Oscillatory Cervical Lateral Flexion (Figure 7-1)

The patient lies in the supine position, with the head and neck supported on the headrest and by the clinician’s hands. The clinician sits or stands at the head end of the table. To produce left lateral flexion mobilization of the cervical spine, the clinician’s right hand comfortably grasps the patient’s chin while the forearm rests on the side of the head. The other hand supports the patient’s occiput. Both hands support the patient’s head and produce a repetitive, rhythmic left lateral flexion movement around the z-axis. An oscillatory movement is produced as the hands move reciprocally, and all excursions have equal value.

Figure 7-1 Oscillatory cervical lateral flexion to produce left lateral flexion mobilization of the cervical spine.

Oscillatory Atlas Lateral Glide (Figure 7-2)

The patient lies in the side-posture position with both knees bent to maintain pelvic stability, the upper arm resting along the side of the body and the hand grasping the thigh, and the head placed in a neutral position on an elevated headrest. The clinician sits or stands, facing the patient, and contacts the lateral aspect of the atlas transverse process with both thumbs, one on top of the other. A lateral-to-medial oscillatory movement is produced, developing a translational lateral glide movement.

Figure 7-2 Oscillatory atlas lateral glide developing a left-to-right translational lateral glide movement of the atlantoaxial articulation (C1-C2).

Progressive Stretch Thoracic Extension (Figure 7-3)

The patient lies in the prone position with the hands interlaced behind the neck and the elbows together (Figure 7-3, A). The clinician stands on the side of the table and grasps the patient’s arms from underneath with the cephalic hand. The caudal hand is used to establish a broad contact over the spine below the section to be mobilized. The clinician simultaneously and progressively raises the arms to the patient’s tolerance while applying stabilizing pressure over the spine. This procedure may also be done in the seated position (Figure 7-3, B). There is powerful leverage produced in both positions, and caution must be used to prevent injury.

Figure 7-3 Progressive stretch thoracic extension. A, Prone. B, Sitting.

Oscillatory Posterior-to-Anterior Glide (Figure 7-4)

The patient lies in the prone position. The clinician stands on the side of the table facing cephalically and in a lunge position (fencer stance). The clinician establishes bilateral thumb contacts over the articular processes of a cervical segment, the transverse processes of a thoracic segment, or the mammillary processes of a lumbar segment. The thumbs may be on the same side of the patient or can cross the spine. The clinician produces a P-A oscillatory movement over the vertebra.

Figure 7-4 Oscillatory posterior-to-anterior (P-A) glide applied to the L3 vertebra. The patient lies in the prone position. The clinician stands on the side of the table, facing cephalically, in a lunge position (fencer stance). The clinician establishes bilateral thumb contacts over the articular processes of a lumbar segment. The thumbs may be on the same side of the patient or may cross the spine (A). A bilateral contact can also be established (B). A P-A oscillatory movement is produced over the vertebra.

Progressive Stretch Lumbar Rotation (Figure 7-5)

The patient lies in a prone position over an elevated table or Dutchman roll. The clinician stands in a square stance at the side of the table opposite the area to be mobilized. The clinician’s caudal hand grasps the anterior superior iliac spine while the cephalic hand establishes a broad contact over the lower rib cage on the side to be mobilized. The clinician raises and lowers the pelvis against the resistance provided by the cephalic hand, producing a rhythmic rocking lumbar rotation of small amplitude.

Figure 7-5 Progressive stretch lumbar rotation to mobilize the right side of the lumbar spine. The patient lies in a prone position over an elevated table or Dutchman roll. The clinician stands in a square stance at the side of the table opposite the area to be mobilized. The clinician’s caudal hand grasps the anterior superior iliac spine while the cephalic hand establishes a broad contact over the lower rib cage on the side to be mobilized. The clinician raises and lowers the pelvis against the resistance provided by the cephalic hand, producing a rhythmic lumbar rotation of small amplitude.

Continuous Stretch Rotation (Figure 7-6)

The patient lies in a prone position over an elevated table or Dutchman roll. The clinician stands at the side of the table, facing cephalically, in a lunge position (fencer stance). The clinician establishes a thumb contact against the lateral aspect of a spinous process with the caudal hand. The cephalic hand is placed over the lateral aspect of the pelvis. A firm, continuous pressure to the patient’s tolerance is applied against the L5 spinous process while the pelvis is stabilized. Continuous pressure is held for 8 to 12 seconds and repeated up to three times.

Figure 7-6 Continuous stretch rotation of L4, producing a left rotational mobilization of L4 over L5. The patient lies in a prone position over an elevated table or Dutchman roll. The clinician stands at the side of the table, facing cephalically, in a lunge position (fencer stance). The clinician establishes a thumb contact against the lateral aspect of the pelvis. A firm, continuous pressure to the patient’s tolerance is applied against the L5 spinous process while the pelvis is stabilized. Continuous pressure is held for 8 to 12 seconds and repeated up to three times.

Manual Lumbar Flexion-Distraction (Cox Method)

Flexion-distraction is a mechanically assisted form of joint mobilization or distraction, blending osteopathic and chiropractic principles into one technique. Flexion-distraction has been advanced in the chiropractic profession largely by the work of chiropractor James Cox. Much of Cox’s initial work in developing his technique of flexion-distraction was based on the work of the osteopath J.V. McManis. Moreover, the design of the early Cox table was a direct emulation of the McManis table of the early 1900s. This manual table provided an advantage to both the patient and the clinician, allowing a multiple-plane approach to distraction, including flexion-extension, lateral flexion, and rotation. The McManis table incorporated many of the features that appear on contemporary tables, including split headpieces, multiple sections adjustable for patient comfort, and positioning for various adjustive maneuvers.¹⁴

A number of lumbar disorders have been presented as conditions suitable for treatment with lumbar flexion-distraction. They include lumbar disc protrusion, spondylolisthesis, facet syndrome, subluxation, and scoliotic curves of a nonsurgical nature.¹⁵ The theoretic benefits that have been associated with this form of spinal manipulation are presented in Box 7-5.

The Cox method uses a process of analysis that incorporates physical examination, orthopedic and neurologic testing, and imaging as indicated to establish the presence of a disc lesion, facet syndrome, or any other condition affecting the low back. Cox distraction therapy typically consists of three 20-second flexion-distraction sessions. Once the patient is properly positioned on the table and the tolerance of the patient to flexion is determined, the sessions can begin. The hand is placed over the spinous process of the superior vertebra of the motion segment to be distracted (e.g., to distract the L5–S1 segment, contact is on the L5 spinous process). The contact hand is slightly cupped, creating an indentation between the thenar and hypothenar eminence to receive the prominence of the spinous process without placing undue pressure and causing subsequent discomfort to the patient.¹⁶ The patient is encouraged to relax, and the clinician depresses the handle at the foot of the table. If there is no handle, the clinician depresses the foot of the table (pelvic section) by hand. The handle is an improvement over placing the hand on the caudal section of the table because it provides increased leverage and a better stance position for the clinician (Figure 7-7).

Figure 7-7 Cox flexion distraction for the L4 disc (L4–L5 segment) with a contact established over L4 spinous process as the caudal section is depressed, producing distraction.

The pelvic section is then depressed until the clinician’s hand detects that the musculature has reached a point of tautness and all tissue and joint play have been removed from the area under treatment. This point is maintained, and an additional 2 to 3 inches of table depression is achieved manually. The caudal section is then allowed to return to neutral, followed by another downward movement to the previous point over a 20-second period. This process creates a “pumping action” and is repeated three times, with a break of a few seconds between each 20-second session (Box 7-6).

A patient with a protruding disc may sense mild pain on traction, whereas a prolapsed disc does not usually produce such a sensation. Too much traction during the session should be avoided because it may produce further annular injury and impairment. In the case of disc involvement, the disc and motion segment are potentially sensitized to pain and mechanical stimuli, and the patient is probably sensitive and sore at the point of the injury. Therefore, it is better to undertreat the patient than to overtreat, and caution is encouraged in the application of the technique. Furthermore, if the patient does not tolerate the flexion-distraction movement or if the pain is peripheralized, the process should not continue. Further traction should concentrate on relieving the pain before the therapeutic distraction begins in earnest. Any intolerance should be viewed with caution and, although this does not become a clear contraindication for the treatment, it certainly should be treated with respect and restraint. In this instance, more is not better but, in fact, may make the patient’s condition worse.

Motorized Lumbar Distraction (Leader Method)

A motorized traction table, such as the Leader table, can be used to assist in the production of lumbar traction (Figure 7-8). Traction to the lumbar spine is applied in the prone position while the pelvic section of the table produces continuous passive motion in the long axis of the spine. The clinician can apply a stabilizing pressure, using both hands over the spinous process of the segment to be distracted to produce a counterpressure against the distractive force produced by the table.

