Positional Release Therapy: Assessment & Treatment of Musculoskeletal Dysfunction

POSITIONAL RELEASE ThERAPY Assessmenr&r;-eannenr Dys/unction

of Musculoskeletal

POSITIONALRELEASE T Assessment&freatment of APY Musculoskeletal Dysfunction iHER 1George B. Roth, B.Se., D.C., N.D.

Kerry]' D'Arnbrogio, B.Se., P.T

Faculty, Department of Post-graduate and

PresIdent, Therapeutic ystems, Inc. Sarasota, Florida;

Continuing Education

Faculty, Dialogues in Contempornry Rehabilitation

Canadian Memorial Chiropractic College;

Hartford, Connecricucj

Director, Wellness Institute

Faculty, Northeast eminar.;

Toronto, Canada;

East Hampstead, New Hampshire;

President, Wellness Systems, Inc.

Director of Manual Thernpy, Upledger Insoitu,e

Caledon, Canada;

West Palm Beach, Florida

Industrial Injury Prevention Consulcant

wid... illustrations by

with phocographs by

] eanne Robertson

Stuart Hal/Jerin

an d

Matthew Wiley

with 256 illustrations with 342 photographs

�T� SI lOUIS

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�.f1 \loshy Vice President and Publisher: Don L1dig Executive Editor: Martha Sasser Associate Develo/>mental Editor: Amy Dubm Develo/nnental Editor: Kellie White Project Manager: Dana Peick Project S/>eciaList: Cathenne Albright Designer: Amy Buxton Manufacturing Manager: Betty Rlchmoml COtler Art: Leonardo Da Vinci Copy right © 1997 by Mosby-Year Book, [nco A Mosby unprmt of Mmby, Inc. All rights reserved. No part of thi� publication may hy reproduced, stored m a retrieval system, or transmitted, in any form or by �my means, electronic, mechanical, photocoPYing, recordmg, or otherwise, without prior wntten permissH.lIl of the publisher. Permission to photocopy or reproduce solely for internal or personal use is permitted for lihranes or other use" regi;tered with the Copyright Clearance Center, provided ,hat the base fee of $4.00 per chapter pIlls $.10 per page" paId directly to the Copyright Clearance Center, 27 Congre" Street, Salem, MA 01970. This conscm doe� not extend to other kind.s of copymg, such as copymg for general distnbution, for advcrtising or promotional purposes, for creming new collected works, or for resale. Printed In the Umted States of America Comp, George B.

Roth ;

with illustrations by Jeanne Rohertson. p.

em.

Includes bibliographIcal references and mdex. ISBN 0·8151·0096·5 I. Manipulation (Therapeutics) 2. Soft tissue mJunes. 3. Muscul,,;keletal system-Wounds amlmjunes. I. Roth, George B.

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About the Authors

KERRY J. D'AMBROGIO, B.Sc., P.T. Kerry D'Ambrogio, B.Sc., PT., graduated from the University of Toronto, Canada. He has studied in a great number of manual therapy and exercise cOllrses from around the world in the Osteopathic, Chiropractic, and Physical Therapy professions' This diverse back. ground provides Kerry with an integrated approach in the evaluation and treatment of musculoskeletal dysfunction and rehabilitation. Kerry has been actively involved in teaching seminars and speaking at research, physical therapy, and athletic therapy ccnven· [ions throughout Canada, the United States, Europe, Australia, and South America. He is the founder of Therapeutic Systems Incorporated (T.S.I.) and an international seminar company. He is the Director of the Manual Therapy Curriculum at the Upledger Institute, and he is also on faculty with Dialogues in Contempcrary Rehabilitation (D.C.R.) and Northeast seminar group. Kerry has contributed a chapter in a published manual therapy textbook and has been interviewed on radio [Q educate the public regarding manual therapy. Kerry currently practices and lives in Bradenton, Florida with his wife Jane and three children Carli, Cassi, and Blake.

GEORGE B. ROTH, B.Sc., D.C., N .D . George Roth is a Doctor of Chiropractic and a Naturopathic Physician based in the Toronto area. He has actively pursued the study of advanced musculoskeletal therapy with a number of innovators in the field and has contributed to the field through several inno· vation . He has publi hed articles in several journals and is on the faculty in the depart· ment of postgraduate and continuing education at the Canadian Memorial Chiropractic College. George has taught seminars through the Physical Medicine Research Foundation, the American Back Society, the University of Western Ontario (Department of Athletic Therapy). chiropractic. sports medicine. and physical therapy conventions and at numerous educational and clinical institutions throughout North America. He has been in practice since 1978 and is the founder of the Wellness Institute. He is also currently involved as a consultant to industry regarding injury prevention and rehabilitation and in the development of wellness programs. George lives with his wife and son in the Caledon countryside. north of Toronto.

v

Dedication

The authors would like to dedicate this book to Dr. Lawrence Jones, D.O., FA.A.O.

(1912-1996) for his pioneering discoveries in the field of musculoskeletal treatment and his contributions to the service of mankind. Dr. Jones spent over 40 years developing Strain�Counterstrain. During the process he gave his time, energy, and talent so that future generations of practitioners could enhance the care of their pariencs. His contribu.. tions have gained the respect and admiration of a broad spectrum of health professionals worldwide. Dr. Jones made it his life's work to share his knowledge for the benefit of others. We hope that our contribution [Q this continuing work will do his memory justice.

vi

Forewords

The body is a symphony of movement orchestrated by the

problem and practitioner B is using method B to treat the

natural oscillations of its component parts. The beat starts

same problem as he or she perceives it, and they are both

at the cellular {probably subcellular} level with the oscilla­

successful in their outcome, then they must both be doing

tions of the individual cells. The organs, the heart, the

the same thing to the same thing, no maner what they say

lungs, the brain and spinal fluid, the gut, kidneys, liver, and

they are seeing or doing. I suspect that we are all treating

muscles all contribute their rhythm, pitch, and timbre, fir.;t

mechanical discords of the musculoskeletal system, inter�

to their organ system, and then to the orchestrated body.

ferences with the normal oscillations that we, somehow,

When it all functions together, it is a harmonic work of

may set right.

great complexity. When one of the players misses a beat it

George Roth and Kerry O'Ambrogio have put all these

can produce a discordant mess. The New York Academy of

thoughts together in an insightful book. They recognize the

Sciences has held conferences on the nature of biologic

oneness of the musculoskeletal system and have built on

rhythms and their dysfunctions and uses the terms dynamic

the work of others to devise a treatment method based on

diseases to describe the illnesses caused by these arrythmias.

scientific principles of nonlinear dynamic systems. If there

These are disorders of systems that can be described as a

is a musculoskeletal dysfunction, we may be able to facili�

breakdown of the control or coordinating mechanisms, in

tate the normal rhythms of the system by stopping the

which systems that normally oscillate stop oscillating or

orchestra, giving it a downbeat, and allowing the natural

begin to oscillate in new and unexpected ways.

oscillations, built into the structure, to get things back in

To many of us in the field of musculoskeletal medicine it

tune. This is the principle used in defibrillating a dysfunc­

has become apparent that what we treat is usually not

tional heart by shocking it still, and it seems to be the prin­

pathology in the classic Vercovian model, where each dis­

ciple underlying positional release therapy.

ease has a verifiable tissue injury or biochemical disorder,

Positional release therapy is remarkably simple and is

but rather a perturbation of the normal rhythms of the mus­

guided by the recognized diagnostic duo of somatic dysfunc­ tion (which is characterized as loss of joint play at the joint

culoskeletal system-a dynamic disease. New models that can explain both the static and dynamic mechanical fune,

level and similar tissue restrictions at each level studied)

tions of the body as an integrated whole are being devel­

and tender points (which are unrelated to local inflamma­

oped. In these models the body is a nonlinear, hierarchical,

tion or injury). These appear to be the diagnostic sine qua

structural system with every part functioning indepen#

non of dynamic diseases of the musculoskeletal system.

dently and as part of the whole, like instruments in a sym­

Learning is made easy by this copiously illustrated book that

phony orchestra. How do we fix what is out of tune? Dynamic systems function nonlinearly. Linear processes,

is both a "how to" manual and a "why for" text. The mar�

once out of whack, tend to stay out of whack. Nonlinear

therapy, makes this a particularly important book. However,

processes tend to be self-correcting. A slight nudge may

as pointed out by George and Kerry, this is a book for all practitioner.; in the field of musculoskeletal medicine.

encourage a nonlinear process to correct itself. We take

riage of the two disciplines, chiropractic and physical

advantage of this when we jar a dysfunctional television set,

Because the technique is so simple, safe, and easy to learn,

scare away a hiccup, or defibrillate a heart. In the muscu� loskeletal system practitioners may treat similar problems

it can serve as an introduction to musculoskeletal tech�

with a variety of interventions. Joint manipulation of var�

niques for the less skilled and also as a valuable adjunct technique for the more experienced practitioner. It is a pow�

ious ilk, cranial manipulation, acupuncture, massage, exer�

erful tool that should be included in every clinician's bag.

cise, and so on all seem to work, in the right hands and at the right time, often for the same problem. John Mennell,

Stephen M. Levin, M.D., EA.C.S.

a pioneer in the field of musculoskeletal medicine, said that

Director, Potomac Back Center

if practitioner A is using method A to treat a perceived

Vienna, Virginia vii

viii

FOREWORDS

Positional release therapy is an extraordinary means of reducing hypertonicity, both protective muscle spasm and the spasticity of neurologic manifes[ation. Irs great achieve� ments are correction of joint hypomobiliry. improvement of articular balance (which is the normal relationship between twO articular surfaces throughout a full range of physiologic motion), elongation of the muscle fiber during relaxation, and increase in soft tissue flexibility secondary to reduced excessive sensory input into the central nervous system. Pain and disability may be remarkably reduced with this approach. Therapists and physicians can use Positional Release Thera/ry: Assessment arul Treatment of Musculoskelewl Dys­ function with almost every patient, in all fields of health

carc. Orthopedic patients enjoy improved function and decreased pain with increased motion. Chronic pain patients experience decreased discomfort, possibly less inflammation, and more functional movement. Neurologic patients, when this approach is slightly adapted to meet their unique requirements, attain positive gains in tone reduction with improved function in all aspects of activities of daily living. Positional release therapy is a comprehen� sive approach for all persons with stress�induced and dys� function�induced muscle fiber contraction. Dr. Lawrence Jones introduced the correction of muscu� 10 keletal dysfunction by correlating tender points with positions of comfort as described in his book Strain arul Counrersrrain. He based his findings on the theory that the treatment positions resulted in a reduction of neuronal activity within the myotatic reflex arc. Kerry D'Ambrogio and George Roth have extended and organized this approach and have included several new theories to account for the clinical manifestations. They have provided a total body scanning process for increased efficiency in practice management. Muscle and tissue references are listed, to provide a clear and pertinent anatomic and kine� siologic basis for treatment. The phomgraphs and illustra� tions are remarkably supportive for the study and practice of these techniques. Body mechanics, as it relates m the reduction of strain on the patient and the practitioner, are addressed in some detail.

Positional Release Therapy: Assessment arul Treatment of Musculoskelewl Dysfunction is an exceptional textbook that

addresses neuromusculoskeletal dysfunction in an effective and efficient manner. My belief is that their work will enhance our goal of improving health care through the use of manual therapy. My personal thanks are extended to Dr. Lawrence Jones for his landmark contribution of strain and counterstrain technique. My patients will be forever grateful. And my congratulations are extended to George Roth and Kerry D'Ambrogio for this valuable new book. Sharon Weiselfish, Ph.D., P.T. Co-partner, Regional Physical Therapy West Hartford, Plainville, and South Windsor, Connecticut Co�partner, Mobile Therapy Associates Glastonbury, Connecticut; Director, Dialogues in Contemporary Research (D.C.R.) Hartford, Connecticut

Acknowledgments

Many people over the years have helped to develop my

Thanks to Jane D'Ambrogio, B.A., B.Ed., Conrad

belief system wid1 regard [Q my healing and treatment

Penner, P.T., and Sharon Weiselfish, Ph.D., P.T., for editing

intervention philosophies. It is sometimes difficuh to say

chapters and for construccive advice and support.

where specific ideas originated because all these people

I would like to thank Dr. George Roth, D.C., for his

shared similar beliefs. I would like to acknowledge this out­

patience and guidance. I've enjoyed the collaboration,

standing group of professionals for helping me put this book

friendship, and learning experiences in the writing of

together. It has been an honor to be associated with those

this book.

who are

M>

dedicated to haTing their knowledge, thoughts.

and ideas over the years:

A special thanks to Sharon Weiselfish, Ph.D.,P.T., for her friendship, contributions, incredible insight, and sup�

John Barnes, P.T., Jean Pierre Barral, D.O.,

pOTC. Sharon is an innovative thinker with her finest

Paul Chauffeur, D.O., Doug Freer, P.T.,

accomplishmel'Hs yet to come.

Dr. Dan Gleason, D.C., Phillip Greenman, D.O., Dr. Vladmir Janda, M.D., P.T., Dr. Lawrence Jones, D.O.,

Most of all, I'd like to thank Illy loving wife Jane and Illy family, who have provided me with the love and support

Dr. David Leaf, D.C., Goldie Lewis, PT.,

needed to write this book. They have comended with more

Frank Lowen, L.M.T., Edward Stiles, D.O.,

than anyone with regard to time spent and patience

Dr. Fritz Smith, D.O., John Upledger, D.O.,

required in ''''Titing this lxJok.

and Sharon Weiselfish, Ph.D., P.T. Thanks again to Doug Freer who originally inspired me.

Sincere thanks to all of YOll.

Kerry J. D'Amhrogio

I would like to thank Harold Schwartz, D.O., for helping

Working with Kerry has been stimulating, and I feel

to resolve my back pain and for opening me up to a new

that, despite occasional challenges, we have become better

way of looking at the body. Dr. Lawrence Jones inspired me

(riends and developed a greater respect for each other

through his down�[Q�earth comlllon sense and his humility,

through this collaboration. It can truly be said lhal the

and I hope that he would find this book a worthy testament

whole is greater than the sum of each of our parts.

to his goal of bringing these therapies to the world.

Several gifted practitioners, whom I can also call friends,

Last, but not least, I wish to thank my loving wife Deb­ orah and Illy son Joshua for their love and support. The

have been a continuing source of constructive criticism as

past 2 years has been a strain on them because of the long

positional release therapy has evolved over the years: Garry

hours I spent on this book, often hibernating away well

Lapenskie, P.T., Stephen Levin, M.D., EA.C.S., Iris Wev­

into the night with my computer to write and edit the

ennan, P.T., Iris Marshall, M.D., Heather Hartsell, Ph.D.,

text. I cannot begin to express my gratitude for their

P.T., and

ecil Eaves, R.M.T., Ph.D. I am specifically

grateful to Garry Lapenskie, P.T., for his help in editing the

patience with their part�time husband and dad during rhis time.

manuscript. Stephen Levin, M.D., has been a continuing source of inspiration and a good friend.

