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Myofascial Manipulation - Theory and Clinical Application PDF
Myofascial Manipulation - Theory and Clinical Application PDF
Myofascial Manipulation - Theory and Clinical Application PDF
Myofascial Manipulation
Theory and Clinical Application
THIRD EDITION
Robert I. Cantu
Alan J. Grodin
Robert W. Stanborough
All rights reserved. No part of the material protected by this copyright notice may be reproduced
or used in any form or by any means, electronic or mechanical, including photocopying,
recording, or by any information storage and retrieval system, without prior written permission of
the copyright owner.
The author has made every effort to ensure the accuracy of the information herein. However,
appropriate information sources should be consulted, especially for new or unfamiliar
procedures. It is the responsibility of every practitioner to evaluate the appropriateness of a
particular opinion in the context of actual clinical situations and with due considerations to new
developments. The author, editors, and publisher cannot be held responsible for any typographical
or other errors found in this book.
Photo used in design on opener pages reprinted from Histology (p. 212) by A. W. Ham and D. H.
Cormack with permission of J.B. Lippincott Co.,© 1979.
Cantu, Robert I.
Myofascial manipulation : theory and clinical application/ Robert I. Cantu, Alan J. Grodin,
Robert W. Stanborough. - 3rd ed.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-4164-0498-9 (Print) ISBN 978-1-4164-0600-6 (e-book PDF)
1. Myofascial pain syndromes-Physical therapy. 2. Manipulation (Therapeutics)
I. Grodin, Alan J. II. Stanborough, Robert W. III. Title.
RC925.5.C26 2012
616.794-dc22
To my wife, Carol,
and my children,
Jason, Evan, Seth, and Lisa,
for their support and tolerance
of my personal and professional life.
A.J.G.
To my wife, Becky,
for her never-ending patience and support,
and to my children,
Abby and Jake,
whose inquisitive nature is ever-inspiring.
R.W.S.
Contents
PART I
Historical Development and Current Theories
of Myofascial Manipulation ................................ 1
CHAPTER 1
Hi stori cal Basis for My ofasc ial Ma nipul ation ......................... 3
Robert I. Cantu and Robert W. Stanborough
Anc ient Times . ........................................................ .4
Mode rn Tim es: The Trend Toward Mobility and Diagnos is of Pathology ...... 10
Futur e Cons iderations .................................................. 13
CHAPTER 2
M od ern The ori es and System s of My ofasc ial Ma nipul ation . . . . . . . . . . . 17
Robert I. Cantu, Alan J.Grodin, and Robert W. Stanborough
Autonomic Approaches ................................................. 17
Mechan ical Approaches ................................................. 21
Movemen t Approaches ................................................. 25
Conc lusion . .......................................................... .28
PART II
Scientific Basis for Myofascial Manipulation .................. 31
CHAPTER 3
Hi stolo gy and Biom ech ani cs of My ofasc ia .......................... 33
Robert I. Cantu and Robert W. Stanborough
VII
v111 Contents
CHAPTER 4
Histopathology of Myofascia and Physiology
of Myofascial Manipulation .................................. 69
Robert I. Cantu, Alan J. Grodin, and Robert W Stanborough
Histopathology of Myofascia ............................................ 69
Physiology of Myofascial Manipulation ................................... 80
Conclusion . .......................................................... .86
CHAPTER 5
Neuromechanical Aspects of Myofascial Pathology
and Manipulation .......................................... 91
Clayton D. Gable
Basic Afferent Neurology of Connective Tissue ............................ 92
Receptor Influence on Movement ....................................... 105
Muscle Tone.......................................................... 111
Application to Specific Therapeutic Techniques ........................... 117
Conclusion . ......................................................... . 121
CHAPTER 6
Muscle Pain Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Jan Dommerholt and Robert W Stanborough
Soft Tissue Lesion and Mechanical D ysfunction ........................... 126
Myofascial Pain Syndrome ............................................. 128
Fibromyalgia ........................................................ . 149
PART Ill
Evaluation and Treatment of the Myofascial System .......... 181
CHAPTER 7
Basic Evaluation of the Myofascial System. . . . . . . . . . . . . . . . . . . . . . . . . 183
Robert I. Cantu, Alan J. Grodin, and Robert W Stanborough
Histor y ............................................................. . 184
Postural and Structural Evaluation ...................................... 185
Contents IX
CHAPTER 8
Atlas of Therapeutic Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Robert I. Cantu, Alan J.Grodin, and Robert W Stanborough
Techniques for the Lumbar Spine ...................................... 205
Techniques for the Lumbopelvic/Lower Quarter Area ..................... 248
Techniques for the Thoracic/Upper Thoracic Spine and Upper Extremity ..... 279
Techniques for the Cervical Spine ...................................... 305
XI
Foreword
If you have picked up this book, chances are high that you are not a greenhorn in
the field of rehabilitation and manual therapy . Most likely you belong to the most
experienced and knowledgeable bodywork practitioners in your community , or
are on your way there . Or-less likely-you chose this book as an attempt to boost
your image in the eyes of your peers . The book you have selected is one of the
absolute masterpieces in the field. The previous edition sits on the bookshelves of
virtually all the leading massage and bodywork schools worldwide and decorates
the desks of hundreds of ambitious authors and teachers within this field.
Most massage and other manual therapies direct their techniques toward en-
hanced functioning of muscular tissues; improved vascular , lymphatic flow; or
better skeletal positioning . Myofascial therapies , on the other hand , target more
specifically the muscular connective tissues (myofasciae). These tissues include
broad sheets of dense connective tissues such as the fascia lata of the lateral thigh
or the plantar fascia of the sole of the foot. They also include a complex network
of thin connective tissue bags and sheets on the insides of muscles as well as sur-
rounding the muscles . Most muscle electromyography experts agree that muscle
activity at rest is electrically silent. The passive tissue stiffness of muscles at rest
therefore appears to depend to a large degree on the local properties of this fas-
cial network . One of the advantages of myofascial therapies , as described in this
book, is that they include a detailed repertoire of working techniques for address-
ing fascial contractures and adhesions , which often underlie musculoskeletal pain
problems .
For several decades , fascia has been neglected as the "Cinderella" of orthope-
dic medicine . Medical doctors were introduced to this tissue by learning to "clean
it off" in their dissection courses to reveal the distinct organs enveloped within .
These colorless tissues were regarded mainly as packing material , which some-
times assists the muscles as passive force transmitters . However, during the last
few years, new measurement tools have shown that fascial tissues serve many
important functions in the body and contain some surprising tissue properties .
The First International Fascia Research Congress , held at Harvard Medical School
in Boston in 2007, signaled an important turning point and was celebrated with
worldwide acknowledgment. There is now global recognition that this underesti-
mated contextual tissue plays a much more important role in health and pathology
than was estimated during previous decades .
XIII
xiv Foreword
Among the many surprising fascial properties that are now being discovered
and investigated are two that I would like to mention briefly: the proprioceptive
importance of fascia and the discovery of active fascial tonicity . Although in the
past it was often assumed that mechanoreceptors in joint capsules and associated
ligaments were the main input devices for proprioception , more recent investiga-
tions have revealed that these ')oint receptors" are mostly stimulated only at the
end ranges of available movements and provide very little input during regular
everyday movements . In contrast , fascial membranes are often positioned much
farther away from the movement axes and are therefore in much better positions
to register smaller movements around these joints . These sheets are densely popu-
lated by sensory nerve endings , which are excellent input devices for propriocep-
tion . It has therefore been postulated that myofascial manipulations may largely
work by stimulating those fascial receptors , with resulting physiological as well as
neuromuscular responses from the central nervous system . If you want to study the
specific fascial mechanoreceptors in detail-for example , to direct your manual
techniques more specifically toward their different subtypes-this book provides
detailed information . Chapter 6, "Muscle Pain Syndromes ," in this new edition
contains the best description of fascial innervation that I have seen .
The other property I wish to mention is fascial tonicity . Recent evidence sug-
gests that fascia contains its own active motricity; it can contract and relax au-
tonomously , independent of the skeletal musculature . Laboratory work with rat as
well as human fascia by our group (Fascia Research Project , University of Ulm,
Germany) and by the group working with Ian Naylor (Bradford University, United
Kingdom) has shown that fascia contains contractile connective tissue cells, called
myofibroblasts . The cells enable fascia to actively contract , both in the form of
smooth muscle-like temporary contractions and in chronic tissue contractures
that include tissue remodeling (as in frozen shoulder or Dupuytren contracture) .
How to best influence the active tonus regulation of fascia therapeutically-via
mechanostimulation as well as other means-is currently an exciting subject of
interdisciplinary research .
In contrast to most fields of academic exploration , the field of myofascial ther-
apies continues to be dominated by the existence of so-called schools . Each school
is organized around a charismatic founder and emphasizes a specific manual mo-
dality and a particular explanatory concept. Although such distinction served well
in providing followers with an almost tribal social affiliation , it has also attenuated
a healthy culture of questioning , cross-pollination , and mental collaboration . This
book is one of the rare exceptions in the field. Rather than focusing on only one
school and providing a semireligious body of congruent belief concepts (and ig-
noring contrasting concepts that are taught elsewhere) , it describes with academic
precision the different schools and concepts that have been able to describe their
work in an anatomical language . It clearly distinguishes proven facts from current
assumptions and provides accurate references behind the different sources of in-
formation . Nevertheless , rather than being an academic textbook only, it is written
Foreword xv
in a practical and reader-friendly manner and does include several excellent practi-
cal descriptions of clinical working approaches .
Be warned , dear reader-and I am writing that of course with a twinkle in
my eye-that if you are looking for a cozy home to help you feel superior and
safe with one newly learned method of fascial manipulation and one related belief
concept , this book will not help you sleep more comfortably . However , if you have
picked up this book as an experienced practitioner who is interested in expand-
ing your understanding of fascial manipulation , and if you seek to be exposed to
an internationally recognized , state-of-the-art review of different techniques and
concepts , then you have found the true masterpiece within this field .
XVII
xv111 Preface
The three main divisions of the book have remained. Part I provides the his-
torical background of manual therapy and current theories, Part II provides the
scientific basis for myofascial manipulation, and Part III provides a system for
evaluation and treatment of the myofascial system.
Readers familiar with the previous editions will feel right at home with this
edition. We hope new readers will find this edition useful and refer to it often in
clinical practice . Enjoy!
ROBERT I. CANTU
A LAN J. GRODIN
ROBERT W. STANBOROUGH
text book out lines the scientific basis of myofascial manipulation. Management
of certain clinical problems is also discussed. Part III focuses on evaluation and
treatment techniques that have repeatedly proved effective in the clinical setting
and includes an atlas of therapeutic techniques.
For the sake of clarity throughout the text, manual therapy is divided into
joint manipulation and soft tissue manipulation. As understanding of connective
tissue has increased, the distinction between joint and soft tissue manipulation has
become somewhat clouded. Joint manipulation has been defined as "the skilled
passive movement of a joint." The tissues being mobilized, however, are all histo-
logically classified as connective tissues, and in this respect, any type of manual
therapy can be considered soft tissue manipulation. The distinction made in this
text is in the arthrokinematics, or lack of arthrokinematics, in the application of
the techniques. Soft tissue manipulation is generally less concerned with arthro-
kinematic rules than is joint manipulation; a majority of the techniques are not
concerned with individual joints but with myofascial relationships and the interre-
lations of the joints to the soft tissues. For the purposes of this text, we have defined
myofascial manipulation as: The forceful passive movement of the musculofascial
elements through its restrictive direction(s), beginning with its most superficial
layers and progressing into depth while taking into account its relationship to the
joints concerned.
Myofascial Manipulation is not meant to be a panacea or an exhaustive criti-
cal review of the literature, but a representation of what we feel strongly about
clinically. These are techniques that we use every day, integrating them with joint
mobilization, alternate somatic therapies, and exercise. Our hope is that this in-
formation will be integrated into the readers' arsenal of techniques and into their
philosophy of treatment, so that each clinician's style, or "handwriting," will be-
come more distinct as well as more effective.
ROBERT I. CANTU
ALAN J. GROD I N
Second, the first edition relied heavily on basic science principles. We went to
the literature, for example, to explain the mechanisms of injury and repair, and to
delineate pain of mechanical versus nonmechanical origin. We carefully extrapo-
lated and integrated these principles into the principles of management and treat-
ment of soft tissue dysfunction. For the second edition, we wanted to strengthen
that scientific foundation. To that end, we enlisted the help of gifted professionals
and content experts, to add material, and to retool and revise existing material
in the previous edition. The chapter on neuromechanical aspects of myofascial
pathology and manipulation, for example, adds a dimension of understanding
we did not offer before. Also, the chapter on muscle pain syndromes (i.e., pain of
mostly nonmechanical origin) was completely rewritten due to the explosion of
research in that area. The chapter on the histopathology of connective tissue has
also been completely updated due to advances in research over the last 8 years.
As we mentioned in the first edition, Myofascial Manipulation is not designed
to be a panacea for manual therapy, but a great utility tool to be used in conjunc-
tion with joint mobilization and exercise. In our courses, we often refer to that
triad (soft tissue mobilization, joint mobilization, and exercise) as the "pinball
triad of manual therapy." This is because the three aspects of treatment are virtu-
ally inseparable and totally integrated in the clinic. The savvy clinician knows how
to effectively "bounce off" all three aspects of treatment to arrive at the desired,
optimal result.
We respectfully submit the second edition of Myofascial Manipulation for
your consideration as a tool to help expand the horizons of our profession. Man-
aged care, Medicare cutbacks, market saturation of therapists, and turf erosion
have put us in a position where it is no longer an option for us to be the very best.
Our professional lives and the health and longevity of our profession in general
depend on it. We hope that this tool will be useful in helping us all forge ahead to
expand our individual and collective horizons.
ROBERT I. CANTU
ALAN J. GRODIN
Acknowledgments
The authors thank the following persons for their assistance in the preparation of
this edition: To Rebecca J. Stanborough, BA, MFA, for her help in proofreading
and copyediting the manuscript; Glen Coad for his photographic and cinematog-
raphy excellence; and Melissa Nunnally, DPT, and Marisa Ball, DPT, MTC, for
being the "patients" in Chapters 7 and 8.
Once again we wish to acknowledge all the professors who adopted the second
edition for their courses and curriculums as well as all the readers who have pro-
vided feedback. Thank you.