Figure 7-8 Leader lumbar distraction for the L4–L5 segment. Motorized pelvic section allows both hands to be used for contact.

Manual Cervical Traction

Cervical traction can be applied manually or with mechanical assistance. Manual cervical traction is generally accomplished with the patient in the supine position. The clinician sits or stands at the head end of the table and establishes contacts with the fingers of both hands on the posterior aspect of the cervical spine. Contacts taken over the C5–C6 segment (Figure 7-9, A) will allow the neck to extend slightly to provide more distractive separation and stretch to the anterior structures (the disc and longus coli muscles). Contacts taken under the base of the occiput (see Figure 7-9, B) will allow the neck to flex slightly to provide more distractive separation and stretch to the posterior structures (facets and paraspinal muscles). A towel may be substituted for hand contacts (see Figure 7-9, C).

Figure 7-9 Manual cervical distraction. A, Contacts taken in the midcervical region to stretch anterior structures. B, Contacts taken at the base of the occiput to stretch suboccipital and posterior structures. C, Use of a towel as a substitute for hand contacts.

Motorized Cervical Traction

A motorized traction table, such as the Leader table, can be used to assist in the production of cervical traction (Figure 7-10). Traction to the cervical spine is usually applied in the prone position while the pelvic section of the table produces continuous passive motion in the long axis of the spine. The clinician can apply a stabilizing pressure at the base of the occiput or anywhere in the cervical spine to produce a counterpressure against the distractive force produced by the table’s moving pelvic piece (Box 7-7).

Figure 7-10 Motorized cervical distraction. Contact at base of occiput applying resistance to moving pelvic piece (may also be done in the prone position).

Postural Syndrome

For those patients presenting characteristics of the postural syndrome, applying an understanding of the basic mechanics of postural stresses and their removal is fundamental in treatment. Once an abnormal posture has been identified as the source of the patient’s symptoms, treatment is directed toward postural correction. The primary consideration is to develop within the patient the ability to control pain-producing mechanisms.

Slouch-Overcorrect Exercise (Figure 7-11)

The patient sits in a slouched posture, provoking LBP. This posture is then corrected by forming an increased lumbar lordosis and retraction of the head. The patient should be able to feel that the pain can be abolished or at least reduced by changing the posture. Regular performance of the exercise encourages a postural awareness that reduces or eliminates pain of postural origins. The exercise can also be done in the standing position.

Figure 7-11 McKenzie method (slouch-overcorrect exercise). A, Patient slouches. B, Patient exaggerates the lumbar lordosis. C, Use of a lumbar roll while sitting.

Dysfunctional Syndrome

Treatment of the dysfunction syndrome is directed at remodeling of adaptively shortened structures by stretching maneuvers. The most common pattern of the dysfunction syndrome is loss of spinal extension, except in the upper to middle cervical spine, where flexion is most likely to be limited.²¹ To achieve the required tissue response, end-range stretching procedures should be performed in a slow, repeated movement in sets of 10 to 15 every 2 hours throughout the day. The presence of significant degenerative changes or stretch irritation to neural structures may make the repetitive rate difficult to tolerate. The involved spinal region and the specific loss of movement pattern determine the movement chosen for treatment. In this case, correction of posture alone is not likely to enhance the lengthening of shortened structures. However, postural dysfunction, if present, must still be addressed because chronic poor posture often leads to tissue shortening and dysfunction. Moreover, when progress is slow or nonexistent, the use of manual procedures or other external forces is introduced. This can include the use of rhythmic end-range mobilizations designed to assist in the phenomenon of creep to lengthen soft tissue. However, these are used to augment, not replace, the exercise program. The repeated movements used in evaluation and treatment of the dysfunction syndrome include flexion, extension, and side-gliding in both the seated and lying positions (Figure 7-12). The treatment exercises will reproduce the patient’s pain, but the increased pain should not persist for prolonged periods after treatment.

Figure 7-12 McKenzie method (prone lumbar extension exercises). A, Patient rises to forearms. B, Patient straightens arms.

Derangement Syndrome

For treatment of the derangement syndrome, a conceptual model of disc pathomechanics must be considered. The model is based on the premise that certain movements can be applied to reduce internal disc derangements and bulging intervertebral discs (IVDs). Movements that are successful in reducing disc protrusion are accompanied by a reduction in the patient’s most distal symptoms (centralization) as the conflict between the protruding disc and associated spinal nerve root is reduced. As symptoms centralize, it is also common for the patient’s repeated ROM to increase with exercise. Using this approach, the suspected derangement patient is directed through a series of movements to ascertain which movements or positions will be most effective in reducing the segmental derangement. The evaluation results in the patient being classified into one of seven derangement categories. The first six derangements are variations of posterior disc disruptions, often requiring extension reductions. In certain instances, coronal plane movements, such as side-gliding (Figure 7-13), or even rotational movements will be required for reduction. The seventh derangement is an anterior disc derangement, requiring a flexion reduction (Figure 7-14).

Figure 7-13 McKenzie method (side-gliding movement). A, Clinician assisted. B, Patient exercise.

Figure 7-14 McKenzie method (flexion reduction exercise). The seventh derangement is an anterior disc derangement, requiring a flexion reduction.

To complement the use of extension (or flexion) reduction exercises, avoidance of stressful static and dynamic flexion (or extension) postures and activities must be reinforced. These activities often cause peripheralization of the patient’s symptoms, as well as painfully reduced ROMs. Recovery of function is considered complete when full normal repeated weight-bearing flexion produces no more than the expected strain at the end range of all movements.²¹

Blood Flow and Temperature Effects

STM has been purported to produce an increase in blood flow and cutaneous temperature. Deep stroking and kneading of the soft tissues in the extremities of normal patients, patients with rheumatoid arthritis, and patients with spasmodic paralysis create a consistent and clinically significant increase in blood flow and cutaneous temperature.³⁷ These findings are supported by other studies.38 39 40 However, it must be emphasized that the clinical procedure being tested in all of these reports was a deep or heavy massage application. Therefore, conclusions on the effects of light-force stimulation of the body wall cannot be drawn from these data.

Massage can induce a fall in blood viscosity, hematocrit count, and plasma viscosity. Ernst, Matrai, and Magyarosy⁴¹ found massage to equal pharmacologic agents used to treat blood flow problems. The proposed mechanism may be hemodilation resulting from either an increase in blood plasma volume or reactive hyperemia. Therefore, the effect of massage and circulation appears to be an increased perfusion of blood with plasma fluid, allowing for improved blood flow.

Metabolic Effects

Cuthbertson⁴² performed a literature review on the effects of massage on metabolic processes, including vital signs and waste products of the body. He reported that in normal subjects there was no increase in basal consumption of oxygen, pulse rate, or blood pressure, although an increase in urine output was observed. His conclusion hypothesized that to effect a change in the vital signs, a systemic effect must be achieved and that the massage procedures used did not do it. Schneider and Havens⁴³ did find that STM produced an increase in red blood cells needed to bring oxygen to the tissues. This provides some support for soft tissue procedures being able to increase circulation and nutrition to desired areas. Again, these were vigorous massage procedures described, so caution is necessary when trying to apply these principles to other procedures.

Massage therapy has been further evaluated as a treatment for reducing blood pressure. Hernandez-Reif and colleagues⁴⁴ reported that 10 30-minute massage sessions over 5 weeks reduced diastolic blood pressure, as well as anxiety and depression, to a statistically significant level over a control group receiving progressive muscle relaxation instructions. These findings supported an earlier study also demonstrating a decrease in diastolic and systolic blood pressure.⁴⁵ In a study of light massage of preoperative patients, it was reported that there was a relaxation response from the parasympathetic nervous system producing a decrease in both blood pressure and heart rate, as well as an increase in skin temperature.⁴⁶

Reflex Muscle Spasm Effects

Changes in muscle length and tension are monitored by two stretch receptors: muscle spindles and Golgi tendon organs (GTOs). The muscle spindle has a highly sensitive filament, the annulospiral ending, that fires rapidly and with high velocity with the smallest change in length. It also has smaller filaments and slower spray receptors, which are slower in response and more likely to respond to the magnitude and speed of stretch. The GTOs are located at the junction of the muscle and its tendon and monitor the tension exerted on the contracting muscle or imposed by external forces. Massage procedures can cause an overload of the GTOs, resulting in reflex inhibition and muscle relaxation.⁴⁷ Lumbar muscle strain with concomitant hypertonicity has been treated by many means with mixed results. Yu⁴⁸ reports on 55 cases treated with massage therapy that showed good results in decreasing pain, inflammation, and hypertonicity. In a review article, Goats⁴⁹ reports on the effectiveness of massage therapy for reducing muscle spasm. Massage was shown to significantly diminish motorneuron excitability when compared with controls, forming the basis for suggesting that massage can lead to muscle relaxation.⁵⁰ The effect of massage intensity was also studied.⁵¹ Light-pressure and deep-pressure massage was applied to the triceps surae muscle. H-reflex amplitudes were significantly reduced in both massage groups as compared with the control group. Moreover, deep massage reduced the H-reflex more than the light massage, suggesting that the mechanism involved is pressure-sensitive.⁵¹

Massage Techniques

Massage therapy is older than recorded time, and rubbing was the primary form of treatment until the pharmaceutical revolution of the 1940s.⁵² Today, classical or traditional massage procedures form the basis for many other procedures. Simply defined, massage consists of hand motions applied to the surface of the body with a defined therapeutic goal.⁵³ In a more clinical or practical definition, massage is a term used to describe certain manipulations of the soft tissues; it is a form of manipulation most effectively performed by the hands and administered for the purpose of producing effects on the nervous, muscular, circulatory, and lymph systems.⁵⁴ The variations of massage movements include effleurage, pétrissage, roulomont, tapotement, and friction. With most forms of massage, some form of lubricant is useful. It is recommended that for short sessions, a water-based lotion be used, because it will be absorbed by the skin. For longer sessions, an oil-based lotion is preferred.