George B. RDlh ix

x

ACKNOWlEOOMENTS

Kerry and George would both like to thank the following: Photographers Stuart Halperin and Matthew Wiley and

put in and an extra thanks to Robin and Mary-Ellen for the

illustrator Jeanne Robertson for their professionalism,

second photo shoot. Mosby staff Amy Dubin, Kellie White, Catherine

patience, and remarkable talentS. They have created an

Albright, and Martha Sasser for their advice, support, and

incredible visual learning experience for the reader. Models Mary-Ellen McKenna, N.D., Carol Fisher-Short,

patience with timelines.

R.M.T., and Robin Whale, D.C., for the long hours they

Preface

liThe magic is not in the medicine but in [he patient's body , in the vis medicacrix naturae, the. recuperative or self,correcnve energy of nature. \Vha( the treatment does is to stimulate nat, ural functions ar to remove what hinders them."

Miracles, C.S. Lewis, 1940 The purpose of this book is to provide the practitioner with a powerful set of tools to precisely and consistently resolve difficult cases of soft tissue injury and muscu­ loskeletal dysfunction. This text is an attempt [0 bring this information co the reader in a format that is concise, orderly, and user-friendly. We have formulated a system of assessment and treatment that can be easily learned and readily used to benefit patients. This material is appropriate for physical therapists, chiropractors, osteopaths, medical practitioners, occupational therapists. athletic trainers, and massage therapists. We acknowledge the pioneers in this field for their con­ tributions and view this (ext as a step coward a greater understanding of the complex nature of the human body. We 3re hopeful that this work will represent a measure of progress in the field of musculoskeletal therapy and enhance the clinical applicability of these powerful techniques. The basis of the treannen[ program described in this text can be traced to related practices in antiquity. In this cen· tury, positional release therapy (PRT) has evolved through the work of various clinicians, but the discovery of the clin· kal application of these principles is credited primarily to Dr. Lawrence H. Jones, D.O. His dedication to uncovering the basic principles of this form of therapy was a monu· mental achievement. Jones exemplifies the essence of Thomas Edison's definition: "Intelligence is perseverance in disguise." He is recognized as one of the great pioneers in the field of musculoskeletal therapy. Positional release therapy has had a powerful impact on both of us in terms of clinical success and patient accep· rance. In addition, our personal experience in dealing with our own painful conditions was instrumental in directing us to the development of this art. In George's case a severe, chronic condition of upper back pain developed subsequent to a motor vehicle acci-

dent that occured during childhood. The condition was exacerbated periodically on exertion. After becoming a chiropractor, George began seeking more effective and gentle methods of treatment, which eventually led him to study with several prominent osteopaths. He read an article by Jones that described counterstrain and subsequently met Dr. Harold Schwartz, D.O. (a student of jones), who was the head of the department of osteopathic medicine at a prominent teaching hospital. At about this time, George was experiencing an acute episode of his back condition that prevented him from sleeping in a recumbent position. It had proved resistant to several other modalities over the previous J months and was relieved by Schwartz in less than 10 minutes. This experience motivated him to begin a concerted quest to uncover the mysteries of this amazing therapy. He spent the next 5 years commuting between Toronto and Columbus in order to continue studying with Schwartz and eventually with jones. George then began assisting and coteaching with Jones and developed courses for chiroprac­ tors, physical therapists, and other practitioners throughout Canada. He also developed a specialized treatment table that was designed to facilitate the application of this form of therapy. While playing varsity football at the University of Western Ontario, Kerry D' Ambrogio experienced several recurring injuries to his groin, hip flexors, and right knee. These injuries plagued him during his 3 years at Western and limited his activity. As a result, he spent some time in the athletic injury clinic and received traditional therapy, which consisted of cold whirlpools, ultrasound, and stretching. While attending therapy Kerry observed other ath­ letes being treated, and this exposure sparked an interest in physical therapy. He decided to enter into studies at the Uni­ vetsity of Toronto to become a physical therapist. Throughout this period he continued to suffer from chronic pai.n. Kerry was first exposed to counterstrain by his professor, Doug Freer, and eventually attended a workship with jones. At the workship, Kerry discovered several severe tender points in his pelvic region and one on his right patellar tendon. Upon treatment, he experienced a dramatic xi

xii

PREFACE

improvement in the function of his pelvis, hip, and right

approach. The clinician is also encouraged to perform a

knee. Consequently. he was able to fully resume sports

number of reality checks to establish clinical indexes for

activities. This one treatment was able to accomplish morc

improved function. These can include standard orthopedic

than the countless previous therapy sessions. This extraoT'

and neurologic tests and specialized functional procedures.

dinary response motivated Kerry to pursue the study of

(See Chapter 7.)

countersrrain. He eventually assisted with Jones and then

The scanning evaluarion (SE), discussed in Chapter 5,

developed his own series of seminars so that he could share

and provided in its entirety in the Appendix, is designed to facilitate the cataloguing of the tender points. The SE pro­

this technique with other professionals. Both of us had been exploring soft tissue skills over the

vides a system to organize assessment findings and serves as

past several years and found that our paths were inter'

a reference that quickly allows the practitioner [Q deter­

seeting along synchronous lines as we pursued this knowl­

mine a prioritized treatment program. This format can save

edge. We both became involved with teaching and writing­

a great deal of time and provides an efficient method to

manuals for our seminars. When the idea to write a formal

track progress of the patient's condition and plan subse�

text was presented to George. he contacted Kerry, who,

quem treatments.

suprisingly, had been thinking of writing a book as well.

Jones coined the terms CDunrfTsrrain aml strain and coun�

The collaboration naturally evolved and was seen by both

terstrain (the latter being the title of his orginal text). Sev­

of us as a unique opportunity co provide a greater degree of

eral authors, including Jones, have referred to the general

depth to the material and intergrate the concepts of chiro�

therapeutic approach as release by positioning and posi�

practic, osteopathy, and physical therapy.

tional release therapy. We feel that the term positional

We have attempted to provide a theoretical and histor­ ical perspective for positional release therapy. This founda­

release therapy best describes this form of therapy in its broader. generic sense.

tion is intended to support the clinical experience and pro­

With respect to the terminology used in the treatment

vide a level of confidence in the rationale for these

section, we have endeavored to keep this as simple as pos­

techniques. An awareness and understanding of the under­

sible while attempting to maintain a degree of structural

lying principles and context of a therapeutic model can

relevance. In certain cases, the terminology as coined by

play an important role in sustaining the perseverance

Jones is used; however, every attempt was made to correlate

required to develop the skills necessary for its application.

the treatment approach to the anatomic tissues involved.

The reader is provided with criteria for deciding whether

In a few instances, a positional reference is used where this

it is appropriate to lItilize PRT as a treatment modality.

has been determined to be the most logical format. Abbre­

With the numerous emerging therapies available

the stu..

viations have been assigned for each treatment; these con�

dent of musculoskeletal therapy, we felt that is was neces�

sist of two to four letters plus numeral designations. For

[Q

sary to provide a "road map" in order to plot a course of

those trained in the Jones method, a cross-reference with

appropriate treatment. It should be noted that PRT is nor a

PRT terminology is provided (see the Appendix). There is

panacea and is best utilized within a complementary range of

also a cross�reference in the Appendix that correlates mus­

therapeutic options as indicated for each individual patient.

cles and other tissues with the appropriate PRT treatment.

An outline of genenll treatment principles and rules is presented to provide a framework for consistent application

This can be used to quickly locate a particular treatment according to the involved tissue.

of the procedures. These guidelines have been established

Modifications of treatment positions and changes in ter­

during the past 30 to 40 years and can serve to increase effi­

minology are intended to improve the efficiency of treat�

ciency and save the therapist from repeating much of the

ment and simplify the recording and communication of

trial and error that was involved in the evolution of this

clinical findings. These changes should not detract from

PREFACE

pre\'iou� discoveries but \\fill hopefully serve to continue the development of this art ami science. Evolution is a pro' cess of building on previously established foundations. The descnption of the pomt locations and treatment procedures represents the core of this text. The underlying principle In the design of the illustration!'; and photographs has heen to c1e;uly portray the location of the tender pOInts, rhe anatomic structures Involved, and the general ptlSltion of treatment. The treatment section is divided into upper quadrant and lower quadrant sections. Each region of the body (cranium, cervical spine, thoracic spine, upper limb, etc.) b prefaced by an introduction to its clmicai rei, evance and general guidelines for the application of PRT. Each region is also headed by anatomic illustrations out, lining the general location of the most common tender fXllnt:,. Each lender point or group of tender points has a separate page that consists of'1 photograph and illustrmion With the speCific point location, detailed phorographs of

XIII

the treatment positions, anu written descriptions of the location of the tender points and the position ofrreatll'lent. Chapter 7 provides a realistic clinical context to rhe application of PRT. Strategies to help refine the techniques and optimize results arc provided, as well as mO In ratlcntS with chronic Introc.:wble hcniJ!fl rilln of the m ..'Ck amI/or hack. Pam 37:279. 1989.

30. 31.

RI)[h GB: CounLm[Tlun: posifional release rhef'aJ1)' htudy �U1dc). T(lhlnto. 1992, Wdlnt-··" IruILlU(C. -.elf-published, Roth CiR: Tuw;!n.!" a umfu -J mndel u( mU!>I.:ull",kderal J�';,funC{Jon. .. Prc..c.:nteJ at Canao.'1n Chlwpmtlc A'ltlonal rcle�. j Am O�[CoplJ(h Assex: 2,141.1990. Schwan: HR: The u...e of countersmun In an acutely illm-hmrnal population.} Am O�leopalh .A.5.mc 86:4B. 19H6.

31.

31.

H.

15. 36.

Schwarr: JS� HLmum L'TleTSO' .�'mcms. New York. 19&), l\muo. .. ">f�l: aguLJ.:. W('I1L'Tg)' mot't'1llc'fll tlnJ hlld'Y struclUTe, Snuth FF: lnn Adanta. 1986. HumallLc�. Sutherland WG: The cranL,ll huwl. } Am OSCt>j)palh AHf)( 2:348, 1944 Tnwcll JG. SLmon!) [X]: MyofrucidJ. t)(lln "oJ J'Y,fUIlCIIOIL rho: m,IW.'T I)oin! manual, f\lhLmore, 1983, WtlIL.lIn�& Willom,. Wei�l(i.'ih S; Manual lheratry far !he OTlho/Jidsc and neumk� panc11I emt�,,::mg SCTam and coun!rolTam lechmqLlf. Harrfmd. Conn. 1993,

RegLonal PhYMcal Therapy. �1f.pubIL"hcd. Woodroffc WOl,)lerron H, Mclean CJ: Acupuncllm� t'nI..>rg:V In h.:>allh and ducase· a IW'Ck'Ufal gUide fm a,d,."anceJ snulcrtLS. NurrhamplOmhLrl.'. En�lanJ, 1979. ThuN,\Ils.

2 The Rationale for Positional Release Therapy Somatic Dysfunction

7

A New Paradigm

7

The Tissues

8 9

Therapy in Somatic Dysfunction

10

Positional Release Therapy

This chapter establishes a ra[ional basis of understanding

ociceptors: Pain Pathways

12

Crossroads

13

Fascial Dysfunction: Connective

The Role of Positional Release

Treatment

10

Feedback The Facilitated Segment: Neural

The Significance of the Tender Point

P r opr iocep tor s: Neuromuscular

Tissue Connections Summary

14 15

10

have been supported by the advent of imaging devices such

for [he clinical phenomena associated with positional

as the x-ray and its modem derivations (CT scan, MRI).

release therapy (PRT). Somatic dysfunction is discussed in

The aim of therapies based on this model is to reshape the

the light of recem discoveries regarding the physiologic

stnlC(ure according to an architectural ideal. The assump#

properties of the variolls tissues of (he body. Several models

tion is that, by reestablishing the optimal physical relation�

of dysfunction are introduced within the context of their

ship between body parts, everything will be restored to per#

possible role in explaining the effects of PRT. Certain pre­

fect working order. The

vailing doctrines may be challenged by the arguments pre­

designed to remodel the components of the body and to

sented, and we hope (hat the reader will keep an open mind

relieve perceived structural stress within the system.

and judge these theories on their rational merit and on the

Stretching shortened tissue, vigorously exercising hypo#

basis of how they fit with clinical experience.

tonic muscles and surgically refashioning osseous and artic#

, SOMATIC DYSFUNCTION A NEW PARADIGM

aim of achieving this architectural ideal have had limited

Prevailing theories regarding the development of muscll�

therapeutic intervention is

ular components of the musculoskeleml system with the success. The belief that these procedures should work because they are consistent with this model of the body

loskelctal conditions are undergoing intense scrutiny.

encourages persistence, even though the objective results may contradict the underlying prernise.17•18,45 Unfortu­

Patients and insurers are demanding effectiveness and reli�

nately, in many cases, the StruCture resists our efforts. The

ability in therapeutic intervention. If the underlying theory

result is often frustration (or the practitioner and torment

regarding the development of somatic dysfunction IS incon�

for the patient.

sistenr with clinical anu physiologic realities, therapeutic models based on these principles must be questioned.