XXI
PART I
Historical Development
and Current Theories
of Myofascial Manipulation
Historical Basis
for Myofascial Manipulation
Rob ert I. Ca ntu and Rob ert W. Sta nbo rough
3
4 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
second period, starting with the early twentieth century, the philosophy and theory
of manual medicine began to emphasize mobility. Restoring mobility to a joint that
"was locked" became the focus of manual medicine . The science of arthrokinema-
tics developed, and terms such as accessory movements appeared. This spurred the
curiosity of researchers in the middle and late twentieth century, who pushed the
study of manual medicine into a third phase -u nderstanding how manual therapy
affects the biomechanics of connective tissue. They viewed the increased mobility of
the joints as a result of mechanical changes in connective tissues. Largely because
of the chronicity and recurrence of many types of back pain, the focus of the pres-
ent period of research in manual medicine is on neural mechanisms of back pain
and movement reeducation (see Chapter 5, "Neuromechanical Aspects of Myofas-
cial Pathology and Manipulation"). The science of motor learning and control will
have much to offer in this area. The immediate future of manual therapy lies in the
combination of passive manual therapy techniques and movement reeducation or
motor learning techniques for prophylaxis. The philosophy and history of each
movement is discussed in the following sections.
Ancient Times
Early recordings of manual medicine date back to the time of Hippocrates around
the year 400 BC. Two relevant works, "On the Joints" and "On Setting the Joints by
Leverage," describe various combinations of manipulations, massage, and traction
performed on a patient prone on a wooden table. 1 Much of Hippocrates' work in
early manual medicine can probably be attributed to the popularity of wrestling in
his day. Entries in early manuscripts include descriptions of both joint manipula-
tion and massage in treatment of a dislocated shoulder.
And it is necessary to rub the shoulder gently and smoothly. The physician must
be experienced in many things, but assuredly also in rubbing; for things that have
the same name have not the same effects. For rubbing can bind a joint which is
too loose and loosen a joint that is too hard. However, a shoulder in the condition
described should be rubbed with soft hands and, above all things, gently; but the
joint should be moved about, not violently but so far as it can be done without
producing pain. 2<p4>
Figure 1.1 The Hippocratic method of traction and manual pressure as described by Galen. Source:
Reprinted with permission from E. H. Schoitz, Manipulation Treatment of the Spinal Column From the
Medical-Historical Standpoint, Part I, Journal of the Norwegian Medical Association (1958;78:359- 372).
Copyright© 1958, Norske Laegeforening.
Figure 1.2 Method for "repositioning of an outward dislocation" of the spinal column. Source:Reprinted
with permission from E. H. Schoitz, Manipulation Treatment of the Spinal Column From the Medical-
Historical Standpoint, Part I, Journal of the Norwegian Medical Association (1958;78:359- 372). Copyright
© 1958, Norske Laegeforening.
the head, or towards the hip. This method of repositioning is harmless; indeed,
it will do no harm even if one sits on the hump while extension is applied ... nay
there is nothing against putting one's foot on the hump and making gentle suc-
cession by bringing one's weight upon it [Figure l.2]. 1<P4)
Renaissance
The most well-known contributor to manual medicine in the Renaissance period
was the French surgeon Ambroise Pare, who lived in the l SOOs.1•4 Pare was also
instrumental in the development of some of the early orthopedic surgical tech-
niques. The positional theory was still strong, as evidenced in the following quote:
The exogenous causes of dislocation include falls, hard blows, and prolonged
work in a greatly bent position, e.g. among vineyard workers .... If the vertebrae
are dislocated and far apart, a good method is to lay the patient on a board, face
down, fasten him to it with bands beneath his armpits, around his trunk and
thighs, then pull from top and bottom as hard as possible, but without violence.
If such tension cannot be tolerated, no treatment can be applied. Then you may
place your hands on the out -curving part and press the projecting vertebrae. 4
Again, during this period evidence exists for traction and manipulation into ex-
tension, with the fundamental theory being repositioning of the vertebra as in the
Hippocratic method .
Bone Setters
From the mid- 1600s well into the nineteenth century, the "bone setters" of En-
gland flourished. Bone setters, considered "quacks" by traditional medical practi-
tioners, had no formal training; their art was generally passed on from parents to
children, generation after generation. Bone setters were known locally, had other
Historical Basis for Myofasc ial Manipulation 7
Another physician of the day who defended manual medicine was English sur-
geon Sir James Paget (1814-1 899), a respected medical school professor. In a lecture
to his students and later in an editorial to one of the medical journals, he wrote,
Few of you will enter into practice today without having a so-called bone setter
as a competitor. There is little point in presenting a lecture on the injuries which
these persons cause; it is more important to consider the fact that their treatment
can do some good .... Learn then to imitate what is good and avoid what is bad in
the practice of bone setters. Fas est ab hoste doceri! (It is advisable to learn from
one's opponent.) l(p6)
Still another surgeon of the day wrote, "The success of certain bone setters is
due -i n addition to their skill -t o the lack of practice and ignorance with which
8 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
Strong as the love of service to suffering is among many doctors as a whole; there
exists some things much stronger and less worthy in prejudice and jealousy,
which have from the beginning of time darkened the pages of surgical history,
and smirched its record of noble endeavors. 5
Eventually, the medical community could no longer argue with the success of
bone setters, and in 1925 an editorial in Lancet stated,
The medical history of the future will have to record that our profession has
greatly neglected this important subject ... the fact must be faced that the bone
setters have been curing multitudes of cases by movement ... and that by our
faulty methods, we are largely responsible for their very existence. 6
Thus, the rule of the artery and the rule of structure governing function be-
came the cornerstones of osteopathic thought. Unfortunately, the treatment
scheme included "cures" for all sorts of systemic diseases. Fortunately, osteopathic
medicine continued to evolve into a more scientific and realistic philosophy. In
1956, the Register of Osteopaths in England compiled the osteopathic Blue Book,
which stated in part that "osteopathy is a system of therapeutics which lays chief
emphasis upon the diagnosis and treatment of structural and mechanical derange-
ments of the body." 8 By imposing these limitations, osteopathic physicians and
osteopathic practice have become more accepted even though the theories are still
debated. Three areas in osteopathic medicine that are currently applicable to myo-
fascial manipulation are muscle energy techniques, positional release techniques,
and strain/counterstrain techniques. 9 - 11
In 1895, 21 years after Still had founded osteopathic medicine, David Daniel
Palmer founded chiropractic. Some of the cure-all claims of osteopathic practice
were being relinquished and were subsequently adopted by chiropractors. Palmer
learned his technique through rediscovery of the ancient Hippocratic methods
and from osteopathic medicine. He did, however, claim to be the founder of a new
.
science.
But I maintain to have been the first who repositioned dislocated vertebrae by us-
ing the spinous process and the transverse process as levers ... and starting from
these fundamental facts to have founded a science that is destined to revolution -
ize the theory and practice of the healing art. 7
From ancient times to the end of the nineteenth century, manual medicine
had been practiced with an apparent high degree of success. The emphasis during
10 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
this era was on repositioning a subluxation for the reduction of pain and restora-
tion of health . With traditional medicine coming closer to embracing the value of
manual medicine, the advent of the scientific age spurred new clinical investiga-
tions and research on the subject. Today, the subluxation philosophy has been par-
tially replaced with the mobility philosophy in explaining the theories of manual
medicine.
fact that pain could be caused by dysfunction of various or selective soft tissues,
including, but not limited to, periarticular connective tissue, is a foundation of
soft tissue manipulation today. Cyriax was also the first to introduce the concept
of "end feel" in the diagnosis of soft tissue lesions. Cyriax summarizes his own
philosophy as follows:
In particular, I have tried to steer manipulation away from the lay notion of a
panacea - the chief factor delaying its acceptance today. My only important dis -
covery, on which the whole of this work rests, is the method of systematic exami-
nation of the moving parts by selective tension. By this means, precise diagnoses
can be achieved in disorders of the radio-translucent moving tissues. 17(pxi)
Thus, by moving joints in selective ways, the connective tissues surrounding the
joint are appropriately stretched and normal movement is restored . The extensibil-
ity of the surrounding tissues is what ultimately allows for normal arthrokinemat-
ics in the joint.
12 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
thrust manipulation. 25 These studies are impressive and validate the effectiveness
of manual therapy for increasing mobility.
The next logical step in the evolution of manual medicine was the emphasis on
the histology and biomechanics of connective tissue. Because restoration of mo-
tion is manual therapy's primary goal, and because all the periarticular tissues af-
fected during manual therapy are connective tissues (soft tissues), understanding
the biomechanics of connective tissues became paramount. Substantial research
was performed by Akeson, Amiel, Woo, and others to determine the biomechani-
cal characteristics of normal and immobilized connective tissues. This research
provided the building blocks for much of what is known today. The findings of
this research are discussed in detail in Chapter 3, "Histology and Biomechanics of
Myofascia," and Chapter 4, "Histopathology of Myofascia and Physiology of Myo-
fascial Manipulation." Advances in the understanding of connective tissue have
helped explain the effectiveness of manual therapy, especially that of myofascial
manipulation.
Such advances increasingly support the need for an integrated treatment ap-
proach. Research to date is beginning to shed light on some of the biomechanical
mysteries of soft tissue as well as some of its functions, not previously known or
merely suspected . Not only does connective tissue help hold the body together, but
it is a living, responsive, ever-changing tissue. One area that is gaining notoriety
is that of "tensegrity." As described by Buckminster Fuller, tensegrityis an archi-
tectural concept referring to structures under continuous tension. It is a concept
observed even at the cellular level in the cytoskeleton. 26 This concept is further de-
veloped in Chapter 4, "Histopathology of Myofascia and Physiology of Myofascial
Manipulation," and Chapter 5, "Neuromechanical Aspects of Myofascial Pathol-
ogy and Manipulation." Additionally, preliminary findings suggest that the ability
of connective tissue to contract may be similar to that of smooth muscle (discussed
in Chapter 4).27- 29
Future Considerations
Manual therapy continues to evolve. The number of journals dedicated to this
profession and to soft tissue work alone has increased tremendously. Although
manual therapy can be an effective tool for treating and managing spinal prob-
lems, the incidences of chronic low-back pain continue to soar. One state alone
showed a significant increase within a 14-year period (3.9% in 1992 to 10.2% in
2006), which may exemplify similar increases nationally. 30 Integrative therapies
and theories of movement science, in conjunction with manual techniques, can
help overcome patient fear avoidance and may lead to education, wellness, and
prevention.
The idea of exercise for prevention of low-back pain is widely sanctioned, and
conventional exercise can be considered movement science in rudimentary form.
Manual techniques can correct the dysfunction, and movement therapies may
14 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
help prevent future recurrence. Together, they create a much needed and more
complete form of treatment.
Myofascial manipulation not only produces mechanical and autonomic re-
sults but also fosters the continued growth of modulated central nervous system
mechanisms. The idea that myofascial manipulation can be a form of "sensory-
motor education," helping to establish more efficient movement patterns, is
strongly emerging to complement motor learning theories. 31 Such topics are gain-
ing momentum. The topic under current investigation is whether connective tissue
is an unrecognized, whole body communication system. It may be the "missing
link needed to improve cross-system integration in both biomechanical science
and medicine." 32<P3l
References
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TidsskrNor Laegeforen.1958;78:359- 372.
2. De Domenico G. Beard'sMassage:Principlesand Practiceof Soft TissueManipulation. St. Louis,
MO: Saunders Elsevier; 2007.
3. Loubert P, Paris SY. Foundationsof ClinicalOrthopaedics.Saint Augustine, FL: Institute Press;
2008.
4. Lomax E. Manipulative therapy: a historical perspective from ancient times to the modern era.
In: Goldstein M, ed. The ResearchStatus of SpinalManipulative Therapy.Bethesda, MD: Na -
tional Institute of Neurological and Communicative Disorders and Stroke; 1975.
5. Hood W On the so-called bone setting, its nature and results. Lancet. 1867:336- 338, 441-443,
499- 501.
6. Paget J. Clinical lecture on cases that bone-setters cure. BMJ. 1867.
7. Schoitz E. Manipulative treatment of the spine from a medical-historical point of view. II: Oste-
opathy and chiropractic. TidsskrNor Laegeforen.1958;78:429- 438.
8. Schoitz E. Manipulative treatment of the column from the medical-historical point of view.
III: The last 100 years. J NorwegMed Assoc. 1958;78:946- 950.
9. Deig D. PositionalReleaseTechniques.Course notes. Krannert Graduate School of Physical
Therapy, University of Indianapolis, IN; 1991.
10. Jones L. Spontaneous release by positioning. The Doctor of Osteopathy. 1964;4:109- 116.
11. Jones L. Strain and Counterstrain. Colorado Springs, CO: American Academy of Osteopathy;
1981.
12. Cyriax E. CollectedPapers on Mechano-1herapeutics.London, UK: Bale and Danielson; 1924.
13. Ghormley R. Low back pain with special reference to the articular facets. JAMA.
1933;101:1773- 1777.
14. Mixter W, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal.
New Engl Surg Soc. 1934;2:210- 215.
15. Mennell J. Physical Treatment by Movement, Manipulation and Massage. Boston: Little,
Brown & Co; 1945.
16. Mennell JB. The Scienceand Art of Joint Manipulation. London, UK: Churchill; 1949.
17. Cyriax J. Textbook of OrthopaedicMedicine. Vols 1, 2. London, UK: Bailliere Tindall; 1982.
18. Mennell JM. Joint Pain. Boston: Little, Brown; 1964.
19. Mennell JM. History of the development of medical manipulative concepts: medical termi-
nology. In: Goldstein M, ed. The ResearchStatus of Spinal Manipulative Therapy.Monograph
Historical Basis for Myofasc ial Manipulation 15
No. 15. Bethesda, MD: National Institute of Neurological and Communicative Disorders and
Stroke; 1975:19-24.
20. Kaltenborn F. Manual Mobilization of the Joints: 1he Extremities. 6th ed. Minneapolis, MN:
Orthopaedic Physical Therapy Products; 2002.
21. Paris S. The Spine:Etiology and Treatment of Dysfunction IncludingJoint Manipulation. Saint
Augustine, FL: Institute of Graduate Physical Therapy; 1979.
22. Paris S. Mobilization of the spine. Phys 1her. 1979;59:988- 995.
23. Paris S. Spinal manipulative therapy. Clin Orthop. 1983;179:5561.
24. Maitland GD. PeripheralManipulation. Woburn, MA: Butterworth-Heinemann; 1981.
25. Atlanta Craniomandibular Society/Life Chiropractic College Joint Seminar. August 1987;
Atlanta, GA.
26. Chen C, Ingber, DE. Tensegrity and mechanoregulation: from skeleton to cytoskeleton. In:
Findley T, Schleip R, ed. Fascia Research:Basic Scienceand Implicationsfor Conventional and
Complementary Health Care. Boston: Elsevier; 2007:20 - 32.
27. Schleip R, Klingler W, Lehmann-Horn F. Active fascia l contractility: fascia may be able to
contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics.
Med Hypotheses. 2006;65:273 - 277.