Effleurage

Effleurage is a French word that means gliding or stroking, and it is applied over a large area using broad contacts. It may be deep or very superficial, creating general relaxation and a superficial warming as a result of a mild erythema. During a single therapeutic session, it is desirable and recommended to begin and end with effleurage. This maneuver is a slow rhythmic stroking in which the hands of the clinician make light contact with the skin of the patient (Figure 7-18). A broad palmar contact is used over large surfaces, but the thumbs or fingers can be used over smaller areas. The clinician’s hand should be sufficiently relaxed to mold itself to the area being treated as it passes almost insensibly from distal to proximal over the region being treated. Hand pressure is evenly dispersed, and the degree of pressure varies with the size and the region of the part being treated. The strokes are made in long, gliding sweeps. The movement should be slow, at the rate of about 15 sweeps per minute, with the returning stroke traveling a little faster than the treating stroke. Effleurage produces a soothing relaxation and mild hyperemia for the patient while decreasing pain in the superficial soft tissues and reducing muscle tension (Box 7-11).

Figure 7-18 Effleurage (focus is along muscle fibers). A, Double hand contacts. B, Forearm contact. C, Loose fist contact.

BOX 7-11 Effects of Effleurage

Relaxation

Improved circulation

Hyperemia

Pétrissage

Pétrissage involves grasping the skin and underlying muscular tissue while applying a cross-fiber stroking or stretching action to the tissue beneath. Pétrissage is a French word for kneading, although it has also been called pinching. This technique is directed at improving the tissue-fluid exchange, vascularity, and normal texture of subcutaneous and deep soft tissue. This is accomplished through alternate traction, or taking up or squeezing and relaxing movements of a localized mass of tissue held between the thumb and fingers. The hands raise a large fold of skin and underlying muscle between the thumbs and other fingers (Figure 7-19). The tissues are rolled, squeezed, and raised by alternately tightening and loosening the grasp. As the hold is loosened, the tissues are allowed to fall back to their original position because of their elasticity. The fingers should be held close together. The hands work together, changing the direction of the torsion. If the hands slip over the surface or pinch the skin, the maneuver will be painful.

Figure 7-19 Pétrissage (focus is across muscle fibers). A, Two hands grasping. B, Grasping and lifting tissue.

Pétrissage is thought to diminish swelling and fluid accumulations, produce hyperemia in muscle, and improve elasticity and contractility of connective tissue. Furthermore, pétrissage can decrease muscle tone as the lifting, rolling, and squeezing action affects the spindle cell proprioceptors in the muscle belly. As the muscle belly is squeezed, the muscle feels less stretched. The lifting action produces stretch in the tendons, causing a potential reaction by the Golgi tendon receptors. When these two phenomena occur, the sensory input can reflexively relax the muscle. Pétrissage also has the mechanical effect of softening and creating space around the actual muscle fibers and making the tendons more pliable.⁵⁵ Moreover, it has the potential to break cross-linkage adhesions that have formed between fascial planes, connective tissue, or muscle fibers (Box 7-12).

BOX 7-12 Effects of Pétrissage

Reduction of pain

Release of adhesions

Reduction of edema

Increased tissue temperature

Roulomont

Roulomont, or skin rolling, lifts the skin away from fascial surfaces beneath; when adhesive areas are encountered, a pull is applied to the skin to allow freer movement (Figure 7-20). Skin rolling is a procedure suitable for long muscles. Skin rolling has been considered a variation of pétrissage. However, with skin rolling, only the skin is lifted from the underlying muscle layer; pétrissage attempts to lift the muscular layer. Skin rolling has a warming and softening effect on the superficial fascia and can cause reflexive stimulation of cutaneous receptors. It can also be used directly over the spine. Areas where the skin does not easily come away from the fascia may have an underlying joint dysfunction problem (Box 7-13).

Figure 7-20 Roulomont (skin rolling). A quick tugging is applied to pull the skin away from fascial adhesions.

BOX 7-13 Effects of Roulomont

Release of adhesions

Reflex stimulation of cutaneous receptors

Increased tissue temperature

Softening of superficial fascia

Tapotement

Tapotement is described as a tapping or vibratory action applied to the soft tissue in a rapid fashion creating a stimulatory effect. The tapping vibration is produced typically through a rapid series of blows by the hands that are held with the palms facing each other. The fingers and wrist remain relaxed as the elbows flex and extend. The ulnar borders of the hands and the fingers produce a rapid multiple percussive stimulation over the area being treated (Figure 7-21, A). In addition, the fingertips can be used to produce a compressive tapping by rapidly alternating wrist flexion and extension (Figure 7-21, B). This procedure is most useful in the extremities. A variation of tapping uses the cupped hand to produce a deep percussive vibration especially useful over the thorax and abdomen (Figure 7-21, C). The vibration is applied perpendicular to the muscle fibers, with an impulse frequency of 8 to 10 sinusoidal vibrations per second. The resulting tonal effect may not immediately be apparent; the average time needed before results can be seen is 2 to 5 minutes. Vibration must be done long enough and at a sufficient intensity to produce reflexive physiologic effects. Vibration is used to tone muscles and to produce sensory stimulation. It may be given with the entire hand or with the fingertips, depending on the area to be treated. Rapid continuous vibrations are transmitted to the skin through movements of the hands. Initially, the hand contacts produce tissue compression, followed by the trembling form of vibration produced by alternating contraction and relaxation of forearm muscles (Box 7-14).

Figure 7-21 Tapotement (tapping percussion). A, Double loose knife-edges. B, Fingertips. C, Cupping.

BOX 7-14 Effects of Tapotement

Hyperemia

Improve muscle tonicity

Reflex stimulation of cutaneous receptors

Friction

Friction is the application of moderate, steady pressure, typically with the palmar aspects or edges of the thumbs in small areas. During the application of friction massage, the thumb induces rapid side-to-side or small circular movements, moving the skin over the subcutaneous tissues and muscular layer (Figure 7-22, A). The fingers, palm, or flat part of the elbow can be used as alternative contacts (Figure 7-22, B and C). The purpose of using friction is to move tissue under the skin; therefore, lubricant is usually avoided to prevent sliding of the tissues. The goal is to induce rapid transverse movements through the underlying myofascial or ligamentous tissue (Box 7-15).

Figure 7-22 Friction. A, Edge of supported thumb moves rapidly across muscle fibers (levator muscle). B, Stabilized fingers move across muscle fibers (rhomboids). C, Forearm and elbow stretch along muscle fibers and move across fibers.

BOX 7-15 Effects of Friction

Stretching or release of adhesions

Reduction of edema

Reduction of fibrosis

Dispersion of pathologic deposits

Reduction of pain

Diminished muscle spasm

When applied vigorously across the fibers of the tissue treated, it is called transverse friction massage. The treatment goal of friction is to break up adhesions and to encourage absorption of exudates. The focus of friction is to produce a controlled inflammatory response that causes heat and redness from the release of histamine and increased circulation. Although a small amount of edema will occur as water binds with the connective tissue, there should not be any bruising. Friction can also be used in combination with compression and passive joint movement. This is considered a form of myofascial release and is discussed in that section.

Friction massage is a vigorous procedure and because of the forceful nature, the patient’s tolerance must be considered. As the procedure is applied, a “friction anesthesia” will be produced, allowing the contact pressure to increase. Friction massage is generally performed for 30 seconds to 10 minutes, depending on the patient’s tolerance and treatment goals. Friction is a mechanical approach best applied to areas of high connective tissue concentration, such as the musculotendinous junction. Consideration can be given to whether the myofascial tissue in the area to be treated should be in a stretched or relaxed position.