The functional model of the musculoskeletal system holds that biomechanical discurbances are a manifesta#

The structural model of musculoskeletal dysfunction is

tion of the intrinsic properties of the tissues affected.])

associated with gross anatomic and postural deformations

The tissue changes may be the result of trauma or inflam#

and degenerative changes (scoliosis, disc degeneration,

mation and are seen as a direct expression of fundamental

oSteophytes, etc.). The presence of these physical anomalies

processes at the ultrastructural and biochemical levels.

are considered a direct cause of sympcoms. These theories

These changes, which are collectively referred to as somatic

7

8

CHAPTER 2

The RatiOlUlIe for Positional Release Therapy

dysfunction, may be expressed as reduced joint play; loss of tissue resilience, rone, or elasticity; temperature and trophic changesi and loss of overt range of motion and postural asymmetry. This model views the form of the body as an expression of its function. Posture is seen as an outward manifestation of the degree of balance within the tissues, and greater emphasis is placed on the interaction of all of the body parts during physiologic and nonphysiologic mmion. This model emphasizes the role of the soft tissues, especially the myofascial elements. A growing body of knowledge supports the premise that a large proportion of musculoskeletal pain and dysfunction arises from the myofascial elements as opposed ro neural or articular rissues.J8 Rosomoff and ochers35 have concluded that over 90% of all back pain may be myofascial in origin. In fact, they contend that one of the mOSt popular theories for [he origin of back pain, that of pressure on a nerve, as in disk degeneration or disk protrusion. would result in a so� called silent nerve. They state that "back pain must be con­ sidered to be a non,surgical problem, unrelated to neural compression." Pressure on a nerve results in reduced sensa� tion and motor function, not pain. This can easily be proven by the common experience of placing the arm on the back of a chair and noting how the arm "falls asleep." During this episode, there is a sensation of numbness and loss of mOtor control-not pain. Ir is only when the pressure is relieved that pain is experienced. along with the gradual return of motor function. Saal and othersJa have proposed that, when disks are injured or are in the process of degeneration, they release water and proteoglycans. This material undergoes biochem� ical transformation through glycosylation and is subsequently targeted by the immune system as a foreign substance. This results in the initiation of an inflammatory response. As the leakage of this Uforeign" protein into the epidural space continues, there may be a significant rise in the levels of phopholipase (a component of the arachadonic cascade), leading (Q the production of nociceptive chemical mediators and biochemically induced pain.Ja BrownS notes that disk herniations may be a "red herring" in many cases of thoracic pain and that, barring any significant indications of spinal cord compression, a conservative approach to relieving the myofasdal source of the pain is all that is required. Rosomoff and others)5 point out that, in most cases of musculoskeletal trauma, the accompanying soft tissue injury and the resulting release of inflammatory chemical media, tors produce the sensation of pain. Myofascial responses to injury result from an increased level of proinflammatory chemicals present because of the injury or from direct trauma to the tissues.49 In the latter case it is postulated that calcium is released from the disrupted muscle, which in tum combines with adenosine triphosphate to produce sustained contracture) Proprioceptive and neuromuscular responses are other potentially important mechanisms associated with somatic dysfunction. The sudden strain that accompanies many injuries engages the mYOtatic reflex arc.n.5) These

events may account for the development of myofascial trigger points, protective muscle spasm, reduced range of motion, and decreased muscle strength, which consistently accompany musculoskeletal injury. The effect of trauma to the fascial matrix is also a subject of much speculation. The discoveries of Levin27•29 may shed some light on this complex issue. He and others have demonstrated that the underlying structure of all organic tissue determines its responses to traumatic forces and may account for certain properties that can lead to persisting dysfunction. 19•36.51 PRT, and other functional therapies, do not alleviate or attempt to treat any tisslle pathology. The primary role of these therapies is to relieve the somatic dysfunction, which, according to Levin,29 is a nonlinear process. A nonlinear process is one that exerts an influence over a relatively brief period ohime. These processes tend to be functional rather than pathologic and respond rapidly to functional therapy. Functional restoration establishes an environment in which the linear healing process of the pathologic component of the injury may occur more efficiently. Musculoskeletal dysfunction therefore appears to origi­ nate and be maintained at the molecular and ultrastructural level within the tissues. The intrinsic properties of tissue and their inherent pathophysiologic response to trauma seem to be consistent with many of the external manifesta, tions associated with somatic dysfunction. It is imperative that we examine our beliefs and hypotheses so that we can accommodate this developing knowledge base within our working model of somatic dysfunction. Effective therapy must be congruent with these principles regarding the response of the body tissues to trauma. We will now examine PRT within the context of its influence on these properties of tissue.

THE TISSUES The body is composed of several major tissue types. For the purposes of this discllssion, with respect to musculoskeletal dysfunction, we will consider three main classes of tissue: muscle, fascia, and bone. Even though these tissues are con� sidered separately and are often discussed in isolation from each other in the literature, we should recognize that they are interconnected functionally. The kinetic chain theoryli and the rensegrity model of the body21-29 support the concept that the effects associated with somatic lesions are trans� mined throughout the organism. Restriction or dysfunction in one area or type of tissue can result in reactions and symptoms in other areas of the body. Effective muscu� loskeletal therapy, including PRT, should address the source of the dysfunction, and thus it is essential to have a thor, ough understanding of the physiology and pathophysiology of the somatic tissues. The muscular system, despite its massive proportions, is maintained in a subtle state of balance and coordination throughout a wide range of postures and activities. The

The Rarionnle fCYT Posirionni Release Therapy muscles are the source and the recipient of the greatest amount of neural activity in the body. This includes sensory and motor activity, vertical (conscious, cerebral) pathways, and auronomic activity in relation to the metabolic, vis� ceral, and circulatory demands required during muscular exertion. The muscles, according to Janda, are "at the cross� roads of afferent and efferent stimuli" and arc, in fact, "the most exposed part of the motor system."zz Range of motion, segmentally and globally, is largely dependent on the state of balance ohhe muscles that cross the involved joints, and restriction of motion may be directly auributed [Q abnor� maliries in the tone and activity of this system. The response of muscle to injury is protective muscle spasm, and this reflex is mediated by local propriocepcors and monosynaptic reflexes at the spinal level. The neuro� muscular reflexes involved in this response will be discussed in greater detail later in this chapter in the section on pro� prioceptors. Muscle is interwoven with collagenous and elastic fibers and therefore shares certain characteristics with fascial tissue. Fibrous tissue changes within the muscle may thus be a feature of posttraumatic dysfunction. The fascial system is a vaSt network of fibrous tissue that contains and supports muscles, viscera, and other tissues throughout the body. Injury or inflammation results in adhesive fibrogenesis, which may result in the loss of normal elasticity. According to Barnes! and Becker,] the collagenous matrix of the fascia is in a state of dynamic adaptation to changing conditions, including the effects of strain, trauma, and inflammatory processes. Fascia contains a higher percentage of inelastic collagen fibers than elastin fibers and thus plays an important role in limiting excessive motion and conmining inflammation and infection. Alter� ations in the electrochemical bonds between collagen fibers results in the formation of cross�linkages in response to chemical irritation related to inflammation, overstretch, or other mechanical influences. As these cross�linkages form, the elasticity of the fascia becomes reduced and the tissue alters from a sol to a gel state within the area of involve� ment. The net effect is the development of an area of restriction and reduced elasticity, or fascial tension . US Neural tension and visceral dysfunction have also been cited as separate foci of dysfunction.2,6 These lesions may represent specific manifestations of fascial tension within these tissues. Osseous Structures have long been ignored as active ele� ments in the pathophysiology of mu culoskeletal dysfunc­ tion. Recent evidence indicates that bone is much more plastic and responsive than had been previously appreci­ ated. Chauffour" states that fresh long bone has flexibility of up co 30 degrees before the induction of fracture. The collagenous matrix of bone and the periosteum exhibit characteristics similar to fascia elsewhere in the body. In an injury, bone is no less affected than any other component of the musculoskeletal system and will display persisting injury patterns depending on the nature of tile event. Many of the therapeutic modalities used for muscle and fascia

CHAPTER 2

9

may, theoretically, be applied (Q the osseous component of the dysfunction . IO,'ll

THE SIGNIFICANCE OF THE TENDER POINT Tender points may arise in any of the somatic tissues: muscle, fascia (including ligaments, tendons, articular cap� sule, synchondroses, and cranial sutures), periosteum, and bone. The tender points in positional release therapy are used primarily as diagnostic indicators of the location of the dysfunction. The diagnostic and therapeutic utilization of tender points is central to a wide range of therapies, including PRT.' An understanding of their pathophysiology and role in the etiology of somatic dysfunction will help us in pursuing our study of PRT. Myofascial pain syndrome (MPS) is defined by Travell and Simons" as follows: "localized musculoskeletal pain originating from a hyperirritable spot or trigger point (TrP) within a tallt band of skeletal muscle or muscle fascia." A thorough review of the literature with respect to MP reveals a decided lack of objective criteria for evaluating and treating this common condition. IS The tender point (TP) is palpable as a small (0.25 co 1 .0 em) nodule, usually located in the subcutaneous, muscular, or fascial tissues, There appears to be a close association between the tender points used in PRT and by Jones with the Ah Shi points as described in Chinese writings,S the neurolymphatic points as described by Chapman and Owens,9 and the neurovas� cular points described by Bennett.' (See Chapter I . ) The association o f myofascial trigger points or tender points with musculoskeletal dysfunction has been estab� lished by numerous authors.' Sedentary lifestyles and occu­ pational repetitiveness limit the number of muscles used on a regular basis. Therefore a relatively small percentage of our total muscle mass tends to be ovenvorked, while other muscles become atrophied and reduced in their ability to tolerate loads or strain, Postural stress, trauma, articular strain, and other mechanical factors may excessively load myofascial tissues, leading to the biochemical changes involved in the production of TPs. Tender points are most prevalent in mechanically stressed tissues, notably those subject to increased postural demands, such as the upper trapezius, the levator scapula, the suboccipitals. the psoas, and the quadratus lumborum.l0 On deeper palpation, the intrinsic muscles of the axial skeleton (the multifidus, rota� tOres, levator costorum, scalene, and intercostal muscles) are also often found to contain active TPs. The "weekend warrior" often strains the underused muscle groups and demands phasic responses from muscles which have adapted to a primarily tonic function. inflammarion caused by the initiating injury releases proinflammatory and vasoconstrictive chemical mediators such as histamine and prostaglandins. Acute or repetitive 'Refecences 8, 22, 3 1 , 35, 39, 4Z, 45, 48. 'References 15, ZO, 35, 41, 45, 46, 54·57. 58.

10

CHAPTER 2

The Ralionale for PoSItional Release Therapy

trauma may result In the rupturing of the sarcoplasmic

to 3 degrees." (See Chapter 4. ) It may be speculated that

reticulum. The ensumg £loot! of calcium ions Into rhe toter·

positionll1g heyond this Ideal range places the antagolllstic

stlrial compartment leads (0 uncontrolled actin anJ myosin

muscles or opposing fascial structures under increased 111

interaction and rhe development of the palpable taut bands

suetch, which

of muscle associated with myofascial Involvement. The

spillover, resulting in reactivation of the facilitated seg#

turn causes a proprioceptive/neural

result of these traumatic events is hypertonicity, inflamma·

ment. The iueal position is dNermll1cd subjectively by the

[ion, bchemia, anti an increascu concentration of mcrabol·

patient's perception of tenderness "nd objectively by the

ically active chemical mediators. This vicious cycle, which

reduction 111 palpable tone of the tender point. We refer to

will be further perpetuated by repetitive trauma, is thought

thIS change as the comfort zone (CZ). This mtrlnsic feed·

to be responsible for rhe maimenance of these hypcnrri·

back system assists In the diagnosis and treatment of mus#

tahle, constricted focal areas of inflammation (TPs) within

culoskeletal dysfunction and affords PRT a high level of

the tissues. Z J.4 1,1'1

reliahility within the c1l1lical setting.

Sensitization of nociceptive and mechanoreceptive

O'AmbroglO and Welselfish, in their lectures, descnbe

organs within the affected tissues appears to have a role In

twO major phases of the release phenomenon: the neuro#

mediating the formation TPs. Group I I I and IV nerve fibers

muscular phase, which lasts approxllnateiy 90 �econds, and

are sensitive to chemically active compounds such as

the myofascial phase, which may last for up ro 20 minutes.

prosraglam.lllls, kinins, hbtamine, and potassium. Micro#

WeisclfishSl further Mates that the neuromuscular pha'oC in

scopic examination of muscular TPs reveals the presence of

neurologic patients usually lasts for approxllnately 3 mlll#

mast cells (source of histamine) and platelets (source of

utes. (See Chapter I .) Clrmcally, several phenomena occur

serotonin). These prolnflammatllry suhstances may con#

during the pOSitioning. As one approaches the ez, (he tis#

tribute to the local hypersensluvity that activates the TPs

sues 111 the area of the tenuer POInt soften and become less

when mechanical deformation or direct pressure occurs.'o

tender. After a period of time, several other observations

The myofascial tis:,ues are, in essence, a continuous net#

may he noted. There IS often an II1crease II)

III

local tempera­

work thar surrounds and penetrates all of the structures and

ture. Vibration and pulsation

organs of the body without IIlterruption. This can be com#

are also common findlllgs as the treatment progresses. The

the area of the tenuer point

pared wlrh a piece of woven fabric or a net. Any disruption,

breath may he observeJ to alter during the session,

pressure, or kink wlthm this net IS II1stantaneously trans#

becomll1g shallow and rapid, followed by several slow, Jeep

mitred to the entire structure and will create a distortion of

hreaths. This may occur several times during the treatment.

the previously symmetric architecwre.IU7,}.4 The tender

Fascial unwinding may he sensed extendtng from the area of

point may be conceived of as a focus of constriction of the

the tender point. The patient often reports several (ransient

myofascial tissues. These nodular focal points of tension

symptoms during: the course of the positionmg, includmg

(TPs) within the myofascial continuum may result 111 dis# tort ions

111

the biomechanical integrity of thiS matrix. I

They may also play a role

111

generating Irritable stlilluil,

which Illaintain the dysfunction via a facilitated segment (discussed later).

paresthesia. sensation of heat, fleeting pall1� in other areas of the lxxJy, headaches, emotional episodes, and ultimately, a sense of deep relaxation, The ohserved phenomena associated With somatic dys# function anJ the therapeutic effect of PRT may be explained hy several pathophysiological mechanisms: pro­

H HE R OLE OF POSITIONAL R ELEASE T HERAPY IN S OMATIC D Y S F U NCTION

pnoceptlve systems, nOCiceptive pathways, the facilitated segment, and fascial dysfunction.

The role o f PRT in the resolution o f somatic dysfunction i s assessed within the context o f several o f the current theo#

PROPRIOCEPTORS: NEUROMUSCULAR FEEDBACK

ries of myofascial and neuromuscular pathophysiology. Each

In the 1 940s Denslowll and Korr!'U6 began investigating

of these pn.:lCesses may explain a certain aspect of the dys#

the role of neuromuscular feedhack sysrem> In the develop·

function, and a combination of effects may account for the

ment of somatic dysfunction. In functional technic, as

range of manifestations found in clinical practice.

uescribed hy HrK.wer, UI range of motion I� mOnitored for the degree of ease or billd. He describes a lesion as having an exceSSively resistant range of motion

POSITIONAL RELEASE THERAPY TREATMENT

111

one direction and

an excessively compliant range in another direction. These

Positional release therapy treatment is accomplisheu by

characteristics are nor ascribed to any pratry, vol 5, New York, 1 983. Raven Press.

50.

51.

52.

53.

54. 55.

56.

57.

58.

