less stimulation to reinjure. Also, it will take less time to heal that area again. This seems to also explain why the more massage one receives, the easier it is to relax. Davis'Law
If muscle ends are brought closer together, the pull of tonus is increased, thereby shortening the muscle, which may cause hypertrophy. If muscle ends are separated beyond normal, then tonus is lessened or lost, thereby weakening the muscle. If soft tissue is placed under unremitting tension, the tissue will elongate by adding more material. This law seems to indicate that if we do not use it, we will lose it. Imagine a muscle imbalance in which the set of hypertonic muscles has chronically shortened and become hypertrophied while the antagonist set of muscles has become chronically over stretched and weakened. An example of this might be hyper tonic pectoralis major and minor muscles versus weakened, overstretched rhomboid major and minor muscles. Hilton'sLaw
A nerve trunk that supplies a joint also supplies both the muscles of the joint and the skin over the attachments of these muscles. When there is an injury, it is hard to decide whether the pain is coming from the skin, muscle, or joint. Stimulation of any of these areas will have an effect on all of the areas. This seems to explain two things. The first is why working superficially may
create a release of spasm in deeper tissues of the body. The second is why applying the skin rolling technique works to help decrease tenderness in the deeper tissues. Arndt-SchultzLaw
Weak stimuli activate physiological processes; very strong stimuli inhibit physiological responses. This law indicates that one should use a gentle approach, slower and less stim ulating, if one's intent is to activate physiological responses. Using force to an area will be less effective than a gentle, slow approach to deeper work. If we gently stimulate the tissue, it will heal faster than if it is ignored. A weak stimu lus activates tissue healing and growth processes. Trigger points usually give strong impulses that tend to tum off certain processes. An example of this is that a whip lash injury may actually affect the thyroid gland in a nega tive way. So, to tum off a physiological response, one may use a strong stimulus. Thus, we could use deep transverse friction for several minutes to actually stop pain. Pfluger's Laws
Pfluger's laws are a series of laws that explain how a body can transition from acute pain to chronic pain. These describe the progress from acute injury left untreated to chronic pain. Law of Unilaterality If mild irritation is applied to one or more sensory nerves,
the movement will take place usually on one side only, on the side that has been irritated. This law explains that at the site of an injury, the body will respond to the tral.ma with the sensation of pain. Any light stimulation will remain localized. If this person were to experience mild irritation, it may affect the localized site and stay on the side of the body that has been injured. Law of Symmetry If the stimulation is sufficiently increased, motor reaction
is manifested not only by the irritated side but also in similar muscles on the opposite side of the body. This law indicates that if the trauma to the body was great enough, the opposite side of the body may also begin to feel pain. If the therapist uses increasing levels of pressure on one side only during treatment sessions, there will be a bilat eral effect. If the unaffected side were also massaged, the therapist would actually be addressing the injured side indirectly. Law of Intensity Reflex movements are more intense on the side of irritation
and less intense on the opposite side. This law is similar to the law of symmetry, but now the levels of pain have increased.
C H A P TER 2
Law of Radiation
If me excitation continues to increase, it is propagated upward and reactions take place through centrifugal nerves coming from the cord segments higher up. This law indicates that irritation will move up the spinal cord and create reactions in corresponding areas of the body that are innervated by those nerve segments impacted. Spasms and pain above the actual site of injury are possible, which is called "muscle guarding. " In this case, the body is trying to protect the site of injury. Law of Generalization When the irritation becomes very intense, it is propagated in the medulla oblongata, which becomes a focus from which stimuli radiate to all parts of the cord, causing a gen eral contraction of all muscles of the body. When a client is in this state, the therapist must not use rough or intense massage techniques, as they can cause the person's body to go into muscular contractions or complete muscle guarding. This condition is sometimes called "general adaptation syn drome." When a client receives work that is too rough or too deep too quickly, the body's experience is identical to that of receiving trauma. In other words, the therapist can
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19
traumatize this individual's body if gentleness and sensitiv ity are not used. This person's body will react with a general ized contraction of the entire body. Wolff'sLaw
Every change in the form and the foundation of a bone, or in its function alone, is followed by certain definite changes in its internal architecture and secondary alterations in its external conformation. This law is also known as the law of bone transformation. It states that form follows function. Righting Reflexes
Righting reflexes are reflexes through various receptors in the labyrinth, eyes, muscles, or skin that tend to bring the body back to its normal position in space and which resist any force acting to put it into an abnormal position. This law speaks to why we can, for example, have a high shoulder on one side of our body with a tilted occiput high on the other side of the body and still see levelly on a horizontal plane and not feel dizzy. The bones of the face and head will become asymmetrical to realign the eyes and ears to the horizon, allowing us to see straight and not experience vertigo.
C H A PT E R S UMMA R Y In this chapter, we have considered various factors and principles involved with the physiology of neuromuscu lar therapy. You should now have a basic understanding of trigger points and referrals, including their anatomy, biochemistry, sources, interaction with the nervous
system, and activation. The laws of physiology have been presented to give you the information necessary to help a client understand his or her condition and why it will be important for him or her to follow a specific plan to rehabilitate.
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� REVI EW QU ESTIO N S
Short Answer Questions
1 . Describe a motor end plate. 2. What is a statin? 3. What does it take to aggravate a trigger point and its
referral pattern? 4. What is a law of physiology? 5. Name one law of physiology. Multiple Choice Questions
6. The following are characteristics of trigger points:
A. Referred pain, local tenderness upon palpation, adhesion formation B. Jump sign, local twitch response, nerve entrapment, ischemia C. Paresthesia, local twitch response, referred sensa tion, tight bands D. Ischemia, referred sensation, hyperirritable upon palpation 7. The difference between a latent and active trigger point
is that A. a latent trigger point does not exhibit referred sen sation patterns. B. an active trigger point is usually in spasm. C. an active trigger point is clinically painful, whereas a latent one is painful only upon palpation. D. a latent trigger point has not come out of the closet. 8. Which is a suggested reason for why the calcium
switch will not tum off in the presence of a trigger point?
9. Trigger points are activated by
A. playing sports while not eating in a nutritious way. B. uncaring massage therapists applying incorrect pressure during a massage. C. acute overload, overwork fatigue, direct impact trauma, and radiculopathy. D. only indirect methods. 10. Which are patterns of trigger points to referral areas ?
A. From somatic tissue into a visceral organ B. From somatic tissue into somatic tissue C. From a visceral organ into somatic tissue D. All of the above E. None of the above True/False
1 1 . There should be no concern regarding where one begins
when it comes to rehabilitation after a soft tissue injury, because everything helps. 1 2. As a neuromuscular therapist, it is not important to
have an understanding of the laws of physiology to be able to properly grasp the physiological principles of neuromuscular therapy. 1 3. Trigger points usually set up within somatic tissue;
however, they are capable of setting up within any of the body's soft tissues as well as in visceral organs. 1 4 . Radiculopathy is the sensation referring from a trigger
point. 1 5 . Neuropathy is a disease of the bones. Matching
A. Mechanical stress to the sarcoplasmic reticulum
a. Law of Facilitation
g. Law of Intensity
B. The ATP production has been interrupted
b. Davis' Law
h. Law of Radiation
C. The sarcoplasmic reticulum has reabsorbed too much calcium
c. Hilton's Law
i. Law of Generalization
d. Arndt-Schultz Law
j. Wolff's Law
e. Law of U nilaterality
k. Righting Reflexes
D. The person is not taking the right kind of drugs
f. Law of Symmetry
C H A PT E R 2
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21
1 6. When an impulse has passed through a certain set of
1 9. Reflexes that through various receptors i n the laby
neurons to the exclusion of others, it will tend to take the same course on future occasions, and each time it traverses this path, the resistance will be less.
rinth, eyes, muscles, or skin tend to bring the body i nto its normal position in space and that resist any force acting to put it into an abnormal position.
1 7 . Reflex movements are more intense on the side of irri
20. If mild irritation is applied to one or more sensory nerves, the movement will take place usually on one
tation and less intense on the opposite side. 1 8. Every change in the form and the foundation of a bone,
side only, on the side that has been irritated.
or in its function alone, is followed by certain definite changes in its internal architecture and secondary alterations in its external conformation.
REFEREN CES 1 . Simor.s DG, Travell JG, Simons LS. Upper Half of Body . 2nd ed.
4. Hong CZ, Simons DG. Response to treatment for pectoral is
Baltimore: Lippincott Williams & Wilkins, 1 999. Travell &
minor myofasc ial pain syndrome after whiplash.
Simons ' Myofascial Pain and Dysfunction: The Trigger Point
Pain. 1 993 ; 1 ( 1 ):9- 1 3 1 .
Manual; vol 1 . 2 . Coers C, Woolf AL. The Innervation of M uscle , A Biopsy Study. Oxford: Blackwell Scientific Publications, 1 9 59; Fig. 9- 1 5 . 3 . Gunn Cc. Prespondylosis and some pain syndromes following denervation supersensitivity. Spine . 1 980; 5 ( 2 ) : 1 85 .
]
Musculoskel
5 . Hong CZ. Considerations and recommenclations regard i ng myofascial trigger point injection. 2( 1 ) : 29-59.
]
Musculoskel Pain. 1 994;
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CLIENT ASSESSMENT Bruxism: clenching the jaw and grinding the teeth, especially
Paradoxical breathing patterns: an imbalance in osseous
during sleep
structures above the core (determined by the integrity of
Informed consent: competent and voluntary permission for a
the fascial planes of the body) that causes the osseous and
procedure, test, or medication; consent given on the basis
myofascial structures to begin to pull down unevenly on
of understanding the nature, risks, and alternatives of the
the respiratory diaphragm, affecting the thoracic inlet and
procedure or test
causing serious implications for the proper functioning of
Inert tissue: tissue remaining in a sluggish state until acted upon by an outside force
IsometrIC contraction' a contraction in which a muscle increases its tension without shortening
our breathing apparatus
Perpetuating factor ' Something that prolongs the existence of a condition, such as neck pain due to improper work station setup causing neck strain daily; also, a chronic condition or disease that a person must learn to manage and work with,
Malocclusion' malposition and imperfect contact of the
such as an athlete with diabetes or a person with post-polio
mandibular and maxillary teeth
syndrome
Orthopedic assessment: the assessment of disorders involving the locomotor structures of the body, especially the skeleton, joints, muscles, fascia, and other supporting structures such as ligaments and cartilage
Orthopedic testing various tests developed to help in the assessment of disorders and injuries of the locomotor
Rotoscoliosis: rather than or along with a lateral curve of the spine, the vertebrae are rotated to one side or the other
Thoracic kyphosis: derived from Greek, meaning humpback or hunchback; an exaggeration or angulation of the normal posterior curve of the spine
structures of the body
As a neuromuscular therapist, you must thoroughly assess your
neuromuscular therapist must have many ways of assessing a
client, as findings of the initial assessment will determine your
client. It is this assessment along with the client's report of
treatment plan, To work effectively and efficiently with any cli
symptoms that give the therapist the clues necessary to form a
ent, it is important that the assessment be correct and encompass as much of the client's lifestyle as possible. Some therapists like to
well-rounded and comprehensive treatment plan. This chapter equips you to effectively assess your client and
have a first session with a client include extra time for the assess
covers such topics as obtaining the client's health history, inter
ment, whereas others like to have the first appointment be only
viewing the client, performing range of motion and postural
about assessment and education of the client, while making a
assessment on the client, palpation, and consideration of predis
second appointment to begin treatment.
posing and perpetuating factors.
A client visiting a neuromuscular therapist will most likely be in pain due to a postural dysfunction or an injury. Thus, a 23
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• HEALTH INFORMATION FORM As a therapist, it is your responsibility to gain comprehen sive health information from the client as the initial por tion of your assessment of each client you treat. It is this information that governs your analysis as well as your for mulation of a therapeutic regimen, or plan, for each client. This health information gives you clues as to contraindica tions, for instance. It is always important to be safe in regard to treatment of a client. This information from the client will also help decide where to begin your work, how long it might take to complete the work, which techniques to employ, and possibly where you might expect to find trigger points. This information must be recorded in a health infor mation form and include a date and the client's signature (Fig. 3-1 ) . Moreover, it is wise to include a disclaimer of diagnosis and any policies regarding treatment and pay ment in a statement in the form prior to the signature. This way, there can be no miscommunication of either your expectations of the client or your intent and treatment policy. The health information form is a legal document and must be filled out, dated, and signed by the client in ink. Should you ever be involved in a lawsuit either as the defendant or as a witness, it will be important to have writ ten on the form further information gained by questioning the client. This should also be in ink with a date and your signature. This information should be preceded by a state ment such as "As stated by the client." This proves that you have done your job well while placing the responsibility for this information on the client. It also demonstrates that the therapist has gained informed consent from the client before beginning treatment. You will most likely want several sections to this form. The first section will contain personal information, such as name, phone number, address, birth date, occupation, and so on. Within this first section be sure to include space for the client's physician and phone number. The second sec tion could include any present symptoms the client is pres ently experiencing; for this you might want to consider check boxes so the client does not have to write much. A third section could have illustrations of bodies, both ante rior and posterior, with instructions to color in any area that has difficulties. A fourth section might include information about previous massage the client has had, any medications being taken and what the medications are taken for, and any previous injuries with the dates they happened. For the final section, you might wish to include a disclaimer that massage therapists do no diagnosis or prescribing, nor do they perform spinal manipulation, and so on. Also consider including a positive statement about the benefits of massage therapy.