Connective Tissue Massage

Elizabeth Dicke, a German physical therapist, developed connective tissue massage in 1929. Ebner⁵⁶ defines connective tissue massage as a form of STM carried out in the layers of connective tissue on the body surface. This stroking technique is a form of friction that consists of a tangential pull on the skin and subcutaneous tissues away from the fascia with tips of the third and fourth fingers. It is applied to identified segmental changes in the tension of the skin and subcutaneous and other connective tissue corresponding to the location of head reflex zones. Head zones are hyperalgesic areas of the skin speculated to be to be referred from diseased internal organs. The systematic application of connective tissue massage is time-consuming to learn and apply; however, aspects of this technique can be used without applying the whole system. This technique may have both a reflex (circulation and pain) and a physical (stretching and mobilizing connective tissue) effect.

The essential feature of connective tissue massage is that a tensile strain is applied to the connective tissue to produce the desired physical and reflex effects. The patient is most commonly in a seated position with the knees and hips at right angles. However, the side-posture, prone, and supine positions may also be used. Assessment begins with observation for symmetry, followed by palpation. The palpatory procedure moves the skin against the deep fascia by using the middle and ring fingers to produce small pushing strokes. Comparison is made from side to side, with asymmetric increased tension indicating a problem. The stroke produces a pressure that causes a bulge of tissue. Alteration in the tension of connective tissue will change the size of the bulge and the sensation produced, indicating a compromise in the fascial tissue. A combination of short and long strokes applied to specific regions of the body are done to locate fascial changes. One commonly used procedure incorporates a long vertical stroke performed by the middle and ring fingers, starting along the L5 segment and pulling up along the spine to C7.

Treatment is applied with a long or short stroking action, carried out using the second and third fingertips of the relaxed hand to draw the skin slack (Figure 7-23, A and B). A pulling stroke similar to the one used in assessment is used for treatment. Sufficient tension must be developed between the fingers in the skin; therefore, a lubricant is not used. The treatment strokes start at the sacrum and work up along the trunk and neck. Although connective tissue massage exerts an effect using the skin and subcutaneous tissue, it is primarily a superficial form of STM on the lighter end of the depth spectrum. Cantu and Grodin⁵⁷ suggest that connective tissue massage can be applied to individuals who have hypersensitivity of the autonomic nervous system, such as in the case of reflex sympathetic dystrophy. The purported effects include a marked hyperemia and sweat gland stimulation. Bruising sometimes occurs after treatment, depending on the degree of capillary fragility.

Figure 7-23 Connective tissue massage. A, Second and third fingertips draw skin slack. B, Pattern of long and short strokes.

The mechanism for the effect of connective tissue massage is based on a reflex hypothesis. This procedure is purported to cause a release of a histamine-like substance that acts on the autonomic nervous system. Histamine acts as a powerful vasodilator of small blood vessels and causes an increase in vascular permeability that leads to increased fluid loss from fine blood vessels. It is thought that the mechanical stimulation of the pulling stroke on the connective tissue is an adequate stimulus to elicit the proposed reflex. Excitation of neurologic receptors in the skin produces impulses that travel from the skin either through the somatosensory spinal nerve via a posterior root ganglion to the gray matter or over the vascular plexus to the same segmental sympathetic ganglia or to the ganglia of the neighboring segment.⁵⁸

Functional Techniques

This group of techniques focuses on the interrelationship of structure and function in the body with the tendency toward self-regulation.⁵⁹ These procedures place emphasis on motion rather than position and quality of movement rather than quantity of movement. The theory is that dysfunctional motion segments alter neural input, which in turn produce abnormal efferent signals, particularly to the NMS system.⁵⁹ Functional technique restores normal ease of movement and reduction of abnormal afferent input. These techniques have in common the goal of reducing exaggerated mechanoreceptor and nociceptor input and spindle responses from facilitated segmental muscles, thereby restoring joint mobility and muscle tone. Typically, the involved joint is passively positioned so that the facilitated muscle spindle is shortened, reducing the afferent discharge.

Positional Release Therapy

Positional release therapy (PRT) is a form of counterstrain developed by D’Ambrogio and Roth.⁶¹ Its major characteristics include specific body positioning, the use of tender points, and an indirect approach to treatment. Treatment using PRT is accomplished by placing the involved tissues in an ideal position of comfort. This is designed to reduce the irritability of the tender points and normalize the tissues associated with the dysfunction. This ideal position is determined subjectively by the patient’s perception of tenderness and objectively by the reduction in palpable tone of the tender point. PRT theoretically addresses neuromuscular hyperirritability and muscular hypertonicity as mediated by the proprioceptive system.⁶¹

These procedures involve localization of a sensitive myofascial tender point followed by positioning of the muscle and related joint into a position of comfort or ease (Figure 7-24, A and B). Pressure is applied to the tender point while the muscle and related joint are maintained in the position of maximal relaxation. The abnormal reflex and resultant muscle spasm are inhibited by the tender point pressure and opposite counterstrain created by the positioning. The pressure and position are held for 90 seconds, followed by a slow passive return to neutral. A return to normal length of the muscle is achieved through the positional release of abnormal neural reflexive activities. This has led to this procedure also being called positional release technique.

Figure 7-24 Strain and counterstrain (positional release). A, Tender point located on the posterior aspect of the C3 articular pillar. Patient’s head is laterally flexed and rotated away. B, Tender point located at the upper lateral border of the scapula. Patient sits with arm at the side and elbow bent. Clinician grasps the forearm and extends, adducts, and externally rotates the shoulder.

Myofascial Release Technique

Although used for decades, very little has been documented or written about MRT. MRT procedures are the product of a variety of concepts originating from orthopedics, physiotherapy, osteopathy, and chiropractic. Today MRT is most frequently associated with physical therapist John F. Barnes. Barnes⁶² defines MRT as a whole-body, hands-on approach for the evaluation and treatment of the human structure, focusing on the fascial system. MRT evaluation of the fascial system includes analysis of the human frame by palpating the tissue texture of the fascial layers and observing the rate and rhythm of the craniosacral mechanism.⁶² Release, in the myofascial release concept, is the tissue relaxation (including muscle relaxation) that follows adequate application of stress on the tissue.⁵⁹

The goal of myofascial release treatment is to establish functional three-dimensional whole-body symmetry and motion by removing fascial restrictions and restoring the body’s equilibrium.⁶³ The indicated application of this method requires the determination of the best location of entry into the musculoskeletal system, selection of the most suitable types of stress to induce the inhibitory effect, and sensitivity in palpation to react properly to tissue response.⁶⁴

MRT is reported to reduce muscle spasm and fascial restrictions, eliminating irritation to these pain-sensitive structures and allowing increased ROM.⁶² Myofascial release is thought to soften connective tissue, rehydrate it, and remold it. This is done by spreading the tissue, pulling or stretching it, and creating motion where the tissue was adhered. The effect of myofascial release is a relaxation of tissue tension and subsequent decrease in myofascial tightness. Therefore, MRT is used to normalize myofascial activity, regain tissue extensibility, and reduce pain.

MRT is performed by applying carefully directed manual forces against soft tissue barriers (Figure 7-25). Deep, long, gliding strokes using the palms, fists, or forearms to engage various layers of the fascia are used to spread and lengthen the fascia. A lifting and twisting motion is used more often than compression.⁶⁵ When a fascial restriction is identified, gentle pressure is applied in the direction of restriction. This pressure pulls the elastic fibers, producing a springy feel. As the stretch continues, a firm barrier will be engaged, representing the collagenous connective tissue component. Sustained pressure is maintained until a “release” is felt.⁶² Connective tissue stretching occurs when the tissue is taken to a point of resistance and then stretched. This is usually done across fibers with the muscle in a specific position. Box 7-16 identifies the ways that myofascial releases can occur. MRTs are not always painless, although the initial discomfort typically subsides as the contact is maintained over time.

Figure 7-25 Myofascial release (Barnes method). A, Cervical release to relieve fascial restrictions through the neck and upper back. Patient’s occiput is cradled in the clinician’s hands with cephalic traction sustained without producing too much flexion. B, Alternate cervical release emphasizing the sternocleidomastoid and levator areas.