CIiAPTER 2

17

Wall PD: Physlolo�lCal mechanisms mvolved In the pro­ duction and relief of pam. In Bonica J, Procacci P, Pagm CA. editors: Recent admnces in pam� pcuhophysiologrcal and clonical aspects, SpnngflclJ, III, 1974, Charb C TI,0m. Wang N . Butler JP, Imgber DE: Mechanotransduction across the cell surface and through the cytOskeleton, SCience 260, 1 1 24, 1993. Weinstein IN: A natomy and neurophYSiologic mecho.lOl!)ms of spinal pam. In Frymoyer JW, editor: The adult sl>me: prin, ciples and practice, New York, 1 99 1 , Raven Prcs�. Welsclf"h 5, Manual rherapy for the ormol>th acute and chronic parients. With

ease. The therapISt should feel the tissues becoming relaxed.

chronic patients, there are w;ually several aretlS of long�

As long as these gUideltnes are followed, the nsk of harm to

standing dysfunction. Positional release therapy by Itself or

the patient will be mmimized.

in conjunction With other manual therapies can he used [0 reduce spasm, jOint hypomobility, and fascial rension. This

, WHICH CONDITIONS RESPOND BEST TO POSITIONAL RElEASE THE RAPY?

can result In improved postural alignment anu an Increase

As mentIOned earlier, PRT treats protective muscle spasm,

pain. This enables the patient to move much more easily

in functional mobility and flexibIlity In the spine, nbs, pelvis, and penpheral jomts. There is usually a decrease

10

fascial tension, and JOtnt hypomobility, which are usually the

and comfortably. At this point, mobility and Strength­

result of a physical tnJury. Therefore any patient who has a

ening exercises can be adJed to further facilitatc changc

distmct, phYSical mechanism of tnJury wtll respond favorably

and to progress the patient to the next phase. This phase

to PRT. These mclude injuries resultmg from falls; improper

prepares the patient's boJy for movement.

lifting;

throwing; motor vehicle accidents; sudden, unex�

Phase Ill. Phase III deals with the restoration of hmc­

peeted movements; and sports. The degree to which the

tionaI movement. Once the pauent has overcome (he

patient responds depends on the degree of dysfunction that

acute and srnlctural phase, he should be moving more

preceded the acute IIlJury.

easily with less dIscomfort and be ready to progress to a

Those patients whose pain commenced Insidiously with

more dynamic movement program. This Includes cardio�

no obvious immediate mechanism of mjury but who have a

vascular fitness (aerobics), strengthening (weIght lifting),

hIStory of trauma also tend to respond well to PRT. In these

and a continuation of flexibility and mobility exercises

Ca5C>, the pain may be the result of surpassing a physiologic

from phase II. The patient at this stage should not be ex­

adaptive range. So-called repemlve strain injunes (RSls) may

penencing any sharp pain, although Jull pam may occur

result from excessIve challenge to the acccumulated muscular

with the healing process. The patient's range of motion

guarding, fascial tension, anti/or Jomt restrictions. Treatment

should be relatlvely pain free. The focus of therapy is on

directed to these background dysfunctions may allow for res­

improving functional movement, strengthening muscles

olution of these rypes of conditions. Those patients who have

for structural support, and improving cardiovascular fitness.

had acute or chroniC pam that arose insidiously with no clear

Phase IV. Phase IV deals WIth nonnalozatlon of lIfe activ­

mechanism of injury or history of trauma tend not to respond

Ities. It takes mto consideration the patient's lifestyle and

as well. Their dysfunctIons tend to be related to stress, visceral

goals. Is the patient able to continue with hiS work, actIv�

dysfunction, pathology (e.g., infections, tumours), or surgical

ities of daily living, and sports or recreational activities?

Intervention. Initial evaluation of the patient and subjective

Does he need retraining, lifesryle modification, or addI­

findtng> should help identify these red flags. An appropriate

tional therapy? Appropriate refef bridge.s-a guUk 10 energy mOt-'t!meflf and body mucwre, Atlanta. 1986. Humanics New Age. UpleJgcr JE: CrlllniosacraI lherapy, Seattle, 1983,�tli1nd Pr�...... Weisclfish S: Manual therapy far the arcJwpedic and flt?urofogic patient emphasj�mg main and cOImlmrrain techniqcle. Harrfon.l. Conn, 1993, Regional Physical Thcmpy, self-published. Weis elfish S; Personal communication, 1995.

370279,1989.

10. 11. 12.

13.

4 C linical Principles What Is the Clinical Significance 28

of the Tender Point ?

28

Where Are the Tender Points?

What Is the Comfort Zone?

29

of Comfort

Points Be Palpated during the Assessment ?

Graded?

30

How Long Is the Position of

28

Comfort Maintained ?

How Is the Severity of Tenderness

30

The Immediate Posttreatment

28

Response

What Happens If the Patient Is

31

Frequency, Duration, and

28

Scheduling of Treatment

Preparing a Positional Release Therapy Treatment Plan

29

Achieving the Optimal Position

How Hard Should Tender

Unable to Communicate?

General Principles of Treatment

32

Summary

29

31

This chapter outlines the clinical significance of the tender

For example, in Fig. 4, I a patient develops symptoms in

point (TP), identifies where to find TPs, and explains how

his right knee as a result of running. The patient has a

ro grade the severity of their tenderness. It explains how to

hypomobile right 5,1 joint that is causing excessive prona,

prioritize these tcnder points in order [Q prepare a treatment

tion in the right foot and ankle. If there is prolonged

plan and explains the general rules and principles to follow

pronation during toe off this will result in internal rotation

when performing positional release therapy ( PRT). The fre­

of the tibia and external rotation of the femur, causing a

quency, duration, and scheduling of trearmenrs are dis#

torque through the knee Over time this can lead to the

cussed. It is important to understand the general principles

development of symptoms in the right knee. If one were

so

that the treatment sessions will be as efficient as possible.

to treat only the symptoms the problem would persist.

Before beginning treatment, it is important to undcf#

Trearing globally first (Le., the hypmobile right 5-1 joint)

global and local treatment. The

would reduce the torque on the knee and reduce the

stand the difference between

scanning evaluation (SE) will reveal the most clinically sig·

chance of reoccurrence. After trearing the global dysfunc,

nificant lesions. There may be several significant lesions as

tion, the therapist may elect to treat the knee locally

the result of successive injuries, creating a layering effect of

for symptomatic relief.

the dysfunction pattem. This pattem of interrelated lesions is referred to as the global dysfunction.

I AGGRAVATING FACTORS I

Given the presence of several possible significant lesions within the global dysfunction, the practitioner must never, theless find a place to begin therapy. By comparing these lesions in a sequential manner, the practitioner will be able to determme the one or two dominant lesions, each of which is represented by a dominant tender point (DTP). The primary aim of therapy is to treat the global dysfunc­ tion via the DTPs because this pattern represents the source of the patient's symptoms.

ICAusel (e.g.. S-I hypomobility) Fig. 4·1

""r""

.

" �I

(e.g.. Knee pain and swelling)

Global

tlerSlloS

local treatment. 27

CHArTER 4

28

Clinical Priniciples

, WHAT Is THE CLIN ICAL SIGNIF ICANCE OF THE TENDER POINT?

•

-

A lender point may be defined as a remiC, tender, edema� mCll[S, fasc ia, or bone. I t can measure I

elll

�

acro&> or less,

Tension IS abo felt In the tissues surrounding the [cnJer#

Extremely sensitive

e Very sensitive

tOllS region that is located Jeep in muscles, tendons, "ga� With the most acute pOint being about 3 !TIm in diameter.

-

o

Fig. 4-2

-

-

Moderately sensitive No tenderness

System used [0 grade the �el't"TU:'l of lender POUlts.

ness. The tenLier poil)[ is usually four times as sensitive as normal tissue. S As mentioned

III

Chapters I and 2, the

tender pOints associated with PRT share common charac# tcrhrics and locations with trigger poinrs,R neurolympharic POIlHS, J neurovascular pOints, U and acupuncture (Ah Shi POints) · Most people feel that the tenJer point itself IS the

, H ow Is THE SEVE RITY OF TENDERNESS G RADED?

dysfunction. l lowever, it is only an outward manifestation

When evaluating the body fot tender pomb, a grtluing

of the reaction of the tisslies (() an underlying lesion.

:'::Iystem is necessary In order to measure the seventy of each

Patient!) orten find it IIHeresnng to learn that there I::' ten� ucrne:,::,

In i.l

body region thac is nO( obviously paln(ul for

them. They often have no palpable renJernes!'! in rhe area of pam.

point, In thb text, four clrcle� with various amounts of shading as shown

111

Fig. 4�2 are u"ied to graue the seventy

of the tender points. When palpating a patient who hl.ls an extremely sensl� [lve tender POll1t, there IS

�l

Visual Jump sign, and the

, WHERE ARE THE TENDER POINTS?

patient will express extreme sen�ulvity to touch. ThiS point

Tender poims are found throughout the body, anteriorly,

is shaJed (e). If the point is very tenJer hut there IS no Jump

is labeled extremely seruirit'e, and

111

the SE the entire circle

posteriorly, meJlally, and laterally. A diagram of these

SIgn, the point is IabeleJ very serulli.'e and only the top half

tender points i!'i ::,hown in the Appendix. As illustrated,

of the clTcle is fdled in (e). The pattent srates that the pOint

thc:,c lcnucr point!'i arc founu on muscle origin!'! or in5cr�

is very tenuer but does not flinch or jump away when TP

tions, within the muscle belly, over the ligaments, tendons,

is wuched.

fascia, and bone.

, H ow H ARD SHOULD TENDER POINTS B E PALPATED DURING T H E ASSESSME NT? When documentlllg the tender points, the tissue should

If the patient notices some tenderness of the point but there is no jump sign, it is labeled moderme anu only the bonom half of [he mcle IS (tIleJ

In

( � ). If there

IS no tenderness at all, the mcle " left hlank ( 0 ). The Scannll1g Evaluation

Rccordmg Sheer

I�

�hown

m

the AppenJix.

not be pressed so hard that tenderness on all the POllltS IS elicited. Likewise, If the touch IS toO light tender points may he misseJ. There is no suhstitute for clinical experi� ence and objective trial and error. We recommend that the

' W HAT HAPPENS IF THE PATIENT Is U NABLE TO COMMUNICATE?

practitioner find one tender point on the patient and then

The mabillty to directly communicate the severity of ten­

uetermine how hnle pressure is required ro elicit the Jllmp

derness is a (ac£Or With certam neurologic patients and

siKn. A Jump sign is characterized by certain responses,

infmus, among others. Occasionally a Jump sign mtly he

such �lS a sudden Jerking motion, grabblllg of the therapist\

detected with palpation. If nm, other cues must be used.

hanu, a facial grimace, or the expression of a vocal exple�

Posture, range of motion, and tenSIOn In the muscle must he

tive. Through practice, the precise degree of pressure will

evaluMed and used as " gUIde. Wel'ellish has developeJ a

be learned. The depth of the ti"ue bemg palpated must

chart ro evaluate movement anu po�turtll restriclions assn�

also he considercJ. Deeper tissue requires more pressure

ciateu with tender point!'! to as.''i[st thempists treating these

than "iuperficial tissue, but It must be done gently and with

types of pattent>. (Sec p. 243

finesse. It IS Important to he firm when palpating, but

example of the postural pmhokineslologic l11odel'CI for

tI��ue mu�t he entered gently, and only necessary pre:,sure

determination of treatment.) For example, If a patient has a

III

the AppenJIX for an

mu�r he used to palpate through the layers of tissue. The

TIght protracted shoulJer, she Intght be able to horizontally

patient being evaluated should be taken into account.

adduct WIth ease hut finJ Jifficulty with horizontal abduc­

Bahle"

tion. TenSion may abo be founu on palpation o( the right

chddren, athletes, anJ elJerly patients may

respond differently to touch. Patients' belief systems, how

pectoralis minor. In (hi:, Situation, hypertonicity of the right

much pam they are m, and abbrevia­

over the filled-in circle (,o). It is important to identify which

tions of the treatment names. For example, no.

40 in Chapter 6, Section IV, Anterior Thoracic Spine, looks like this:

point was treated so that the effects of those treatments can be observed during reevaluation of the patient at subse, quent sessions. Finding and treating the most severe tender

40. AT I

point often results in the elimination of many of the sec­

00000

ondary tender points. which may have been adapting around The five circles are used to help us evaluate the extent of the dysfunction for each area of [he body. The circles should be filled in with a pen or pencil appropriately

the primary dysfunction. This procedure is what affords PRT such a high degree of efficiency and effectiveness. There are approximately

2 1 0 points, and each point has

a number, an abbreviation, and five circles to the right.

as follows:

During the initial evaluation, palpate the patient's body for e ·Vcry

e.Exuemely sensitive

Q·Modernte

O-No tenderness

tender points and record them on the recording sheet. Use the key given at the beginning of this section to grade the

The key is lIsed to record the severity of the tender

tender poims. On the initial evaluation, fill in only the first

points. If a point is palpated and there is an observable

circle of each number. If there is no tenderness, leave the

jump sign

(wherein the patient responds with a jerking

point blank (0). In the example below, it is found that no.

motion, pulling away from the contact, with facial grimace

40, ATI, is the most severe tender point. the recording

or vocal expletive), label that point

would appear as follows:

exrremely sensitive and

fill in the whole circle (e). If the patient feels that the point is very tender but does not have the jump sign, the

IV.

point is .ery ,ender and the top part of the circle is filled in

( e ) . If the patient has no jump sign and feels only a mod­

40. AT!

erate amount of tenderness, the point is

41. AT2

moderately semi,

li.e and the bottom part of the circle is filled in ("). If the patient experiences no tenderness whatsoever, the point is left blank (0).

Anterior Thoracic Spine

eoooo

[po 85]

iJ. AT; ecoco

46. AT)00000

SO. ATtOOOOOO

QOOOO

H. ATS00000

47. AT8 QOOOO

SI ATiI 00000

4l. ATJ eooco

45. AT600000

48. AT9

52. ATI200000

Once the therapist has identified the DTP from the

After recording the severity of the tender point by filling

SE using the general rules and principles, [he position of

in the circle, its location is noted. If, for example, a central

treatment should be looked up in Chapter

point is found on the superior aspect of the manubrium and

page reference is provided in the SE recording sheet in

it is extremely tender, the circle for no.

40, ATI, is marked

6. The exact

brackets to the right of the section heading that is cross ref­

as follows: e. However, if a tender point is found on either

erenced with Chapter

side of the body (for example, no.

ATI. If you look to [he right of [he heading IV Anterior

170, MK), the following

Thoracic Spine you will see the page reference (p.

keys are used to label it properly:

\ Right

/ Left

+

Most sensitive

6. In this example the DTP is no. 40

0

YOll tum to p.

Treated

85). If 85 you will see an illustration of all the ante,

rior thoracic tender point . If you rum the page over and look up No.

40, which is found on p. 86, you will see:

- A sketch of the involved anatomy with the TP super-

For example:

imposed on it

1 70. MK,

1 70. MK,

This means that the extremely sensitive

- A photograph of the location of the TP

tender point is found on the medial

- A description of how to find the location of the TP

aspect of the lef[ knee.