28. Schleip R, Klingler W, Lehmann-Horn F. Fascia is able to contract in a smooth muscle-like
manner and thereby influence musculoskeletal mechanics. In: Liepsch D, ed. Proceedingsof
the 5th World Congressof Biomechanics.Munich, Germany: Medimond: International Pro-
ceedings; 2006:51- 54.
29. Schleip R, Klingler W, Lehmann-Horn F. Active contraction of the thoracolumbar fascia: in-
dications of a new factor in low back pain research with implications for manual therapy. In:
Vleeming A, Mooney V, Hodgers P, eds. Paper presented at: 5th Interdisciplinary World Con-
gress on Low Back & Pelvic Pain, 2004, Melbourne. www.fasciaresearch .de/MelbourneReport
.pdf. Accessed December 3, 2010.
30. Freburger J, Jackman AM, Castel LD. The rising prevalence of chronic low back pain. Arch
Intern Med. 2009;169:251- 258.
31. Juhan D. Job'sBody:A Handbookfor Bodywork. Barrytown, NY: Station Hill Press; 1987.
32. Langevin H. Connective tissue: a body-wide signaling network? Med Hypotheses.
2006;66:1074 - 1077.
Modern Theories and Systems
of Myofascial Manipulation
Robert I. Ca ntu, A lan J. Grodin, and Robert W. Sta nbo rough
This chapter provides an overview of some of the alternate somatic therapies con-
sidered myofascial in nature. Its purpose is neither to give the reader a comprehen-
sive background of each individual system nor to include every system currently
being practiced - such undertakings would be books in themselves. The systems
reviewed represent those that have most influenced the authors over the years and
that have contributed to the development of personal treatment philosophies. The
manual therapist interested in myofascial manipulation should also have a basic
working knowledge of the fundamental philosophies behind various systems and
theories both to become a more educated consumer in the continuing education
market and to understand the orientation of the respective practitioners.
Modern theories and systems are arranged in three categories: autonomic, or
reflexive, approaches; mechanical approaches; and movement approaches. Auto-
nomic approaches are those that exert therapeutic effect on the autonomic ner-
vous system, mechanical approaches are those that actually attempt mechanical
changes in the myofascia by direct application of force, and movement approaches
are those that attempt to change aberrant movement patterns and establish more
optimal ones. Ideally, the manual therapist should have a basic working knowledge
of theories or systems in all three areas, along with some application techniques
from each approach.
Autonomic Approaches
The autonomic, or reflexive, approaches attempt to exert their effect through the
skin and superficial connective tissues. 1•2 MacKenzie defined the autonomic, or
reflexive, component as "that vital process which is concerned in the reception of
a stimulus by one organ or tissue and its conduction to another organ, which on
receiving a stimulus produces the effect." 3<P47l Soft tissue mobilization performed
for autonomic effect stimulates sensory receptors in the skin and superficial fas-
cia. These stimuli pass through afferent pathways to the spinal cord and may be
17
18 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
which is beyond the realm of this book The effects outlined by Dicke that are per-
tinent to modern manual therapy are as follows:
1. CTM can directly influence connective tissue that is locally altered by illness
(i.e., scars, local blood supply, and other disturbances).
2. CTM can set general circulation in order. Subcutaneous connect ive tissue is
extremely vascularized and can absorb varied quantities of blood as a result
of constriction or dilation.
3. CTM can release nerve impulses along quite specific paths by means of re -
flexes that are locked into the central nervous system. It can create reactions
in distant organs. Dicke refers to certain aspects of this phenomenon as the
"cutivisceral reflex." 1 Dicke uses the example of the application of a mother's
warm hand to alleviate a child's stomachache. Obviously, the intestine would
not be affected from the surface of the skin, and the reaction must be due
to an autonomic response affecting the intestines via the skin. The skin and
subcutaneous tissues, which are highly innervated and vascularized, are the
primary tissues for the reception of outside tactile stimuli.
Hoffa Massage
Albert Hoffa's text, published in 1900 and later revised by Max Bohm in 1913, rep-
resents more classical massage techniques, such as eflleurage, petrissage, tapote-
ment, and vibration. 4- 6 Although most therapists learn these as standard massage
techniques in entry-level programs, they are recognized and discussed because of
their importance in the overall treatment scheme . Some clinicians may disregard
this type of massage, regarding it as too basic to include in the realm of advanced
manual therapy; however, leaving behind traditional myofascial manipulation
techniques can handicap even the most advanced manual therapists. A technique
is not necessarily more effective just because it is more complex.
Some may consider these techniques to be more mechanical in nature, but
the strokes can be lighter and designed to be relaxing, which categorizes them
as reflexive, or autonomic. Many myofascial manipulation systems are neither
exclusively reflexive nor exclusively mechanical but may lean toward one more
than the other. Hoffa massage certainly inclines toward the reflexive. Hoffa states
that forces used should be gentle and "light-handed" so the patient feels very little
pain. 5 Hoffa advocates that massage should never last more than 15 minutes, even
for the whole body.
As with CTM, Hoffa massage emphasizes using autonomic, or reflexive, tech-
nique as an entryway for other, more mechanical techniques. With Hoffa mas-
sage or CTM, the patient is prepared - and more specifically, the myofascia is pre-
pared - for techniques designed to promote histological changes in the myofascial
tissues. The changes can be made without forceful maneuvers that can create mi-
crotrauma or exacerbate painful conditions. Some of Hoffa's basic massage strokes
are described as follows:
Effleurage techniques slide or glide over the skin with a smooth, continuous mo -
tion. Pressure may be light to moderate, as when applying oil or warming an area,
or may be deep, as when facilitating venous return in heavily muscled areas ....
When effleurage is performed with moderate pressure, slowly and smoo thly on
the back, it may stimula te the parasympathetic nervous system and evoke the
relaxation response. 4<P73>
Mode rn Theories and Systems of Myofascia l Manipulation 21
Hoffa was one of the first clinicians to describe massage in an actual textbook.
The fundamental strokes of traditional massage are still performed widely today,
although many variations have been introduced . Hoffa's massage techniques are
considered basic by modern standards, but advanced manual therapists continue
to use his techniques in their treatment schemes.
Mechanical Approaches
Mechanical approaches differ from autonomic approaches in that they seek to
make mechanical, or histological, changes in the myofascial structures. Superfi-
cial tissue rolling to mobilize adhesions, elongation of a superficial fascial plane,
and stretching of a hamstring are examples of mechanical techniques. The pur-
pose of each is to improve the mechanical mobility of the tissue treated . As pre-
viously stated, mechanical techniques should generally be performed following
some form of an autonomic technique. Even if the patient is not suffering acute
pain, a few minutes of an autonomic technique may facilitate the application of
a mechanical technique. The application of a mechanical technique is not neces-
sarily aggressive. For the most part, tissue mobility should not be forced; instead,
the clinician should make changes gradually, properly going through the "layers"
until the deeper tissues are accessed. That is not to say that aggressive, more force-
ful mechanical technique is an inferior form of treatment; at times, such forceful
technique is necessary to free up long-standing restrictions. Gentler technique,
however, should always be attempted first.
Remember that the systems described in the following subsections are just
that: systems - they can be very protocol oriented and very ordered. An eclectic
approach is useful, because each patient is different and will respond to each tech-
nique differently. Principles may be borrowed from any system, however, and may
be effective if used at the proper time and in the proper sequence.
-
"7
--..
--- -
;
--
-
- - --- _.., -·
-- - ;
According to Rolf, changes in the body, which she called "functional disorganiza-
tion," are a direct result of exposure to the continuous force of gravity.7 Although
her work included emphasis on the client's entire being, the tissue of focus during
treatment is fascia, as it constantly reorganizes and responds to stresses. She often
likened the relationship of fascia and muscle to that of the fibrous pulp and juice
of a citrus fruit. She equated the fibrous pulp to the fascial connective tissue as the
organ of structure or posture .7,8 Rolfs treat-
Table 2.1 The Rolfing "Recipe" ment technique involves manual soft tissue
Sessions 1-3: sleeve sessions manipulation with the goal of balancing
1. Respiration the body with the forces of the gravitational
2. Balancing under the body (legs and feet) field (Figure 2.1). This is achieved using a
3. Lateral line-front to back (sagittal plane
standardized, nonsymptomatic approach to
balance)
soft tissue manipulation, administered in-
Sessions 4-7: core sessions dependent of specific pathologies.
4. Base of the body/mid line (balance left to The treatment involves what is called
right) "the recipe" of 10 one-hour sessions, each
5. Rectus abdominus/psoas for pelvic balance
6. Sacrum-weight transfer from head to feet
emphasizing a particular aspect of posture
7. Balance of head/neck to the rest of the (Table 2.1). Treatment begins at the periph-
body ery, the outside, and works in. Two or three
advanced sessions may be added, as well as
Sessions 8-10: integration sessions
subsequent occasional "tune-up" sessions.
8. Individual upper and lower half relationship
9. Individual upper and lower half relationship
Rolf's work established a number of
10. Balance of the whole system insights, including the fact that the fascial
Source:Rolf I. Rolfingand PhysicalReality.Rochester, network is continuous throughout the body.
VT: Healing Arts Press; 1977. It is said to become denser and shorter as it
Modern Theories and Systems of Myofascia l Manipulation 23
l
heals. Such "thickenings," if left untreated,
can transmit strain in many directions,
leading to distal restrictions, much like a
snag in a sweater can create strain and fiber
distortion throughout (Figure 2.2).7 Based
on this philosophy and others, her treatment
principle states that "if tissue is restrained,
and balanced movement demanded at a
nearby joint, tissue and joint will relocate in
a more appropriate equilibrium.'' 7
Another premise underlying Rolfing is
that a person's psychological components
are manifested in structure and that chang-
ing the structure can change the psycholog-
ical component. Rolfing strives to integrate
the structural with the psychological:
The technique of Structural Integra -
tion deals primarily with the physical
man; in practice, considerations of the
physical are inseparable from consid-
erations of the psychological. ... Emo-
tional response is behavior, is function.
All behavior is expressed through the
musculoskeletal system .... A man's
emotional state may be seen as the
Figure 2.2 The fascial sweater concept showing
that a fascial restriction in one area will strain ar- projection of his structural imbal -
eas away from the restriction and cause abnormal ances. The easiest, quickest and most
movement patterns. Reprinted from Rolfing:Re- economical method of changing the
establishing the Natural Alignment and Structural coarse matter of the physical body
Integration of the Human Bodyfor Vitality and Well- is by direct intervention in the body.
Being (p. 39) by I. Rolf with permission of the Rolf
Change in the coarser medium alters
Institute of Structural Integration,© 1998.
the less palpable emotional person and
his projections. 9
Trager ®*
Tragering is a mechanical soft tissue and neurophysiological reeducation approach
developed by Milton Trager, MD. The approach has no rigid procedures or proto-
cols like some other systems. It uses the nervous system to make changes, rather
than making mechanical changes in the connective tissues themselves. The Trager
*Trager• is a registered service mark of the Trager Institute.
24 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
practitioner "uses the hands to communicate a quality of feeling to the nervous sys-
tem, and this feeling then elicits tissue response within the client." 10 Trager began
developing his system in his late teens, while training as a boxer. He subsequently
left boxing to protect his hands and to pursue the development of his system. Eight
years later, Trager undertook formal medical training, earning his medical doctor-
ate at the University Autonoma de Guadalajara in Mexico. He opened his private
practice in 1959 in Waikiki and, in the early 1970s, began teaching his system on
an individual basis in California. The Trager Institute was formed, and there are
currently thousands of Trager practitioners throughout the world.
Tragering is directed toward the unconscious mind of the patient : "For every
physical non-yielding condition there is a psychic counterpart in the unconscious
mind, and exactly to the degree of the physical manifestation." 11 The system uses
gentle passive motions that emphasize mobilization techniques, concentrating on
traction and rotation, and a system of active movements termed Mentastics. The
intensity of the movements is in the moderate range, with integration of cervical
and lumbar traction. The oscillations and rocking techniques serve as relaxation
techniques that encourage the patient to relinquish control gradually. Finally, the
active movement part of the treatment serves as a neuromuscular reeducation
technique similar in principle to that of the Feldenkrais method (discussed later in
this chapter). The idea is to alter the patient's neurophysiological set and give the
patient the tools to maintain the changes. 12 The therapist is not attempting to make
mechanical changes in the soft tissues but is trying to alter the neuromuscular set
to establish more normal movement patterns.
Myofascial Release
The term myofascial releasewas first used in reference to specific soft tissue tech-
niques in 1981.Robert Ward, DO, Anthony Chila, DO, FAAO, and John Peckman,
DO, are credited with coining this term when they taught courses titled "Myo-
fascial Release" at Michigan State University. 13 Two distinct styles of myofascial
release techniques exist: direct and indirect. Most of the techniques provided in
this text are from the direct approach.
The intent of the direct technique is to improve the mobility of soft tissue
through application of a slow, controlled mechanical stress directly into a restric-
tion. This is usually done using fingers, thumbs, forearms, or elbows. Pressure is
gradually increased or repeated until the mobility of the tissue is felt to improve.
The tissue may be manipulated while the patient is either passive or actively mov-
ing, depending on the patient's tolerance.
Indirect techniques are applied similarly, with a drastic difference in the
amount of force used. The force used in indirect techniques, compared with that
in direct techniques, is lower in intensity but much longer in duration, which gives
the tissues an opportunity to "melt," or release. These techniques are considered
gentler and are often used when patients are tender or extremely guarded. For
that reason, patient feedback is essential and considered a key component of the
treatment.
Mode rn Theories and Systems of Myofascia l Manipulation 25
Regardless of the style, director indirect, using heavy-handed or light force, the
goal of myofascial release is to increase mobility of the tissue in order to improve
the underlying mechanics of the tissue and ultimately restore proper function.
Movement Approaches
The movement approaches differ from the others in that the patient actively partic-
ipates in therapy. Both autonomic and mechanical approaches rely on the clinician
to impart the changes and movement. In the movement approaches, the clinician
guides the patient through a series of movements to change aberrant patterns and
retrain into more efficient movements and postures.
Alexander Technique
F. Matthias Alexander was a Shakespearian orator at the turn of the twentieth
century. He developed a consistent problem in projecting his voice. He studied
the relationship of head and neck posture to voice projection and, from that study,
developed a system of movement that can teach the entire body to become more
efficient, regardless of the activity. The technique objectives are improvements in
both posture and body mechanics. Many vocalists, musicians, and other perform-
ing artists use the Alexander technique to improve efficiency.