BOX 7-16 Ways Myofascial Releases Can Occur

Forcible separation or compression of joints

Forcible loading of asymmetrically tightened tissue

Myotactically controlled mechanoreceptor responses

Muscle tightening and asymmetries

Active MRT (active release technique [ART]) is a modification promoted by Leahy.⁶⁶ Leahy asserts that ART is best suited for treatment of soft tissue conditions that fall under the category of cumulative injury disorders.⁶⁶ These problems result from acute injury, repetitive injury, or a constant pressure-tension injury. The soft tissues are examined for changes in texture, tension, movement, and function. When any of these factors are altered, there are changes in the mechanical function of the joints and soft tissues. The identified affected tissue is placed in a shortened position at the start of treatment. The soft tissue lesion is contacted, pressure is applied, and the tissue is stretched through slow active or passive movements (Figure 7-26).

Figure 7-26 Active myofascial release (Leahy) for the left supraspinatus muscle. A, Starting position, with patient’s arm abducted and double thumb pressure applied to muscle. B, Ending position, with patient actively and slowly lowering and adducting the arm while pressure is maintained.

Manual Resistance Techniques

This general classification of soft tissue manipulative techniques includes those procedures that have varying degrees of contact pressure and joint movement or positioning. They also use varying degrees of muscle contraction from none to strong sustained contractions. Some use light or no contact pressure over painful areas, and others use heavy pressure. This variability has the advantage for these procedures to be applied based on the clinical presentation (acute or chronic) and patient ability (tolerance). These procedures have similar characteristics, which leads to some confusion in terminology and specific intent.

Muscle Energy Technique

MET was developed by Fred Mitchell, D.O., as a procedure that incorporates the use of the patient’s muscular effort in the application of the procedure. The primary effect of MET is to influence joint function, although there will certainly be effects on the muscles being used as well. The aim of MET is to restore normal joint position and function while influencing proper posture. Mitchell’s basic principle is that voluntary muscle contractions are exerted against a precisely executed counterforce to loosen the specifically localized joints for passive articulation during postcontraction relaxation.⁶⁷ Patient-initiated muscle contractions are used at varying intensities from a precisely controlled position, in a specific direction, against a distinctly executed counterforce. The corrective process requires active patient participation, encouraging the patient to assume responsibility for self-care.⁶⁴ METs are applied with facilitation and gravity during the lengthening phase, classically with no passive stretching performed by the therapist. However, many modifications and variations have led to different applications of this procedure and significant confusion in nomenclature, as well as in proposed therapeutic intent.

METs involve two opposing forces, the patient’s and the clinician’s, producing isometric or isotonic contractions or both. Variability in the direction, type of contraction (isometric or isotonic), patterns, and amount of force produced by the patient or the clinician serves to distinguish the various forms of MET. To effectively deliver MET procedures, the restrictive barrier must be found and accurately engaged.

The barrier phenomenon was first described in relationship to joints, but it can be applied to nearly all structures of the locomotor system. The barrier concept provides an important distinction between massage procedures and manipulative procedures for the soft tissues. The barrier is perceived by the clinician when the slightest resistance is engaged. Slight overpressure should produce a springing movement characteristic of elastic. Characteristics of specific dysfunctional barriers are identified in Table 7-1.

TABLE 7-1 Types and Characteristics of Dysfunctional Barriers

ROM, Range of motion.

The barrier phenomenon makes accuracy of diagnosis and positioning very important. Localization of the force to the affected spinal level is more important than the amount of force and counterforce (Figure 7-27). Full maximal contraction of the muscles is not required for this method of joint treatment, and often very light force is desirable. It is sometimes necessary to caution the patient not to use too much force. The patient should use only enough force to match that provided by the physician. If excessive force is used, accessory muscles will be brought in, and this detracts from the effectiveness of the treatment on the specific tissues that need to relax. The procedure for applying muscle energy for joint mobilization is detailed in Box 7-17.

Figure 7-27 Muscle energy technique for joint dysfunction (L4–L5). A, Isometric procedure for a right rotational restriction and right lateral flexion restriction with barrier engaged. Patient is instructed to left rotate and left laterally flex against the clinician’s resistance. B, Isotonic procedure for a right rotational restriction and right lateral flexion restriction with barrier engaged. Patient is instructed to right rotate and right laterally flex against the clinician’s resistance.

Postisometric Relaxation

METs have undergone significant modification and evolution with many variations. With modification, METs can increase joint mobility and muscle flexibility. PIR is one such evolution. The focus of PIR techniques is on the muscular system and on inducing muscle lengthening, whereas MET focuses primarily on joint changes. However, both MET and PIR affect the joint and related muscles. PIR refers to the effect of subsequent relaxation experienced by muscle after brief periods of isometric contraction. PIR techniques tend to be simplistic and gentle and can be given as home treatment. Because PIR has evolved from MET, both procedures are being used interchangeably. Moreover, modifications to PIR techniques have also occurred.

MET techniques are applied to aid in the lengthening of shortened tissue by reducing the limiting effects of active muscle contraction and contracture. These procedures can be helpful even in instances in which muscle shortening may not be just a product of active muscle contraction but rather a product of contractures within the muscle’s connective tissue. By relaxing the active elements within the muscle, the lengthening procedure may be more effective at stretching the connective tissue elements, normalizing the function of the contractile and noncontractile elements in the muscle.

These MET procedures are based on the observed phenomenon that maximal muscle relaxation often follows strong isometric muscle contraction. Sherrington⁶⁸ first noted this phenomenon in 1909. This principle is applied in the variation of MET known as PIR. Modified forms of MET involve three phases: contraction, relaxation, and stretch. The patient contracts into the resistance provided by the clinician. This is followed by a period of muscle relaxation and passive stretching by the therapist (Figure 7-28).

Figure 7-28 Example of modified muscle energy technique applied for decreased right cervical rotation.

1. Patient is in the seated position.

2. Clinician stands behind the patient.

3. Clinician assesses cervical rotation, moving to the point of engaging the barrier (A).

4. Patient is then instructed to contract the cervical musculature to produce either left rotation or right rotation against the clinician’s resistance.

5. If right rotation is produced against resistance, postisometric relaxation is produced (B).

6. If left rotation is produced against resistance, a reciprocal inhibition effect is produced (C).

7. Clinician reassesses cervical rotation, noting increase in right cervical rotation (D).

Different models of how these procedures may produce a therapeutic effect have been presented, but the precise mechanism by which these techniques accomplish a soft tissue change remains unclear. One theory stresses the role of the GTOs. In this model, sustained isometric contraction increases tension in the already contracted muscle, causing the Golgi receptor system to sense the increased tension and reflexively induce muscle relaxation or lengthening.

Another method of induced muscle relaxation is generated by taking advantage of the phenomenon of reciprocal inhibition (RI). When a muscle contracts isometrically, its antagonist is inhibited, and the antagonist relaxes immediately after the contraction. This principle is applied in procedures that imitate isometric muscle contraction in the direction of reduced flexibility.

PIR appears to work best in chronic cases, and RI is better in acute settings.⁶⁹ However, both may be used in either case, providing that no pain is produced or no attempt is made to force or stretch joint structures.⁶⁹ When applying PIR, the isometric contraction phase of treatment is held for approximately 7 seconds (range of 4 to 10 seconds; increasing contraction time enhances the effect of PIR) and the relaxation and passive stretching phase lasts approximately 15 seconds (Figures 7-29 and 7-30). The isometric contraction should be of minimal force, and it is important that it equal the force exerted by the patient and be unyielding. The patient should be instructed to match the resistive force of the doctor and not overpower the doctor. Failure to maintain the position and failure to reach the barrier accurately will make the treatment less effective.

Figure 7-29 Postisometric relaxation procedure for a cervical flexion restriction.

1. Patient flexes the head to the point of restriction (barrier).

2. Patient looks up and contracts against the counterpressure applied by the clinician (A).

3. Patient looks down and exhales, and the clinician passively stretches the patient’s head forward (B).

Figure 7-30 Postisometric relaxation procedure for the hamstring muscle.

1. Patient lies in a supine position.

2. Patient’s hip is positioned in full flexion, with the knee extended as far as the shortened muscle will allow.

3. Doctor stands on the side of the involved leg, rests the patient’s knee on his or her shoulder, and grasps the patient’s leg just above the knee (A).

4. Patient is instructed to contract against the doctor’s shoulder, attempting to extend the hip or flex the knee or both.

5. Patient maintains contraction for approximately 7 seconds.

6. Patient is instructed to relax, and the doctor gradually flexes the hip and extends the knee (B).

The barrier concept is very important to the application of PIR techniques. During the relaxation phase, the clinician applies gentle pressure and lengthens the muscle to engage a new barrier, the point at which restriction or pain is again felt. This process is repeated using the newly achieved ROM until the restriction of mobility is reduced, the spasm of the muscle is relieved, and the intensity of the pain can be alleviated (Box 7-18).

The patients themselves can also carry out many useful types of self-administered PIR. After patient education, such procedures are useful in bridging the intervals between patient visits. Although they are useful, they have limitations in their efficiency. This is particularly true in the upper cervical and occipital regions.