Another statement you may wish to place in this final sec tion is a statement of your policy regarding change or can cellation of an appointment. The final thing for this form would be a line for the client's signature and the date. There are many more things that could appear on such a form, however. It might be wise to check out others' health information forms to see what you would like to include. The part of the health information form that is especially important in helping you locate trigger points and pain refer ral patterns in your client consists of simple sketches of the human body, both anterior and posterior views, on which clients may indicate the areas in which they feel discomfort by drawing. On questioning a client who has completed such a drawing, you may darken in the areas that are worse while leaving the other areas of discomfort lighter. This will give you an "at-a-glance" summary of the information regarding the person's pain. When compared with a good trigger point chart, this is very valuable information, as it may show the referral areas from the trigger points this person is experienc ing, helping you pinpoint the actual trigger points. Also, be sure to record any additional information regard ing the quality of the client's discomfort gained from inter viewing the client, as discussed below, on the chart next to the drawings. As the quality of discomfort changes, be sure to chart this information as well. You may go back over this history form again and again looking for more clues as to how to proceed with treatment. The more information that is provided on this form, the more clues there are to consider-it is that simple.
INTERVIEWING THE CLIENT Another critical component of the assessment process is to thoroughly interview the client regarding his or her health. Clients will often not record key information about their health on a health information form, and in other cases infor mation that they do provide will require further explanation. In interviewing the client, remember to be sensitive to the client's feelings regarding his or her pain and previous treatment. Be sure to actively listen to the client's responses to questions while maintaining eye contact. Gaining this person's trust and confidence will be extremely important to the outcome of the course of treatment you decide upon. If the client has no confidence in you or does not think you are competent, he or she will not return for more sessions and/or will not be compliant regarding home care. Another tip regarding interviewing is to have a few refer ence books on anatomy and good, comprehensive trigger point charts on hand. Using these references, you may be able to show clients where the work must be done on them, along with confirming their pain. Again, this goes toward
C L I ENT ASSESSMENT
C H A PT E R 3
HEALTH INFORMATION
Manual Therapist Patient Name
25
_______
Date
________ _
ID#/DOB
Date of Injury A. Patient Information
Address City
____________ __ __ _
State
_______
__
Zip
_ _ __
List Daily Activities Limited by Condition
Work
_________________ __
Phone: Horne Work
______
Employer
_ __ _ ___ _ _
________________
Work Address Occupation
_______________ _
Phone: Horne
______________
_
Cell
________ _
Primary Health Care Provider
Name
_ ________________ _
Sleep/Self-care
_ __ _ _ _ _ __ _ _ _ _
Social/Recreational
___________ __
List Self-Care Routines
How do you reduce stress? Pain?
__ __ _ _ _ _
_________________ _
________________ _
City/State/Zip Phone:
_ _ __ _ _ _ _ __ _ __ _
__ ________ _ _
______
Address
Horne/Family
_____________ _
Emergency Contact
Work
Cell
___ __________
_______
Fax
__ _ __ __ _
List current medications (include pain relievers and herbal remedies)
__________ __
I give my massage therapist permission to consult with my health care providers regarding my health and treatment. Comments Initials
_ _______________
______
_ _ _ _ __ _ _
Have you ever received massage therapy before?
___
Frequency?
_______ _
B. Current Health Information
What are your goals for receiving massage
List Health Concerns Check all that apply
therapy?
Primary
D D D D
symptoms i w/activity
D J, w/activity getting worse D getting better D no change
Secondary
D D D D
_ __________ _
C. Health History
List and Explain. Include dates and treatment received. Surgeries
________________ _
_ ______________ _
D moderate D disabling D intermittant symptoms i w/activity D J, w/activity getting worse D getting better D no change mild
constant
treatment received Additional
D D D D
_ ____ _ __ ___ ___ _ _
___ _______________
mild D moderate D disabling constant D intermittant
treatment received
________________ _
_ __ _______ _ _
D moderate D disabling D intermittant symptoms i w/activity D J, w/activity getting worse D getting better D no change mild
constant
FIGURE 3-1
Injuries
_ _ __ __ _ _ _ _ _ _ __ _
treatment received •
Date
Major Illnesses
_ _ _________ _
Health information form, includ i ng anterior and posterior views of the h uman body. (Reprinted with perm ission from Thompson DL.
Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Philadelphia: Lippi ncott W i l li a m s & Wilkins, 1 996; pp. 2 50, 2 51 , 2 63.)
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HEALTH INFORMATION page Check All Current and Previous Conditions General
current D D
past D headaches D pain
comments _ _ _ __
D sleep disturbances
D
D fatigue
D
D infections
D
D fever
D
D sinus
D
D other
_____ _
____ _ __
past D rashes
comments
D
D other
Muscles and Joints
D D D D D D D D
comments pas t D head injuries, concussions
current D
D
D dizziness, ringing in ears
D
D loss of memory, confusion
D
D numbness, tingling
__
D
D detergents D other
D
__ _ _ _
___ ___ _
Digestive /Elimination System
current D
comments past D bowel problems
_ __ _
D
D gas, bloating
_ _ _ __
D
D sCiatica, shooting pain
D
D bladder/kidney/prostrate
D
D chronic pain
D
D abdominal pain
D
D depression
D
D
D
D other
Respiratory, Cardiovascular
current D comments
past D rheumatoid arthritis D osteoarthritis D osteoporosis D scoliosis D broken bones D spinal problems
past D heart disease
comments
current D
D
D blood clots
D
D stroke
D
D lymphadema
D
D high, low blood pressure
D
D irregular heart beat
D lupus D TMJ,jaw pain D spasms, cramps
D
D swollen ankles
D
D varicose veins
D
D chest pain, shortness of
D tendonitis, bursitis
comments
_ _____
D diabetes
___ __ _
past D pregnancy
comments
_____ _
D
D painful, emotional menses
D
D fibrotic cysts
current D D
D poor circulation
D
past D thyroid
____ _
Cancer /Tumors
D
D sprains, strains
current D D
D
Habits
Contract for Care I promise to participate
D stiff or painful joints D weak or sore muscles
__
current D D D D
D asthma
___ _
______ _
Reproductive System
D disk problems
D
other
Endocrine System
__
breath
D D
past comments D scents, oils, lotions
_ ______
D athlete's foot, warts
D
Allergies
current D
______ _
D
current D
Nervous System
_____ _
Skin Conditions
current D
Please Explain
______ _
D
2
past D benign
comments
_ ______
D malignant past D tobacco D alcohol D drugs
_____ _
comments __ _ _ __
_ _ __ _ _
__ _ _ _ _ _
D coffee, soda
_____ _
fully as a member of my health care team.
I will
make
sound choices regarding my treatment plan based on the information provided by my manual therapist and other members of my health care team, and my ex perience of those suggestions.
I
agree to participate
in
the self care program we
select. I promise to inform my practitioner any time I feel my well-being is threat ened or compromised. I expect my manual therapist to provide safe and effective
D
D neck, shoulder, arm pain
treatment.
Consent for Care It is my choice to receive manual therapy, and
•
I
give my consent to receive
D
D low back, hip, leg pain
treatment. I have reported all health conditions that
D
D other
Signature
FIGURE 3-1
(Continued)
I
am aware of and
will
inform my practitioner of any changes in my health.
_______________ __ __
Date
_ __ _
C H A PT E R 3
____ ____ ____ ______ ____ __ _
Date of Injury
CLIENT ASSESSMENT
HEALTH REPORT
Manual Therapist Patient Name
I
Date
_ _ __ _ _ _
ID#/DOB
A. Draw today's symptoms on the figures.
1. Identify CURRENT symptomatic areas in your body by marking letters on the figures below.
Use the letters provided in the key to identify the symptoms you are feeling today. 2. Circle the area around each letter, representing the size and shape of each symptom location. Key P
=
S
=
N
=
pain or tenderness joint or muscle stiffness numbness or tingling
"' /
)
r
\
J
B. Identity the intensity of your symptoms. 1. Pain Scale: Mark a line on the scale to show the amount of pain you are experiencing today.
No Pain "'1-----------------------tl Unbearable Pain 2. Activities Scale: Mark a line on the scale to show the limitations you are experiencing today
in your daily activities. Can Do Anything I Want ..1-----------------------11 Cannot
Do Anything
C. Comments
Signature •
FIGURE 3-1
_ ___ ______________ _______ _
(Continued)
Date
_ _ ____ _
27
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trust and informed consent. This too will be charted on the history form by you. Two specific areas to cover when interviewing a client are the cause of the client's pain and previous treatment that the client has undergone for the condition. Cause of Pain
Of specific interest in this interview process is to learn more about the origination of the client's pain. For instance, a person may or may not write down how his or her pain originated, even though there is a portion of the health information form that asks about the reason for making the appointment or about previous injuries. Whether the client has it written down, it is imperative to ask many questions about injuries. It is impor tant to know about the injury or event that led this person to the therapist as well as about all previous injuries. The therapist must determine whether the pain is stemming from an acute trauma, chronic overload, or some other source. Any or all previous injuries may have set up trigger points that have remained latent until the event that brought the client to seek treatment caused them to become active. Again, it is imperative that you ask as many questions as you can think of. Here are some sample questions: • How exactly did this injury occur? •
In what position did you land?
•
How did it feel as you landed?
•
How did it feel to get up?
•
Were you sore immediately after the accident, or only after a day or two?
•
When did you first notice that you were experiencing the pain/discomfort?
•
What activities do you do on a daily basis?
•
What makes it feel better? Can you demonstrate that?
•
What makes it feel worse? Can you demonstrate that?
•
How does it feel right now?
The goal of this questioning is to understand your client's pain and discomfort as clearly as possible. To this end, try to imagine how this individual feels, possibly by putting your body into the client's dysfunctional posture so you may experience a similar discomfort. This exercise may give you even more questions and insights. Again, be sure to write the answers to all questions down in ink with your initials and the date right on the health information form. Previous Treatment
Often, clients will have undergone medical diagnosis and treatment before seeking massage therapy. These experi ences could have been either positive or negative. If there
has been a negative experience, try to refocus this person on his current treatment so that he is feeling positive. There will be quite a bit of information you can use due to his previous treatment, however. By finding out what worked and what did not work, you can more easily setup your treatment plan while avoiding those things that pre viously did not work. This information also gives you fur ther information regarding any contraindications that may be present. Another factor to consider here is the opportunity to contact the client's other health care professionals to gain even further information about his condition. You will most likely want to have a permission for medical information form for the client to sign. Often this client has had various testing such as MRI, CAT scan, X-rays, and so on, amI you will be able to receive a copy of the reports from these tests. These reports will often give you very valuable information regarding the client's condition. Should the client still be working with these other health care professionals, you will have the opportunity to work with them as a team, which may lead to future referrals. A series of questions about previous treatment will be helpful to gain the information you will need. Here are some sample questions: • Have you sought medical attention for this problem before coming here? •
If so, what was the diagnosis and course of treatment?
•
What was the outcome of the treatment?
•
Do you feel this diagnosis and/or treatment was com prehensive and/or correct?
•
How do you feel about your outcome from the previous treatment?