- A photo of how to perform the treatment

This means that the extremely sensitive

- A description of how to position the patient in the

tender point is found on the medial aspect of the right knee.

treatment

PositiolUll Release Therafry Scanning Evaluation

CHAPTER

37

5

As you can see the SE is very user friendly and will assist

AT4 and ATIO were moderately sensitive. AT7 was treated

you in the planning and implementation of YOUT treatments.

during the first visit. As a result of the treatment, we 3re left

Therefore onc can quickly appreciate the simplicity of

with AT! extremely sensitive and AT7 and AT12 very sen­

the scanning evaluation. First u e the Tender Point Body

sitive. AT I was treated during the second visit, and, as a

Chart showing all of the tender points as a guide. Then

result, all the points were resolved.

record the tender points on the SE recording sheet, using

There are a total of five circles, representing five treat�

the keys given on p. 232 to grade the severity. Then use the

ment days. Normally this is sufficient to eliminate all of the

general rules and principles from (Chapter 4) to prioritize

tender points. The scanning evaluation will also help iden#

the tender points. Once the tender points that require treat�

tify any red flags. For example, if a tender point persists in

ment have been located, refer to the page number for the

being extremely sensitive after each visit and PRT does not

6). In the treat#

seem to be shutting off that point, there may be another

ment section, you will find a sketch of that particular part of

point in the body which is also extremely sensitive that

the body, with the dysfunction indicated by name, a descrip­

must be treated before this. There may also be a pathologic

tion of the location of the tender point, and the position of

condition or visceral disorder causing this dysfunction. This

corresponding treatment section (Chapter

treatmenc. Any necessary clinical nQ[es are also included. A

is explained in greater detail in Chapter 7, which will iden�

photograph demonstrating the most common position of

tify different treatment strategies.

treatment is also provided to help visualize the correct pro�

If the time is taken to do a full evaluation of the patient

cedure. Therefore the scanning evaluation, when combined

on the first visit, a clear picture will form showing the loc_�

Sternocleido· mastoid

ACS _ Middle scalene

AC6 _

Posterior scalene

Clavicle First rib Second rib

O-AC7 --ACe

",

l

Location of Tender Point

Position of Treatment

This tender point is located on the anterior surface of the tip of the transverse pro­ cess of CS at the level of the inferior border of the thyroid cartilage. Pressure is applied posteromedially.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head and produces cervical flexion down to the level of the tender point and rotation and lateral flexion away from the tender point side. Note:

The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.

Treatment Procedures

25. Anterior Sixth Cervical ( AC6)

71

CIIAPTER 6

Scalenus Ant., Longus Colli Kectus capltJs anterior

AC2

capitis -""t-\"I...c.:'Dt��� Y.

AC3 _ AC4

AMC

Sternocleido­ mastoid

AC5 Middle scalene Anterior ,c.,lon.,_

AC6 _

Posterior scalene

First rib Second rib

::'-AC7 - -ACe l

Location of Tender Point

•

Position of Treatment

This tender point is located on the anterior surface of the tip of the transverse pro­ cess of C6 at the level of the cricoid cartilage. Pressure is applied posteromedially.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head and produces cervical flexion down to the level of the tender point and rotation and lateral flexion away from the tender point side.

Note:

The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.

72

CHAPTER 6

Treatment Procedures

Anterior Cervical Spine

26. Anterior Seventh Cervical ( AC 7 )

Sternocleidomastoid Rectus capitis anterior

Rectus capitis lateralis AC2

Longus capitis -1-fl.":;flil�"'r::;' �

AC3 AC4

AMC

ACS __ AC6

Sternocleido­ mastoid

;:;::!�- Longus Colli AC7

__

Clavicle First rib Second rib - -ACS

l

Location of Tender Point

Position of Treatment

This tender point is located on the posterior superior surface of the clavicle approx­ imately 3 cm ( 1 .2 in.) lateral to the medial head of the clavicle. Pressure is applied anteriorly and inferiorly.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist supports the patient's midcervical area and markedly flexes and laterally flexes the cervical spine toward the tender point side, rotating the cervical spine slightly away from the tender point side.

Treatmenr Procedures

27. Anterior Eighth Cervical (AC8)

CHAPTER 6

73

Sternohyoid, Omohyoid

Rectus capitis Basilar part of anterior occipital bone Rectus capitis lateralis AC2

Longus capitis -"i-��'JJ

AC3 AC4 _

AMC

AC5 _

,,�.....::;;:)

Sternocleido­ mastoid Middle scalene Anterior swlene_

AC6 _

Posterior scalene

First rib Second rib

--Ace

'1

l

location of Tender Point

Position of Treatment

This tender point is located on the medial surface of the proximal head of the clav­ icle. Pressure is applied laterally.

The patient lies supine with the therapist at the head of the table. The therapist grasps the patient's head and flexes the cervical spine slightly, laterally flexes slightly away from the tender point side, and rotates markedly away from the tender point side.

CHAPTER 6

74

Treatment Procedures

A N TERIOR MEDIAL CERVICAL

28. Anterior Medial Cervical ( AMC )

Longus Colli, Infrahyoid

Rectus capitis Basilar part of anterior occipital bone Rectus capitis lateralis

AC2

Longus capitis -i-'�C4

AC3 AC4 __

Sternocleido· mastoid

ACS __

Middle scalene

AC6 __

Posterior scalene

WJ.iIl:::;?�- Longus Colli

AMC

Clavicle First rib Second rib

O-AC7 • Ace _ _ _ .....I Location of Tender Point

l

Position of Treatment

These tender points are found along the lateral aspect of the trachea. The trachea is pushed slightly to the side to palpate the point. Pressure is applied posteriorly.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head and markedly flexes the neck while adding slight side bending toward and rotation away from the tender point side.

Treatment Procedures

CHAPTER 6

75

LATERAL CERVICAL

29. Lateral First Cervical (Le I )

LC I----'

•

location of Tender Point

i

Position of Treatment

...-+

- MAS

-

=· --cl AC I

Rectus Capitis Lateralis

•

- - . MPT

This tender point is located on the lateral aspect of the transverse process of C I . Pressure is applied medially.

The patient is supine with the therapist sitting at the table. The therapist grasps the patient's head and laterally flexes the head toward or away from the tender point side depending on the response of the tissues.

Trearmem Procedures

CHAPTER 6

76

LATERAL CERVICAL

30. Lateral Cervical ( LC2�6)

Scalenus Medius

LCI

LC2 LC3

SH

ce'·--Cl ACI

l

Location of Tender Point

Position of Treatment

•

- - - LPT MAS --. MPT

C4

cs

C6

LC4 LCS LC6

These tender points are located on the lateral aspect of the articular processes of the cervical vertebrae. Pressure is applied medially.

The patient is supine with the therapist at the head of the table. The therapist grasps the patient's head and side bends the head and neck toward or away from the tender point side depending on the response of the tissues. Flexion, extension, or rotation may be needed to fine-tune the position.

P 0 S T E RI O R C E R V I C A L S P I N E Tender

Points

Posterior Rectus minor capitis Posterior major PC 2

::S;���

Transverse process of C I

PC3 PC4

PC6 PC7 PCB

���,,", -/

:\''"it't---f- :Superior

�

'- '-_ Inferior

-rl-�i]�

)

Obi��us capitis

)

Lon�us Rotatores BrevIs cervicis

==::����:-�

Le�tor

77

Posteri o r Cervi cal S p i n e 3 1 . Posterior First Cervical-Flexion (PC 1 ,F) Rectus Capitis Anterior

PCI PCI-t--_

PCI-E

• .. PC6 • PC7

___ pca -Location of

Tender Point

1

Position of Treatment

78

•

•

•

•

•

This tender point is located on the base of the skull on the medial side of the inser­ tion of the semispinalis capitis approximately 3 cm ( 1 .2 in.) inferior to the posterior occipital protuberance. Pressure is applied laterally and superiorly.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head by putting one hand on the occiput and pulling in a cephalad direction and the other hand on the frontal bone pushing caudad. This will create marked occipital flexion. Fine-tuning may include slight side bending toward and rotation away from the tender point side.

Treatment Procedures

HAPTER 6

79

32. Posterior First Cervical-Extension ( PC l �E) Obliquus Capitis Superior

PCI

PC I -E

PC I -E -_--' PC2 ---

PC6----­ PC7

•

•

•

•

•

.----. PC8 -

Location of Tender Point

Position of Treatment

•

This tender point is located on a flat portion of the occipital bone approximately I to 1.5 em (0.4 to 0.6 in.) medial to the mastoid process. Pressure is applied in a cephalad direction.

The patient lies supine with the head resting on the table. The therapist sits at the head of the table. The therapist then places the hand under the patient's head with the fingers pointing caudally. With pressure from the heel of the hand, the therapist pushes caudally on the head in such a manner as to induce a local extension of the occiput on C I . The therapist can also add moderate rotation and slight side bending away from the tender point side to fine-tune.

Note:

One hand may be used to palpate the tender point and to apply caudal pres­ sure on the top of the posterior aspect of the head; the other hand is posi­ tioned on the frontal bone to assist the movement (not shown).

80

CHAPTER 6

Treatment Procedures

Postenor Cervical Spine

3 3 . Posterior Second Cervical ( PC 2 )

Rectus Capitis Posterior

Major/Minor

1,.-;;...--r PC2

PC I -F

....

PCI-E-----.; PC3

PC6

. . . _ .. . • • --

-

PC7 -

-

l

l

� Pce------

Location of Tender Point

Position of ' Treatment

•

This tender point is located on the base of the skull on the lateral side of the inser­ tion of the semispinalis capitis. Pressure is applied medially and superiorly. Another tender point may be found on the superior surface of the spinous process of C2. Pressure is applied inferiorly.

The patient lies supine with the head resting on the table. The therapist sits at the head of the table. The therapist then places the hand under the patient's head with the fingers pointing caudally. With pressure from the heel of the hand, the therapist pushes caudally on the head in such a manner as to induce a local extension of the occiput on C I . The therapist can also add moderate rotation and slight side bending away from the tender point side to fine-tune. Note:

One hand may be used to palpate the tender point and to apply caudal pres­ sure on the top of the posterior aspect of the head; the other hand is posi­ tioned on the frontal bone to assist the movement (not shown).

Treatment Procedures

CHAPTER 6

34. Posterior Third Cervical ( PC3 ) Rotatores, Multifidus, Interspinalis

PCI-F PC I-E--_-.:

J...-- PC3

PC6----­ PC7

•

___

•

•

•

•

•

pca--

Location of Tender Point

l

Position of Treatment

This tender point is located on the inferior surface of the spinous process of C2 (pressure applied superiorly) or on the articular process of C3 (pressure applied anteriorly). Slight flexion may be needed to allow the tender point to be accessible.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head and extends the cervical spine to the level of C3 and laterally flexes and rotates it away from the tender point side. This lesion may require flexion, in which case the treatment is identical to that for AC3.

81

82

CHAPTER 6

Treatment Procedures

Posterior Cervical Spine

3 5 �3 8. Posterior Fourth, Fifth, Sixth, and Seventh Cervical (PC4� 7 ) Rotatores, M u ltifidus, Interspinalis

• -.. PC6-• PC7 ____ pcs--

l

Location of Tender Point

Position of Treatment

PC4 PC5 PC6 •

•

•

•

��r_

�

­

��� ------�I --: �t:2 PC7 ----:;:;��� -

�

-

•

This tender point is located on the inferior surface of the spinous process of verte­ brae above (pressure applied superiorly) or on the articular process of the involved vertebral segment (pressure applied anteriorly). Slight flexion may be needed to allow the tender point to be accessible.

The patient lies supine with the therapist sitting at the head of the table. The thera­ pist grasps the patient's head and extends it moderately and laterally flexes and rotates it away from the tender point side. Extension is increased progressively as one treats progressively caudal lesions.

Trearmenr Procedures

39. Posterior Eighth Cervical (PCB)

CHAPTER 6

83

Levator Costorum

PCI-F PCI-E-_-.: PC3 ---:-

PC6-----

•

•

---. . . ___

PC7 -

•

PCB

pcslocation of Tender Point

1

Position of Treatment

The therapist palpates anterior to the upper portion of the trapezius to locate the upper border of the first rib_ The tender point is found by palpating medially toward the base of the neck until the transverse process of C7 is encountered and then moving onto the posterosuperior surface of the transverse process_ Pressure is applied anteriorly on the posterior surface of the transverse process of C7_

The patient lies supine with the therapist Sitting at the head of the table. The thera­ pist grasps the patient's head and induces marked lateral flexion and slight rotation away from the tender point side along with slight cervical extension.

THO R ACIC S PIN E AN D RIB C AG E HHORACIC DYSFUNCTION The thoracic spine and rib cage contain no less than 84 syn;

syndrome, carpal tunnel-like syndrome, and respiratory and

ovial joints. They form a protective housing for several vital

cardiovascular dysfunction. It is important to assess for and

organs. are the site of the origin of the sympathetic nervous

treat any significant thoracic lesions when there is upper

system, and are an important structural link with the upper

limb involvement. In general. treatment of the thoracic

limb. Although gross motion of the thoracic spine is limited

spine and rib cage may be determined by postural distortion,

by the presence of the ribs, physiologic and nonphysiologic

if present. Therefore a hyperkyphotic upper back will usu­

mocion arc crucial [0 the respiratory, cardiovascular. and

ally be treated in flexion, and a hypokyphotic ;pine will

digestive organs. Trauma. postinfectious visceral adhesive

usually be treated in extension.2J The rules of priority, as

pathology, and surgical intervention are possible causes of

detennined by the scanning evaluation and by the applica­

local lesions.7 Assessment of spinal and rib mmion may be

tion of the rules of treatment, will ultimately dC[ermine

useful in determining the site of clinically significant areas

where and how to treat.

of fixation. Posterior tender points may be found on the spinous pro; cesses, in the paraspinal musculature, on the transverse pro­

HREATMENT

cesses, over the rib heads, or on the posterior angles of the

Posterior lesions are treated in extension, and head and

ribs. Anterior tender points are usually found on the ante­

shoulder position is used to localize the release of the

rior aspect of the ternum, over the sternocostal joints, on

involved tissues at the level of the dysfunction. From

the anterior angles of the ribs, or on the anterolateral mar­

appearances, it may seem, in some cases, that the area being

gins of the ribs. The tender points on the sternum are

treated is under stretch; however, review of the pertinent

reflexly related to the anterior aspect of the thoracic spine,

anatomy will clarify the rationale used. Through its myofas­

which is of course inaccessible to direct palpation.

cial connections to the rib cage, the ipsilateral arm, when

As a guide to palpation, it should be noted that T2 is

elevated, causes the ribs to elevate, which in turn elevates

usually located at the level of the superior, medial angle of

the lower attachments of the levator costOTUm or multifidus

the scapula, TJ at the level of the spine of the scapula, and

toward their insertions on the lamina of the vertebrae one

T7 at the level of the inferior border of the scapula. The

or twO segments above.17 Anterior lesions are treated with

eleventh rib is usually found at the level of the iliac crest.J·" Clinical manifestations of thoracic dysfunction include back pain, neck pain, shoulder and arm pain, thoracic outlet

84

varying degrees of flexion with the addition of rotation or lateral flexion to fine-tune the position.

AN T E RIO R THO R AeI C S PIN E Tender

Points

Upper Anterior Thoracic Region

Lower Anterior Thoracic Region 85

Anterior Thoracic Spine 40,42. Anterior First, Second, and Third Thoracic (ATl,3) Internal Intercostal, Sternothyroid ..