Evjenth and Hamberg⁷⁰ recommend modifying PIR by stimulating the antagonistic muscle or muscles at the end of the treatment sequence. This variation of PIR incorporates an additional active contraction on the part of the patient. In this method, the patient assists in producing the desired movement after the stretching phase by actively contracting the antagonist muscles. This is accomplished by having the patient actively increase movement in the direction of restriction against mild resistance applied by the clinician. This modification of PIR is referred to as the contract, relax, antagonist contract method or RI. When a muscle contracts isometrically, its antagonist is inhibited from contracting. Therefore, by isometrically contracting the antagonist of a shortened muscle, the shortened muscle relaxes through RI. Contraction of antagonist muscles may be useful when the shortened (agonist) muscle is too painful to contract. There are a number of other procedures that use the antagonist contraction mechanism.

Proprioceptive Neuromuscular Facilitation

PNF was developed by Herman Kabat, M.D., and Margaret Knott, P.T., as a method to treat patients with neurologic dysfunction. Dr. Kabat developed the PNF method during the 1950s after being introduced to the work of Sister Elisabeth Kenny, the “Kenny method,” and Sister Kenny’s treatment of polio patients. The early focus of their methods paralleled that of Sister Kenny and focused on the treatment of patients with paralysis and polio. Over the years, the procedures have evolved and techniques have been applied to a broadening array of conditions affecting motor function and the NMS system. It is now common for these procedures to be applied in a wide variety of conditions, ranging from rehabilitation of stroke and spinal cord injury patients to the management of common NMS injuries and disorders.⁷¹ Kabat’s conceptual goals for PNF were to neurologically strengthen weak muscles. Mitchell, in developing MET, adapted these concepts for use in joint mobilization, which were in turn modified to release muscle shortness (PIR). These procedures, with their proposed mechanisms and uses, continue to evolve.

PNF is defined as the use of proprioceptors to hasten or make easier the learning of a neuromuscular task.⁶⁴ Patients are directed through a series of complex movement patterns directed to effect maximal elongation of muscle. These patterns involve spiral and diagonal movements and are modeled after normal patterns of motion associated with tasks and movements of daily living. It is through the learning or relearning (facilitation) of these complex patterns that PNF is speculated to stimulate proprioceptors and hasten recovery. PNF is considered by its developers to be a philosophy of treatment rather than a technique. It purports to have a global effect on function, involving multiple muscles and multiple planes of movement.

The basic neurophysiologic principles that serve as a foundation for this procedure include the concept that a muscle response can be influenced by resistance, stretch reflex, and other proprioceptive input. Therefore, PNF uses the concepts of resistance, stretch reflex, approximation, traction, and manual contacts to facilitate efficient motor or recruitment patterns. Through applying these basic principles, the patient’s postural responses, movement pattern, strengths, and endurance can be assessed and theoretically enhanced.

Physical manipulations using proprioceptive neuromuscular technique often use hold-relax-stretch procedures to obtain an increase in ROM and normalize muscle function about a joint. The hold-relax-stretch technique and terminology is comparable with the contract-relax-stretch technique in both application and effect.⁷² The PNF approach is based on the ability to identify dysfunctions of neuromuscular control using observation, palpation, and motion evaluation. The evaluation procedures used to identify dysfunctions are listed in Box 7-19.

Definitions and descriptions for the evaluation procedures listed in Box 7-19 follow. Passive mobility assesses a PNF diagonal for the presence of an accessible passive ROM and the patient’s ability to relax. Active mobility adds active muscle contraction to move the part through the PNF diagonal that was previously tested passively. The quality of movement initiation is evaluated for sluggishness, delayed response, hyperactive response, or inappropriate recruitment.

Coordination and control are evaluated with the addition of resistance to initiated movements to identify deviations of movement or jerky and uncoordinated movements. Again through the use of resistance, the strength of muscle and speed of contraction can be evaluated for insufficiencies. A combination of isotonics assesses the performance of and transition between the types of isotonic contractions (concentric, eccentric, and maintained). In addition to isotonic contractions, isometric contraction is evaluated for weakness.

The ability to reverse direction is a necessary feature of the neuromuscular system, and inadequate control, speed, or strength of the reciprocal movement results in altered arthrokinematics. Identification of a functional imbalance of the agonist and antagonist muscles is important because it may result secondarily from structural dysfunction, disc herniations, or overuse syndromes. Trunk control depends on the integration of stability and mobility and is essential for efficient function and health of associated structures.

The extensive array of procedures and principles associated with PNF make it a difficult procedure to classify. Although initially perceived as a program of rehabilitative exercise, it is clear that many of the techniques applied in PNF are not easily categorized as exercise. The common incorporation of muscular effort during the application of these procedures has led to the common classification of PNF as an MET, which is likely an oversimplification. There are nine variations in the application of PNF that can be applied based on the patient’s functional needs (Box 7-20). Each of these has a specific purpose, indication, and application.

Rhythmic Initiation

Rhythmic initiation (Figures 7-31 and 7-32) is used to evaluate and treat the patient’s ability to allow passive motion; actively contract in a smooth, rhythmic fashion; and perform movement at a constant rhythm against resistance. It is therefore used to treat those functions that affect the initiation, speed, direction, or quality of the contraction. To apply the procedure, the patient is positioned in a posture conducive to relaxation and the clinician performs the desired joint movement passively. Once a smooth and rhythmic passive movement is achieved, the clinician asks the patient to minimally assist with the movement. Resistance by the clinician is applied as the patient increases active participation.

Figure 7-31 PNF rhythmic initiation for acute pain. Patient is positioned in a posture conducive the relaxation, and the clinician produces the desired motion passively. Patient then minimally assists with the movement.

Figure 7-32 Proprioceptive neuromuscular facilitation rhythmic initiation facilitating gluteus maximus contraction (hip extension) activity for low back stability. A, Hip extension (crawling) begins. B, Hip extension is complete. This procedure is done passively, actively, and with resistance to facilitate trunk stability.

Combination of Isotonics

Combination of isotonics (Figure 7-33) is used to evaluate and develop the ability to perform controlled, purposeful movements. It is indicated for the treatment of deficiencies in strength, ROM, and decreased neuromuscular coordination. It is applied to problems of concentric contraction, eccentric contraction, or efficient maintained (isometric) contraction. Concentric, eccentric, and isometric contractions of the agonist muscle pattern are combined in any sequence with relaxation to perform controlled, purposeful movements.

Figure 7-33 Proprioceptive neuromuscular facilitation combination of isotonics applied to the scapula patterns. A, Scapula is protracted, elevated, and abducted. B, The scapula is retracted, depressed, and adducted. The sequence of treatment is: (1) passive movements produced by the clinician, (2) some patient assistance with the movement pattern, (3) Fall active movement by the patient, and (4) resisted movement.

Receptor-Tonus Technique (Nimmo)

Dr. Raymond Nimmo was one of the first chiropractors to focus on the soft tissue component of dysfunction and subluxation, advocating specific soft tissue treatment since 1950. Clinically, Nimmo observed spots on the shoulders that, when pressed, referred pain to various areas that he called noxious generative points.⁷⁴ In 1952, he discovered the work of individuals such as Travell and later Simons in researching myofascial pain and dysfunction. The term Travell used for the painful areas in the myofascia was trigger points. Nimmo called the procedure for treating trigger points the receptor-tonus technique to emphasize his theory that it is a reflex technique and not a form of massage therapy.⁷⁵

In the Nimmo method, evaluation and treatment emphasis is placed on posture and related muscular involvement. The soft tissues are palpated for tenderness, spasm, and trigger points with their characteristic patterns of referred pain. Nimmo devised treatment procedures that involved the application of firm manual pressure at the site of the trigger points. Nimmo technique uses deep pressure applied directly over the irritable lesion for approximately 5 to 7 seconds to produce the compression effect.75 76 77

The pressure is applied evenly throughout the treatment and then is quickly released. As pressure is applied, the patient will feel local or referred pain or both, which usually increases in intensity even though the manual pressure remains steady. Once the pressure is released, the initial pain intensity will slowly drop to a lower level. This process is repeated over the same trigger point once or twice more during a single office visit. Methods of applying pressure include the thumb, the index or middle finger, the elbow, a pincer grasp (thumb against the middle and index fingers), a knife-edge contact (ulnar side of the hand), and a T-bar (a mechanical hand-held device with a rubber tip) (Figure 7-34). The steps involved in Nimmo’s form of ischemic compression are summarized in Box 7-21.

Figure 7-34 Nimmo receptor-tonus technique to disperse a trigger point in the levator scapulae muscle using thumb pressure (A) and a T-bar (B).