• ORTHOPEDIC TESTING Once you have an understanding of the client's health his tory, current pain or discomfort, and previous treatment, it may be helpful to put the client through a series of ortho pedic testing procedures. Orthopedic testing may also be referred to as manual muscle testing or evaluative muscle testing. There is an art to these tests. A therapist must be very carefu l when handling an injured body part, for instance, being very gentle when positioning the person for the test to avoid any pain or discomfort, being very careful and working slowly with a muscle that is either very weak or fatigued, and also having the ability to give the right amount of counter pressure to allow the client to give the optimal responding pressure. There is also a science to these tests. The therapist must be attentive to each detail that has the capacity to change the test's accuracy and alter results. The tests will only be
CHAPTER 3 /
useful if they are accurate. Accurate muscle testing must include knowledge, skill, and experience by the therapist. Orthopedic testing is a very important part of client intake, as it will give usable information regarding specific muscles and/ or joints to help us plan the course of treatment. This testing can also be used at various times during the course of treatment to help keep the treatment plan on track. There are many neuromuscular conditions that include muscle weakness, muscle fatigue, and muscle imbalance; orthopedic testing will give insight regarding these condi tions. A therapist with extensive knowledge of muscle action and joint range of motion will usually be able to perform well in regard to this testing. Keep in mind that our ultimate goal with treatment is to restore and maintain good range of motion, good postural alignment, and muscle balance. Be sure to document all findings of each test, as this information will help you determine where to begin and what the exact course of treatment must be. Once you note that the client's condition is changing, these tests may be used again and again to measure improvement. In fact, demonstrating improvements in range of motion and level of discomfort the client is experiencing through repeated tests can be a significant psychological boost to the client. Having objective proof of improvement can moti vate the client to continue and help him or her heal com pletely and as quickly as possible. As this text was not meant to teach orthopedic testing, it will be important that you take a course to learn these tests if this information was not included in your initial massage therapy program. Range of Motion Assessment
One type of orthopedic testing is range of motion assess ment. Along with inflammation that stems from an injury comes loss of function or range of motion. This loss of func tion may begin simply in response to pain, but then may continue to develop because of scar tissue that is not prop erly formed. The longer a person experiences loss of range of motion, the greater the loss of range of motion becomes. In time, a person will have no use of the area and will be in danger of developing a compensatory injury. First, however, you must have an understanding of the normal range of motion of each joint in question, so you will know whether the test is positive. Table 3-1 lists the degree of motion each joint should be capable of. Range of motion refers to the number of degrees of motion that are present in a joint. These tests can be done actively, passively, or actively against resistance, with the last one being more involved with muscles that are painful and most likely involved in the injury or dysfunction. It may be necessary to use all three
CLIENT ASSESSMENT
29
tests, although discrepancy between the types of tests should be noted. Passive Testing
Passive testing provides information about passive struc tures, such as joints, bursas, or ligaments, also known as inert tissues. The client stays relaxed while the therapist moves the joint in question in each direction. The effect of conscious control and muscular effort is eliminated; thus, this test separates the muscles from the passive structures. The client should report whether pain is provoked. Keep in mind that even relatively small differences in range of motion, in conjunction with varying levels of pain, can be significant. For instance, 5 degrees of limita tion of movement without pain could indicate a signifi cantly different condition from full range of motion with pain, in a given joint. Thus, it is important to be precise in your assessment. Moreover, you may need to persuade a client to move through a painful arc to find out whether the pain ceases at full range. The beginning of pain may not correspond with the extreme range; for example, a straight-leg raise may start to hurt at 45 degrees, but con tinue to 90 degrees without increased discomfort. Thus, the examiner must determine whether the appearance of pain and the extreme of the range of motion are reached together or separately. Each primary movement of the joint must be tested pas sively to allow the emergence of a pattern, the relation between the degree of movement obtainable in all directions. This will distinguish capsular from noncapsular limitation of movement. If there is pain upon this passive movement, most likely the problem will be within a passive structure. Be sure to refer back to your information on this type of testing from your general therapeutic massage course. Again, as this book is about performing neuromuscular therapy, it is suggested that you take a class or perhaps purchase a hook for further study of these tests. The author's favorite refer ence book for orthopedic testing is Muscles, Testing and Function with Posture and Pain, Fifth Edition, by Kendall, McCreary, Provance, Rodgers, and Romani published by Lippincott Williams & Wilkins. Active Testing
Active testing will give you a sense of the involvement of the injury-the seriousness of the injury. In this type of test ing, the client provides all of the effort to move a joint through its range of motion. For example, an active test might involve having a client begin to lift his arm out to the side and then above his head to show lateral shoulder move ment. If he must also move his shoulder along with the arm during the test, it will be obvious to the observer. Thus, in this case, an active test is called for instead of a passive test,
30
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•
TABLE 3-1 Range of Motion for Fundamental Movements
N�ck
ROM
�houlder
���
Flexion
90°
Flexion
90°
Extension
0°
Extension
0°
Hyperextension
45°
Hyperexten sion
45°
Lateral flexion
45°
Abduction
90°
Rotation
1 80 °
Adduction
0°
Me�a��1
Outward rotation
90°
Inward rotation
90°
Hori zontal flexion
90°
Hori zontal a bd uction
90°
Wrist
Flexion
90°
Flexion
80 -90°
Extension
0°
Extension
90° 80 -90 °
Hyperextension
0-20°
Hyperextension
A bd uction
30°
Ulnar flexion
35-45°
Adduction
0°
Radial flexion
20-25°
Proximal lnterjthalangealJoint Flexion
DistallMerphalal!!ll1al�oint 1 00-1 1 0 °
Extension
Knee
Flexion
200
Extension
0°
�tata[sal Phalang�alJoint
Flexion
1 30-1 35°
Flexion
20°
Extension
0°
Extension
0°
Hyperextension
90°
Ankle Plantar flexion
50 -60°
Dorsi flexion
1 0 -20°
Abduction
1 5-20°
Adduction
0°
rroximallnterphalanl J eal JQinJ{fooO Foot Plantar flexion
50 -60 °
Dorsi flexion
1 0 -20°
Inversion
40-45°
Eversion
2 0 -2 5°
Flexion
50 °
Extension
0°
Distal lnterpl)Miffilel al Joint (FooO Abduction
Flexion
Add uction
Extension , ,
which would not have revealed the restriction resulting from injury. Active Against-Resistance Testing
The goal of resistive testing is to gain clear information on the state of each muscle group in question. The client con tracts his muscles forcibly against resistance using enough strength to prevent all articular movement, or joint move ment, while the joint is held somewhere near mid-range. Mid-range of motion is halfway through the arc of move-
ment for that particular joint. No movement takes place at the joint; the only tension that alters is within the muscle itself. The person is using the muscle and tendon but not moving through space. Both the therapist and the client will push into each other using equal and opposite force, an isometric contraction. An example of pushing into E;ach other would be having the client lie supine with a leg lifted to a 90-degree angle. The therapist provides support at the distal end of the anterior femur, just above the patella to be sure the client does not bend his knee during the test. With
CHAPTER 3 /
the other hand, the therapist applies pressure to the poste rior. calcaneus. Both the therapist and the client push into each other using the exact same force. The leg will not move through space. If the client tells the therapist that he feels pain in a hamstring muscle, the test is positive. When muscles contract, they squeeze together the opposed cartilaginous material of the joint they span. Cartilage contains no nerves, so this compression is pain less. This increased approximation of the bone ends relaxes ligaments and joint capsules. Thus, if the joint is arthritic, the resisted movements are found painless. So, this type of test tells us about the muscles, not the joint. This remains so, surprisingly enough, when a tendon blends with a joint capsule, such as in the case of the supraspinatus. A resisted movement may provoke pain or demonstrate weakness, occasionally both. If this test elicits a pain response, it will help you localize and identify an injury and/ or weakness in a muscle or muscle group. You must pay close attention to where you stand and how you apply your hands. When strong muscles are tested, minor weakness may not be detected unless your hands are well placed for resistance and counter pressure and body mechanics are proper. It is due to neglect of these simple practices that muscle weakness is so often overlooked. If in doubt, you may have to encourage the client to push fairly hard to arrive at a true assessment. Below are some basic principles of resistive testing: • The first time working with an individual, use very gentle force. If the client tolerates it well, next have her push a bit harder and then possibly with all her might •
Stabilize the joint properly when using this type of testing. For example, stabilize above the wrist at the styloid processes when testing the wrist. This allows for only the movement of the wrist without having to move the forearm
•
Always begin with the joint at neutral, if possible. If the client is stronger than you are, try beginning in a slight stretch position. This will increase the strain on the structure
•
If the client is very strong and can overpower you, place him as well as yourself into positions to give you the mechanical advantage
•
Always give equal and opposite force to the effort of the client, so there is no movement through space tak ing place
31
see how well they align with the various anatomical planes of the body. When a person is off of his anatomical planes, stress is being placed on certain structures, chronically shortening some muscles while overstretching their antagonists. Either of these extremes will create a condition that allows trigger points to occur, but mostly the trigger points will occur within the chronically shortened muscle fibers while the overstretched fibers feel tight and painful. The overstretched muscles are continuously microtearing, causing a feeling of discomfort. For example, in an anterior pelvic tilt, the pelvis is in too much flexion, causing overstretching of the ham strings and shortening of the quadriceps-especially rectus femoris, tensor fascia latae, and iliopsoas. The client will probably complain of pain and stiffness in his hamstrings; this will be due to the microtearing. There may be reports of pain or other sensation in the knee and thigh area, low back, and hips. If so, this will most likely be referral from trigger points within the shortened muscles. The therapist can treat the shortened muscles specifically using neuromuscular therapy to help lengthen the muscle fibers and alleviate the referral issue caused by the trigger points. The therapist can also help the overstretched muscle fibers to unlock and return to their normal resting length with some specific work there. As a neuromuscular therapist, you will see client who have slight postural distortion along with those who have whole body dysfunction-the "vertically ill" (Fig. 3-2). According to Bob King, "when looking at this person, it is easy to see how they can be compressed, repressed, oppressed, and depressed." The following is a list of some of the postural findings you will encounter during orthopedic assessment in clients who have whole body dysfunction: • Flattening of the arch of the feet •
Tibial torsion with improper patellar tracking (the patella is not riding properly within the condylar groove of the femur)
•
Anterior and lateral pelvic tilting (the pelvis has both too much flexion and is high on one side while being low on the other)
•
Functional leg length differences
•
Abdominal protrusion (the belly appears to be large, such as having a "beer belly")
•
Diaphragmatic compression (this person has a "banana back," with rounded shoulders, and his lower rib cage has dropped, placing pressure on the diaphragm) and intercostal adhesions (the intercostals muscles are being squeezed with this posture and the layers are now glued to each other)
•
Respiratory dysfunction (with the above posture of "banana back" and diaphragmatic compression
Postural Assessment
Another type of orthopedic testing of the body that is important for neuromuscular therapy is postural assess ment. This type of testing determines the extent of a client's postural dysfunction and how it is impacting this person. This involves a comparison of bony landmarks to
CLIENT ASSESSMENT
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N E U RO M U SC U LAR T H E RAPY BASICS
happening, the client may not be able to breathe cor rectly or very well) •
Abducted scapulae and internally rotated humerus
•
Pronated forearms and hands
•
Cumulative trauma disorders such as epicondylitis
•
Brachial plexus entrapment and radiculopathies
•
Lower erector shortening
•
Protracted head, upper cervical jamming, and TMJ instability (when our heads ride forward, there is quite a bit of pressure being placed upon our TMJ s and upper cervical vertebra)
•
Shortened sternocleidomastoids, scalenes, and poste rior cervicals
•
Mechanical pressure on d isks from j ammed osseous structures
•
Uncoordinated gait pattern
•
Chronic pain and/or depression along with drug dependence
•
Varicosities and poor circulation
•
Easily fatigued with frequent headaches
•
Self esteem issues and psychological manifestations
•
Energetic, sexual, and spiritual depletion
As this author likes to examine a person's core muscles first, we will begin with postural distortion of the pelvis (Fig. 3 -3 ) . Anterior Pelvic Tilt
•
FIGURE 3-2
"The vertically i l l."
Anterior pelvic tilt is a condition in which the pelvis is chron ically flexed too much. To check for this, consider the degree of difference by comparing the location of the posteriol' superior iliac spine (PSIS) against the location of the anterior superior iliac spine (ASIS) on each side of the body (Fig. 3-4). If balanced, there will be only a slight degree of angle there. For men, this will be approximately between 0 and 5 degrees; for women, this will be approximately between 5 and 1 5 degrees. Anything h igher than this is considered an anterior pelvic tilt. Consider learning how to use a goniometer, an instru ment that measures degrees of angles. If you do not have a goniometer, a visualization of the ASIS to the PSIS having a line linking them as well as a base l ine that is straight from the ASIS to somewhere inferior of the PSIS as being zero degrees will help. There will be several postural findings included with this condition, such as the following: • Pubis drops anteriorly •
Coccyx elevates posteriorly
•
Excessive lumbar lordosis
•
Distended abdominal contents
•
Weakened lower abdominals
CLI ENT ASSESSMENT
CHAPTER 3
A
B
1
i
(
)
D
c
Functional Scoliotic Strain Pattern The bony structure is involved. The cause of most cases of scoliosis is u n known i n the medical realm, however, some situations have been traced to polio, tuberculosis, tumors, or a birth defect.
F
E •
•
FIGURE 3-4
FIGURE 3-3
Postural d i stortion of the pelv i s.
Comparing ASIS versus PSIS for anterior pelvic ti l t
.