ATI

Internal intercostals Transversus thoracis External intercostals

Location of

l

Tender Point

(All)

Location of Tender Point

(An)

l

Location of Tender Point

(All)

l

Position of Treatment

ATl

This tender point is located on the superior surface of the suprasternal notch. Pres­ sure is applied inferiorly.

This tender point is located on the anterior surface of the manubrium. Pressure is applied posteriorly.

This tender point is located on the anterior surface of the sternum on or just infe­ rior to the sternomanubrial joint. Pressure is applied posteriorly.

The patient sits in front of the therapist with knees flexed and hands on top of the head. A pillow may be used between the patient and therapist for comfort. The ther­ apist places his or her arms around the patient and under the patient's axillae. The patient leans back toward the therapist, and the therapist allows the patient to slump into marked flexion down to the level of the tender point. The patient's trunk is folded over the tender point. Fine-tuning is accomplished with the addition of rota­ tion or lateral flexion. Note:

86

ATl

AT 1-6 may be performed in the supine or lateral recumbent positions with minor modifications.

Treatment Procedures

87

CHAPTER 6

43A5. Anterior Fourth, Fifth, and Sixth Thoracic (AT4,6) Internal Intercostal

ATI An AT3

AT4 ATS AT6

AT7

location of Tender Point

Internal intercostals Transversus thoracis External intercostals

AT4 ATS AT6

This tender point is located on the anterior surface of the sternum at the level of the fourth interspace. Pressure is applied posteriorly.

(AT4) location of Tender Point

This tender point is located on the anterior surface of the sternum at the level of the fifth interspace. Pressure is applied posteriorly.

(ATS)

1

location of Tender Point

This tender point is located on the anterior surface of the sternum at the level of the sixth interspace. Pressure is applied posteriorly.

(AT6)

1

Position of Treatment

The patient is seated in front of the therapist with the knees flexed and the arms extended off the back of the table. A pillow may be used between the patient and the therapist for comfort. The patient leans back toward the therapist. The therapist places pressure on the patient's upper back to create thoracic flexion down to the level of the tender point. The flexion is progressively increased as the level of treat­ ment proceeds caudally. Local flexion may be augmented by grasping one or both of the patient's arms and applying caudal traction and internal rotation or by having the patient clasp his or her hands behind the therapist's knee. Fine-tuning is accomplished with the addition of rotation or lateral flexion (see photo above left). The photo above right illustrates an alternate, lateral recumbent position.

88

CHAPTER 6

Treacment Procedures

Anterior Thoracic Spme

46�48. Anterior Seventh, Eighth, and Ninth Thoracic (AT7 �9) Diaphragm, Diaphragmatic Crura

ATI

l

Location of Tender Point (AT1)

Location of Tender Point (AT8) l

Location of Tender Point (AT9)

l

Position of Treatment

This tender point is located on the inferior, posterior surface of the costochondral portion of the seventh rib (pressure applied anteriorly and superiorly), approximately I cm (0.4 in.) inferior to the xyphoid process and I cm (0.4 in.) lateral to the mid­ line. Pressure is applied posteriorly. This tender point is located approximately 3 to 4 cm (1.2 to 1.6 in.) inferior to the xyphoid process and 1.5 cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly. This tender point is located approximately and 1.5 cm (0.6 in.) late .

1.5 cm (0.6 in.) superior to the umbilicus

Assume, for the purposes of illustration, that the tender point is on the right side. The patient sits in front of the therapist with the therapist's left foot on the table to the left side of the patient. The patient rests his or her legs on the table with the knees pointing to the left while the left arm rests on the therapist's left thigh. The therapist flexes the patient's trunk down to the level of the tender point and side bends the trunk to the right by translating it to the left. The therapist then rotates the patient's trunk to the left by having the patient bring the right arm across the body and grasp the left wrist. Note:

A physical therapy ball or chair may be used to support the arm for AT 7-9.

Treacmem Procedures

CHAPTER 6

89

49,51. Anterior Tenth, Eleventh, and Twelfth Thoracic (ATI0,12) Psoas, Iliacus

::-;Jr+- AT7

'-�F-f- AT8 An

ATI

ATiO ATII

location of Tender Point

This tender point is located approximately 1.5 cm (0.6 in.) caudal to the umbilicus and I .S cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly.

(ATlO) 1

location of Tender Point

This tender point is located approximately 4 cm (1.6 in.) caudal to the umbilicus and 2 cm (0.8 in.) lateral to the midline. Pressure is applied posteriorly.

(ATlI)

1

location of Tender Point

This tender point is located on the inner table of the crest of the ilium at the midax­ illary line. Pressure is applied caudally and laterally.

(ATl2)

1

Position of Treatment

The patient is supine and the therapist stands on the tender point side. The head of the table may be raised or a pillow may be placed under the patient's pelvis. The patient's hips are markedly flexed and may be rested on the therapist's upraised thigh. The thighs are rotated toward the tender point side, and lateral flexion may be toward or away from the side of the tender point.

Note:

Treatments for AT I 0-12 are similar, with slight variation in fine-tuning. A phys­ ical therapy ball may be used to support the legs. AT7-9 may be performed in the supine or lateral recumbent position.

AN T E RIO R AN D

M E D I A L RIB S

Tender Points

��� ----1t

AR2 AR3--....w�...

ARS -�_ AR6-� . ...._-AR7---\,e ARB ----'Ie'___� AR9 --�,.::.; ARlO

--1�i;,:L..._i==k����1).J Anterior Rib Cage

Posterior view of anterior chest wall Relationship of tender points

90

MR3-IO

Anterior, Medial Ribs 52. Anterior First Rib (ARl) ARI

:::---..

AR2 __ AR3_ AR4-.-. ARS AR6 AR7 ARB AR9 ARlO

ARI • • •

•

Location of Tender Point

l

Position of Treatment

Scalenus Anterior, Scalenus Medius

MR3-IO

Internal intercostals Transversus thoracis External intercostals

This tender point is located on the first costal cartilage immediately inferior to the proximal head of the clavicle. Pressure is applied posteriorly.

The patient may be supine or sitting. The therapist grasps the head and places the patient's neck in slight flexion, marked lateral flexion toward the tender point, and slight rotation (usually toward the tender point) to fine-tune the position.

91

92

Treatment Procedures

CHAPTER 6

Antenor Medial Ribs

53. Anterior Second Rib (AR2)

Scalenus Posterior

AR I :::::----..

AR2 __

AR3_ AR4-. AR5 AR6 AR7 ARB AR9 ARlO

l

Location of Tender Point

Position of Treatment

• •

MR3-IO

Internal intercostals Transversus thoracis External intercostals

This tender point may be found in two locations. One is on the superior surface of the second rib inferior to the clavicle on the midclavicular line (pressure is applied inferiorly and posteriorly). Another tender point may be found on the lateral aspect of the second rib high in the medial axilla (pressure is applied medially).

The patient may be supine or sitting. The therapist grasps the head and places the patient's neck in slight flexion, marked lateral flexion toward the tender pOint, and slight rotation (usually toward the tender point) to fine-tune the position.

Treamlenr Procedllres

CHAPTER 6

93

54,61. Anterior Third through Tenth Ribs (AR3,lO) Internal Intercostal

ARI _____ � AR2 __ AR3_ AR4_ • MR3·IO ARS- • • AR6 : AR7 • AR8 • AR9 • ARlO

l

Location of Tender Point

l

Position of Treatment

������;;[2�r -AR3 to::::;S:;Q, :; c AR4 """"f�3� ���l -ARS

Internal intercosta Is T thoracis External intercostals""-..�":>---7 ransversus>

AR6 � tJL """ -AR7 ' AR8 ctf'-AR9 \."'l \'
!::

Scapula

Multifidi External

intercostals

Levator costae Brevis Lev.tores Longus costarum

}

These tender points are located on the side of the spinous process (pressure is medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of the transverse processes (pressure is anterior) at the corresponding levels for each segment_

The patient lies prone with the arms alongside the trunk or abducted to 90· off the sides of the table. The therapist stands at the head of the table and supports the patient's head on the therapist's hand and forearm. The therapist extends the patient's head to the level of involvement and rotates and laterally flexes the head away from the tender point side.

Note: 96

PTI-2

I

•

PT I , 2 may be treated in the supine position by extending the head off the end of the table and rotating and laterally flexing away from the tender point side.

Treaunenr Procedures

97

CHAPTER 6

72,74. Posterior Third, Fourth, and Fifth Thoracic (PT3,5) Interspinales, Multifidus, Rotatores

PRI PR2 PRJ PR4 PRS PR6 PR7 PRe PR9 PRI O PRI2 PRI I

"I

l

Location of Tender Point

Position of Treatment

I

•

PTI _PT2

• • .-••

· ._PTl ··_PT" ··-PTS ·· . . -PT6 --•• ___ PT7 . . ......

PT8 .. �m • • � PTI O ·.� PTI I

Scapula PTJ PT4 PTS

Interspinales Multifidi External intercostals Levator costae BreviS Levatores Longus costarum

}

These tender points are located on the side of the spinous process (pressure is medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of the transverse processes (pressure is anterior) at the corresponding levels for each segment.

The patient lies prone with the arms on the table along the side of the head to create more spinal extension. The therapist stands at the head of the table and sup­ ports the patient's head with the therapist's hand and forearm. The therapist extends the head to the level of involvement, markedly rotates, and moderately laterally flexes the head away from the tender point side.

98

CHAPTER 6

Treatmem Procedures

Posterior ThoraCic Spine

75,78. Posterior Sixth through Ninth Thoracic (PT6,9) Multifidus, Rotatores

PRI PR2 PR3 PR4 PRS

I•

PR8

Location of Tender Point

l

Position of Treatment

Clavicle • • ..-••

PTI _PT2 • • ..-PT3 ··"-PT4 ··-PT5 ··-PT6 ---. PT7 ........ ... • • ____.... PTa • • � PT9 • • �PTIO ·.� PTII PTll

Scapula

i

I

External intercostals Levator costae Brevis Levatores Longus costarum

}

These tender points are located on the side of the spinous process (pressure is medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of the transverse processes (pressure is anterior) at the corresponding levels for each segment.

The patient lies prone with a cushion under the chest and with the arm on the tender point side resting alongside the head. The opposite arm is abducted to 90· resting off the side of the table or is placed alongside the trunk. The therapist stands near the head of the table between the patient's head and shoulder on the side opposite the tender point. The therapist grasps the axilla on the affected side and pulls the shoulder posteriorly and in a cephalad direction, producing traction, exten­ sion, rotation, and lateral flexion away from the tender point side.

Note:

The more lateral the tender point, the more flexion and rotation will be used.

Treafmem Procedures

79,81.

PRI I Location of Tender Point

1

99

Posterior Tenth, Eleventh, and Twelfth Thoracic (PT10, 12) Multifidus, Rotatores, Quadratus Lumborum

PRI PR2 PR3 PR4 PRS PR6 PR7 PRB PR9 PRIO

1

HAI'TER 6

Position of Treatment

I

•

....-PTI ..-PT2 PT3 PT4 ··-PTS ··-PT6 .. --•• •• •• ..• • ..-

Clavicle Scapula

:r;:o.,...;:-c-""""')\- Levacor costae

• • ____

PT7 ......... PT8 •• � PT9 .. � ·. � PTI

Incerspinales ���_ Multifidi Excernal incercostals Brevis L Levacores costarum

ilW..."....,...,,,,,- LongusJ PTI 0 --\iW:7Z��:;1 PT I I -jj 'fi';;z;..o'b � PTI 2

-f,�������

These tender points are located on the side of the spinous process (pressure is medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of the transverse processes (pressure is anterior) at the corresponding levels for each segment.

The patient lies prone with the head end of the table raised or with cushions under the patient's chest. The therapist stands at the level of the patient's pelvis opposite the tender point side. The therapist reaches across the patient and grasps the ante­ rior ilium on the involved side and pulls posteriorly and toward the therapist, cre­ ating a rotation of the pelvis of 30° to 45°. For lateral tender points additional lateral flexion may be needed. This is accomplished by moving the patient's legs along the table away from the tender point side (see photo above left). Alternatively, the hip on the tender point side may be abducted and flexed (see photo above right.)

P 0 S T E RIO R RIB S

Tender Points

PRI

PR2·I O

100

Posterior Ribs 82. Posterior First Rib (PR1) PRI

PR2 PR3 PR4 PRS PR6 PR7 PR8 PR9 PRI O PRI 2 PRI I

l

location of Tender Point

Position of Treatment

I

•

PTI _PT2 ..-PTJ ··"-PT4 ··-PTS ··-PT6 •• ..-•• ••

.........

•• ____. •• ____. •• � ••

PT7 PT8

PT9 PTI � O ·.�PTI

Scalenus Medius, Levator Costorum

Scapula

Multifidi External intercostals levator costae Brevis Levatores Longus costarum

}

This tender point is located on the superior aspect of the first rib deep to the ante­ rior margin of the upper portion of the trapezius. Pressure is applied inferiorly.

The patient is sitting with the therapist standing behind the patient. The therapist places his or her foot on the table at the side of the patient opposite the tender point side. The patient's axilla rests on the therapist's thigh, and the therapist trans­ lates the patient's trunk away from the tender point side. The therapist supports the patient's head against the therapist'S chest and places the neck in slight extension and fine-tunes the position with lateral flexion (usually away) and rotation (usually toward) the tender point side. 1 01

1 02

CHAPTER 6

Treatment Procedl�Tes

Posterior Ribs

83�91. Posterior Second through Tenth Ribs (PR2�10) lntercostals, Levator Costorum

PRI I PR� __ ..--PTI PRJ ___� -__ PT2 -- _ PTJ PR4-... - -_ PT4 I'K"i r-_ _ --_ PTS PR'7-jI----__ _..;. -__ PR,'-ir--_-...:. -- ---. PT6 PT7 __ __ PTa __ PRln-lIl-­ -- �PT9 .... -PTI O PR 12 -1-1;--. -PTI I PRI I

Clavicle

�- -�

!::::: �

l

l

Location of Tender Point

Position of Treatment

PR2·IO

�; ���

i�

i I ��!r Multifidi External intercostals

'D'��Y.-,\-

Levator costae Brevis L Levatores ��-rti\- LongusJ COStarum

These tender points are located on the posterior angles of the ribs. To access ribs 2 through 10 it may be necessary to protract the ipsilateral scapula by adducting the involved arm across the chest. Pressure is applied anteriorly.

Assume, for the purposes of illustration, that the tender point is on the right side. The patient sits in front of the therapist with the therapist's right foot on the table to the right side of the patient. The patient rests the legs on the table with the knees pointing to the right while the right arm rests on the therapist's right thigh. The ther· apist side bends the patient's trunk to the left by translating it to the right. The ther· apist then rotates the patient's trunk to the left.