Before treating a trigger point for a second or third time on the same visit, it is important to assess the muscle tissue for changes in tension and nodularity. Many times after the first application of pressure, the patient notes a significant reduction in the local or referred pain or both. Additional treatment of a trigger point on the same office visit should not be done if substantial decrease in tension or nodularity is noted after the first application of pressure. Moreover, if the trigger point still does not show signs of improvement after three applications of treatment, an interval of a few days is recommended before attempting further treatment. Common mistakes are using excessive pressure and treating patients too frequently. Excessive pressure, beyond the compliance of the tissues, becomes a form of trauma that may result in a hematoma or new trigger point formation.

Frail patients or those with capillary fragility, vascular disease, or a history of corticosteroid use should be treated very gently to avoid iatrogenic sequelae. Larger muscles, such as the gluteal group, may require more pressure to achieve ischemic compression, whereas small muscles, such as the suboccipital group, require very little pressure. The clinician must always work within the pain tolerance of the patient; when in doubt, it is wiser to use too little pressure than too much.

It also appears that even patients with well-developed musculature develop some post-treatment soreness the day after a treatment and should be advised accordingly. It is recommended that a day or two be interposed between office visits and that patients get treated on a twice-weekly basis (three times weekly in acute cases). This allows the muscle tissue a chance to heal from any treatment microbruising and gives the nervous system a chance to reestablish equilibrium in the sensory-motor reflex pathways. Some chiropractors perform daily spinal manipulations with good results. However, daily treatments with Nimmo’s method may lead to delayed healing from post-treatment bruising and is not recommended.

Nimmo postulated that local application of deep pressure hyperstimulates nociceptors, which in turn produce neurologic modulation, resulting in reflex inhibition of motor output and a reduction of muscle tonus. He suspected a neurologic explanation of treatment results because patients reported instantaneous pain relief after a treatment. He reasoned that only the nervous system was capable of creating changes in muscle tone within a few seconds. Clinically, release of contracted muscle has been noted to occur before the usual 5- to 7-second application time has finished. Receptor-tonus technique is therefore presented as a reflex technique that is thought to reduce muscle tonus through reflexes mediated by the central nervous system.

Trigger Point Therapy (Travell and Simons)

Janet Travell,⁷³ a medical doctor, placed a significant emphasis on the role of the myofascia in health and disease. She was the first to use the term trigger point to describe the tender nodules in the soft tissues. Travell and Simons⁷³ define a trigger point as a hyperirritable spot, usually located in a taut band of skeletal muscle, that is painful on compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena.

Evaluation consists of postural assessment to identify gross muscle imbalances and specific palpation of the myofascia. Charts have been developed identifying the referral patterns of pain that are specific to individual muscles (Figure 7-35). Examination findings are summarized in Box 7-22. Travell⁷³ promotes the use of vapocoolant spray while the irritable tissue is being stretched, as well as the injection of an anti-inflammatory medication (e.g., procaine) into the trigger point.

Figure 7-35 Chart of common trigger points (triangle) and referral patterns.

(Modified from Chaitow L: Modern neuromuscular techniques, London, 1996, Churchill Livingstone.)

Manual pressure is also advocated to inactivate a trigger point. Travell and Simons⁷³ were the first to use the term ischemic compression to refer to this procedure. The length of applied pressure is significantly longer in duration than the ischemic compression method described by Nimmo. Travell’s method uses firm digital pressure with deep stroking massage, kneading massage, or vibratory massage to produce hypoxia, followed by a reactive hyperemia. Pressure is gradually increased over a period of 30 to 60 seconds or until the trigger point tenderness is eliminated. Massage, stretch without spray, ultrasound, heat, drug therapy, biofeedback, and transcutaneous electrical nerve stimulation (TENS) are all discussed as alternative means to inactivate a trigger point.

Acupressure Point Stimulation

Acupressure is a method of massage or point pressure applied to acupuncture points for the usual purpose of producing analgesia.⁶⁴ Much has been written on the clinical aspects of acupuncture, acupressure, and meridian therapy. Acupuncture points are organized along meridians that have no known neurologic or vascular pattern. There appears to be a measurable change in electrical potential in irritable points, and they can be treated by electrical stimulation, needle application, or manual pressure. Theoretically, blockage or other dysfunction in the meridian causes a departure from health.²⁹

There is a growing body of clinical research exploring the effectiveness of acupuncture. As with any treatment procedure, there are a number of contradictory studies. In a randomized single blind trial examining the effects of acupuncture on chronic myofascial neck pain, acupuncture was found to produce a modest pain reduction.⁸⁰ In a study of diabetic patients with chronic painful peripheral neuropathy treated with acupuncture analgesia, it was found that acupuncture was a safe and effective therapy for long-term management of painful diabetic neuropathy, although its mechanism of action could not be determined.⁸¹ Acupressure was studied for effectiveness in reducing nausea and vomiting of pregnancy. The results indicated that acupressure was effective in reducing symptoms of nausea but not frequency of vomiting in pregnant women.⁸² A small population study on acupuncture for neck pain revealed no significant difference between acupuncture and placebo, although both groups demonstrated moderate improvement. The conclusion was that acupuncture may have no greater effect than a placebo.⁸³ Ernst⁸⁴ reports in a systematic review of the literature that the results of studies are highly contradictory with many trials suffering from methodologic flaws. In a randomized placebo-controlled clinical trial of acupressure for weight loss, it was concluded that acupressure appeared to be safe but did not promote significantly greater weight or fat loss, nor did it promote a decline in blood pressure.⁸⁵ A particularly disturbing concern was identified in an article about acupuncture for chronic conditions in the United Kingdom. The survey⁸⁶ revealed that acupuncture was widely used in the treatment of chronic pain but that one fifth of the practitioners had not received any formal training in acupuncture. This brings to light concerns that many individuals may be practicing forms of complementary care without adequate training. The conclusions of a consensus process on acupuncture identified that there were many studies of potential usefulness, but that these studies provide equivocal results because of flaws in design and sample size.⁸⁷ However, promising results exist demonstrating efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting.⁸⁷ Furthermore, there are conditions such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoporosis, LBP, carpal tunnel syndrome, and asthma in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or may be included in a comprehensive management program.⁸⁷

Acupuncture points are usually located beneath the skin, although at times they are deep enough to require penetration of the needle to reach tendons and ligaments. It is thought that an acupuncture point becomes active and in need of treatment because of some form of reflex stimulation. They become sensitive to pressure, which therefore serves as a diagnostic finding. Acupuncture points are located in palpable depressions, with the skin over the point being somewhat thinner.⁸⁸ Beneath each acupuncture point lies a combination of tissues including fibrous tissue, fat, nerves and nerve trunks, large veins, muscle, and tendon receptors. Therefore, a number of tissues are simultaneously affected by the application of an acupuncture needle or finger pressure.

Active acupuncture points will typically be sensitive to correctly applied pressure and can often be neutralized by manual pressure or a combination of chilling, manual pressure, and stretching.⁷⁸ Acupressure is typically applied with the fingertip to produce pressure in a circular, transverse, or deep fashion (Figure 7-36). The applied pressure should produce some local tenderness that decreases during the treatment session. The pressure is usually applied for 30 to 90 seconds, although one point can be treated for as long as 3 to 4 minutes. To sedate an overactive acupuncture point, up to 5 minutes of sustained or intermittent pressure or rotary massage maybe required. To stimulate an acupuncture point, pressure is applied from 20 seconds to 2 minutes. The caveat is that pressure sustained beyond a certain point can produce the opposite effect.

Figure 7-36 Acupressure applied using circular friction massage over spleen 6.

Acupressure and acupuncture are theorized to have an effect on pain reduction through the modulation of endorphin levels⁶⁴ or through the stimulation of local mechanoreceptors and nociceptors (stimulus-produced analgesia) or both. Nociceptor activity may be reduced by the activation of sensory mechanoreceptors and nociceptors in the involved myofascial area.⁶⁴ The nerve reflex theory of acupuncture contends that when an abnormal condition occurs in an internal organ, alterations will take place in the skin and muscles related to that organ by means of the nervous system. Reflex symptoms are classified into sensation reflexes, interlocking reflexes, and autonomic system reflexes. A sensation reflex occurs when an abnormal impulse travels to the spinal cord and the reflex action causes a hypersensitivity reaction in the skin. An interlocked reflex occurs when an abnormality in any internal organ causes a limited contraction or stiffening of muscles in an area near the part of the body that is connected neurologically to the affected organ. An autonomic system reflex occurs when abnormalities in the internal organs set up a reflex action in the sweat glands, sebaceous glands, pilomotor muscles, and blood vessels in the skin. Acupuncture points represent areas of abnormal physiologic activity that produces a continuous, low-level input to the central nervous system.⁸⁹ This might lead to a combining with noxious stimuli from other structures innervated by the same segments. Melzack, Stillwell, and Fox⁸⁹ report and that there is a 70% correlation between trigger point maps and acupuncture point charts.