33
34
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Compressive loading on the lower body
•
Sacroiliac joint is jammed on high hip side
•
Hyperextended ( locked ) knees
•
Femur internally rotates on high h ip side
•
Flattening of the medial longitudinal arch of the foot
•
Femur abducts on low hip side
•
Indentation/groove in the iliotibial band
•
Trochanteric bursitis may occur on low hip side
•
Possible internal femoral rotation
•
N arrowing of the greater sciatic notch with sciatic
•
Tendency toward forward head postures
•
People who commonly exhibit an anterior pelvic tilt include the following: Pregnant women
•
People who are obese or have a "beer belly"
•
Gymnasts, dancers, and skaters
•
Hypermobile individuals
•
Children ages 3 to 8 (at this age it is normal )
•
Tho e who wear high-heeled shoes
•
Hyperkyphotic individuals
Lateral Pelvic Tilt
Lateral pelvic tilt is a condition in which a person has a high hip on one side and a low hip on the other side. To check for this condition, compare the two sides of the pelvis at the iliac crests, the ASISs, and the PSISs. Upon comparison, these three readings will confirm this condition ( Fig. 3 - 5 ) . If balanced, each of these three comparisons will b e level. If not level, one side will be higher than the mher and the postural findings will include the following: Body weight sways toward the h igh hip ( most obvi
Pelvic rotation causes L5 to rotate toward the low hip side (rotoscoliosis)
•
•
•
nerve impingement •
Lumbar vertebrae above LS compensate by laterally flexing ( scoliosis)
•
Disc compression at the level of L4-LS and LS-S 1
•
Hyperpronated foot more obvious on low hip side
•
Knee pain
People who commonly exhibit a lateral pelvic tilt include the following: •
Mothers of young children who carry them on their
•
Those with scoliosis
•
Those with a long torso and short humerus
•
People with flat feet and/or Morton foot structure
hips or those who tend to carrying weight one-sided
Shoulder Asymmetry
The ideal position for a person's shoulders is for them to be level when comparing the two acromions ( Fig. 3 - 6 ) . Simply looking a t the shoulders may give a false reading, due to the side with a low shoulder having a built up upper
ous fi nding)
trapezius. This side will appear high when, in reality, it is
Hip appear uneven and client tends to lean toward
low. Many massage therapists make this mistake. Always do
the high hip
an actual physical comparison of bony landmarks. There
•
PSIS is higher on side of high hip and pubis symphysis is uneven
will be certain postural findings that correspond to this pos
•
Leg on the side of the high hip appears shorter when
•
Tightness in lumbar erectors on high hip side
other when the person stands with the arms hanging at
•
Il ium rotates anteriorly on high hip side
the sides
•
the client is lying down and longer when standing
•
FIGURE 3-5
ture, such as the following: • One shoulder presents higher than the other •
The fingertips of one hand appear to be lower than the
Comparing both ASIS and then both PSIS along with the i l iac crests for lateral pelvic tilt.
C H AP T E R 3
•
FIGURE 3-6
•
CLI ENT ASSESSMENT
Comparing acromions for shoulder asymmetry.
One arm hangs closer to the side of the body than the other
•
The body appears to sway toward the low shoulder side
Scoliosis is the posture that will most l ikely develop shoulder asymmetry. This will most likely be the case if a person has a h igh h ip, low h ip situation. Thoracic Kyphosis
The word kyphosis is Greek, meaning humpback or hunch back. Thoracic kyphosis is an abnormally large posterior curve of the thoracic spine. This condition involves having certain weak muscles along with others being chronically shortened. We observe this condition by looking at a person from a side view ( Fig. 3 - 7 ) . There will b e certain postural findings with this condi tion, such as the following: • Abnormal fascial accumulation in the lower cervical and upper thoracic areas • •
Dowager's hump Depressed sternum with locked ribs inhibiting threedimensional breathing
•
Elevation and depression of the thoracic cage
•
Paradoxical breathing patterns
•
Hyperventilation from poor diaphragmatic function
•
Gasping or wheezing while speaking
•
Frequent yawning, sighing, or attempting to catch one's breath
•
Elevation of the first rib with a tendency toward tho racic outlet syndrome
•
Internal rotation of the humerus, scapular abduction and elevation
•
Hand position anterior to the thigh w ith palms facing posteriorly
•
FIGURE 3-7
Diagram ofthoracic kyphosis.
35
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•
Inclination toward rotator cuff tears, bursitis, and ten donitis at the shoulder
•
Clavicular angulation (v-shaped) , compression of the acromioclavicular and sternoclavicular joints
•
Restricted elongation of the longitudinal a x is of the body
•
Anxiety, panic attacks, often with indiscriminate use of medication due to paradoxical breathing patterns
•
Fascial binding of the esophagus and vagus nerve at the diaphragm
•
Fascial restriction of the aorta, vena cava, and the main lymphatic ducts
•
S tomach distress, reflux disease
•
Compressed organs
•
Exaggerated spinal curves that narrow the intervertebral foramen
•
Fascial pull on the dural tube and spinal nerve roots
•
Migration of disc toward the spinal tube
•
Memory loss
The type of postures exhibiting the above findings would be imilar to those of the anterior pelvic tilt postures along with roor occurational postures. There may be perpetuating factors involved with these postures in the form of chronic resriratory disorders such as asthma. Forward Head Posture
In ideal rosture, the ear should be vertically in line with the head of the humerus when viewing a person from the side. Forward or protracted head posture is a condition in which the head is out of alignment in a forward position. Postural findings associated with this condition are as follows: • Hyperextension of the atlantooccipital joint •
Imringement of occipital nerves
•
Chin poking out posture
•
Stretch strain on the interspinous and supraspinous ligaments
•
Radiculopathy in the cervical region
•
Increased cervical curve squeezing discs with risk of herniation
•
Cervical misalignment creates the possibility of arthritis
•
Loss of range of motion increases the possibility of fusion
•
A powerful fascial downward pull on the mandible
•
Mandible is pulled posteriorly and superiorly, forcing the temporomandibular joint (TMJ ) forward
•
Clicking and pain in the TMJ
•
Bruxism and/or malocclusion in effort to hold the jaw
in its prorer place •
Lateral pelvic tilt affects the jaw laterally
1X 2X 3X •
FIGURE 3-8
Diagram of the weight of a forward head posture.
•
Anterior pelvic tilt affects the jaw anteriorly
•
Anterior fascia of the chest pulls into the hyoid area
Postures that exhibit a forward head would be all descriptions of anterior pelvic tilt, lateral pelvic tilt, and thoracic kyphosis. Forward head posture and thoracic kyphosis perpetuate cervical hyperextension because of the righting reflex. For each inch the head migrates forward from an ideal position, the lower cervicals are compressed by one time the weight of the head, resulting in fatigued cervical extensor muscles. The lumbar musculature must then work very hard to maintain an erect posture (Fig. 3 - 8 ) .
PAL PATION After performing range of motion testing and postural anal ysis on your client to gain an understanding of the bigger picture, you will need to use palpation to fine tune your assessment. Palpation is examination of the skin and under lying structures using one's hands. Palpation can be used when assessing, warming, or treating a client. The palpation
C H A PT E R 3
discussed at this point is that used for locating trigger points on a body, that is, for assessment. Palpation is an art as well as a science. A refined and skill ful ability to apply knowledge of anatomy to hands-on palpa tion is necessary, especially in working with painful and sen sitive tissues. Be clear on what structures are to be accessed and be direct in that palpation. Also, use visualization and be gentle and sensitive with the work while using enough pres sure to get the job done. Ultimately, the client is in charge of how much pressure you use. It might be wise to explain the difference between pa in, which prevents the client from relaxing and benefitting from the work, and discomfort, which a client feels but is still able to relax. This approach working in the zone of discomfort without crossing over into pain-is known as the optimal therapy zone (OTZ). Note, however, that OTZ is different for each client. Pressure that is experienced as discomfort by one client may be experi enced as pain by another. Therefore, be sure to encourage and respond to clients' feedback regarding pain. According to Travell and Simons, there are specific recom mended criteria for identifying active and latent trigger points. 1.
Taut bands palpable in an accessible muscle
2. An exquisite spot of tenderness of a nodule in a taut band of fiber 3 . A spot of pain experienced by the client upon pressure on the tender nodule 4. Compromised range of motion with painful limits of
full stretch 5 . Either visual or tactile identification of local twitch
response 6. Altered sensation, as with referrals, upon compression
of the tender nodule Three types of palpation are useful in assessing for trigger points. They are flat palpation, pincer palpation, and snap ping palpation.
•
FIGURE 3-9
/
C L I E NT A S S E S S M E N T
37
Flat palpation. (Reprinted with permission from Simons
DG, Travell JG, Simons LS. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1 : U pper Half of Body. 2nd ed. Balti more: Lippi ncott Williams & Wilkins, 1 999; p. 1 20, Fig. 3.7.)
Pincer Pal pation
Pincer palpation is the examination of a muscle or a trigger point by holding the area in a pincer grasp between the thumb and fingers. The therapist may actually roll the tissue between the tips of the digits in order to detect any taut bands of fibers, identify tender points in a muscle, and elicit a local twitch response (Fig. 3 - 1 0 ) . This technique will best work with a muscle that can be lifted off of the body, such as the upper and sometimes middle trapezius, brachioradialis, and gastrocnemius, to name a few. Snapping Palpation
In snapping palpation, a fingertip is placed against the tense band of muscle at a right angle to the direction of the tight band. You then quickly press down while drawing the finger back in an effort to roll the underlying fibers under the fin ger. This motion is quite similar to plucking a guitar string, except that when "plucking" a muscle fiber, the contact with the surface is maintained. If a tight band is snapped at
Flat Pal pation
Flat palpation is accomplished by using one's fingers to apply pressure either across the muscle fibers or through the muscle fiber's length, compressing against a firm underly ing structure such as bone. Using this technique, you are feeling for tight bands of muscle or fascia, dense or thickened soft tissue (such as adhesions) , tenderness, trigger points, and possibly thermal information such as coolness from ischemia or heat from inflammation. Depending upon the depth of the struc ture one is trying to locate, the pressure may be anything from very superficial to extremely deep (Fig. 3 -9 ) . This tech nique for palpation can be used on muscles anywhere in the body and will be quite effective when used on the larger muscles.
•
FIGURE 3-1 0
Pincer palpation. Reprinted with permission from
Simons DG, Travell JG, Simons LS. Travel l & Simons' Myofascial Pain and Dysfu nction:The Trigger Point Manual. Vol. 1 : Upper Half of Body. 2nd ed. Baltimore: Lippi ncott Williams & Wilkins, 1 999; p. 1 20, Fig. 3.8.
38
PART I
N E U RO M U S C U L A R T H E RAPY BASICS
limb may be shorter than the other, for example, and the pelvis and face on this side will probably also be smaller. Simple observation might be the first step in assessing for leg length discrepancy. For example, you might see the cli ent walking with a slight tilt to one side or standing with his or her weight on one leg ( usually, the shorter leg) . If you observe such a condition in a client, it is likely that there will be trigger points set up in quadratus lumborum that must be eliminated. To confirm this suspicion, you must next palpate the cli ent. Kneel behind the client, who is standing straight. Palpate both iliac crests and then the posterior superior iliac spines ( PSIS; there may be dimples here ) . Once a discrepancy is discovered, correct it by placing an object beneath the entire foot of the shorter limb. Be sure this feels comfortable to the client. A legal pad of paper, a magazine, or something similar may be used for this. The client must relax at this point, so you may need to simply converse about something else with the client in an attempt to allow this to happen. Once it appears that the client's weight has settled onto both feet, the muscles will be relieved of their attempt to compensate for the limb length d ifference and they may release the protec tive control. It is then possible to accurately compensate for •
FIGURE 3-1 1
Snapping palpation.
a trigger point, there should be a local twitch response ( Fig. 3 - 1 1 ) . This technique will work well for almost anywhere in the body.
any remaining limb length inequality by adding correction under the foot until the pelvis appears level. This should also level out the shoulders and straighten the spine. In order to confirm accuracy of the correction, add a mil limeter or two of additional l ift under the person's foot to see whether the pelvis or shoulders tip the other way. This is
PREDISPOSING FACTORS In addition to the methods of assessment discussed thus far,
considered overcorrection. The cl ient will most likely become aware immediately, as this will be an unfamiliar strain on his body.
you can also predict the presence of pain and trigger points
It will then be useful to refer this client to a health care
in clients with certain predisposing factors related to skele
professional to have corrective, full foot lifts made. A half or
tal anatomy asymmetry and disproportion or structural inad equacies. These predisposing factors include leg length dis
toes and could end up leading to other pathologies setting in.
three-quarter length orthotics will place this person up on his
c repancy, short humerus, small hemipelvis, and foot hyperpronation. Leg Length Discrepancy
Leg length discrepancy, also known as lower l imb length inequality, is often an important perpetuating factor.