Treatmem Procedl�res

CHAPTER 6

103

92, 93. Posterior Eleventh, Twelfth Ribs (PRll,12) Intercostal, Levator Costorum, Quadratus Lumborum

PRI PR2 PR3 PR4 PR5 PR6 PR7 PRB PR9 PRIO PRI PRII

l

l

Location of Tender Point

Position of Treatment

I

•

Clavicle PTI

•• ...-•• _PT2 •• e-

PT3 ··e-PT4 ··-PTS ··-PT6 ......... PT7 ...... •• ____... PT8 •• � PT9 • • � PTIO ·.� PTI

Multifidi External intercostals

Scapula

These tender points are located on the tips of ribs posteriorly or medially.

Levator costae Brevis Levatores Longus costarum

}

I I

and 12. Pressure is applied

Assume, for the purposes of illustration, that the tender point is on the right side. The patient sits in front of the therapist with the therapist's left foot on the table to the left side of the patient. The patient rests the legs on the table with the knees pointing to the left while the left arm rests on the therapist's left thigh. The therapist flexes and side bends the patient's trunk to the right, down to the level of the tender point, by translating it to the left.

UPP E R LIMB elmical presentations involving the upper limh Include

UPPER LIMB DYSFUNCTION

pain, pareMhesia, weakness, restriction of morian, repetitive

Pam and resfric[(on of motion 10 the upper limb can arise from Jr,my sources. Local articular changes and syn� ovialfcapsu:ar mOammatory processes can produce reflex

strain injuries, thoracic outlet symptoms, hursltis, arthritis. tendonitis, and "frozen shoulder." With peripheral joint mvolvement, (he tender point will

any of the soft

often be found on the opposite side of the perceived ten�

tis�ues: joint capsules. tendons. musculotendinous regions,

demess. In general, it is advised that significant thoracic

muscle. fascia, and even in intraosseous lesions of the long

and cervical lesions be treated first according to the general

honcs.'i

rules and principles. (See Chapter 4.)

muscular hypertonicity. Pain can originate

III

The wide range of motion mherent in the upper limb aff",ded by the bipedal posture of the human has allowed for increased case of manipulation am.! control of the cnvi# rooment. As

111

all of nawre, every advamagc has its price.

'hEATMENT

Essentially, PRT is "applied anatomy" and trc..llment is

ThiS IIlcreased range of motion exposes us to an increased

directed toward reproducing the action of and shortenmg

risk of trauma. The myriaJ uses of this versatile limh (in

the involved tissues. In many cases the position IS accom#

the quadruped ItIi

use

is limited primarily to iOCOll'lOtion)

pllShed simply by folding the body over the tender pomt.

..;,ubjeclS.4

-

• • • • •

• • • • •

CIIAf'fER 6

179

Levator Ani

• -PI.I • -pu • -pu • -PL4 • -PLS

151

1

1

Location of Tender Point

Position of Treatment

This tender point is located approximately I cm (0.4 in.) superior and medial to the inferior lateral angle of the sacrum. Pressure is applied anteriorly.

The patient is prone. The therapist applies an anterior pressure on the sacral base on the side opposite the tender point, resulting in rotation around an oblique axis.

CHAPTER 6

180

Treatment Procedures

Posterior Sacrum

167. Coccyx (COX) Pubococcygeus, Sacrotuberous Lig., Sacrospinous Lig.

-

QL{

-

PS2 PS3 PS4 PSS 151

cox

l

l

location of Tender Point

Position of Treatment

This tender point is located on the inferior or lateral edges of the coccyx. Pressure is applied superiorly or medially.

The patient is prone. The therapist applies an anterior pressure on the sacral apex in the midline. Rotation or lateral flexion of the sacrum, usually toward the tender point side, may be added to fine-tune the position.

DMT2,3

7 The Use of Positi onal Release Therapy in Clinical Practice Can Po itional Release

How to Incorporate Positional

Therapy Address Repetitive

Release Therapy with

221

Other Modalitie The Use of Reality Checks

222

222

222

How Do You Treat

223

Any Suggestions When Working with Obese Patient ?

223

Regard to Ergonomics and

223

Does Positional Release

Sensations Occur during the Treatment while the Patient Is in a Position of Comfort?

225

What Activities Can the Patient Perform after a Positional Release Therapy

225

What Can Patients Do about Posttreatment Soreness?

225

Do You Offer Any Home

Therapy Specifically Treat Soft Tissue Damage?

224

Treatment Session?

Any Further Sugge tions with Proper Body Mechanics?

Has Pain? What Happens If Pain or Other

What Happens If a Tender Point

Conflicting Points?

What Happens If You Are Unable Points and Yet the Patient

Patients Regarding Positional

Does Not Shut Off?

224

to Locate Significant Tender

How Do You Communicate with Release Therapy?

Strain lnjurie ?

224

Programs to Your Patients? Summary

225 225

, How TO INCORPORATE POSITIONAL RElEASE THERAPY WITH OTHER MODALITIES

reduced in the first few visits so that the patient can progress with cardiovascular fitness, strengthening,

Positional release therapy helps normalize inappropriate

used for pain management and swelling or to help promote

mobility, and range#of,motion exercises. Modalities may be

proprioceptive activity and promotes the release of muscle

soft.tissue healing. Positional release therapy may not be

guarding and fascial tension, thus increasing soft tissue flex#

the primary treatment for all conditions, but it will help

ibiliry, improving joint mobility, decreasing pain, increasing

many patients overcome certain aspects of the dysfunction.

circulation, and decreasing swelling. By using PRT, the

Based on the evaluation and determination of the calise

patient's muscle, fascia, and articular components are struc#

of the dysfunction, other modalities may be introduced. In

rurally normalized to a point where the therapist can start

the case of persisting articular restriction, these may include

to implement a functional rehabilitation program. It is

manipulation, mobilization, or muscle energy. If the cranial

essential to perform a thorough reevaluation at each visit.

structures are not fully corrected or the dural tube is under

In most cases the patient's pain level will be dramatically

(ension, cranial osteopathy

or

craniosacral (herapy may be

221

222

CHAPTER 7

The Use of Positional Release Therapy in Clinical Practice

applied. With visceral or fascial involvement, the appro�

tion that either through various injuries sustained in the

priarc soft tissue technique is used. If the patient demon�

past or from the present injury, the tissues may have become

s[rares muscle weakness, a strengthening program should be

injured and are in a shortened, tense position. This can

instituted. Frequently, massage and general exercise pro�

result in the tissues being tender to the touch. If these tis,

grams can further release tight, overused muscles, ease fas#

sues (muscles, ligaments, etc.) become short and tense, they

cial tension, and help promote increased circulation.

will create joint stiffness and limit movement.

Modalities slich as ice, heat, and electrical stimulation can

Patients will realize that trauma obtained in the past can

aid in relaxing the patient and can help resolve inflamma�

result in accumulated restrictions throughout the body. To

rion, posureatment soreness, and other reactions.

explain areas of dysfunction that are remote from the per,

HHE USE OF REALITY CHECKS

a sweater or blouse, can be used. This demonstrates that fas,

Reali!y checks are orthopedic and functional tests used to

radiate from the source and thus cause strain in surrounding

confirm various Outcomes. These tests must be objective

"reas. (See Chapter 2, Fig. 2-4.)

ceived symptoms, the analogy of a pulled garment, such as cial restrictions, like fabric, can cause lines of tension to

and measurable. The pain scale from 0 to to may be used

Once the patient understands the purpose of the full,

(0 being no pain and 10 being the most severe) or a range­

body evaluation, the therapist should proceed to explain

of,motion test (the patient lifts his arm over his head while

what the patient can expect during and after the treatment

the practitioner uses a goniometer to measure the range in

session. It is suggested that the therapist find a tender point

degrees). Joint hypomobility tests (spinal

to demonstrate the PRT technique and gently bring the

or

sacral spring

tests) and functional tests (doing a deep squat or going up

patient into and Ollt of the position of comfort. This shows

and down stairs) can also be used. If a patient has low back

the patient that the tenderness will disappear in the posi­

pain, the range of motion should be evaluated in each of the

tion of comfort and demonstrates that the treatment is

three planes. If it is found that there is pain at *0 on left side

gentle and safe. It is important to explain that the patient

bending and extension at X range, these are two reality

may experience release phenomena consisting of pulsation,

checks that can be used to confirm the outcome of treat,

vibration, paresthesias, pain, or heat while in the position of

ment. Therefore when using PRT it is now possible to mon,

comfort. These sensations will dissipate when a release in

itor left side bending and extension after treatment to see if

the soft tissues is completed. The patient should be

there is a change in the pain level or range of motion. Thus

informed that there should be a significant reduction in

it is important to find two or three objective measurements

tenderness. The patient should be relaxed, more comfort,

throughout the treatment program. It is also important to

able, and able to move more freely. During the 24 to 48

make the patient aware of these reality checks because this

hours after the first treatment, approximately 40% of

will be helpful in motivating the patient as changes occur.

patients report some increased discomfort. Reassure the patient that this discomfort will disappear after a day or two

, How Do You COMMUNICATE WITH PATIENTS REGARDING POSITIONAL RELEASE THERAPY?

and that an improvement in the original symptoms will be

Communication is one of the most important aspects in

felt elsewhere. For example, if the sacrum is treated, the

noticed. It is helpful to advise the patient that the discom, fort may be felt directly in the area treated or that it may be

dealing with the public. On the first visit, it is crucial that

patient may feel discomfort in the sacrum, neck, shoulder,

the subjective evaluation of the painful areas be recorded. It

or other areas of the body.

should also be noted whether the pain is constant, periodic,

If these pretreatment discllssions are omitted, the proba,

or occasional. Have the patients grade pain from 0 to 10,

bility of future problems with the patient is extremely high.

with 0 being no pain and 10 being the most severe. What

Thus it is necessary to prepare the patient and make Sllre that

do they expect to get from therapy? As health care

he is aware of the different sensations he may experience.

providers, we must keep our patients focused on their own

When the practitioner clearly explains what is to be ex­

goals. Also, they must decide what they are prepared to do

pected, the patient feels respected and included in the treat'

to obtain these goals. How will they know if they have

ment program. He appreciates that the technique is gentle

obtained their goals? What reality checks will be used? It

and that immediate results may be felr. The pariem values

must be made clear [Q patients how their bodies will move

the time taken, and this ensures satisfaction and confidence

and what they should feel. Some patients have no idea what

with both the practitioner and the rehabilitation program.

wellness feels like. Each patient's expected outcome of therapy should be discussed and recorded by the practi­ tioner to ensure that the goals will be met. It is important to discuss the rationale of PRT. The

'WHAT HAPPENS IF A TENDER POINT DOES NOT SHUT OFF?

patient must understand why a full,body evaluation is crit,

ClinicaHy, this has been found to be a rare occurrence. From

ical even when a specific site is so obviously painful. Men-

our experience, when a therapist is unable to shut off a

The Use of Positional Release Therapy in Clinical Practice

CIIAPTER 7

223

tender pOint, she must first establish if she is palpatmg the

tender TXllnt, The practitioner shllulJ he alert to this

exact location of the tcnder point. Some pomL'; aTC close

possibility if the tissues UO not responu as expected.

rogcrher. For example. the anterior third lumbar, which is on

Further ilwestigations or an appropnate referral may

the lateral aspect of the amerior mferior lilac spme. is In

he required.

close proximity [0 the [cm.lcr point for (he gluteus minnnus, which is I em lateral to the anterior inferior iliac spine. To treat an anterior

, How Do You TREAT CONFLICTING POINTS?

c,,1 hIp l1exlon of 90 Jegree, anJ siJe bent ,harply away

A paticnt who has experienced a whiplash rype of mJury, for

from the tender pom[ siJe (p. 148). To treat a gluteus

example. may have tender pOints

mmimus. only the involved hip is flexed [0 approximately

rior aspects llf the neck. The practitioner may find that an

DO degrees with 0 degrees of abduction and rmarion

attempt to treat the anterior lesion hy flexing the patient's

111

third lumbar.

the anteTlor and rx)stc�

(p. 152). In this situation, these two points are In close prox#

neck ll"'I
•

Motorized thoracic elevation to 85°

•

Leg section flexes to 75°

\� �

. iI

' - ./

-_ .. - -�

-

•

Head piece adjustable through 135'

•

Removeable pelvic section

•

Wide "'nge of possible positions

•

Anterior/posterior cervical

•

Rib treatment

•

Posterior thoracic

•

Posterior lumbar

•

Anterior lumbar/thoracic

•

lliacu

� � -� � � � � � � � � � � � � ----'� [;II LabornlOdes Co., 3 Bacton H;II Rd., F""elen"" 182, 1 9 1 CubniJ render points dorsal,204 , 208 plantar, 204, 209 Cumul.ulvc trauma lhsordcr. 224; see also Repetitive stram Injury Cuneiform tender pOints Jor"'�ll first through third,204, 2 1 2 plantar firS[ lhrough t1md,204, 2 1 3 Cupules,2

epIcondyle, medial, 1 26 , 1 28 olecranon, lateral/medIal, 126, 132

raJial head pronator, 1 26 , 1 30 raJlal hea" supinator, 1 26 , 1 29 EpIcondyle tender POints lateral, 1 26 , 1 27 meJial, 1 26, 1 28 Ergonomics,223-224 Evaluation of lower body form for, 142 scanning, 5, 35-38,232-233 of lIpper body fom) for, 41 Exercises; see also Bioenergetic exer# ci�es at home, 225 role of, 228 Extensor lJigitorum longus tender POint, 1 93 , 203 Extensor tendon tender point, common, 1 3 3 , 135 Extrafusal fibers, I I , I I

D

F

Devices ,"Slstive,22 1, 250 Diagnosis; see also Scannmg evaluation funcuonal. 3 protocol for, 40 Digastric tender point. 44, 50 Direct [cchni4ue. 2; see also Indirect technique Dominant tender POInt,27. 40; see abo Tender pOlllt:-. III '\C,mnmg evaluation, 36�37 Dynamic neutral position, 3 DynamIC recIprocal balance, 3 DY�(lInction; see also Mlisculo�keletal JY�(lInction; Somatic Jysfunc� lion; specific anatomic areas global,27

Facilitated segments, 1 3 , 11-14 Fascial matrix, effect of trauma on,8 Fascial system,8,9 Jysfunctlon of,14-15 tension of; see Fa�cial tt�n�ion Fascial teruion, 9 normalization of,20 patterns of,14, 1 5 Feldenkrais, I Fibrogenesl� aJhe�ive,9 Fingers; see Ham.l/wrist Flexor JigltOrum longus tender pOint,

E Elhow dy�function of,104 tender pOints of, 104, 126-132 coronOId, lateral/medial, 1 26 , 1 3 1 epIcondyle, lateral, 1 26, 1 27