Because Alexander's recurrent laryngitis persisted despite prolonged peri-
ods of rest, he set up a system of mirrors through which he could observe him-
self speaking in his professional oratorical voice. He observed a tendency to pull
his head back, depress his larynx, and inhale through his mouth. After repeated
26 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
practice sessions, he was able to hold his head and neck in a more efficient posture,
and with time, his voice projection improved and his laryngitis subsided. As time
passed, Alexander noticed that the "dysfunctional" head tilting was not an iso-
lated movement but was coordinated with other dysfunctional patterns through-
out his body, such as lifting the chest, arching the back, and tensing the legs and
feet. 15 Alexander theorized that in each human being, there existed an integrating
mechanism that produced more optimal coordination and functioning. Alexan-
der wrote,
I discovered that a certain use of the head in relation to the neck, and of the head
and neck in relation to the torso and other parts of the organism ... constituted a
primary control of the mechanisms as a whole . .. and that when I interfered with
the employment of the primary control of my manner, this was always associated
with a lowering of the standard of my general functioning. 16
Position and motion of the head and neck are, therefore, the cornerstones of
the Alexander technique. The student of the Alexander technique learns to acti-
vate this primary locus of control in the head and neck and to keep it functioning
during activities of daily living. The instructor's approach is usually to give palpa-
tory as well as verbal feedback as the student learns new positions and movement
patterns. As the student masters new patterns, less palpatory and verbal feedback
is given, until the student can independently achieve proper control patterns. Al-
exander was very experiential and deliberate in his approach, reasoning that, like
music teachers who suggest that their students practice slowly, patterns are best
learned slowly and with positive reinforcement.
The technique involves three stages: (1) awareness of the habit, (2) inhibition of
the habit, and (3) conscious control of the habit. These three stages constitute what
Alexander termed "conscious learning," in that the participant deliberately and
actively tries to change old habits while incorporating new ones.
Awareness of the habit carries great importance in the Alexander technique.
For Alexander, public speaking triggered the dysfunctional patterns. He found
he had difficulty even recognizing the patterns that were so detrimental to his
voice projection. He hypothesized that the brain no longer identified the aberrant
patterns of movement as dysfunctional but rather considered them to be normal.
Simply looking in the mirror to correct an aberrant postural or movement dys-
function was insufficient to change the pattern. Developing an awareness of the
pattern was the first step.
Once Alexander recognized the dysfunctional pattern, inhibition of the move-
ment was necessary, but again, being aware of the pattern was not enough to change
it, because the habit was too well established. He began to speak while consciously
trying to "turn off" the dysfunctional pattern. He then used conscious control to
"inhibit" the dysfunctional pattern and integrate the new one.
Some of these principles are integrated into the sequencing of overall treat-
ment. If a patient exhibits poor posture resulting from myofascial restrictions and
Mode rn Theories and Systems of Myofa scial Manipulation 27
movement imbalances, the clinician can use mechanical approaches to free up the
restriction, allowing the patient to assume optimal posture without undue effort.
If new posture is emphasized too early in the treatment sequence, the patient of-
ten may not have the body awareness or the ability to assume it. The new posture,
then, can increase the patient's original pain and establish a negative reinforce-
ment loop. If the clinician addresses mechanical restrictions and emphasizes body
awareness, the patient becomes aware of the problem, is able to inhibit the old
pattern, and can consciously work toward establishing the new pattern, with more
efficient effort.
Alexander's concepts have been used and expanded by others for working with
head and neck posture in relation to mandibular position. As is widely known,
head and neck posture and movement affect mandibular position and function;
the Alexander technique aptly applies to the evaluation and treatment of temporo-
mandibular joint (TMJ) disorders. Whether used for treatment of TMJ, neck, or
other spinal dysfunctions, the Alexander technique merges logically with the au-
tonomic and mechanical approaches in helping myofascial dysfunctional patients
achieve desired changes.
Feldenkrais Method
The Feldenkrais approach seeks to retrain the body away from aberrant movement
patterns into more efficient ones. Moshe Feldenkrais, DSc, was a versatile Israeli
engineer, physicist, and athlete. He participated in soccer and judo, but a persis-
tent knee injury resulting from soccer play led him to explore human movement
from an engineering perspective. His movement approach is based on the idea that
movement abnormalities occur in response to past trauma, rendering one more
susceptible to reinjury. His approach is designed to help the body reprogram the
brain to integrate the whole mind - body entity.
The Feldenkrais method has two basic approaches, separated only for conve-
nience. The first is an experiential approach, termed "Awareness Through Move-
ment," 17 in which the patient receives a series of verbal commands designed to
weaken old movement patterns and to establish new ones. The second is a hands-
on approach termed "Functional Integration." 18 Feldenkrais disliked separating
the two, especially if
the distinction is made that one is for "sick" or "brain damaged" people, and the
other is for "normal, healthy" people. Which of us, after all, is not brain damaged
in the sense that we allow many areas of our brains to atrophy through misuse or
nonuse? We can have terrible posture and movement patterns and habits which
are distorting and damaging to our bodies and brains and still be classified as
"normal." Who are we, then to call other people brain damaged simply because
their particular deficiency produces visible effects that we label" disease" ?19
The idea that all persons exhibit some abnormal movement either from previ-
ous trauma or old habit patterns is a cornerstone of the Feldenkrais method. As
28 HISTORICAL DEVELOPMENT AND CURRENT THEORIES
with the Alexander technique, gentle sequences of movement allow for slow, delib-
erate changing of abnormal, inefficient movement patterns into normal, efficient
movements.
Conclusion
Examples of the three types of approaches (autonomic, mechanical, and move-
ment) described in this chapter merge well with the philosophy and scheme of
treatment presented in this book As later chapters illustrate, the sequencing of
treatment that we recommend includes beginning superficially with a manual ap-
proach and working gradually into deeper tissues. Once the clinician has accessed
and affected deeper tissues, limitations within the joints can be examined and/
or treated. The clinician can then work to elongate the structures that have be-
come facilitated. When optimal length and mobility are established, the focus is
on neuromuscular reeducation, using a variety of strengthening or motor control
techniques to prevent recurrence. Eventually postural integration should be im-
plemented. The progression from a light manual approach (autonomic) to a deep
manual approach (mechanical) and then to an emphasis on movement and pos-
ture (movement approach) is the key to complete treatment.
References
1. Dicke E, Schliaek H, Wolff A. A Manual of ReflexiveTherapyof the ConnectiveTissue.Scarsdale,
NY: Sidney S Simon Publishers; 1978.
2. Ebner M. ConnectiveTissueManipulation. Malabar, FL: Robert E. Kreiger Publishing Co; 1985.
3. MacKenzie J. Angina Pectoris.London: Henry Frowde and Hodder and Stroughton; 1923.
4. Tappan F, Benjamin P. Tappan'sHandbookof HealingMassageTechniques:Classic,Holistic,and
EmergingMethods. 3rd ed. Stamford, CT: Appleton and Lange; 1998.
5. Hoffa A. Technickder Massage.14th ed. Stuttgart, Germany: Ferdinand Enke; 1900.
6. Bohm M. Massage:Its Principlesand Technique.Philadelphia, PA: WB Saunders; 1913.
7. Rolf I. Rolfing:Re-establishingthe Natural Alignment and StructuralIntegrationof the Human
Bodyfor Vitality and Well-Being.Rochester, VT: Healing Arts Press; 1989.
8. Rolf I. Rolfingand PhysicalReality.Rochester, VT: Healing Arts Press; 1990.
9. Rolf I. Rolfing:The Integrationof Human Structures.Rochester, VT: Healing Arts Press; 1977.
10. Juhan D. The Trager approach - psychophysical integration and mentastics. The TragerJour-
nal. 1987;Fall:1.
11. Trager M. Trager psychophysical integration and mentastics. The TragerJournal. 1982;Fall:5.
12. Witt P. Trager psychophysical integration: an additional tool in the treatment of chronic spi-
nal pain and dysfunction. Whirlpool. Summer 1986.
13. Manheim C. The Myofascial ReleaseManual. 4th ed. Thorofare, NJ:SLACK;2008.
14. Adler S, Beckers D, Buck M. PNF in Practice:An Illustrated Guide. 3rd ed. Heidleberg, Ger-
many: Springer Medizin Verlag; 2008.
15. Rosenthal E. The Alexander technique: what it is and how it works. Med Prob/Perform Art.
1987;June:53- 57.
Modern Theor ies and Systems of Myofascia l Manipulation 29
Scientific Basis
for Myofascial Manipulation
Histology and Biomechanics
of Myofascia
Rob ert I. Ca ntu and Rob ert W. Sta nbo rough
The auth ors gratefully ackn owledge the contributions of Deborah Cobb to earlier versions of this chapter.
33
34 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
connective tissues, ligaments, and fascia. The joint itself is simply a space between
two articulating surfaces that allows for movement and that is guided, and some-
times limited, by the connective tissue surrounding the joint.
This chapter begins with a review of the scientific literature related to normal
histology and the biomechanics of connective tissue. Although much of the bench-
mark research dates from earlier in history, it is still accurate and consistent with
more recent research. This information lays the groundwork for an understanding
of how trauma, immobilization, and remobilization affect the connective tissues.
Histology
The four basic types of tissue found in the human body are muscle, nerve, epi-
thelium, and connective tissue. 2 Connective tissue is subclassified into connective
tissue proper, cartilage, and bone. Connective tissue proper is further subclassified
by orientation and density of fiber types. 5 The three basic connective tissue types
are dense regular, dense irregular, and loose irregular (Figure 3.1).5 These tissue
Ground Fibroblast
Eosinophil Substance · Neulrophil..,..._,- Masi cell Lymphocyte Plasma Cell
Figure 3.1 A diagrammatic reconstruction of loose connective tissue showing the characteristic cell
types, fibers, and intercellular spaces. Source: Reprinted from Gray's Anatomy, ed. 35 (p. 32) by R. Warwick
and P. L. Williams with permission of Elsevier, © 1973.
Histology and Biomechanics of Myofascia 35
types are described in detail later in this chapter (see "Biomechanics of Connective
Tissue").
Fibroblasts. Fibroblasts, considered the true connective tissue cells, are the most
prevalent in connective tissue. These cells are the primary secretory cells in con-
nective tissue and are responsible for the synthesis of all components of connec-
tive tissue, including collagen, elastin, and ground substance. They adhere to and
lay down the fibers. In highly cellular tissues, fibroblasts may mix with collagen
fibers to become reticular cells. 3•4 In mature stable connective tissue, fibroblasts
36 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
are converted into fibrocytes, which are mature, nonsecretory versions of the fi-
broblast. Fibroblasts and fibroblastic activity are influenced by various factors, in-
cluding mechanotransduction, steroid hormone, and dietary content. Fibroblasts
are nonphagocytic.
Myofibroblasts. Myofibroblasts are cells that have the ability to contract. Dur-
ing wound healing, myofibroblasts use their actin and myosin to draw the dam-
aged tissues together. Although their contractile abilities are often beneficial,
they can also result in pathological responses within connective tissue, such as in
Dupuytren disease.
Myofibroblasts are found in both fascia and intramuscular connective tissue.
They exist in particularly high densities within the perimysium and are thought
to play a role in passive muscle stiffness or resting tension. Myofibroblast-induced
stiffness is "U-shaped" in that it responds similarly to mechanostimulation of ei-
ther high stresses or the absence of stress .7The thickening effects are seen as early
as 2 days after a muscle is immobilized in a shortened position 8 (see Chapter 4,
"Histopathology of Myofascia and Physiology of Myofascial Manipulation").
Macrophages. Other types of cells, not exclusive to connective tissue, are found
primarily in traumatized or infectious states. Macrophages (a term meaning "big
eater") are responsible for phagocytosing waste products, damaged tissue, and for-
eign matter. In traumatized states, macrophages primarily phagocytose damaged
cells and damaged macromolecular connective tissue fibers, debriding the area
in preparation for repair. In infectious or inflammatory states, macrophages are
capable of phagocytosing bacteria or other invading microorganisms. 3•4 Macro-
phages may be the signal for vascular regeneration to begin.
Mast cells. Mast cells were given their name because they appeared "stuffed with
granules" (mast is German for "well fed"). They are mobile and are important de-
fensive cells, which are formed primarily in loose connective tissue. Mast cells are
responsible for constantly secreting small amounts of the anticoagulant heparin
into the bloodstream. The significance of this is still not known. 6 The disruption
of mast cells also results in the release of histamine. Within the mast cell granules,
histamine is bound to heparin. Histamine causes vasodilation in neighboring
noninjured vessels, resulting in increased permeability. The release of histamine is
linked to inflammatory reactions, allergies, and hypersensitivities. 1- 6
Mast cells can be hypersensitized by certain antigens introduced into the body,
facilitating cell production of histamine, 2 which may explain why individuals with
numerous allergies and diffuse myofascial pain can have an increased histamine
response to soft tissue manipulation. Plasma cells are somewhat related to mast
cells in that they are present primarily during infectious states. They are part of the
immune system and are responsible for synthesizing antibodies.
Other connective tissue cells. With the exception of the fibroblast and fibrocyte,
all other cells found in connective tissue are also related to the reticuloendothelial
Histo logy and Biomechan ics of Myofasc ia 37
Figure 3.2 Photomicrograph of loose connective tissue. The connective tissue fibers lie in a bed of ground
substance. c = collagen; e = elastin; f = fibroblast. Source:Reprinted from Histology (p. 212) by A. W. Ham
and D. H. Cormack with permission ofJ. B. Lippincott Co.,© 1979.
Collagen is divided into four major types: Type I is found primarily in ordi-
nary loose and dense connective tissue; Type II is found primarily in hyaline car-
tilage; Type III is found lining the fetal dermis; and Type IV is found in basement
membranes. Manual therapy techniques are most likely to affect Type I collagen.
The characteristics of each type are described later.
Elastin fibers are less tensile than collagen and have more elastic characteris-
tics. The lining of arteries contains a high percentage of elastin. The ligamentum
nuchae of the spine also contains a high percentage of elastin. 9•10 Reticulin is the
least tensile of the connective tissue fibers; it is found primarily in the delicate
meshwork supporting the body's internal organs and glands.
Another important component of connective tissue is ground substance. This
is the viscous, hydrophilic, gel-like medium in which the cells and fibers are em-
bedded. Ground substance has several primary functions. It contains a high pro-
portion of water, and this accounts for the first of its primary functions-diffusion
of nutrients and waste products. A second function of the ground substance is
to provide a mechanical barrier against invading bacteria and microorganisms.
Connective tissue cells, being part of the reticuloendothelial system, provide the
first line of defense against invading organisms. A third function of ground sub-
stance is to maintain the so-called critical interfiber distance. Collagen fibers that
approximate one another can potentially adhere together if a certain distance is
not maintained between them. The ground substance, which provides some of the
tissue volume, can effectively maintain the distance between fibers, preventing
microadhesions and maintaining extensibility. Ground substance content in con-
nective tissue seems to decrease with age, possibly contributing to a decrease in
flexibility with aging.