S h ort H umerus
According to Travell and S imons, shortness of the upper arms in relation to torso height is a rarely recognized but not uncommon source of muscle strain and perpetuation of trigger points in the shoulder girdle. A discrepancy of this
According to Travell and Simons, correcting this may be
sort places stress on the shoulder girdle elevators, perpetu
essential to inactivating trigger points that are overloaded by the length d iscrepancy as well as to maintaining a trigger
ating trigger points in upper trapezius and levator scapulae
point-free body.
ture is very common among Native Americans, but not
muscles. Travell and Simons mention that this body struc
Trigger points in the hip and torso muscles commonly
limited to this race. If the shoulder-elbow segment of the
cause back pain. There are many studies that show a strong correlation between the presence of leg length discrepancies
upper l imb is short in proportion to the torso, when 't his person is standing, the elbows do not reach the i liac crests;
and back pain. As Travell and Simons note, one side of a person is often slightly smaller than the other. One lower
armrests of a typical chair.
when this person is sitting, the elbows fail to reach the
C H A PT E R 3
I
CLIENT ASSESSMENT
39
This is an observation that may be important for you to
Morton further contends that when the first metatarsal is
not� as it predisposes this client to shoulder and neck pain on a chronic basis. This person must always hold her shoul
shorter and the second is longer than "normal," it is the second metatarsal head that bears more weight. In th is
ders up because she cannot rest d ue to her arms not reaching
case, the foot is balanced on the second metatarsal. In com
the armrests on a chair. The shoulder raising muscles must remain in a hypercontracted state.
pensation, most people mod ify their gait by placing more
Small Hemipelvis
This is a condition in which the pelvis is smaller on one side than the other. The sacrum will most l ikely be t ilted,
weight on the lateral side of the heel and the medial side of the ball of the foot, making their shoes wear in that same pattern. Usually, the foot is sl ightly toed outward during heel strike as well as during stance phase of the gait. The
producing a compensatory scoliosis during both standing
ankle then excessively pro nates ( rocks inward ) during stance phase, and, at the same time, the femur becomes
and sitting.
excessively rotated med ially.
A person with this condition will tend to sit in a crooked
This type of gait w i l l activate trigger points in the
position, leaning to the smaller side. Our ischial tuberosities
posterior portion of gluteus medius that will refer sensa
are weight bearing when we sit, and so magnify the tilt and
tion to the low back. There will also be strain in the
effectively compromise the spine and muscles of the torso,
peroneus longus muscle, activating trigger points in it
as occurs in the pelvic tilt caused by a lower-limb length
that refer sensation to the ankle . Taut bands of fibers
inequality.
here may entrap the peroneal nerve aga inst the fi bula
A small hemipelvis is more commonly overlooked than
j ust below its head, produc ing nu mbness and t ingling
leg length d iscrepancies as a source of chronic muscle strain.
across the dorsum of the foot and sometimes d ropsy of
Often a leg length discrepancy and a small hemipelvis occur
the foot due to motor weakness . There may be add i t ional
together, usually with the shorter leg and smaller hemipelvis
trigger points in g l u teus medius that cause medial knee
on the same side.
pain and might progress to buck l i ng knee syndrome.
To observe this condition, have the client sit up straight upon his ischial tuberosities on a straight, firm surface while you palpate the iliac crests posteriorly. If one side is smaller,
Trigger points may also set up in the posterior gluteus minimus, causing referral sensat ion to the posterior th igh
the crests will not be even. Refer this client to a chiroprac tor or possibly a physiatrist or osteopath for further assess ment and treatment. With the muscular effects being similar to those of leg
and ca lf. Travel! and S i mons c l a i m these symptoms m i m ic radicu lopathy, which explains why so often there is a wrong d iagnosis determined . To assess a client for this cond ition, have him stand bare foot while you check for a dropped arch and medial malleo
length d iscrepancies, the quadratus lumborum must be elim
lus. The client should then walk up and down a hallway or
inated of trigger points.
long room several times while you look for arch drop and toeing out. Refer this client to a professional for further
Foot Hyperpronation
assessment and orthotics casting.
Foot hyperpronation is known by several names: Dudley J . Morton or "classic Greek" foot configuration, Morton toe syndrome, or Morton foot syndrome. According to Travell
PERPETUATING FACTORS
and Simons, this condition is of special interest because it
In addition to the predisposing factors that can lead to pain
is likely to perpetuate myofascial pain in the low back,
and trigger points, there are also factors that can perpetuate
thigh, knee, leg, and dorsum of the foot, with or without
them. A perpetuating factor is any stress-inducing condi
numbness and tingling. A person with this condition will
tion that aggravates a trigger point and its referral pattern,
report ankle weakness, frequently sprained ankles, as well
leading to pain.
as report difficulty learning to ice skate due to having ankles that bend in medially.
identify their perpetuating factors and manage and reduce
Travell and Simons discuss this condition because prob
Part of your role as therapist includes helping cl ients
lems with the foot can produce asymmetries in the lower limb
stress in their l ife. Determining client's stress factors requires asking many questions of this individual rather than simply
that affect the posture of the upper torso. This sort of postural
looking over the health information form he filled out, as
stress will activate and perpetuate trigger points in muscles of
discussed above. Although the treatment of many perpetu
the trunk, neck, and shoulders along with the lower limb.
ating factors lies outside the scope of practice for massage
According to Morton, when weight bearing, the first
therapists, it is important for you to have an understanding
metatarsal head should carry half of the body weight.
of common factors. In some cases, it may be appropriate for
40
PA R T I
N E U RO M U S C U LA R T H E R A P Y BASICS
you to refer your clients to other health care professionals to
ing the hours after work, the cl ient is subject to biome
address these factors.
chanical stress due to overuse.
Some common stress factors include the fol lowing: overuse syndro mes, sleep/rest habits, nutrition, chem i
Sleep/Rest Habits
cals, disease, trau ma, psychoemotional d istress, exercise,
A second stress factor to consider is the client's habits while
and postural dysfunction. Each of these is discussed in
sleeping or resting. Ask the client how he or she sleeps. Is i t
detail below.
o n the back, stomach, o r side ? Is h e o r she using the correct pillow for the chosen sleep position ? If on the back, the pil
Overuse Syndromes
low should be a small cervical support for the neck. If the
An overuse syndrome is something that prolongs the
sleep position is on the side, the spine must be kept straight.
existence of a cond ition. For example, neck pain due to
Th is means that the pillow must be of adequate size to
improper workstation setup can cause neck strain dai ly.
maintain the cervical spine in a straight position. This pil
An overuse syndrome can also be some chronic condition
low must keep the head and neck from laterally flexing
or d isease that the person must learn to manage and work
toward the mattress. Hopefully the client does not sleep on
with, such as post-polio syndrome. One category of over
h is or her stomach. This is not a good position to sleep in, as one must have the head and neck turned to one side for
use syndromes is biomechanics. Biomechanics is the study of the forces exerted by soft t issue ( muscle) and gravity on
long periods of time, thus increasing stress to the srine
the skeletal system. We must also look at biomechanics in
every night.
reference to postural stress when working, driving a car,
Is this person's mattress a good one ? Old, worn-out mat
cleaning house, gardening, and so forth. When we allow
tresses will stress the muscles and prevent a good night's
our bodies to be in poor postural alignment, stress is being
sleep. I nqu ire about how long and how well this person
placed upon our body's tissues 24 hours a day, no matter
sleeps each night.
what activity we do. Biomechanical overuse syndromes and repe t i t i v e
Another factor here may be how the person rests while at home. Many people l ie on their couches watching television.
acti ons m a y occur at work, while driving, or at home.
What is the couch like ? It may be quite soft and not giving
Regarding the occupational setting, i t is important to
proper support. Also, is the client using pillows to help bol
consider what the cl ient does while at work. For instance,
ster and support, and are they the correct pillows as discussed
the c l i ent may work in a factory on an assembly line,
above ? Purchasing a better couch, a new mattress, and pil
stand i ng all day while bend ing forward using an electric
lows might be the best investment this person could make.
screwdriver to attach one obj ect to another as they glide past on a moving belt. Or, this person may sit at a desk all day working on a computer using a mouse. A therapist must look at the factors stressing this person's body from a
N utrition
A client's nutrition can also be a stress factor. Note that
biomechanical point of v iew. How is this repetitive action
although nutrit ion-related concerns are d iscussed here to inform you of the affect of nutrition on pain, you should
on the part of this indiv idual impacting his muscu lar, skel
be careful to stay within your scope of practice and refer
etal, and nervous system ? How is this person's workstation
the c l ient to his or her physic ian or a d ietician for nutri
set u p ? Is it possible for the cl ient to have a qual ified ergo
t ional assessment if you have a concern in this area. Avoid
nomic specialist make suggestions as to how to work using
making recommendations to your cl ients about nutrit ion or "prescribing."
better biomechan ics ? It may be important to take a short drive around the
Nutrition includes water, vitamin, and mineral supple
block with this person at the wheel of his car if there is a chance that this activity is impacting h is body in a negative
ments as well as eating habits. One must drink enough water to enable the flushing of toxins from the body. Now, if this
way or if his occupation involves much driving. Again, the therapist is considering any repetitive actions causing stress
person works out on a regular basis, he or she must add more water to their daily consumption due to losing moisture
along with simple biomechanical stress to the body, such as
through sweating and breathing heavily during exercise. If
sitting on a wallet all day long.
this person drinks alcohol, coffee, soda, and so on, he or she
Finally, evaluate activities that the client performs at home. Does this person participate in sports or garden, for
must add that much more water into the diet to help flush out the added toxins.
instance ? Both of these activities include repetitive use of
Natural vitamins and minerals from a food source can
certain muscles. When pulling weeds, throwing a Frisbee, or hitting a golf ball repeatedly each weekend and possibly dur-
also help a client in chronic pain. A person with an unhealthy diet w i ll be producing toxins as a byproduct of
CHAPTER 3
CLI ENT ASSESSMENT
41
digestion. Eating healthy foods that provide nutrition will
Trauma
make it so that this person's system is less toxic in general.
A l l traumas to a client's body must also be considered, as they, too, are stress factors. While most therapists under
Eating processed foods, refined sugars, and excess proteins makes it so that we need extra minerals stored in our bodies to be able to digest and elim inate them. If the body is defi cient in minerals, toxins build up in the digestive system from unhealthy foods not d igesting entirely and not being eliminated. They are staying in the digestive tract putrefy ing. A lso, dairy products, alcohol, and h igh-fiber foods inhibit mineral absorption. These form mucus l ike plaque onto the lin ing of the colon preventing minerals and water from being reabsorbed by the body, according to Stewart Hare, C.H. Ed . DIP Nt Th . Avoid, however, vitamins pro duced from chemicals and heavy metals, many of which are not absorbed effectively in the d igestive tract. Different minerals have different absorption rates. In general, mineral absorption rates are affected by unhealthy d i ets, by the con dition of the intestines, as well as by the form of the mineral as it is taken into the body. The human body cannot effec tively break down heavy metals to convert them to an absorbable mineral form. Chemicals
Another stress factor that can aggravate trigger points and contribute to pain is exposure to chemicals such as caffeine, alcohol, tobacco, and so on. Such substances dehydrate the body's tissues, which can contribute to chronic pain. Avoiding such substances can help prevent dehydration and promote cleansing at a cellular level. These lifestyle changes that you may suggest to a client
stand to ask about inj uries and accidents, many do not th ink to ask about recent surgery. Surgery shou ld always be considered as having added stress to a body. If the cli ent has had surgery recently, be sure to acqu ire written permission from the client's doctor before beginning mas sage in the affected area. You m ust be certain that it will be doing no harm. Psychoemotional Distress
Psycboemot ional distress can, of course, be a maj or stress factor. As you work with cl ients, you may learn of specific stressors that affect tbem at home or at work. Perhaps they have to drive to and from work in te rror due to bad memor i es of an au tomob i l e accident that previously occ ' lrred. Maybe they do not get a long with their boss at work and l i ve in fear of losing their job. They cou ld be considering or in the middle of a d ivorce. These types of constant emotional stress will help maintain chronic pain at bigher levels. If you have a client w i th signifi cant psy choemot ional d istress, you may want to refer him or her to counsel ing by a qual i fied counselor or therapist. Again, remember to stay within your scope of practice as a mas sage therapist. Exercise
Exercise-either the lack of it or the improper practice of
could be phrased in such a way as to not sound j udgmental.
it-can also be a stress factor. For instance, a cl ient who
This is not about judging a person's life, it is about providing
does not have a proper understanding of biomechanics may
information that can help him begin to fee l better, and
injure himself repeatedly while exercising. [t might be wise
there are times when the information to be conveyed is not
to develop a professional relationship with one or two very
what he wants to hear.
well-trained personal trainers so that you can refer cI ients who have need of assistance with establishing or modifying
Disease
an exercise program.
Any type of disease is also adding stress to a person's body and life. In fact, it is critical that you rule out pain stemming
Postural Dysfunction
from a disease before you begin working on a client, as there
Our final category of stress factors is postural dysfunction.
may be risks involved with working on a client with certain
Postural dysfunction equals stress on the body, pure and
conditions. For example, a client complains of pain in the
simple! One postural dysfunction is having a forward bead,
lower legs. Could he have diabetes ? Or might he have devel
rounded shoulders, and collapsed chest. A person with such
oped phlebitis and have a blood clot somewhere in h is legs ?
posture will likely feel tightness and/or pain in his upper
[n either case, massage would be contraindicated, at least
back and neck areas, with possible headaches. This constant
locally. Another example would be a cl ient feeling pain in
d iscomfort is considered stress to the body. If we can get a
the anterior/lower rib area as a result of gall bladder d isease.
body back on its anatomical planes and help it maintain
[n any situation in which you know or suspect that the cli
that posture, we will have taken away this huge stress factor.
ent m ight have a condition for which massage would be
Note, however, that poor posture often develops over a life
contraindicated, you should stop work immed iately and
time and correcting it takes time and hard work from both
refer the client to his or her physician for evaluation.
tbe client and the therapist.