Chapman (Neurolymphatic) Reflexes

The surface changes associated with Chapman reflexes are presented as palpable and are thought to be from contractions found in the deep fascia, located at specific points. The amount of tenderness is an important consideration in differentiating the contractions from subcutaneous fat globules. These palpable changes are located in specific anatomic areas on the anterior and posterior aspects of the body and are reported to be associated with specific viscera. The palpatory findings may vary in size from a pellet to a large bean. It is thought that these reflexes can be used as a diagnostic aid to locate a pathologic change without knowing its nature and to influence visceral function through nervous system input. Frank Chapman, D.O., was of the opinion that these body wall reflexes are clinically useful for diagnosis of visceral pathologic conditions; for influencing the motion of fluids, mostly lymph; and for influencing visceral function through the nervous system.

The anterior reflexes are located in the intercostal spaces near the sternum, and the posterior reflexes are found along the spine midway between the spinous processes and the tips of the transverse processes (Figure 7-37). There are also points located on the pelvis and the thighs. However, points on the surface of the body are never likely to be precisely located or identifiable by description of anatomic position, although general identification is possible. Therefore, in terms of charts and maps, the positions identified are approximate, and there is great variation from individual to individual.

Figure 7-37 Chart for the location of Chapman reflexes (neurolymphatic).

Reflex	Symptoms or area
1	Conjunctivitis
2	Nasal problems
3	Arms (circulation)
4	Tonsillitis
5	Thyroid
6	Bronchitis
7	Esophagus
8	Myocarditis
9	Upper lung
10	Neuritis of upper limb
11	Lower lung
12	Small intestines
13	Gastric hypercongestion
14	Gastric hyperacidity
15	Cystitis
16	Kidneys
17	Atonic constipation
18	Abdominal tension
19	Urethra
20	Arm and shoulder pain
21	Cerebral congestion (paralysis and paresis)
22	Clitoral irritation or vaginismus
23	Prostate
24	Spastic constipation or colitis
25	Leukorrhea
26	Sciatic neuritis
27	Torpid liver (nausea, fullness, malaise)
28	Cerebellar congestion (memory and concentration)
29	Otitis media
30	Pharyngitis
31	Laryngitis
32	Sinusitis
33	Pyloric stenosis
34	Neurasthenia
35	Wry neck (torticollis)
36	Splenitis
37	Adrenals (allergies, exhaustion)
38	Mesoappendix
39	Pancreas
40	Liver and gallbladder congestion
41	Salpingitis or vasiculitis
42	Ovaries
43	Uterus
44	Uterine fibroma
45	Rectum
46	Broad ligament (uterine involvement)
47	Groin glands (circulation and drainage of legs and pelvic organs)
48	Hemorrhoids
49	Tongue

Chapman reflexes are treated by light digital pressure applied to the anterior point and then the posterior point. After the pad of the middle finger has contacted the surface locus, a firm, gentle contact is maintained, and a rotary motion is imparted to the finger through the arm and hand to express the fluid content of the locus into the surrounding tissues (Figure 7-38). The actual application to a given reflex is expressed in terms of seconds, but in practice it is actually determined by a response to palpation. Therefore, treatment time may vary from 20 seconds to 2 minutes or more.⁷⁸ If the sensitivity of the reflex point has diminished, no more treatment is applied. If the sensitivity of the reflex point is unchanged, a second application is applied. The application of pressure should follow the guideline that overtreatment is counterproductive and may produce an unwanted effect.

Figure 7-38 Treatment of Chapman (neurolymphatic) reflex for sinus involvement, using rapid circular massage over anterior reflex located between the second and third intercostal spaces parasternally (A) and posterior reflex located over the lamina of C2 (B).

The proposed mechanism by which these reflexes located in the intercostal spaces act is through stimulation of receptors lying between the anterior and posterior layers of the anterior intercostal fascia and acting on the intercostal nerve. The intercostal nerve innervates the internal and external intercostal muscles and through its connection with sympathetic fibers can affect the intercostal arteries, veins, and lymph nodes. Impulses from afferent and efferent vessels draining these tissues may increase or decrease because of the stimulation. With involvement of sympathetic fibers associated with specific tissue sites, lymph nodes of vital organs can be affected.⁷⁸

Regardless of the proposed mechanism, there is some research evidence to support the clinical application of Chapman reflexes. In a study determining whether stimulation of a Chapman reflex could reduce blood pressure, it was found that there was no effect on blood pressure but that there was an alteration in aldosterone levels.⁹⁰ Many hypertensive patients have high aldosterone and low renin levels affecting the renal tubules and causing sodium retention. Abnormalities in aldosterone levels have been shown in populations of essential hypertension. Stimulation of Chapman reflexes caused a consistent lowering of aldosterone levels. It was suggested that not enough time was allowed to see the blood pressure lower, because even with drugs that lower aldosterone, it takes 5 to 7 days for the blood pressure to lower.

Bennett (Neurovascular) Reflexes

Terrence Bennett, D.C., described reflex points mainly on the skull but also on other body parts that he believed were irritable reflexes reflecting the vascular condition of organs.^91,92 These reflex points are used both diagnostically and therapeutically. Bennett developed the neurovascular dynamics technique, which he proposed alters and restores autonomic homeostasis as a means to treat visceral and functional physiologic changes.

Bennett describes the palpable tissue changes in much the same way as Chapman: as a change in texture when the tissue is contracted or indurated. Many of the points are located on the head, although there are some on the anterior aspect of the torso as well (Figure 7-39). Treatment of Bennett reflexes consists of a slight degree of digital pressure combined with a slight stretching or tugging of the skin (Figure 7-40). As the skin is stretched, the fingertips are drawn apart slightly and a yielding sensation occurs. Also perceived within a few seconds after the contact is taken is a slight pulsation, believed to be from the microscopic capillary bed. If no pulsation is perceived, change direction of the skin stretch. The contact is maintained until a response is noted in the form of tissue alteration, relaxation, and pulsation. Treatment could take from a few seconds to a couple of minutes for these changes to emerge. As with other body wall reflex techniques, caution must be given not to overtreat.

Figure 7-39 Chart for the location of Bennett reflexes (neurovascular).

Reflex	Area affected
1	Parotid gland
2	Cardiac sphincter
3	Liver
4	Gallbladder
5	Pancreas
6	Pylorus
7	Second segment of duodenum
8	Third segment of duodenum
9	Fourth segment of duodenum
10	Kidneys
11	Ileocecal valve
12	Internal rectal sphincter
13	Appendix
14	Bladder
15	Prostate or uterus
16	Spermatic cord or ovary
17	Super-renal
18	Anterior pituitary
19	Posterior pituitary
20	Thyroid
21	Carotid sinus
22	Aortic sinus
23	Heart tone
24	Subclavian lymphatics
25	Femoral lymphatics
26	Maxillary sinus
27	Bronchial region
28	Frontal-emotional
29	Vagal
30	Parietal
31	Temporal-emotional
32	Anterior fontanel
33	Midsylvian
34	Fissure of Rolando
35	Frontal eye muscles
36	Extrinsic eye muscles
37	Posterior fontanel
38	Menopause-glandular

Figure 7-40 Treatment of Bennett (neurovascular) reflex for the pancreas, holding a light tugging pressure just medial to the sixth and seventh rib heads until a pulsation is felt.

Bennett reflexes are hypothesized as being viscerosomatic reflexes. Therefore, they are believed to have the same characteristics and neurologic mechanisms as viscerosomatic reflexes. Persistent pathologic conditions in visceral structures have the theoretic potential to induce reflexive dysfunction in somatic structures. Visceral disease or dysfunction may activate the autonomic nervous system through connections with the lateral horn cells in the cord to produce vasomotor, trophic, visceral, or metabolic changes. Viscerosomatic reflexes result from afferent stimuli arising from dysfunction of a visceral structure. The reflex is initiated by afferent impulses arising from visceral receptors that are transmitted to the dorsal horn of the spinal cord, where they synapse with interconnecting neurons. The stimuli are then conveyed to sympathetic and motor efferents, resulting in changes in the somatic tissues.

It has been suggested that the body wall manifestations of visceral disease are an integral part of the disease process, rather than just physical signs and symptoms.⁹³ Korr suggests that viscerosomatic reflex activity may be noted before any clinically identifiable symptoms of visceral change and therefore has diagnostic and prognostic value,⁹⁴ although the definitive etiologic factors and the characteristic response of the individual reflex are still unknown. There have been no clinical trials using Bennett reflexes reported in the retrievable literature. There are case reports that suggest there is benefit from treatment of these reflexes, concluding that more study is needed.^92,95