The primary components of ground substance are glycosaminoglycans (GAGs)
and water. GAGs are also referred to as "acid mucopolysaccharides" in the older
literature. GAGs are either sulfated or nonsulfated. The nonsulfated GAGs, such as
hyaluronic acid, are hydrophilic and bind to water, which makes up approximately
70% of the total connective tissue content. 3- 5
Hyaluronic acid, which has long been used to help restore joint function in
the veterinary world, has received Food and Drug Administration approval for
use in the injection of human joints. Chondroitin, which is another component
of ground substance, is sold in alternative medicine settings, purportedly to help
joint function. The idea of using nonhormonal components of connective tissue to
help restore the tissue is a budding idea that may have a significant impact on the
long-term treatment of injured or arthritic joints.
Biosynthesis of Collagen
Collagen synthesis begins in the fibroblast by the absorption of amino acids into
the cell. In the rough endoplasmic reticulum of the cell, the amino acids are syn-
thesized into polypeptide chains. From the polypeptide chains, protocollagen (or
procollagen), a precursor of collagen, is synthesized. Strands of protocollagen are
linked in a triple helix in the cell to form strands of tropocollagen. Tropocollagen,
Histology and Biomechanics of Myofa scia 39
Synt es s o'
round m~ opolysaccha• .es
ubsta 1 olg apparatu,
an• .i~d t c to r te n
l Aminoacids including
praline and lysine
8 Aggregationof collagen
fibrils t o form Assembly of
collagen fibres
2
polypept ide chain
and bundles of fibres
7 Aggregation of
tropocollagen to
form collagen fibrils
3 Hydroxylation of
prol1ne and lysine
in polypeptide chain
•
"
-.r -
J
2.80"•
6 Passageof tropocollagen
to extracellular space 4 Assembly of three
hydroxylat ed
polypeptidechains
5 Addition of
into one
carbohydrate moiety
tropocollagen molecule
Figure 3.3 A schemati c dra wing representing the biosynthesis of collagen by fibroblasts. Source: Reprinted
from Gray's An atomy, ed. 35 (p. 38) by R. War wick and P. L. Williams with permissi on of Elsevier, © 1973.
which is the molecular unit of collagen, is then passed through the cell membrane
into the interstitial spaces. In the extracellular space, tropocollagen strands are
linked in series and in parallel in a quarter-stagger arrangement to form collagen
fibrils (Figure 3.3). Initially, the tropocollagen molecules are hydrostatically at-
tracted to each other and form hydrostatic bonds. Eventually, the collagen matures
and the weak hydrostatic bonds are converted to stronger covalent bonds. 11
To review briefly, hydrostatic bonds are those in which polarized molecules, or
molecules of different polarities, are attracted and weakly bonded to one another.
Covalent bonds are those in which the two bonding atoms bind with a shared elec-
tron. The energy required to break a covalent bond is much greater than the energy
required to break a hydrostatic bond . This accounts for the increasing strength of
collagenous tissue during maturation. Collagen fibrils eventually band together
to form collagen fibers. The configuration of mature collagen can be likened to
the structure of common rope . Small strands intertwine to form threads, threads
intertwine to form larger strands, and so forth (Figure 3.4).
40 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
TROPO-
MICROFIBRIL SUBFIBRIL FlBRIL FIBER
COLLAGEN
(x ray) (x ray) (x ray) (EM, SEM)
(x ray)
(EM) (EM) (EM, SEM) (OM)
•.h ..
35nm
staining periodicity
fibroblasts
SIZE SCALE
Figure 3.4 Architectural hierarchy of dense regular connective tissue, from the tropocollagen molecule
to the collagen fiber. Source:Adapted with permission from J.Kastelic, A. Galeski, and E. Baer, The Multi-
composite Structure of Tendon, Connective Tissue Research (1978;6:11-23). Copyright© 1978, Gordon and
Breach Science Publishers.
Plastic Region
Point of Failure
s Point of Yield
T
R
E
s
s Elastic Region
STRAIN
Figure 3.5 Stress- strain curve.
Collagen Tendons
fibers Ligamen ts
(A) + Connective Joint capsules
Grou nd tissue Aponeuroses
substance Fascia
matrix etc .
(B)
Tensile
Hydraulic cylinder model forc.e
(C)
Tensile
Spring model force
I
I
1twlW1► I•
( D) I Tensile
I force
I
I
Elastic I Viscous
elements I elements
I
Figure 3.6 (A) The primary and secondary organization of connective tissue in the bod y. (B) Schematic
representation of a viscous element in material capable of permanent (plastic) deformation. (C) Schematic
representation of an elastic element in material capable of reco verable (elastic) deformation. (D) A simpli -
fied model of collagenous tissue. Connective tissue is a viscoelastic material: When stretched, it behaves as if
it has both viscous and elastic elements connected in series. Source:Reprinted with permission from Sapega
AA, Quedenfeld TC, Moyer RA, Butler RA. "Biophysical Factors in Range -of-Motion Exercise. " The Physi-
cian and Sports Medicine, Vol. 9, No. 12, p. 58, © 1981, McGraw -Hill Companies.
Histo logy and Biomechan ics of Myofasc ia 43
'\
Stress Reapplied
Figure 3. 11 (A) Elongation of connective tissue (strain) plotted against time. (B) Repeated elongations
of connective tissue (strain) plotted against time. Source:Reprinted from Myofascial Manipulation: Theory
and ClinicalManagement (pp. 5- 6) by A. J.Grodin and R. Cantu with permission of Forum Medicum Inc.,
© 1989.
some range is lost due to the elastic component, but some is retained due to the
plastic component.
Although the plastic component represents a permanent elongation, connec-
tive tissue is still capable of losing the elongation. The half-life of collagen is 300 -
500 days in mature nontraumatized conditions. 21 Over time, new collagen is laid
down to replace older collagen. New collagen is laid down according to stresses (or
lack of stresses) applied to the tissue. If the tissue is not stressed for long periods of
time, it will adaptively shorten as collagen is laid down in the context of the length
of the tissues and lack of applied stress. Wolff's law, which states that "bone adapts
to the stresses applied," 10 is also true of connective tissue. All connective tissue
seeks metabolic homeostasis commensurate with the stresses being applied to it.
Wolff's law, however, when applied to connective tissue, has a functional as well
as a dysfunctional aspect. Abnormal stresses chronically applied to connective tis-
sues may result in dysfunction in the tissues and the adjacent structures supported
by that tissue (fascia, facet joints, etc.). A clinical example of this phenomenon
is the connective tissue band that develops in the patient with spondylolisthesis.
Because the spine in this condition cannot withstand the anterior shear forces ap-
plied daily, the body responds by laying down connective tissue, in time forming a
connective tissue band. Normal stresses, or carefully controlled stresses (i.e., those
stresses imparted externally by the clinician in the form of manipulation or by the
patient in the form of exercises), may positively change the metabolic and physi-
cal homeostasis of the tissue. Collagen production is thus less haphazard, more
organized, and laid down in a quantity and direction more suited to optimal tissue
function. This concept is more fully developed in Chapter 4, "Histopathology of
Myofascia and Physiology of Myofascial Manipulation."
46 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
Specific Characteristics
Various types of connective tissue have spe-
cific characteristics. Such characteristics
support the function of each type.
deep fascia, as well as muscle and nerve sheaths. The supportive framework of the
lymph system and the internal organs is also classified as loose irregular connec-
tive tissue . Loose irregular connective tissue is generally characterized by a sparse,
multidirectional framework of collagen and elastin. Loose irregular connective
tissue contains a greater amount of ground substance per unit area than other
types of connective tissues. Because of sparse concentrations of collagen in this
type of tissue, loose irregular connective tissue is the most elastic and typically has
the greatest potential for change when manipulated by external forces.
Contractility of connective tissue. Connective tissue has long been viewed as in-
active or inert tissue. Its role was primarily thought to be tissue containment, pro-
viding structure and stability to neighboring tissues and joints. Although all its
functions are not yet completely understood, research suggests that fascia also has
an active role through myofibroblast contraction. 27•28
Such contractions are unique, in that they can produce a shortened collagen
matrix, which results in long-term changes without an ongoing contraction. 29
Contraction of collagen matrix or connective tissue may contribute, particularly
in the low back, to vertebral stability or harm by becoming stiff and preventing
freedom of movement. Shortened tissue locks the collagen in an interstitial and
incremental manner as collagen fibrils slip past one another and then relink, much
like a ratchet turns and resets while tightening a bolt. 29
Myofibroblasts are derived from fibroblasts, the most common cell found in
connective tissue. They are responsible for the synthesis of collagen, elastin, reticu-
lin, and ground substance. Fibroblasts are usually protected or "stress-shielded"
within the extracellular matrix. When an injury occurs, or when tissues are ex-
posed to excessive ongoing stress, their protection can be jeopardized. As a result,
they differentiate into myofibroblasts through a two-step process. 29 Two principal
factors are required for this transformation to take place: (1) transforming growth
factor /31 (TGF-/31) and (2) mechanical stress, the latter being the primary fac-
tor. 30 TGF-/31 is produced by platelets, macrophages, parenchymal cells, or injured
epithelial cells. Fibroblasts first differentiate into proto-myofibroblasts by forming
cytoplasmic actin-containing stress fibers. If continually exposed to both TGF-/31
and mechanical stress, the proto-myofibroblasts further differentiate into a myo-
fibroblast, gaining the distinct ability to contract. 31 This process has long been
known and is most often seen during tissue repair.
The contractility of the myofibroblast is due to an inherent contractile appa-
ratus consisting of actin microfilaments and nonmuscle myosin. 29 Myofibroblasts
are identified in tissue by their expression of a-smooth muscle actin (a-SMA),
which is a common and reliable molecular marker. 32•33
Myofibroblasts are known to be present and active in granulation tissue as
part of a mechanotransduction system, whereby forces are transmitted from the
myofibroblasts themselves to the surrounding extracellular matrix. 31 This system
is so extensive that it has been suggested that fibroblasts, myofibroblasts, and their
Histology and Biomechan ics of Myofasc ia 49
Connective tissue plasticity. If connective tissue, or at least fascia, has the ability
to contract or develop a contracture, does it have the capacity to return to a re-
laxed state? If so, how? If not, does it remain shortened similar to muscle, thereby
restricting motion, impeding function, or causing pain and pathology?
A number of pathological conditions can result in such limitations, including
Dupuytren disease 39 and, some have suggested, frozen shoulder. 40 •41 Patients with
chronic low-back pain also experience nonpathological changes. 42 Langevin et al.
found, on average, a 25% greater perimuscular connective tissue thickness in the
lumbar region (L2/L3) in subjects with chronic low-back pain than in a group
without low-back pain.
Rolf explained connective tissue changes based on the gel-sol principle and
piezoelectric effect. Rolf explained that tissue, as a colloidal substance, can func-
tion in two different forms: a gel and a sol.43 The gel state is thick and dense. Heat
or a mechanical stimulus can be used to make the gel more fluid or soluble (sol).
Juhan uses the term thixotropy to describe the viscous transition from gel to sol.44
Ketchup is a familiar thixotropic substance; it is often found in a more gelatinous
state, especially if left unused for a period of time, but it can quickly be made a sol
by shaking the bottle. Within connective tissue, the piezoelectric principle results
in increased mobility of tissue as pressure that is applied to tissues disrupts the
balance of charges, stimulating fibroblasts to produce collagen. 45 Although these
explanations clarify the long-term changes produced by soft tissue manipula-
tion, they do not adequately account for the short-term changes experienced dur-
ing a single treatment session. Schleip et al. suggest that such early changes are
produced via a neurophysiological response. Ruffini organs and interstitial mus-
cle receptors, better termed interstitial myofascial receptors,are the key to such
changes. 38
Both Ruffini organs and interstitial receptors (Types III and IV) are found
within connective tissue. They respond to slow, deep, steady pressure delivered in
a tangential direction. Manual stimulation produces changes in tone, vasodilation,
and local fluid dynamics (plasma extravasation) via the autonomic nervous system.
This process has been described as an "intrafascial circulation loop" (Figure 3.15).
Short-term and long-term soft tissue changes produced by myofascial manip-
ulation seem to include several combined processes. Among these are an intrafas-
cial circulation loop, regulation of the hypothalamus and central nervous system
(not discussed here), and the contractility of connective tissues (Figure 3.16).
Local fluid
dynamics Interstitial & Ruffini
Autonomic
nervous system
Figure 3.15 The "intrafascial circulation loop" (based on Mitchell & Schmid, 1977). Fascia is densely in-
nervated by interstitial tissue receptors. The autonomic nervous system uses their input (plus that of some
Ruffini endings) to regulate local fluid dynamics in terms of an altered blood pressure in local arterioles and
capillaries plus in plasma extravasation and local tissue viscosity. The change might then be felt by the hand
of a sensitive practitioner. Source:Reprinted from Journal of Bodywork and Movement Therapies,Vol. 7
No. 2, Schleip, R., Fascial Plasticity - A New Neurobiological Explanation: Part 2, p. 105. Copyright© 2003,
with permission from Elsevier.
lntrafascial Autonomic
smooth muscle cells nervous system
Figure 3. 16 The "Fascial Contraction Loop" (based on Yahia and on Staubesand). Embedded between
the collagen fibers of fascia are smooth muscle cells, which are regulated by the autonomic nervous system.
Their activation can cause an active intrafascial tissue contraction. Source:Reprinted from Journal of Body-
work and Movement Therapies,Vol. 7 No. 2, Schleip, R., Fascial Plasticity - A New Neurobiological Explana-
tion: Part 2, p. 109. Copyright© 2003, with permission from Elsevier.
repeatedly using fully dissected muscles, where forces at the proximal and distal
ends have been found to be equal. 46 - 49 Although fascia is believed to assist in hin-
dering movement, until recently, it has not been clear whether fascia plays any role
in force transmission. The assistance of fascia in force transmission is now known
to be significant. If fascia did not assist with movement, the forces required to pro-
duce body movements would be so enormous that much of the musculoskeletal
system's efficiency would be lost.
52 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
As muscles generate force or the body responds to outside forces, the fascia and
connective tissue act as an energy broker. Fascia absorbs chemical or mechanical
energy, temporarily stores it in the form of potential energy, and redistributes it
kinetically. The role of fascia as a force transmitter can be seen throughout simple
ambulation. Ambulation is initiated by a concentric contraction, but it quickly
becomes a function using primarily a combination of eccentric contractions and
connective tissue transmission for the purpose of efficiency. As the foot hits the
ground and the center of gravity moves over the foot, energy is absorbed, stored,
and reused through connective tissue. The actual force production by the muscle
is thereby reduced significantly.
When tissues become restricted and more rigid, their ability to absorb energy
lessens. Muscles therefore have to work harder to produce mechanical energy as
potential energy is lost. This can be likened to the potential energy lost while try-
ing to run on soft sand: Muscles are required to generate more energy to create
motion. Each step requires an extra concentric effort to pick up the legs and keep
them moving forward, because the kinetic energy is lost in the give of the sand.