42
PA R T I
N E U RO M U S C U LA R T H E R A P Y B A S I C S
C H A P T E R S U M M A RY This chapter equips you w ith vital information regarding the assessment of the client. The more thorough the
analysis, palpation, and predispos ing and perpetuating factors. Developing a network for referral with competent
assessment is, the faster the rehab i l i tation w i l l be for
medical personnel such as occupational therapists, physi
the client. The key components of assessment that we have covered include the health information form, inter
cal therapists, and physiatrists will also become impera t ive for the neuromuscular therapist. The next step is the
viewing the client, range of motion testing and postural
actual treatment of the client.
C H A PTER 3
CLIENT ASSESSMENT
43
� R EV I EW QUESTIONS
Short Answer Questions 1 . Orthopedic tests were developed to assess what? 2. Besides the pelvic tilting, what dysfunction can a lat eralpelvic tilt lead to? 3. A person with severe thoracic kyphosis will most l ikely demonstrate what sort of breathing patterns/condi tions? 4. According to Travell and Simons, what are the specific recommended criteria for identifying active and latent trigger points? 5. List some perpetuating factors of trigger points. Multiple Choice Questions 6. It is the responsibility of a neuromuscular therapist to do what as the initial portion of assessment with a new client ? A. Gain a comprehensive health history B. Do a postural stress analysis C. Gain payment D. Provide home care instructions 7. To form a well-rounded, comprehensive treatment
1 0. When performing a n active against-resistance test, what exactly is being tested ? A. An extremity B. Passive or inert structures such as joint capsules C. A specific muscle or muscle group D. Arthritis True/False 1 1 . If there is inflammation stemming from inj ury, then there will most likely be loss of function as well. 1 2. Passive testing gives us information about the state of inert tissues. 1 3 . I nert tissues refer to structures such as large muscles. 1 4. With active testing against resistance, there is no move ment of a l imb through space. 1 5 . A joint need not be stabilized when using active testing against resistance. Matching a. Bruxism b. Inert tissue
g. Rotoscoliosis
c. Informed consent
h. Thoracic kyphosis
plan, the therapist must use
d. Malocclusion
A. all of his intuition
e. Isometric contraction
B. tools of measurement C. the client's report of symptoms along with various assessment methods D. a medical model 8. When comparing a client's acromions, what postural dysfunction is being considered ? A. H igh hip/low hip B. Posterior pelvic tilt C. Shoulder asymmetry D. Leg length discrepancy 9. When comparing a client's two ASIS to each other, what postural dysfunction is being considered ? A. Shoulder asymmetry B. H igh hip/low hip C. Anterior pelvic tilt D. Leg length discrepancy
f. Malingerer
i. Active Testing
1 6. Clenching the j aw and grinding the teeth. 1 7 . Vertebrae that rotate to one side. 18. I mperfect contact of the mandibular and maxillary teeth. 1 9. A competent and voluntary permission for procedure, test, or medication based upon ful l understanding by the client. 20. Contraction of a muscle's tension without shortening its fibers.
THIS PAGE INTENTIONALLY LEFT BLANK
BAS C NEUROMUSCULAR THERAPY TECHNIQUES AND BODY MECHANICS Anesthetize: to induce loss of sensation
Local twitch response: a transient contraction of a group of
Carpal tunnel syndrome: soreness, tenderness, and weakness
tense muscle fibers that traverse a trigger point in response
of the muscles of the thumb caused by pressure on the
to stimulation of the trigger point
median nerve at the carpal tunnel of the wrist
Muscle energy technique: a form of proprioceptive neuromus
Cryotherapy: the therapeutic use of cold
cular facilitation designed to promote or hasten the response
Hypoxia: deficiency of oxygen Jump sign: a general pain response of a client in the form of wincing, crying out, or withdrawing in response to pressure applied to a trigger point
Juxtaposition: a position that is adjacent or side by side
After studying this chapter and then practicing the techniques
of the neuromuscular mechanism to lengthen the muscle in question through stimulation of the proprioceptors
Thoracic outlet syndrome: a condition in which nerves and/or vessels are compressed in the neck or axilla area. Usually, it is the first rib pressing into the clavicle, pinching the brachial plexus
TREATMENT TECHNIQU ES
along with the body mechanics necessary to the longevity of a neuromuscular therapist, you will begin to develop the skills of
The use of massage strokes is an art along with a science. To
effective treatment. Not only is it important to practice each type
be refined and skillful in ones ability to apply knowledge of
of technique, but to practice while using proper body mechanics.
anatomy to hands-on massage is important when working
The effectiveness of each technique depends upon your doing it
with painful and sensitive tissues. When treating, to be clear
correctly, at the exact level of tissue necessary, and on using the
on which structures are being accessed, you must be able to
correct body mechanics. This way, you will not hurt yourself
visualize that structure correctly. A lways be gentle and sen
while applying the appropriate pressure to influence and treat
sitive while applying this knowledge and art. Specificity is
even the deepest layer of muscle effectively. Remember that deep
essential to being refined and skillful .
work does not mean rough work. Deep work done artfully is gentle yet effective, while being anatomically precise.
Presented below are some general guidelines o n treat ment along w ith two types of massage strokes: warming
In addition to treatment techniques and body mechanics, this
and direct. A lthough these strokes are basic and not spe
chapter also covers neuromuscular therapy tools, the importance
c ific to neuromuscular therapy, they are reviewed here
of a referral network, home care assignments you can give to
because they may be effectively integrated into neuromus
your clients, and reassessment.
cular therapy.
45
46
PART I
N E U R O M U S C U L A R TH E R APY BA S I C S
Most techniques effectively used with neuromuscular therapy are strokes you have been using for relaxation mas sage. Now you will be using them while providing more pressure and specificity. These strokes will be the ones you use leading up to applying trigger point release.
General Guidelines for Treatment
Warming Strokes Warming strokes are used to quickly yet gently warm and bring about hyperemia to the tissues of both the superficial and deep structures. These strokes are needed to prepare the client for the more focussed trigger point treatment later. Note, however, that with a c l ient in pain, there is quite a bit of trigger point work to be done, so the warming phase of
Three essential components to consider when performing
the session must be kept brief yet effective. The following
neuromuscular therapy are pressure, contact, and direction/
strokes are the most efficient for the purpose of thorough
location. These are discussed below.
warming while examining.
Pressure
Skin Rolling
The use of appropriate pressure is very important in working with chronic pain. The sensitivity of ischemic t issues creates reduced receptivity, which requires that you be careful not to use too much pressure at first, but it still needs to be enough pressure to bring up hyperemia and allow you to be able to palpate the deeper t issues. This tissue must be warmed quickly and worked with using integrated techniques before the trigger points may be addressed.
In skin rolling, the therapist lifts, compresses, and rolls the skin between his thumb and fingers to free it from adhering to the superfiCial fascia and bring about extreme hyperemia very quickly at the same time. This technique may be used on the back, arms, legs, and abdomen ( Fig. 4-1). Effleurage Just as when doing a relaxation massage, we will begin with
As with any massage, the client is in charge of how much
effleurage in general to apply the lubricant (for neuromuscu
pressure may be applied. You must always work within the
lar therapy we use very small amounts) and get the person
client's tolerance to be effective. The more varied the pres
used to our touch while initiating the warming of the body's
sure, the more that gets done by way of building the c lient's
tissues, yet done a bit deeper than when used for relaxation
tolerance to pressure. The pressure for warming strokes can
massage. For this we may use two hands, hand over hand,
vary greatly. As you become more focused with the work
forearms, etc. This portion will last only a short time before
and become more direct with your techniques, the pressure
we continue on with other strokes designed to warm quickly.
will most likely become deeper. Contact The manner of establishing contact will definitely affect the results obtained, especially when working with hypersensi tive tissues. To increase receptivity to deeper work, thorough warming is necessary. This is done quickly by using forearms and heels of hands to effleurage and using thumbs to muscle strip while increasing pressure with each stroke. Another key concept is tissue engagement . The effect iveness of Neuromuscular Therapy comes from its d irectness in isolat ing the muscle or tissue in question. This is a combination of pressure and direct contact in a refined and sensitive way. We will be looking for and then treating an epicenter in each nodule we find within the taut bands in the soft tissues. Direction/Location The proper direction of pressure in palpation and in apply ing a particular technique is crucial to its effectiveness. One's intention must be clearly in mind and at hand, for example, to arrive at a particular layer or level of tissue, to increase c irculation, to lengthen muscle, to free tissue bind ing, or to lengthen fascia. Knowledge of anatomy, body mechanics, and hand positioning become very important in effecting proper direction and effectiveness.
•
FIGURE 4-'
Skin rolling.
C H A PT E R 4
B A S I C N E U RO M U SCU LA R THERAPY TEC H N I Q U E S A N D BODY M EC H A N I C S
47
Direct Strokes Once warmed quickly yet thoroughly, we must begin treat ment. We w i l l want to use techniques that are specific and direct while we treat sensitive and tender areas, taut bands of muscle fiber and fascia, fibrotic areas, and trigger points. Below are some very direct techniques.
Thumb Strlppmg Thumb stripping, a type of effleurage, is the use of both thumbs together applying pressure in a g l id ing motion spec ifically in the direction of the fibers of each muscle. When influencing smaller areas or muscles, one thumb alone may be used . With each pass, the pressure becomes increasingly deeper to examine and treat each layer of tissue/muscle. It is important to use proper thumb and wrist mechanics, as shown in Figure 4-3, along with good body mechanics i n genera l . Wrists are to be held straight along with the metacarpophalangeal j o ints and the inter phalangeal j oints of the thumbs. A lso, keep the thumbs i n an abducted position. A l l of these suggestions of hand and wrist mechanics w i l l help you i n keeping your thumbs and wrists healthy and rel a t i v e ly strain free. If poor •
FIGURE 4-2
Use of opposing thumbs for petrissage.
Petrissage
mechanics are used, the c l ient w i l l notice less and less pressure as the therapist becomes increasingly fatigued or inj u red ( Fig. 4-3).
The petrissage strokes discussed here are very similar to those learned for relaxation massage, except we will use them more specifically. Remember that the definition of petrissage is to l ift the muscle and pull it away from the bone. For a relaxa tion massage, this is done in a very superficial way. For neu romuscular therapy, we wish to impact each muscle directly, so we must be precise with this technique. Kneading, a type of petrissage, is the use of one or both hands to loosen a muscle. This movement is similar to knead ing bread dough. This stroke can be quite specific to a muscle. Using opposing thumbs to get underneath certain mus cles is also specific. With this technique, we w i l l use one thumb in juxtaposition to the other thumb to l ift long mus cles up off of the body. A good place to practice this is on longissimus ( Fig. 4-2). Circular Friction This, again, is a stroke that is used for relaxation massage. We will be using it specifically to warm the areas around joints and possibly into long muscles, as well. This stroke has a good circulatory quality to it and works to warm quickly and efficiently. We can use thumbs or fingertips to move the deeper t issues i n a circular motion while not mov ing across the skin. We w i l l be taking the skin along with our thumbs or fingertips.
•
FIGURE 4-3 Thumb stripping.
48
N E U RO M U S C U LA R T H E RAPY B A S I C S
P A RT I
Cross Fiber Friction Cross fiber friction , also known as deep transverse friction or Cyriax movement, is a stroke in which we friction across the fibers of deeper muscles using thumbs or fingertips. The fin gert ips or thumbs do not glide across skin, the skin moves with the thumbs
or
fingertips as the deeper tissue is being
frict ioned against the bone beneath the area ( Fig. 4-4). This is an extremely d irect stroke and may possibly be the most effective stroke available to help a client. Make friction your friend. As with thumb stripping, it w i l l be important to use proper hand and wrist mechanics while allowing your body to do the work rather than using your shoulders and arms to
create the motion. Longitudinal Friction Longitudinal friction is simi lar to the above cross fiber fric tion, except the movement is in the d irection of muscle fiber rather than across it ( Fig. 4-5). Pincer Technique Pincer technique makes use of the pincer palpation, d is cussed in Chapter 3, for treatment. I n using this technique, we pincer grasp a muscle or port ion of a muscle and roll the tissue between our fingertips and thumbs exam ining it for a trigger point
or
t ight, sore area. Once located, we press it a
•
FIGURE 4-5
Longitudinal friction.
bit harder and hold. Within a few seconds, the soreness and/ or referral sensation lessens. With practice, this will become obvious to you, but as always, be sure to ga in confirmation from the client before moving on to another area by asking him to let you know when the sensation changes ( see Fig. 3-11).