193, 200

Flexor tendon tender POint common, 1 3 3 , 134 Flower spray endings, II, I I Foot dysfunction of, 1 8 1 tender points of, 1 8 1 , 204-2 1 9 calcaneus, lateral, 204, 206 calcaneus,medial,204, 205 calcaneus, plantar, 204, 207 cuboiJ, dorsal, 204, 208 cubOId,plantar, 204, 209 cuneiform, dorsal, fin:.t through tlmJ, 204, 2 1 2

cunciform,plantar, first through th"d, 204 , 2 1 3 mC{atarsab, dorsal, first through fifth, 204, 2 1 4-2 1 6 metatarsals,plantar, fir�t through ftfth, 204, 2 1 7·2 19 navicular, JONal, 204, 2 1 0 navicular, plantar, 204 , 2 1 1 Frontal tender pOint,44, 57 Functional diagnosis, Ji see also DiagnOSIs Functional techniC, 3

G Gamma bias, II Gamma effercnt neurons, I I Gemellt tenJer POlnl, 166, 1 70 Gcriatric patients treatmg, 23 Global dysfunction,27; see also Mus­ culoskelctal dysfunction; Somauc dys(ucnllon; specific anatomic areas

Global treatment, vs. local treatmem,27, 27 Glossary, 251-25 3 Glutcus medlu� tender [XHnt, 166, 172

Gluteus ml1llmU� tem.ler [XHnt, 150, 1 5 2 , 168,

Goigi tcndon organs, I I

H Hamstring render POlllts lateral, 182, 188 medIal, 182, 187 Hand/WrISt dysfunction of, 104 tender pOints of, 104, 133- 1 4 1 carpometacarpal,first, 1 3 3 , 138 common flexor tendon, 133 I

134

common extensor tendon, 1 3 3 , 135

mtero�colls, dorsal, 1 3 5 , 140 interosseous, palmar, 1 3 3 , 139 Interphalangeal JOInts, 1 33 , 141

WrI,t, dorsal, 1 3 3 , 1 3 7 WrISt, palmar, 1 3 3 , 136 Head; see Cranium

INDEX

J

High�gain servomechanism, I I Hip/pelvis anterior tender points oC 1 4 3 , 150-158

Joints; see also s/Jecific anatomic areas hypomobility of, 20

adductors, 150, 158

Jones neuromuscular model, I I , 1 2 , 1 2

iliacus, ISO, 1 5 1

Jump sign, 28, 36

Kinectic chain theory, 8, 1 4

sartorius, ISO, 153

Knee

gemelli, 1 66 , 1 70 gluteus medius, 1 66 , 1 72

fourth-iliac, 159, 163

upper fifth, 1 5 9 , 1 64

pubis, lateral, ISO, 157

1 66-173

1 5 9- 1 65

first through fifth, 159, 160

K

pubis, superior, ISO, 155

posterior tender points of, 1 4 3 ,

po�terior tender points 0(, 1 4 3 ,

lower fifth, 159, 165

152 pubis, inferior, ISO, 156

tensor fascia lata, 150, 154

dy,function of, 1 43

third-iliac, 159, 1 62

gluteus minimus, ISO,

dysfunction of, 1 4 3

M

dysfunction of, 1 8 1

Masseter tender point, 44, 53

[ender points of, 1 8 1 , 182-192

Maxilla tender point, 44, 54

cruciate ligament. amerior,

Mechanoreceptors. 1 0 Metatarsal tender points

182, 190 cruciate I igament, posterior,

dorsal, 204, 2 1 4- 2 1 6 first, 204, 2 1 4

182, 1 9 1

iliotibial band, 166, 1 73

hamstring, medial, 182, 187

fourth and fifth, 204 , 2 1 6

piriformis, lateral/medial, 166,

hamstring, lateral, 182, 188

second and third, 204, 2 1 5

171

lateral, 182, 186

plantar, 204, 2 1 7- 2 1 9

sacroiliac, inferior, 1 66, 1 69

medial, 182, 185

fifth, 204, 2 1 9

sacroiliac, middle, 1 66 , 1 68

patella, 182, 183

first, 204, 2 1 7

sacroliac, superior, 1 66 , 1 67 Humerus tender pain[ medial, lOS, 1 1 3

patellar tendon, 182, 184 pes anserinus, 182, 189 popliteus, 182, 192

L

1 73

The Importance of Sof' Tissues for Stnlctural Suppor, of ,he Body, 244-249

o(�l1lotion assessment normalization of, 20

joint, 20

I l iacus tender point, ISO, 1 5 1

second and third, 204 , 2 1 8 Mobiliry; see Hypomobility; Range­ Muscle spasm

Hypomobility

I l iotibial band tender point, 1 66,

protective, 1 9 Muscle spindles, I I , 1 I

L,mbda tender point, 44, 48

Muscular system, 8-9

Lmissimus dorsi tender point, 105,

Musculoskeletal dysfunction, 7,

1 17 Legs; see Ankle; Knee Lesion; see Facilitated segments; Injury limbs; see Lower limb; Upper limb Lower body

8- 1 0, 2 3 ; see also Global dysfunction; Soma[ic dys� function Myofascial Pain and Dysfunc,ion, 2 Myofascial pain syndrome. 9; see also Pain

Indirect technique, I , 2-4

evaluation form for, 1 42

Myofascial skeletal truSS, 1 4- 1 5

Inflammation

treatment of, 2 3 ; see also s/:>ecific

Myofa!lcial [issue, 1 0

due to injury, 9-10, 1 2 in somatic dysfunction, 8 Infraspinatus tender poinrs inferior, lOS, 1 23

anatomic areas Lower limb

N

dysfunction of, 1 8 1 tender points of, 2 3 , 1 8 1 , 182-

middle, lOS, 1 22

2 1 9; see also specific anatomic

Nasal [ender point , 44, 55

superior, 105 , I 2 1

areas

Navicular tender points

Injury mOtor vehicle, 2 3 tissue, 8- 10, 1 2 Interosseous tender points

Lumbar spine anterior tender points of, 1 43 , 144-149 abdominal second, 144, 146

dorsal, 1 33 , 140

fifth, 1 44 , 149

palmar, 1 33 , 139

first, 144, 1 45

I nterphalangeal joints tender points of, 133, 1 4 1 Intrafusal fibers, I I , 1 1

257

dorsal, 204, 2 1 0 plantar, 204, 2 1 1 Neck; see Cervical spine Neurologic pa[ients treating, 24, 242 Neurolymphatic points, 9; see also

second, 144, 1 47

Acupuncture points; Ah Shi

third, 2 2 3

points; Tender points; Trigger

third and fourth, 144, 1 4 8

poin[s

INDEX

258

Neurovascular poin[�. 9;

see also

Acupuncture points; Ah Shi points; Tender points; Trigger

optimal, 30

points

during treatment, 40;

see aLm spe, cific anatomic areas

NocicepmTs, 1 0 i n somatic dysfunction, 1 2� 1 3

Q

Popliteus tender point, 1 8 2 , 192 Position of comfort, 1 0

Quadratus lumborum tender point, 159, 1 6 1

for fascial dysfunction, 1 5

R

length of treatment in, 1 2 , 30�J I

Nonlinear process of positional release therapy, 8

Position of treatment;

see

Position of

comfort; Treatment procedures

Radial head pronator tender point,

Positional release therapy, I , 20

o

activity level following, 2 2 5 advances in, 5

1 26, 1 29

case srudies in, 37·38

Ohesity considerations in treatment, 2 2 3

Range,of�lllQ(ion assessment, 40

comfort zone in, 29·30, 30

Occipital tender point, 44, 46

contra indications for, 20�21

Occipitomastoid tender point. 44�45

cross�reference charts for, 236�241

Olecranon tender points

diagnosis protocol for, 40

lateral/medial, 1 26 , 1 3 2 O'teopathic positioning table, 250

effects of, 10· 1 5 , 20, 3 1 ergonomics in, 223·224 evaluation forms for, 4 1 ·42, 1 42

Osteoporosis treatment 0(, 23

as global treatment, 27, 27

p P�lin

anterior tender points of. 90, 9 1 ·93

origins of, 1 · 5

first, 90, 9 1

other modalities with, 2 2 1 ·222

second, 90, 92

effects of therapy on, 20

posttreatment reaction to, 3 1 ,

184 Pathokinesiologic determination

2 2 2 · 2 2 3 , 225 forms for, 232·233 tender poims in;

amputee, 24

see

third through tenth, 90, 93 medial tender points of, 90, 94 third through tenth, 90, 94 posterior tender points of, 1 00·103

scanning evaluation in, 35�38

eleventh and twelfth, 100, 103 first, 100, / 0 1

Tender points

treatment

second through tenth, 100, 102 Ruffini receptors, 1 0· 1 1

phases of, 2 1 · 22 plan, 3 1 · 3 3, 37·38, 40

for treatment, 243 Patients

treating, 24 Rib cage

224

patienr relationship in, 222

Patellar tendon tentler points, 182,

Cumulative trauma disorder Respiratory patients

dysfunction of, 84

back, 1 4 3

posttreatmCrH, 225

poims

Repetitive strain injuries, 2 1 ; see also

indications for, 1 0· 1 5, 22·24,

pain arising during, 225

Patella tentler points, 182, 183

Reality checks, 222

Reflex points, 39; see also Tender

home·based, 2 2 5

arising during treatment, 2 2 5

myofascial origins 0(, 8, 9, 1 2

1 26, 130 Radial head supinator tender point,

principles of, 29 procedures, 39·40;

anatomic areas

communication widl, 222

s

see also specific

Sacroiliac tender points

geriatric, 2 3

Positioning table, 250

inferior, 1 66 , 169

in mOtor vehicle accidcms, 2 3

Posnrearment, soreness, 222�223,

middle, 166, 168

225

neurologic, 242

superior, 1 66 , 167

obese, 223

Postural asymmetry, 40

pediatric. 23

Posture, I ;

with sports inj uries, 2 3�24

see also Body positioning;

Yoga postures

respiratory, 24

somatic dysfunction and, 8

Sacrulll posterior tender points of, 1 4 3 , 1 74·180 coccyx, 174, 180

Pectoralis major tender point, /05, I 15

Proprioceptors, 1 0· 1 2

fifth, 1 74 , 179

Pecroralis minor tender point, 105, 1 1 6

Protective muscle spasm, 1 9

first, 1 74 , 1 75

Pediatric patients

PRT;

neating, 2 3 Pelvis;

see Hip/pelvis

Peroneus <ender point, 193 , 202 Pes anserinus tender point, 182, 189 Piriformis tender points

see Positional release therapy

Pterygoid tender points lateral, 44, 52 medial, 44 , 5 1 Pubis tender points inferior, 150, 156

fourth, 1 74 , 1 78 second, 1 74 , 1 76 third, 1 74, 1 77 Sagittal suture tender point, 44, 58 SartOrius render points, 150, 153 Scanning evaluation, 35�38

medial, 1 66, 1 7 1

lateral, 150, 157

form for, 232·233

lateral, 166, 1 7 1

superior, 150, 155

procedure for, 5

INDEX Scapula tender point medial, 105, 1 20 erratus anterior tender point, 1 05 , 1 12

Subscapularis tender point, 1 05 ,

III

Supraspinatus tender poilUS lateral, lOS, 109

high-gain, I I

medial, 105, 1 1 9

T

acromioclavicular, anterior, 1 05 , 108

biceps short head, 1 05 , I 1 4

humerus, medial, 1 05 , 1 1 3

infraspinatus inferior, 105, 1 23 infraspinatus middle, 1 05 , 1 22 infraspinatus superior, 105, 1 2 1 latissimus dorsi, 105, 1 1 7

95-99

tenth through twelfth, 95 , 99 third through fifth, 95, 97 Thumb; see Hand/wrist

Talus tender point, 193, 1 97

Tibialis

Temporalis tender points anterior, 44, 60 posterior, 44, 6 1 Temporoparietal tender points

anterior tender point, 1 9 3 , 201 posterior tender point, 1 93 , 1 99 Tissue injury to, 8 - 1 0, 1 2 , 2 3

anterior, 44, 62

myofascial, 1 0

posterior, 44, 63

soft, 224, 244-248

Tender points, I , 28, 40; see also Acupuncture points; Ah Shi

pectoralis minor, 105, 1 1 6

points; Reflex points; Trigger

scapula, medial, 1 05 , 1 20

points

subclavius, 105, 107

posterior tender points of, 84,

Tables, osteopathic positioning, 250

pectoralis major, 1 05 , 1 1 5

serratus amerior, J 05, 1 1 2

dysfunction of, 84

sixth through ninth, 95, 98

tender points of, 105-125

1 18

tenth through twelfth, 85, 89

first and second, 95, 96

Shoulder

biceps long head, 105, I 1 0

seventh through ninth, 85, 88

Supraorbital tender point, 44, 56

Servomechanism

acromioclavicular, posterior, 105,

body charts for, 234-235; see also

specific anawmic areas

types of, 8-9 Trapezius tender POilU, 1 05 , 106 Trauma musculoskeletal, 8- 10, 1 2 of motor vehicle accident cases

subscapularis, 105, I I I

conflicting, 2 2 3

supraspinatus lateral, 1 05 , 109

dominant, 27, 40

supraspinatus medial, /OS, 1 1 9

grading system for, 28, 28

teres major, 105, 124

history of, 2

thcrapy, treatment; specific

teres minor, 105, 1 25

location of, 28; see also specific

anatomic areas

trapezius, 105, 106 Soft tissue treating, 224 for structural support, 244-249 Somatic dysfunction, 7�8; sec also

anaromic areas in musculoskeletal dysfunction, 9- 1 0

under specific anatOmic areas in scanning evaluation, 36-37 shutting off, 222-223

Smai, I Sphenobasilar tender point lateral, 44, 59 Spine; see Cervical spine; Lumbar spine; Thoracic spine Sports injuries treating, 23-24 Sternocleidomastoid muscle, 23

Slmin and Cowllersrrain, 5 Strain/coulUerstrain; see also Counter� strain terminology cross�reference chart for, 239-241 for treating neurologic patients, 242

Treatmentj see Positional release

Trigger points, 2, 9i see also Acupunc­ ture poimsi Ah Shi points; Tender points

position of treatment for; see

loskeletal dysfunction treating, 229

treating, 2 3

palpating, 28

Global dysfunction; Muscu­ muscle spindles and, 1 1 - 1 2

259

Tensegrity in lower limb dysfunction, 1 8 1 model, 8, 1 4- 1 5, 228, 246-248, 247 Tension fascial; see Fascial tension

u Upper body evaluation form for, 4 1 treatment of, 22-23; lee also specific

anatomic areas

Upper limb dysfunction of, 104 tender points of, 22-23, 104, 1 05 - 1 4 1 ; see also specific

anatomic areas

icosohedron, 1 4- 1 5 Tensor fascia lata tender point, 150, 154 Teres major tender point, 1 05 , 1 24 Teres minor tender point, /OS, 1 25

w Wrist; see Hand/wrist

Thoracic spine anterior tender points of, 84,

y

85- 9

Stylohyoid tender point, 44 , 49

first through third, 85, 86

Subclavius tender point, 1 05 , 107

fourth through sixth, 85, 87

Yoga postures, I , 1