This energy model is called the "legs carry trunk model."
When connective tissue is mobile, the system is much more efficient. Graco-
vetsky describes this more efficient model as the "spine engine" model 50 •51 Based
on his model, as the foot hits the ground, eccentric contractions are produced to
control forward movement and prevent falling. The viscoelastic qualities of con-
nective tissue allow it to absorb ground reaction forces through the lower extrem-
ity connective tissue, even reaching the spine to produce rotation. A contraction
of the gluteus maximus, along with the swing of the opposite arm, preloads the
thoracolumbar fascia, preparing it to further absorb ground reaction forces as
potential energy. 52 As the forces transmit through the connective tissue, they are
eventually released as kinetic energy as the thoracolumbar fascia springs back, re-
versing the rotation of the spine and initiating opposite hip flexion and arm swing,
creating a pendulum effect. 52
Fascia, as a continuous tissue, has been shown to be a force transmitter in a
number of animal studies. Force is transmitted through fascia via intramuscular,
intermuscular, or extramuscular force transmission. In intramuscular force trans-
mission, force is transmitted within the muscle from the endomysial - perimysial
fascial network onto adjacent fibers. 53 - 55 In intermuscular force transmission,
force is transmitted through the connective tissue between the neighboring mus-
cles.56·57 In extramuscular force transmission, force is transmitted through vari-
ous connective tissues, such as compartmental fascia or general fascia/connective
tissue surrounding blood vessels or nerves. 48 •55 •58 - 61 The influence of these fascia
connections is such that passive changes in length and active forces measured at
the proximal and distal portions of the muscle are not equal. 62- 64 Additionally,
although performed on animals, several studies have shown that fascial connec-
tions are significant enough to affect both synergistic and antagonistic related
muscles. 48,59,65,66
Histology and Biomechan ics of Myofasc ia 53
Similar results have been shown in human studies. Smeulders et al. showed
how critical the intermuscular connections are by measuring the active and pas-
sive length-force characteristics of the flexor carpi ulnaris (FCU). 67 While per-
forming an FCU transposition in children with cerebral palsy, Smeulders et al.
were able to measure the length-force of the FCU at specific points of dissection as
the muscle separated from its surrounding fascial connections. Kreulen et al. used
this method of measurement to determine the biomechanical effects of dissect-
ing the FCU. 68They measured the length of the FCU before and after dissection.
While keeping the wrist in neutral (0° flexion), they measured the length of FCU
while intact (221 + 36.2 mm), after tenotomy from the pisiform (216 + 37.7 mm),
and following the dissection of the muscle belly (204 + 36.9 mm) from its sur-
rounding fascia connections. The dissected muscle shortened significantly further
(196 + 36.3 mm) following an electronically stimulated tetanic contraction.
Passive excursion measurements were also taken before and after dissection. 68
Measurements were taken to compare the passive movement of maximal wrist
flexion and maximal extension. With the muscle and tendon intact, the difference
noted was 18.0 + 4.0 mm. After tenotomy, the excursion measured 16.0 + 3.8 mm
(89% of the original excursion despite the tendon being cut). Finally, after com-
plete dissection, the maximal passive wrist flexion/extension excursion measured
2.0 + 1.9 mm (11%of the original excursion).
De Bruin et al. also measured the flexion torque of the FCU during a simi-
lar dissection. 69While performing an FCU transposition in eight patients, they
measured the isometric torque under the same conditions examined above: before
tenotomy, after tenotomy of the distal tendon, and after dissection of the muscle
belly from its fascia connections. The wrist flexion torque decreased, on average,
to 80% following tenotomy and decreased further to 59% following complete dis-
section. A decrease between an intact tendon and tenotomy would certainly be ex-
pected, but the 21% difference between tenotomy and dissection further suggests
that myofascial connections are significant force transmitters.
Kawakami and colleagues have examined the influence of fascia connections
by using ultrasound to measure fascicle lengths during contractions. Longitudinal
ultrasonic images were taken of the tricep surae muscles (medial gastrocnemius,
lateral gastrocnemius, and soleus) in 12 different positions (15° dorsiflexion, 0°,
15°, and 30° plantarflexion, each with the knee in 0°, 45°, and 90° knee flexion). 70
Fascicle lengths were measured between the superficial and deep aponeuroses. The
fascicle lengths were longest when the ankle joint was positioned in 15° dorsi-
flexion with 0° knee flexion and shortest when positioned in 30° plantarflexion
with 90° knee flexion. These measurements were used as a platform to investigate
the role of muscle versus connective tissue in function. Fukunaga et al. exam-
ined the force transmission roles of muscle and connective tissue during ambula-
tion. 71 The researchers measured the lengths of muscle fascicles during toe-off,
swing, heel strike, and double/single support phases of the walks of six healthy
male volunteers (age 25 + 3 years, height 169 + 3 cm, body mass 69 + 8 kg). The
54 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
Histology
Muscle is histologically categorized into three types: skeletal, smooth, and cardiac.
This section focuses primarily on skeletal muscle. Skeletal, or striated, muscle is so
named because of its banded appearance under light microscopy. The striations
reflect the functional contractile unit of the muscle, called the sarcomere.Muscle
is also functionally characterized by fiber type, based on speed of contraction or
relaxation, biochemistry and metabolism, and circulation.
**
***:*.
*->!<;**: •
•
•
•
•
•
•
•
• • • •
•
• •
***:* • • • •
• • • • •
** • •
I
I "4;
I
I
•• I
/
I / Ill
111
'
/ 111
-... 111
,
M
• • '
z
111
•..•
'-..--J
H Sarcomere
A I
Figure 3.17 Diagram showing the organization of skeletal muscle and the mechanism of shortening.
Source:Reprinted from Gray'sAnatomy, ed. 35 (p. 479) by P. Williams and R. Warwick with permission of
Elsevier, © 1973.
56 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
I
I filaments. Myofilaments are arranged in
;,
bundles and are contained in the myofibril,
which is the muscle's cellular unit. Each
myofibril is surrounded by loose connective
tissue called the endomysium. Myofibrils
j
'
I
I
are multinucleated cells that also contain
I
Biomechanics of Muscle
The connective tissues of skeletal muscle
have important roles in the optimal func-
Myosin
tion of muscle. These connective tissues
provide a certain amount of coherence in
the muscle while allowing an appropriate
.
Actin
•. • •. • .• ....
•,..
•
degree of mechanical freedom. The con-
nective tissue layers also serve to carry the
erarchy of muscle tissue. Source: Reprinted from blood supply to the tissue and ramify to
Gray's Anatomy, ed. 35 (p. 481) by P. Williams and form a rich capillary network in the muscle
R. Warwick with permission of Elsevier,© 1973. fiber.26 Additionally, they allow the penetra-
tion of nerves along with this blood supply
to provide for diffusion of nutrients and
ions as necessary for muscular metabolism and excitation. 3 The endomysium is
particularly significant in these roles, because it most closely approximates the in-
dividual muscle fibers. Perimysium is thought to provide both a cushioning effect,
through force transmission, and a stiffening effect, particularly in tonic muscles,
Histology and Biomechanics of Myofascia 57
Functional Functional
Fiber type classification Metabolic characteristics characteristics
Type I Slow twitch High concentrations of myo- Slow contraction
globin, increased numbers of times, fatigue
mitochondria, low content of gly- resistant
cogen, oxidative metabolism
Type Ila Fast twitch/ Moderately high concentrations Faster contraction
oxidative of myoglobin, increased numbers times than Type I.
(fast red) of mitochondria, glycolytic/ less fatigue
oxidative (mixed) metabolism resistant
Type llb Fast twitch/ High glycogen content, gly- Fast contraction
glycolytic colytic metabolism, decreased times, fatigues
(fast white) numbers of mitochondria easily
Type llm Superfast Contains unique myosin configu- Very fast contraction
ration, high glycogen content, times
lycolytic metabolism
58 SCIENTIFIC BASIS FOR MYO FASCIA L MAN IPULATION
more susceptible to strain injuries. The most common site of those injuries is at the
musculoskeletal junction. 26
being fully loaded by the rest of the sarcomeres in the muscle belly. More signifi-
cantly, the decreased extensibility of the terminal sarcomeres also makes the tissue
in this area more vulnerable to tearing, as evidenced by the frequency of injury in
the experimental models. 94•95 The clinical implications are discussed further in
Chapter 4.
'•
.~~
I
• ..
'-
A
-
•
• - -
•
•
• • • •
. ' "' . •
•
•
r ,.
, •
• ..
•
• -
-
.. •
B
Figure 3.19 (A) Direct insertions. The four distinct zones seen in the supraspinatus insertion. The four
zones are tendon (T), uncalcified fibrocartilage (FC), calcified fibrocartilage (C-FC), and bone (B). Blood
vessels (BY) are absent from the fibrocartilage zones. The tidemark (TM) between the calcified and un-
calcified zones of articular cartilage (AC) is continuous with that at the insertion of the tendon. Source:
Reprinted with permission from M. Benjamin, E. J.Evans, et al., The Histology of Tendon Attachments to
Bone in Man, Journal of Anatomy, No. 149, pp. 89- 100, © 1986, Cambridge University Press. (B) Femoral
insertion of rabbit medial collateral ligament. The deep fibers of the ligament (L) pass into bone through the
fibrocartilage (F). The arrow indicates the line of calcification. Source:Reprinted with permission from S.-Y.
Woo, M. A. Gomez, et al., The Biomechanical and Morphological Changes in the Medial Collateral Liga-
ment of the Rabbit After Immobilization and Remobilization, Journal of Bone & Joint Surgery,Figure 6-A,
Vol. 69A, p. 1207, © 1987,Journalof Bone & Joint Surgery.
Histo logy and Biomechan ics of Myofasc ia 61
across all members. Geodomes are examples of such structures. The second type,
developed by Kenneth Snelson, involves compression-resistant structures and
tensile-resistant structures that are organized in a way that prestresses them. The
compression-resistant structures stretch or tense the structures of tensile resis-
tance, and the tensile-resistant structures compress the compression-resistant
structures. Each balances out the other, producing continuous tension and local
compression. The benefit of the latter is that it provides both strength and move-
ment and can be applied to nature and to the entire human body. For example, as
a sculptor, Fuller created numerous self-standing structures that appear to float or
to defy gravity. Some mimic the shape of a swan's neck.
Geodesic forms or spherical shapes composed of interconnecting triangles are
found throughout nature. Structures such as carbon atoms, viruses, enzymes, or-
ganelles, cells, and small organisms are stabilized by having interconnecting sides,
as a way of minimizing energy and mass while maximizing structural integrity.
Cells rely on the principle of tensegrity to maintain a delicate balance between
mobility and strength. The cytoskeleton of each cell can provide both mobility and
strength, because it is composed of an internal framework. The cytoskeleton has
three different types of molecular protein polymers: the microfilament, intermedi-
ate filament, and microtubules. 102 Altering the mechanical forces across the cyto-
skeleton can cause biochemical reactions and can alter the genetic programs of a
cell.103, 104 Cells spread flat are more likely to divide, cells that have no force on them
or that are prevented from spreading activate apoptosis, and cells with mid-range
forces (not too extended or retracted) neither divide nor die. Instead, they differen-
tiate into specific tissues. 105 In essence, force directs the function of the cell. If cells
are stretched, as they are by the myofibroblasts during wound healing, the signal is
clearly to divide and produce more cells. If cells are plentiful, as in the end stages of
remodeling, forces are reduced. The reduction causes the cells to become rounded
and die. Somewhere in between is homeostasis, with mid-range forces, and cells
can differentiate for the purpose of normal tissue function.
Cells make up tissues that provide specific functions or make up organs. Tis-
sues such as the skin perform either specific or a variety of functions during which
they experience force changes. Linear stiffness keeps the tissues intact and can
prevent tissue damage. When skin is pulled, resistance will be felt at some point. It
is thought that more tensegrity "members" line up in the direction of the applied
stress, which determines the stiffness of the tissue. 106•107 Up to a certain point, tis-
sues are able to temporarily deform, but they will eventually change their nature
as a response to sustained forces. Such changes result from prolonged postures due
to sitting, standing, or other static positions. Likewise, linear stiffness or linear
resistance is most likely the force responsible for absorption, storage, and reuse of
the loading forces produced during ambulation as an effort to conserve energy and
provide efficiency of movement.
The principle of tensegrity is clear to see on a macroscopic scale of the hu-
man body. The compression-resistant bones pull up against gravity and yet remain
Histology and Biomechan ics of Myofasc ia 63
Conclusion
The information covered in this chapter serves as an overview of the scientific re-
search available regarding soft tissue. A thorough understanding of basic anatomy
and biomechanics is necessary for the manual physical therapist to be successful
in treatment of the myofascial tissues. Additionally, an understanding of the fluid
qualities of connective tissue, as well as its ability to act as a force transmitter via
the principles of tensegrity, assists the therapist to set realistic goals for manual
treatment. Knowledge of these concepts also is helpful with patient education, be-
cause they can easily be described in lay terms.
As the evidence regarding soft tissue and myofascial manipulation expands,
the pieces of the puzzle start to fit. More and more data demonstrate how immobi-
lization can limit motion, as well as how manipulation can reverse the limitations.
Practitioners compete daily for patients, and insurance company reimbursements
are steadily decreasing; in such an environment, it is essential for manual physical
therapists to educate patients as well as to maintain professional credibility within
the medical community. It is imperative to blend and balance the art and science
of the profession, especially as the science expands and particularly in the areas of
myofascial manipulation.
64 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
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Histopathology of Myofascia
and Physiology of Myofascial
Manipulation
Robert I. Ca ntu, A lan J. Grodin, and Robert W. Sta nbo rough
Histopathology of Myofascia
Understanding any treatment technique requires knowledge of the basic process of
soft tissue healing. In the previous chapter, the normal histology and biomechan-
ics of myofascial tissues are presented. With that groundwork laid, this chapter ad-
dresses the histopathology and pathomechanics of those same tissues. A review of
classic and recent literature is provided to help readers understand posttraumatic
scar formation and the effects of immobilization and remobilization on myofascial
tissues. With an awareness of the changes that occur in the myofascial tissues un-
der dysfunctional conditions, a manual therapist can set realistic treatment goals
and choose the most appropriate treatment techniques to accomplish them. The
intuitive aspects of myofascial manipulation must always be balanced by a solid
understanding of tissues and their response to dysfunction.
The authors gratefully acknowledge the contributions of Deborah Cobb to earlier versions of this chapter.