TREATMENT OF TRIGGER POINTS After warming the area and using more d irect techniques to find the t ight bands and trigger points within the muscles, we then begin to use the techniques best designed to allevi ate the trigger points. Below is a description of trigger point treatment. There was a t ime when trigger point pressure was known as ischemic pressure. Travel and Simons replaced the term ischemic pressure w i th the term trigger point pressure owing to clinical evidence indicating that when applying d igital
pressure to a trigger point, there is no need to exert the type of pressure necessary to produce ischemia. They go on to say that because the area w i th a trigger point is already suffering severe hypoxia, there is no reason to think that add i tional ischemia would be helpfu l . The idea of trigger point release is really a release of the contractu red sarcomeres of the·nod u les in the trigger points. The actual technique now known as trigger point release •
FIGURE 4-4
Cross fiber friction.
is far less vigorous than ischemic compression and involves
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49
what is known as the barrier release concept. This tech
to influence it, the client will wince, cry out, or possibly try
nique will not produce additional ischemia in the area and
to pull away from the pressure as confirmation-in other
seems to be more effective clinically. The client will learn
words, give a jump sign. Again, remember to always work
what optimal pressure feels like for self-treatment. This
within the client's tolerance. With strong wincing or with a
approach is far more client friendly, according to Travell
major j ump sign, chances are that the more superficial tissue
and Simons.
needs to be massaged to a l leviate the soreness before you
The first step when using this technique is to work with
can successfully apply trigger point pressure to the underly
the intent to lengthen the muscle in question before apply
ing tissue in question. If the client cannot tolerate the pres
ing trigger point pressure. The trigger point pressure is
sure, he will tense up against the work and you will get
applied gradually while increasing pressure until the finger
nowhere with this treatment.
pressing into the tissue encounters a definite increase in
You should apply trigger point pressure directly to any
resistance. This is called "engaging the barrier" by Travell
suspected trigger point found, using either a finger or a
and Simons. The client will feel a degree of discomfort, but
thumb. This pressure should be as pin-pointed as possible:
not pain. The pressure is maintained until there is a sense of
find the exact site of the trigger point and apply pressure
relief of tension under the finger that is applying the pres
with one thumb only. As your thumb tires, begin to use a
sure. Pressure then is increased to engage a new barrier. This
finger, and then back to the thumb, and so on. This pressure
pressure is still somewhat light, waiting for the muscle ten
will take practice. Again, as stated above, the amount of
sion to let go. During this time, you may change the direc
pressure applied depends on the depth of the trigger point.
tion of the technique if necessary to achieve better results.
Hold this pressure for the 10 to 18 seconds, gain confirma
When working with trigger points, use enough pressure
tion that the referral sensation has changed/decreased , and
to effectively release the facilitated reflex arc. The pressure
then let go. Then it is effective to use a couple of strokes of
must not be too light or too heavy as previously mentioned,
thumb stripping through the muscle at the proper depth to
and the time the trigger point pressure is held must also be
see how different it feels to the client. It is important that
correct. Insufficient pressure will not be effective. On the
the client be able to feel the change in that area.
other hand, too much pressure will add excessive stimulus to
You may go back to that same trigger point several times
an already overloaded system, thus aggravating the trigger
using trigger point pressure to gain more change from it. To
point and exacerbating the chronic pain pattern. Also, with
be sure not to fatigue the area, work elsewhere for a few
too much pressure, the client will most likely tense up
moments, then go back to it. This may be done again and
against the pain. Therefore, the amount of pressure used
again with a trigger point. J ust remember that it may take
along with the amount of time held is critical to the success
more than one session to completely a lleviate a trigger
of the therapeutic release and normalization of the reflex
point, especially one that has been active for a long time.
activity of trigger points. The time duration for applying trigger point pressure to
Active Range of Motion of Involved Muscles
trigger points is around 10 seconds. If it goes beyond 18 sec
Trigger points are more likely to decrease referral sensation
onds or so without deactivation occurring, let go and then
once some flexibility has been restored and range of motion
return in a few minutes and try again after adj usting your
has begun to improve. A lso, some trigger points only prove
pressure. You can continue to come back to this trigger
active during motion of a certain muscle or group of mus
point several times during a session to gain further release. If
cles. There may be times during a treatment session when
you were to hold trigger point pressure on a trigger point for
asking the client to demonstrate certain range of motion
longer periods of time, you may cause a fatiguing of the
exercises ( as described in Chapter 3) is essential to the suc
nerves or possibly over stimulate them. ReleaSing a trigger
cess of the treatment. These range of motion exercises, done
point is not similar to myofascial release work.
speCifically, will confirm that the trigger point is still firing
Along with the pincer technique mentioned above, we
during motion as well as how strongly it is firing. This infor
will be using trigger point pressure to a lleviate any type of
mation a l lows you to know when more work is necessary at
trigger point we find. The deeper the muscle in question, the
the site of that particular trigger point.
more difficult it is to influence, so the therapist must use a
Another goal to increase the range of motion of an
deeper palpation to find and then treat. To be able to use
involved muscle is to gain a balanced movement of a par
trigger point pressure successfully with deeper structures, the
ticular j oint. If a muscle loaded up with trigger points stops
pressure used must be deep enough to influence the correct
being used for a certain movement, its synergists will have
layer of tissue, yet extremely specific to the trigger point. If
to take over for it. These synergists are not large enough to
there is a deep trigger point and the pressure is great enough
be competent at this j ob and so become overloaded and may
50
PA R T I
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N E U RO M U SC U L A R T H E R A PY BAS I C S
also set in trigger points. Meanwhile, the prime mover that is loaded with trigger points may become adhered to other structures, causing further dysfunction in the area. Now,
There are precautions to take when applying ice accord ing to Marybetts Sinclair I ; they are as follows: •
more and more muscles begin to set in trigger points.
applying ice by using a hot pack, blankets, hot water
To avoid these issues, take the affected joint through pas sive range of motion after performing soft tissue manipulation
bottles, and so on •
( see Chapter 3 for details). A lso, have the client perform the
chilled •
too cold; be cautious here •
ment you provide in your office or as a self-care treatment
Be extremely cautious when applying cold over super ficial nerves; never apply pressure there with a cold
that the client performs at home. Moist heat is very simple to use. For example, the client could stand in a shower, letting
Children, especially preschoolers, have a d ifficult time letting someone know if something is causing pain or
Using hydrotherapy in the form of moist heat as well as cryo
therapy can facilitate the client's recovery, either as a treat
For clients older than 60 years, be especially sure to keep them warm as it is easier for them to become
exercises actively at home.
Moist Heat and Cryotherapy
If a client is cold, be sure to warm him or her before
pack and never exceed the recommended time •
Caution clients not to exercise immediately after ice
warm water strike a particular area such as the back of the
application, as they may have decreased muscle
neck, or sit in a hot tub or even a bathtub with warm water
strength because of the cold treatment and could injure
covering the area in question. Electric moist heating pads are available, or one could wet and wring out a small bath towel and heat it in a microwave. Be sure to use oven mitts or thick
themselves •
to an area
rubber gloves to remove the towel from the microwave. Then, fold it to the correct size for placement and cover it w i th sev eral layers of dry towels or blankets. The towel may be
Periodically check for cold damage when applying ice
There are also contraindications according to Sinclair; these are as follows:
reheated after it has cooled, so that the moist heat application
•
Aversion to cold applications
can last up to 20 minutes long ( Fig. 4-6).
•
Sensitivity to cold ( this may be the case with one who has fibromyalgia)
• •
If cold applications cause headaches Any impaired sensation in the area being iced such as with one who has a spinal cord injury or diabetic neuropathy
•
Poor circulation as cold will further decrease circulation
•
Raynaud syndrome
•
Areas that have previously been frostbitten
•
Peripheral vascular disease such as diabetes, Buerger disease, and arteriosclerosis of the lower extremities
• •
Malignancy in the area Heart disease: never apply over the heart due to reflex constriction of the coronary arteries
•
If there is an implanted device present in the area, such as cardiac pacemakers, stomach bands, or infusion pumps
•
Any marked hypertension, as the ice will change the blood pressure to a certain degree
•
If an analgesic has been applied to the skin in that area
•
Any open wound
•
Lymphedema
Cryotherapy is the use of ice or very cold water for treat ment of sore muscles. This type of therapy can be used after •
FIGURE 4-6
Application of moist heating pad.
treatment to help relieve soreness from deep massage if
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51
necessary, but a lso to help muscles recover more quickly in general. The d i fferent forms of cryotherapy used might include ice massage, ice pack or cold compress, and immer sion in cold water. In using cryotherapy (or in recommending it to your cli ents) , keep in mind that there are stages the client will go through when using ice. They are as fol lows: first, the area being iced feels cold; second, the area begins to warm and the client even experiences a burning feeling; third, the client feels pain and/or aching; and, finally, the area feels numb-- the nerve endings have been successfully anesthetized. lee massage is easy for you to perform on a client or for the client to perform on himself. Simply freeze water in a paper cup fi lled to two-thirds full. Tear off the upper por tion of the cup once the water is frozen; the lower portion of the cup then may be grasped for massaging. The client, or you, w i l l massage the muscle in question for about 15 to 20 minutes. There are commercial ice rol ler you can pur chase too ( Fig. 4-7). An ice pack or cold compress is ice in a bag designed for this purpose or a disposable zipper closure bag. It can be used directly on an area or wrapped up in a thin towel before placement, depending on how sensitive the client is to the cold. Place the pack or compress on the area and leave for
•
FIGURE 4-8
Cold compress application.
about 20 minutes ( Fig. 4-8). Immersion is ideal for certain areas, such as the legs/feet and forearms/hands. Such treatment requires a container that will hold water, such as a clean waste basket or bucket of the correct depth to be able to place a foot and leg into, as an example. Simply pour ice cubes into the container, filling it to approximately one-third, and then add enough water, so the entire leg is immersed up to the knee. This will be effective for the deeper muscles in the leg, such as tibialis posterior. A simple ice pack will probably have very little impact on a deep muscle, whereas immersion will have far more influence ( Fig. 4-9). Often, there is confusion as to whether to use ice or moist heat with a client. When in doubt, choose ice. lee docs cer tain things that heat w i l l not. lee will anesthetize the nerve endings, help decrease inflammation, and lower the metab olism of the surrounding healthy tissues, so the oxygen and nutrients carried i n the blood can safely go to help the inj ured area without causing hypoxia. Both heat and ice w i l l bring about hyperemia. A lso, if there is any sign of inflammation at a site of inj ury, the heat will increase this. Once there is no inflammation present and it seems that the ice application is decreasing in effectiveness, the client can be taught to use contrast therapy. Contrast therapy is the use of both moist heat and ice together. This is done by alter •
FIGURE 4-7
Ice massage with an ice roller.
nating the placement of heat and cold applications on the
P A RT I
52
N E U RO M U S C U LA R T H E R A PY BAS I C S
icing/heating at home, after the session . Be sure the client is really following through on this treatment, though, as it is important to the overall success of the work.
Stretching Involved Muscles The cl ient should actively stretch all involved muscles at home regularly. Moreover, you should be passively stretch ing and/or using muscle energy technique for the same muscles after performing soft tissue manipulation and trig ger point therapy. Again, trigger points and tight areas are more likely to be alleviated once the muscle in question begins to regain its flexibility. As an example of passively stretching a muscle after treatment, consider rectus femoris, one of the muscles of the quadriceps group. During treatmen t, the client would most l ikely be supine on the table. You would then assist the cli ent in turning to the prone position on the table. While stabilizing at the client's posterior superior il iac spine area of the pelvis to help prevent hyperextension at the low back, lift the lower leg by holding above the malleoli and bend the knee until the client experiences a stretch of the muscle. Using this same muscle for an example of muscle energy technique, when the muscle is in a stretched position, ask •
FIGURE 4-9
Immersion as cryotherapy.
area in question, leaving each application on for about 20 minutes before moving to the next. There are many opin ions out there as to the t iming when it comes to contrast therapy, with the alternating bouts being as short as 2 to
5 minutes each. You must decide how to most effectively use this so that your client receives the most benefit. The client can begin with either the heat or the ice. For comfort, possi bly begin with the ice and end with the heat in winter months and reverse it during the summer.
the client to push his lower leg back down toward the table. Do not allow the lower leg to actually move, turning the client's muscular contraction into an isometric contraction. Hold this for 5 to 8 seconds. Then ask the client to relax the muscle, so you may take it into an even greater stretch. This procedure is to be repeated two or more times until it seems the muscle has successfully lengthened .
NEUROMUSCUlAR THERAPY TOOlS Besides your own hands, there are many massage tools avail
All of the above thermal therapies can be used all day long
able commercially that you can use in treating your clients.
if the client waits 1 hour between bouts. This wait will give the
These tools include Theracanes, Backnobbers, T-bars,
body time to recover from the cold and/or hot treatment.
Thumbbys, molded foam rollers, Ma Rollers, footsie rollers,
Regarding a general application of moist heat, there are a few contra indications here as well: •
Diabetic neuropathy
and icing roller tools ( Fig. 4-10). Theracanes and Backnobbers are made specifically to allow a person to use on themselves to release trigger points
•
Local inflammation in the area
anywhere on his or her body. The design of these tools allows
•
Open wounds, rashes, and eczema
for this by providing leverage for the work. A T-bar with a
•
Tumors
beveled edge is used by a therapist to apply friction to mus
•
Lower abdomen in pregnant women
cle attachments to bony landmarks, whereas a round headed
•
Heat-sensitive skin
•
Spinal cord injury
You can also use cold or moist heat therapies as part of
T-bar is used for effleurage. A Thumbby can be used by a therapist or as a self-help tool. It is made of silicone and so has the feel of your thumb to it. It can be used for effleurage, friction, and trigger point pressure. At home, it will stick to
each session. You may apply ice or heat to an area while
the wall and provide pressure if one presses into it. It can
working on another area, for instance. You may fi nd it to be
also be used on the floor to provide pressure when lying on
a better use of treatment time to have the client do her own
it. The molded foam rollers are another self-help tool that a
CHAPTER 4
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53
satisfaction of helping your clients and, most likely, by refer rals from these professionals, as wel l .
•
HOME CARE
In addition to the work you perform on the client during his office visits, you can further help your client recover by pro viding him with home care assignments that he can com plete on his own. Furthermore, these assignments can address some of the perpetuating factors the client may have ( di cussed in Chapter 3) and help eliminate the source of some trigger points. In addition to thermal therapies, which are discussed above, home care assignments may include the following: work station rearrangement, development of proper postures, stretching, and self-trigger point release. Remember that the goal here is to help eliminate perpetuat ing factors and minimize predisposing factors. Also remem ber to stick to your proper scope of practice as a massage therapist and refer your cl ient to other professionals as needed and appropriate ( Fig. 4-11).
Work Station Rearrangement If a client appears to have a perpetuating factor related to •
FIGURE 4-10
Various massage tools.
his or her work station, learn as much as you can concern ing the work he or she does each day. Ask the following
client can actually roll his iliotibial bands on along with using to do core balancing and strengthening exercises with. A Ma Roller is a wooden object used for self-help. A client would usc it to melt the tension out of his back by lying on it while incrementally moving it up the paraspinals. Then, the client can actually roll himself or herself up and down the roller against the floor. A foot roller is another self-help tool that a client places on the floor and then rolls the plantar surface of the foot against it. The icing roller tool is used by the therapist to provide cryotherapy while applying effleurage. Often, you can find these tools at the small book and sup ply store of a massage school. Usually, this type of store offers this sort of tool at a better price than you would find at an online store, because of the cost of shipping.
THE IMPORTANCE OF A REFERRAL NETWORK Being a massage therapist, you will not have all of the infor mation necessary to address all of client's treatment needs. This is why it will be important to have a referral network available. Development of relationships with physiatrists, occupational therapists, physical therapists, Fe ldenkrais practitioners, ergonomics experts, and personal trainers will be of great value to you and your client. While this will take time and effort on your part, you will be rewarded by the
•
FIGURE 4-11
Client performing stretch of rectus femoris.
54
PA R T I
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N E U RO M U S C U L A R T H E RAPY BASICS
questions: What is i t you do exactl y ? Can you demonstrate
s t retch b e i ng performed a long w i t h s i m p l e written
the repetitive movements you make ? How is your worksta
instructions to the c l ient, which w i l l help this person
tion arranged ?
remember how to do the stretch as well as remember to
Regarding the workstation itself, you will want to know
actually do the stretch.
about each component of equipment and its placement,
Begin by teaching a c l ient j ust two stretches, as this may
such as the height of the desk and where the computer
be a l l she can learn at once. At the next session, ask her
monitor is along with where the keyboard is placed. For
how the stretches are going. You may need to encourage
example, a client may have his keyboard in front of him
her to actually do them daily. Have her quickly demon
while his monitor is to the side, forcing him to have his neck
strate that she still knows how to do them. If it appears
turned to one side a l l day long. Sometimes a simple sugges
incorrect, do not demonstrate other tretches; work with
tion about how to rearrange a workstation can be helpfu l .
her to perfect the two she is supposed to be doing. Once you
For example, you may suggest that the client place the mon
are confident that this person is doing the stretches cor
itor on a telephone book or bring it to eye level . Sometimes,
rectly and daily, it is time to add one or two more into the
it is the simple things that can make an impact on a person's
client's routine. Once this client is ready for some strength
health and well-being. If the c l ient has more complex issues, you may want to
ening exercises, you can use this same recipe. Remember that the goal here is to help the client increase his stress
refer him or her to a speci a l ist in ergonomics. If you are
tolerance of the involved muscles. Again, only instruct the
intere ted in learning more about this subj ect, consult
client in stretches that you are trained in and that are
the fol lowing books: Ergonomics of Workstation Design by
within your scope of practice.
T. O . Kvalseth and Industrial Ergonomics by R . T. L i n and C. C. Chan.
There are excellent books available on stretching that can be used by both the therapist and client, and several are
Development of Proper Postures As a neuromuscular therapist, you must help clients under stand why it is important for them to begin to develop proper
listed below. •
Stretch to Win by A. Frederick and C. Frederick
•
Stretching Anatomy by A. N elson and J. Kokkonen
•
postures when sitting, standing, l ifting, sleeping, and so on. You must al
0
help them find these postures. It may be a
good idea to get to know an Alexander technique practi tioner or possibly read a book or two on that subject, as it is a l l about adopting proper postures for whatever it is you do in life. As an example of the above, to help a client when sit
The Whartons' Stretch Book: Active-Isolated Stretching by J . Wharton and P. Wharton
•
Facilitated Stretching by R. McAtee and J. Charland
•
Stretching by B. Anderson
Trigger Point Release Another home care treatment a cl ient may be taught is to
ting, for instance, he must be in a good chair with a back to
apply his own trigger point pressure to any active or latent
it sitting upright while resting his back against the chair
trigger points he can reach. Having the abil ity to actually
back. H is thighs at the hips should be in about a 90-degree
reach these trigger points is important. If there are trigger
angle. The knees should also be at a 90-degree angle, with
points in muscles of the back, this person might need to
the feet flat on the floor directly under the knees. The c l ient
purchase a tool to use such as a Backnobber. If you do
must be told to use his abdominal muscles to remain in that
encourage the c lient to purchase such a tool, be sure to
position rather than using back muscles. This is the sort of
carefu l ly instruct him or her in how to safely and properly
help most folks need; j ust something simple like this can
use the tool.
make a huge difference in their lives. As the c lient practices his new, proper postures each day
The procedure for the cl ient w i l l be simi lar to what you do. Let us consider a trigger point in the rectus femoris.
while continuing his neuromuscular therapy sessions, he
For a warming stroke, the cl ient can sit down and do some
w i l l begin to experience better quality of life-a l ife with
simple compression on the muscle to bring about hypere
les and less pain each week.
mia. Next, he w i l l begin to apply trigger point pressure to the actual area with the trigger point. Once he feels the
Stretching
barrier, he w i l l stop pressing and simply hold the area with
Stretch i ng is another area in which you can provide
steady pressure, waiting to fee l a release in tension i n · the
home care assignments to your client. It is probably w ise
soft t issue. As this tension l essens, he wi II press a bit
to demonstrate a stretch fi rst, and then help the person
harder to find the next barrier. He w i l l continue this for
d o the stretch properly. If possible, provide a photo of the
up to 18 seconds. I f nothing happens in L O seconds or so,
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BASIC N E U RO M U S C U L A R T H E R A P Y T E C H N I Q U E S A N D BODY M E C H A N I C S
he should let go, wait a couple of minutes and try again
•
with different pressure, ei ther l ighter or harder. On suc cessful release of the trigger point, he w i l l then do a stretch specific to that musc le.
Client Compliance It will be crucial for the client to be compliant with her home care. The person who chooses to ignore her part in recovery will most likely not recover fully and certainly will not recover as quickly as the person who is compliant. Therefore, d iscuss this with the client. For the person who forgets to do her home care, suggest that she place large notes about home care in places where she will see them daily. If whenever she sees a note she does some of her home care, she will not forget. Pretty soon, it will become a habit for her.
REASSESSMENT
•
55
BODY MECHANICS FOR THE NEUROMUSCULAR THERAPIST
Using correct body mechanics is important to the longevity of your career. Using proper body mechanics means working smarter rather than harder; it means using your body in uch a way as to ease your work. Many massage therapists wind up injuring themselves repeatedly by using poor body mechan ics and have a very short career consequently. One of the goals of this textbook is to bring about an awareness and interest in the use of proper body mechanics by massage therapists. There are textbooks solely devoted to this sub ject that you may purchase and study. One in particular is
Body Mechanics for Manual Therapists, A Functional Ap/)roach to Self-Care by Barbara Frye. You not only use your fingers, hands, and forearms when working on a body, you use your entire body. Your fingers are simply the tools at the end of your body. So many ti mes
Reassessment of the c lient must happen at regular intervals.
a simple adjustment of your body placement w i l l make a
There will be several things to take into consideration at
technique much easier to apply. These adj ustments are
each session. Following is a list of some of the considerations
things such as changing which foot is in front while lung
for rea sessment. •
ing into a technique or even the simple act of performing
The client's level of pain experienced in general. Has
a lunge while working rather than bending at the waist
the client been feeling better with each session ? If so,
( Fig. 4-12). Strive to save your back, neck, shoulders, arms, and hands
by what percentage ? •
The client's level of tolerance for the work. This should
from strain when working. When at all possible, keep your
also have been changing with each session, allowing for the therapist to get deeper and deeper into the work •
Each trigger point must be checked. Are trigger points sending out less and less referral sensat ion ? Are they al leviated completely ?
•
The specific muscles with trigger points must also be checked. Is the muscle more flexible? Is it softer to the touch, allowing for deeper work ?
•
Range of motion must also be considered during a reas sessment. Has the range of motion improved in a given joint? Because using a muscle to provide active range of motion can make a trigger point refer, we also need to ask if the referral stopped happening while doing that exercise
•
Coordination and ease of movement in general. Has the client's ability to move with ease and in a coord i nated way improved ? Does he or she have more energy in general ?
•
And, of course, reassessment of home care must always be included here
You might consider charting each of these above catego ries along with anything else you can think of with each reassessment. Also, remember that the course of treatment will most likely change as a result of reassessment.
•
FIGURE 4-12
Lunging posture.
56
PART I
/
NEUROMUSCULAR TH ERAPY BASICS
back and neck straight while your hips and legs hold you in
far more pressure on a body than relaxation massage. Keep
a lunge position.
your wrists as straight as possible, using hyperextended wrists
Your shoulders must also be held straight, not internally rotated. This helps you to keep a straight neck. If you con
as little as possible. Overuse of wrist movement may lead to conditions such as carpal tunnel syndrome.
stantly work with internally rotated shoulders, you are at risk
When performing thumb stripp ing, keep your thumbs
for developing thoracic outlet syndrome. Also, avoid keep
in a position to be able to push forward through musc le
ing your neck flexed toward the work; you can see what you
t issue deeply. For this technique, the thumbs must be
are doing ju t fine from a straight position. A common mis
held c lose to the fingers, not out away from the hand,
take made among massage therapists is flexing the upper body,
dragging along while straining the thumb adductor mus
shoulders, and neck forward to be close to the work. This
c les ( Fig. 4-4).
author has observed massage therapists with their face so
If you have weak flexor muscles and tendons in your
close to the client's body that their nose is only two or three
hands along w ith lax l igaments at the carpometacarpal
inches away from where they are working! If poor eyesight
joints and interphalangeal joints, consider regularly squeez
causes you to use improper body mechanics as you strain to
ing a rubber ball in your hands to help strengthen your fin
see your work, consider having your vision checked and get
ger flexors.
ting glasses or contacts or having your prescription strength ened so you can move back into proper body mechanics.
A l l of this information regarding body mechanics is merely an overview. As mentioned above, consult other
Most important are your wrist and hand mechanics.
sources on this topic and take a seminar devoted to the sub
N euromuscular therapy is deeper work and requires placing
ject of body mechanics as part of your continued education.
C H A PT E R S U M M A RY In preparing to treat clients, you must understand how to
ments to your c l ients to further faci l i tate their health and
apply warming and direct massage strokes and treat trigger
following up with them to ensure their compliance. Finally,
points with d igital pressure, as well as with tools designed
to avoid inj uring yourself and to improve the effectiveness
espec ially for this purpose. It is also important to know
of your treatments, it is critical that you learn to use proper
your treatment l imits and develop a network of healthcare
body mechanics while work ing w i th clients. Once you
profes ionals to whom you can refer your c lient for help
have become proficient in all of these areas, you are pre
with issues beyond your scope of practice. Another impor
pared to successfully perform neuromuscular th�rapy on
tant element of treatment is provid ing home care assign-
your cl ients.
C H A PT E R 4
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