69
70 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
acute inflammation
fibrous repair
remodelling and contraction
months
1 2 3 4 5 6 7 8
• ice, compression , elevation, gentle movements
• protect weak joint, ensure joint is stable, remove hematoma
• allow new collagen to feel normal tensions
• prevent undesirable shortening, e.g., muscles, joint capsules
Figure 4.1 Encouraging favorable healing conditions. Source:Reprinted with permission from P. Evans,
The Healing Process at Cellular Level: A Review. Physiotherapy,Vol. 66, No. 8, pp. 256- 259, © 1980, Phys-
iotherapy Canada, and G. Hunter, Specific Soft Tissue Mobilization in the Treatment of Soft Tissue Lesions,
Physiotherapy,Vol. 80, No. 1, pp. 15- 21, © 1994, Physiotherap y Canada.
lntramolecular Cross-links
Collagen filament
Cross-link - ~
Collagen filament [
Figure 4 .2 Collagen bonding increases tensile strength: (A) Weak intramolecular cross-links form be-
tween amino acid chains within one collagen filament. (B) Stronger intermolecular cross-links form from
one collagen filament to another. Source:Reprinted from Hardy, A., Biology of Scar Tissue, Physical Ther-
apy, Dec. 1989, Vol. 69, No. 12, with permission of the American Physical Therapy Association.
tendon), wound closure occurs in 3- 5 weeks. 6 During this phase, gentle handling
of the wound is essential, and gentle manual therapy techniques may be appro-
priate. Soft tissue manipulation designed to break up scar tissue will inflame the
wound, leading to further collagen deposits. 5•6
The final stage of scar formation is the maturation or remodeling phase. This
stage may last from 3 weeks to 12 months. 4 During this phase, collagen must
change in order to reach maximum function. A reduction in wound size, a re-
alignment of collagen fibers, and an increase in the strength of the scar are all
characteristics of this phase. Arem and Madden confirmed that a physical change
in scar length could be achieved through the application of low-load, long-dura-
tion stress during this phase. 12 Throughout this phase, the scar tissue is responsive
to manual therapy, but the progress will be somewhat slowed. Without controlled
stress or manipulation during this phase, however, tensile strength of the scar will
not improve, and optimal function will be diminished.
Chronic irritant
~
Abnormal movement Macrophages activated
(biomechanics)
stresses and more chronic irritant (Figure 4.3). As long as an irritant is present, the
cycle continues.
Since the introduction of technologically advanced imaging, changes in soft
tissue have been documented. Palpable taut bands identified in patients diagnosed
with myofascial pain syndrome have been confirmed visually using magnetic res-
onance elastography. 13- 15 Soft tissue changes have also been visually recorded in
patients with low-back pain (LBP). Langevin et al. examined 107 human subjects
(60 with LBP and 47 without LBP).16 Using diagnostic ultrasound, they compared
the perimuscular connective tissue thickness bilaterally, 2 cm lateral to the mid-
point of the L2- L3 interspinous ligament. Subjects with LBP had, on average,
25% greater thickness than those without LBP, after adjusting for body mass index.
Researchers found no differences related to sex, age, or activity level.
connective tissue that has been immobilized has also been traumatized. Trauma
has an effect on the histology and biomechanics of the healing of connective tis-
sue. It is also important to consider the process of scar formation and the effects of
immobilization on the developing scar tissue. We address these clinical consider-
ations in detail because the response of normal connective tissues to immobiliza-
tion provides a basis for understanding traumatized conditions.
of the American Physical Therapy Association. Schollmeier et al. immobilized the fore-
limbs of 10 beagles for 12 weeks. At the end
of that time, the passive range of motion
of the glenohumeral joints was markedly decreased and intra-articular pressure
was raised during movements. The capsule showed hyperplasia of the synovial
lining and vascular proliferation of the capsular wall. Functional and structural
changes began to reverse after remobilization and returned to normal limits after
12 weeks. 30
In a study of rat ankles immobilized for 2- 6 weeks, Reynolds et al found
slightly different results. This study found that dense connective tissues remodel
in such a way that mobility is unaffected after 2 weeks of immobilization but is
markedly limited after 6 weeks of immobilization. 31 The authors attribute these
changes to dense connective tissue undergoing remodeling between the 2- and
6-week periods. Earlier studies implied that cyclic manipulation of the immobi-
lized joints caused rupture of the remodeled tissues, which limited early mobility.
In Figure 4.5, following each yield point, the angle of the slope of the curve is un-
changed. This finding supports the idea that the remodeled tissue, which initially
limited motion, had not ruptured; rather, discrete adhesions between folds of tis-
sues were responsible for the limitation.
Langenskiold et al. performed a study on immobilized, healthy rabbits. 32 The
authors found that casting for 5- 6 weeks significantly decreased knee flexion.
The resumption of normal activity, however, restored 90% of joint mobility after
3 weeks. When immobilization was increased to 7 or 8 weeks, only 28% of knee
flexion returned after 10 weeks of reconditioning. It took as long as 12 months for
some of the animals to regain full mobility. The study suggests that the longer the
76 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
75 t
:j:
~
(/)
Q)
Q)
~
Cl
Q)
-0
~
C
0
50
\
)(
Q)
25 11 *
;;:::
11
(/)
~
0
*
0 *
..0
0 20 40
Loading Time (seconds)
Figure 4.5 Diagrammatic representation of the qualitative difference in pattern of dorsiflexion between
limbs casted for 6 weeks (:j:)and all other limbs (t). In all ankles casted for 6 weeks, the curve exhibited
intermediate plateaus (11),followed by small but sudden slipping further into dorsiflexion (*), suggesting
rupture of an adhesion with each slip. Source:Reprinted from C. A. Reynolds, G. S. Cummings, and P. D.
Andrew, et al., The Effect ofNontraumatic Immobilization on Ankle Dorsiflexion, Journal of Orthopaedic
and Sports Therapy,Vol. 23, No. 1, p. 31, with permission of the Orthopaedic and Sports Sections of the
American Physical Therapy Association.
period has not been unduly long. More research is needed on duration of mobility
and changes occurring within the connective tissues. Clinicians need to consider
the early changes occurring in the immobilized connective tissues and adjust their
treatment plans accordingly. Before 4-6 weeks, the stress-deprived, weakened cells
may require gentle mid-range movement and protection from excessive forces;
however, after 6 weeks, treatment protocols should incorporate sufficient stress
to induce connective remodeling, which can accommodate lengthened positions
until full joint mobility is achieved. 28
traumatized but were affected chemically by the traumatic exudates. Third, trau-
matic exudates infiltrate these surrounding, nontraumatized areas and, acting as
chemical catalysts, create changes in the connective tissues.
Scar tissue versus.fibrosis. Scar formation and fibrosis are two different histologi-
cal processes, although some similarities exist. Scar formation is a localized re-
sponse, with activity limited to a traumatized area, whereas fibrosis is a homoge-
neous change in the "fabric" of the connective tissue. Limitation in mobility caused
by scar tissue results from the lack of extensibility of the scar tissue and from the
adhesions formed with adjoining healthy connective tissue. Fibrotic changes cause
the entire tissue to become less extensible, which then limits movement. Also, as
previously mentioned, fixation methods may exacerbate the effects. Semirigid im-
mobilization (immobilizer or cast) may allow sufficient movement to decrease the
effects of immobilization.
For example, a shoulder may be frozen because of a macroscopic scar adhesion
in the folds of the inferior capsule, in which case a manipulation under anesthesia
would tear the scar adhesion and restore mobility. A frozen shoulder may also be
caused by a capsulitis, where the entire capsule shrinks (an analogy here is the
size 5 capsule and a size 8 glenohumeral joint-the sock is simply too tight). The
distinction is that motion is limited by homogeneous changes in the capsule rather
than a single scar adhesion. A manipulation under anesthesia may not be as suc-
cessful in the latter case, because an entire tissue is responsible for the immobility.
The benefit of increased mobility is outweighed by the potential damage to the
capsule fabric and the restimulation of the fibrotic cycle.
Muscle Tissue
The response of muscle tissue to immobilization is less simplistic and more multi-
factorial than the response of connective tissue to immobilization. Being a contrac-
tile tissue, a muscle can be passively or actively immobilized, and the muscle may
be immobilized in a shortened or lengthened position. The muscle may be inner-
vated or denervated and predominantly slow twitch or predominantly fast twitch.
Because muscle is highly metabolic, it can undergo various metabolic changes,
depending on its activity level. The purpose of this section is to outline briefly the
histological response of muscle tissue to immobilization and to review the factors
influencing immobilized muscle most applicable to myofascial manipulation.
One of the classic works on muscle response to immobilization was performed
by Tabary et al. 34 In this study, cat soleus muscles were immobilized at various
lengths and for various durations. The animals were immobilized by plaster
cast. Some of the animals were euthanized, and the muscles were biomechani-
cally and histologically analyzed. The passive length-tension was increased in
muscles immobilized in the shortened position, probably because of the connec-
tive tissue changes within and surrounding the muscle. Muscles immobilized in
the lengthened position had no significant changes in the passive length-tension
Histopathology of Myofa scia and Physiology of Myofa scial Manipulation 79
the cervical and upper thoracic paravertebral muscles, the scapulothoracic mus-
cles, and the shoulder girdle muscles. In many cases, the surrounding muscula-
ture remains tonically active long after the facet or ligamentous strain has healed.
The body learns a new recruitment pattern for the surrounding muscles, and this
hypertonic pattern remains long after healing. The muscles are then actively "im-
mobilized," causing some of the histological changes mentioned previously. Often,
the most difficult part of the therapeutic process is dealing with this hypertonicity,
which is secondary to the original injury.
from increased blood flow to the part, may well depend on the manner in which
the massage is administered. The authors found that the moderate-depth Hoffa
massage affected only the blood flow of subjects with flaccid paralysis, whereas the
deep stimulating massage had the effect of increasing the blood flow of all subjects
studied. 42
Effects of deep kneading massage on venous blood flow were also examined
by Wolfson using animal models (dogs).43 A "deep, kneading type of massage"
was applied to the limbs above and below the knee (after anesthetizing). Wolfson
measured blood flow by cannulation of the femoral vein during anesthesia. The
blood draining outward was measured and reinjected into the opposite limb at
the same rate the blood was being removed . The massage initially caused a fairly
rapid increase in blood flow followed by a decrease in blood flow to a rate less than
normal. This decrease in blood flow continued throughout the administration of
the massage. Following cessation of the massage, blood flow slowly returned to
normal. Thus, Wolfson concluded that massage causes an increase in the rate of
blood flow by mechanically emptying the blood vessels and allowing them to refill
with fresh blood .
The findings in these studies are similar. Deep kneading massage, as per-
formed on human as well as animal models, increases the blood flow to the area
being treated. Caution should be exercised, however, when generalizing the results
of animal studies to the human population.
The reaction of normal blood vessels to mechanical stimuli was microscopi-
cally examined by Carrier. 44 Gross visual observation of skin reaction was made
following mechanical stimulation of the skin by a blunt instrument. With light
stroking, the area in the path of the stroke blanched after a latent period of 15-
20 seconds. The blanching lasted for several minutes. A harder stimulus resulted in
a hyperemic line in the immediate path of the stimulus. With microscopic inves-
tigation, light pressure resulted in instantaneous opening of all capillaries in the
microscopic field. A heavier pressure opened the underlying capillary for a longer,
unspecified, duration.
Carrier's observations 44 may correspond with the results of the studies by
Wakim et al and Wolfson. 42 •43 If the moderate-depth Hoffa-type massage (non-
stimulating) is similar to the light stroke produced by a blunt instrument in Car-
rier's study, an immediate superficial capillary reaction is an effect of massage. The
light stroke or Hoffa massage creates capillary dilation but for too short a duration
to affect blood volume, blood flow, or temperature in the underlying stroked area.
When vigorous stimulating massage is administered, the result is a longer lasting
dilation of the underlying capillaries, which creates a change in both blood flow
and skin temperature. Both the vigorous stimulating massage and lighter Hoffa-
type massage are used in myofascial manipulation.
In other research, Pemberton described the work of Clark and Swenson, who
studied the capillary circulation in the ear of a rabbit following massage .45 A per-
manent window was surgically created in the rabbit's ear, allowing observation
82 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
9 without H IV) received daily massage for 1 month. After the 1 month of massage,
a significant increase in the number of natural killer cells was noted in the H IV-
positive men. Thus, massage appears to enhance the immune system's cytotoxic
capacity. Further research in this area is required .48
The findings of increased blood flow, increased temperature, and increased
metabolism in the area being massaged have strong clinical implications. They
support the notion that massage is definitely indicated in areas where increased
tissue circulation and nutrition are desired.
Injury
i----------,✓
-
.c
O>
C
~
t;
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<I)
C
~
________________ _
....._
Time
Figure 4.6 General trend of increase in tensile strength of injured soft tissue during healing process.
Source:Reprinted with permission from P. Evans, The Healing Process at the Cellular Level, Physiotherapy,
Vol. 66, No. 8, pp. 256- 259, © 1980, Physiotherapy Canada, and G. Hunter, Specific Soft Tissue Mobilisation
in the Treatment of Soft Tissue Lesions, Physiotherapy,Vol. 80, No. 1, Jan 1994, pp. 15- 21. © 1994, Physio-
therapy Canada.
subjected to both internally and externally generated forces. Without stress ap-
plied through the tissues, the tensile strength will decrease. 53 Stearns observed
the effect of movement on the fibroblastic activity in healing connective tissues
and concluded that fibrils form almost immediately. 54 External factors were re-
sponsible for assuming an orderly arrangement of these fibrils. Cyriax and Russell
asserted that gentle passive movements of the soft tissues will prevent abnormal
adherence of the fibrils without affecting their proper healing. 55
The manual therapist should use his or her knowledge of the stages of heal-
ing to determine when specific massage techniques should be used (Figure 4.6).
Chapter 3, "Histology and Biomechanics of Myofascia," discussed the soft tissue's
inability to withstand stress immediately after injury. It is, therefore, important to
protect the injured tissues from stress during the early inflammatory stage. The
fibrin bond holding the wound together can easily be disrupted, ultimately leading
to an increase in the amount of scar tissue formed. 56 Because collagen does not ap-
pear in the wound for 4 - 6 days after injury, the value of friction and deep massage
before this time is questionable. 57
As the tissues move into the regeneration phase, fibroblasts begin to lay down
collagen, and the tensile strength increases. Gentle transverse friction is often used
at this point. The repetitive force is applied perpendicular to the fibers of the tissue
as an imitation of the muscle's normal mobility. It is used with progressive force
to help broaden but not stretch or tear the healing fibers in an effort to enable
pain-free movement as the tissues heal. 58 The increased movement will encourage
realignment, lengthening, and strengthening of fibers.
Histopathology of Myofa scia and Physiology of Myofa scial Manipulation 85
the thickened tissues using skin rolling, a common technique where the superficial
tissues are rolled, pressed, and squeezed between the fingers and thumb.
After noticing changes, including increased warmth, greater mobility, and
palpably thinner tissues, she remeasured the collagen distribution. Although no
baseline data are available, the same data were measured and treatment performed
on 10 nonafflicted areas. A comparison of the data from the subjects' afflicted tis-
sues and nonafflicted tissues provides some insight as to the changes clinically
perceived. No pre- and posttreatment differences were found in the nonafflicted
tissues; however, a significant change was noted in the afflicted tissues. The differ-
ence of the mean height of the highest peak in the dermis pretreatment (M = 3.72,
SD = 0.68) and posttreatment (M = 2. 59, SD = 0.55) was highly significant (t test
for matched pairs, t29 = -8.03, P < 0.000 1).71 These measurements suggest less
collagen density and a more homogeneous tissue as a result of superficial soft tis-
sue manipulation.
Conclusion
The literature supports the use of myofascial techniques to influence the healing
of soft tissues. The choice of technique by the physical therapist should be based
in part on the stage of healing of the injured tissue. Gentle techniques may be
beneficial early on to ensure an orderly arrangement of fibrils and to prevent adhe-
sions. In the later stages of healing, deeper techniques may be more appropriate to
decrease adhesions, improve scar extensibility, and increase overall mobility of the
soft tissues. A good manual therapist not only must understand the histopathology
of myofascia and the stages of healing but also must remember to use this knowl-
edge when choosing treatment techniques. Choosing the appropriate technique at
the appropriate time is essential to successful treatment.
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N euromechanical Aspects
of Myofascial Pathology
and Manipulation
Clayton D . Gable
The mere motion of muscular and/or fascial tissues through stretching feels good
to humans and many other vertebrate animals. The tendency to stretch upon
awakening in the morning, or upon completing a long journey by airplane or car,
is nearly universal . Even pets seem to love a good, long stretch. Walsh cited E. K.
Borthwick, Emeritus Professor of Classics at Edinburgh University, for the follow-
ing account:
The verb "stretch" (reiyv, teino) is the common form and is used by Homer of
stretching of a bow, reins, etc.- "to stretch oneself in running." Aeschylus uses it
of straining the voice. Galen uses it of stretching tendons, etc.
As one can surmise from the passage above, muscle contraction has, for almost
2,000 years, been associated with stretching.
Given that stretching is such an integral part of normal human and verte-
brate behavior and has given rise to the study of the influence of various sensory
mechanisms on movement, it is necessary to review some neurology associated
with myofascial tissues. To that end, in this chapter, I review the basic neurology
of myofascial tissues, emphasizing the afferent or stimulus perception side of the
equation. In addition, I review some of the more contemporary findings regard-
ing (1) the influence of somatosensory receptors on movement control, (2) muscle
tone, and (3) the interaction of biomechanical properties of myofascial tissues and
the nervous system.
91
92 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
Following the review of the basic science regarding neurology and movement
control is a discussion of how science relates to the clinical application.
Mechanoreceptors
Mechanoreceptors are exactly what the name implies; they are peripheral sensory
receptors of mechanical events. They transduce mechanical energy into nerve im-
pulses, which are then transmitted to the central nervous system via their afferent
neuron axons. They are located throughout the musculoskeletal system, the vascu-
lar tree, and the skin. They include specialized neuronal structures and free nerve
endings (Table 5.1).
Each of the various mechanoreceptors listed in Table 5.1 has its own anatomy,
firing characteristics, threshold, conduction velocity, and - most important for a
clinician- functional and physiological effects. Therefore, the following subsec-
tions review some of the pertinent characteristics and functional implications of
the various receptors. It is important to note that even those receptors listed in
Table 5.1 as being primarily located in the skin contribute to proprioception and
kinesthesia. Gardner and colleagues state the following:
Three types of mechanoreceptors in muscle and joints signal the stationary posi -
tion of the limb and the speed and direction of limb movement: (1) specialized
stretch receptors in muscle termed muscle spindle receptors; (2) Golgi tendon
organs, receptors in the tendon that sense contractile force or effort exerted by a
group of muscle fibers; and (3) receptors located in joint capsules that sense flex-
ion or extension of the joint. 2<p443>
Fiber size
Receptor type and group Location and information transduced
Meissner's corpuscle A/3 Skin: touch
Pacinian corpuscle A/3 Skin: flutter
Fibrous connective tissue: compressive stimuli
Ruffini's corpuscle A/3 Skin: steady indentation
Fibrous connective tissue: tension on structures such
as ligaments
Merkel's receptor A/3 Skin: steady indentation
Hair-guard. hair-tylotrich A/3 Skin: steady indentation
Hair-down A/3 Flutter
Primary muscle spindle Aa Dynamic change of length
la
Secondary muscle spindle A/3 Muscle length. mostly static
II
Golgi tendon organ Aa Tension on a tendon
II
Joint capsule receptors A/3 Extremes of joint position (i.e .. maximum tension on
(Type 11) II joint capsule)
Muscle afferents (Ill) Ao Mechanical. chemical. and thermal stimuli in muscle
111
Muscle afferents (IV) C Mechanical. chemical. and thermal stimuli in muscle
IV
Free nerve endings A-C Mechanical chemical. thermal. and pain
to mechanical stimuli, such as skin indentation (Figure 5.1). The rapidly adapting
characteristic is common to several skin mechanoreceptors. It indicates that a rap-
idly adapting receptor will respond to a stimulus event with an action potential,
and then the receptor will go silent for a period of up to several seconds failing
receipt of another mechanical event.
In the case of a Meissner's corpuscle, a single indentation of 70- 1,000 µm
into the skin would result in a single action potential with a subsequent silent
period of up to several seconds. Although this behavior would appear to be some-
what dysfunctional, rapidly adapting receptors have another characteristic. They
are responsive to repetitive stimuli (at various frequencies) with repeated action
potentials.
Meissner's corpuscles, specifically, respond to repetitive stimuli, such as si-
nusoidal indentations of the skin, at frequency ranges of 2 or 3 Hz up to around
300 Hz. Compared with Pacinian corpuscles, this range is a relatively slow fre-
quency range. As previously mentioned, this range of stimulus indentation is from
70- 1,000 µm, with the greatest sensitivity between 10 and 100 Hz of stimulus (Fig-
ure 5.2). With a rapidly adapting system, the perception of relatively low-frequency
94 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
THICK(HAIILESS)Sl<JN SKIN
THIN(HAIRY)
Hair-
Figure 5.1 The organization of skin, comparing the structures found in thick, hairless skin with thin,
hairy skin. The epidermis has been partially peeled back to show the interdigitating dermal and epider-
mal papillae. Source: Reprinted from Gray's Anatomy, ed. 40 (p. 146) by S. Stranding with permission of
Churchill Livingstone Elsevier,© 2008.
Meissner's corpuscle
1000 I
-
I
-E ,I
I
C
_,.,
(/) -
:::1.
,,,
-0 0C 100
c ·-
...,
;'
...,
......
0
::, ~
E
~-g
C
Q) -
10
Pacinian corpuscle
Figure 5.2 Sensitivity to skin indentation. Source:Reprinted with permission from J.H. Kandel et al.,
eds., Principlesof Neural Science,3rd ed., pp. 533- 547, © 1991, McGraw-Hill Companies.
Ruffini Corpuscles
Ruffini corpuscles are found in the subcutaneous tissue beneath both hairy and
glabrous skin. 2 They are also found in the superficial layers of fibrous joint cap-
sules and other connective tissue surrounding joints. 6 Their intertwining with the
connective tissue is functional, because they are stimulated by the displacement of
the collagen fibers surrounding them. They are slowly adapting receptors and have
very large receptive fields. One major advantage of their slowly adapting charac-
teristic is of functional significance: because they do not "turn off" following a
stimulus but continue to fire with a consistently applied stimulus, they contribute
to steady-state position sense and tactile sensation.
Merkel's Receptors
Merkel's receptors are probably the most peripheral of all the sensory receptors.
They are located in the epidermis of glabrous (hairless) skin. They have unusual re-
ceptors, in that the receptors appear to synapse with epithelial cells. This synapse,
or connection, of epithelial cells directly with the Merkel's receptors results in an
action potential for the neuron serving the receptor with any mechanical stimulus
to its related epithelial cell(s). Like Ruffini endings, Merkel's receptors are slowly
adapting, but unlike them, Merkel's receptors have very small receptive fields.
Theref ore, these endings can respond to very small stimuli and localize well with
their 2- to 4-mm-sized fields along with their capacity to continue to send "tonic"
signals to the central nervous system without a change in stimulus intensity. 2
Hair Receptors
Hair receptors are divided functionally into two categories based principally on
the type of stimulus to which they respond . Tylotrich (stiff) hair receptors are
responsive to steady skin indentation, and down hair receptors are sensitive to
flutter. Basically, hair receptors are specialized nerve endings incorporated in the
connective tissue at the base of a follicle and are very sensitive to mechanical defor-
mation of the hair. Their implications for clinical practice of the manual therapist
Neuromechanical Aspects of Myofasc ial Pathology and Manipulation 97
Staticbag,
fiber
Dynamicbag,
fiber Longchain
fiber
Shortchain
fibers
Dynamicy-efferent
II
Afferentfibers
la
Staticy-efferent
Staticp-etferent
Dynamic
p-etferent
Collateralsto
extrafusalmuscle
Figure 5.3 Nuclear bag and nuclear chain fibers in a neuromuscular spindle. Dynamic /3-and y-efferents
innervate dynamic bag 1 intrafusal fibers, whereas static /3-and y-efferents innervate static bag 2 and
nuclear chain intrafusal fibers. Source: Adapted from Gray's Anatomy, ed. 40 (p. 61) by S. Stranding with
permission of Churchill Livingstone Elsevier,© 2008.
are most likely restricted to an awareness of their presence and the knowledge that
they, like most any receptor, can be sensitized under conditions of paraesthesia. 7
Muscle Spindles
Muscle spindles are located in striated (skeletal) muscle and transduce changes
in length of the muscle. They fall into three categories and are named for their
shape and function (Figure 5.3). The dynamic nuclear bag fibers transduce infor-
mation about rapid changes in length and the rate of change of length. They are
most heavily concentrated in phasic muscles. The static nuclear bag spindles (so
named because of the central bunching of the muscle fiber nuclei) transduce more
tonic information about spindle length. Nuclear chain fibers (muscle fiber nuclei
are evenly distributed throughout the muscle fiber) transduce information about
98 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
slower changes in length and are more concentrated in tonic muscles. The physi-
ology of muscle spindles, as well as their influence on muscle tone, is worthy of
discussion here.
Muscle spindles are specialized encapsulated structures that are arranged in
parallel with skeletal muscle fibers (Figure 5.3). They consist of (1) a group of spe-
cial muscle fibers (intrafusal fibers), which are located in the spindle; (2) sensory
axons that terminate as a spiral ending around the intrafusal fibers; and (3) motor
axons (gamma efferent fibers), which adjust the sensitivity of muscle spindles. For
clarification of the differential physiology of muscle spindles, it is helpful to dis-
cuss the two sensory endings (i.e., afferent fibers) that transduce length informa-
tion from the spindles.
Secondary endings. Group II afferents branch into secondary endings, which in-
nervate the static nuclear bag fibers and the nuclear chain fibers in a spiral fashion,
like the primary endings. The secondary endings function similarly to the slowly
adapting receptors already discussed. That is to say, secondary endings exhibit a
fairly steady firing rate in either the presence or the absence of movement. These
slowly adapting receptors are, therefore, ideal for signaling the length of muscle
without the need for movement to increase their sensitivity.
Gain adjustment of muscle spindles. As can be surmised from the previous dis-
cussion and Figure 5.4, when the extrafusal muscle fibers of a muscle contract in
response to a stimulus from an alpha motor neuron, the intrafusal fibers would be
left slack. Therefore, there would be a silent period in the firing of both the primary
and secondary endings. To eliminate this silent period, the gamma motor neuron
Neuromechanical Aspects of Myofasc ial Pathology and Manipulation 99
Sustained stretch
of muscle
la discharge I I 11I I I 11I I I
----J t
Tension /
Pull
B Weight
Stimulate alpha
motor neuron
t
C Contraction
Stimula te alpha
la responses ls "filled In"
motor neuron
'
+ t
11111111111111111111
Stimulate gamma
motor neuron
t
Contraction
Figure 5.4 During active muscle contractions the ability of the spindles to sense length changes is main-
tained by activation of gamma motor neurons. (Adapted from Hunt and Kuffler, 1951.) (A) Sustained ten-
sion elicits steady firing of the Ia afferent. (B) A characteristic pause occurs in ongoing discharge when the
muscle is caused to contract by stimulation of its alpha motor neuron alone. The Ia fiber stops firing because
the spindle is unloaded by the contraction. (C) If during a comparable contraction a gamma motor neuron
to the spindle is also stimulated, the spindle is not unloaded during the contraction and the pause in Ia dis-
charge is "filled in." Source:Adapted with permission from C. C. Hunt and S. W. Kuffier, Stretch Receptor
Discharges During Muscle Contraction,Journal of Physiology,Vol. 113, pp. 298-315, © 1951, The Physiologi-
cal Society.
system activates the intrafusal fibers and maintains the sensitivity of the spindles.
When the gamma motor neuron system activates the intrafusal fibers simultane-
ously with the alpha motor neuron system, the extrafusal fibers are also activated,
and the sensitivity of the primary and secondary endings is maintained. 8
During gait, the gastrocnemius is active from mid-stance (as a decelerator) until
toe-off (as an accelerator). Assuming a relatively normal foot posture and equal
forces, rate of change of length, and length changes being generated by the medial
and lateral head of the gastrocnemius, the afferent stimuli coming from the medial
and lateral head of the gastrocnemius would, under nonpathological conditions,
be approximately equal. With the current condition-that is, with a contusion in
the process of healing and bearing some scar tissue-the afferent information is
different between the two heads of the gastrocnemius. In the medial head, the
afferent information is altered because of the scarring of the collagenous connec-
tions of the intrafusal fibers. This results in a mechanical "mislink" from collag-
enous cross-bridges and scarring and results in a perceived change in length that
reflects the actual change in length. In addition to the mismatch between the two
heads of the gastrocnemius relative to the length of the muscles, there is a problem
with tension information from the GTOs.
The serial arrangement of the GTOs makes them sensitive to tension gener-
ated along the mechanical chain of the muscle. Therefore, changes in the visco-
elastic properties of the muscle to which it is attached can produce a differential
in tension (particularly at the initiation of contraction). This differential tension
produces another mismatch between the tendinous origin of the medial and lat-
eral heads and even creates the possibility of differences within the fascicles of the
medial head attaching to the Achilles tendon. With the decreased elasticity of the
muscle from the collagenous cross-bridges and scarring, there is a relatively higher
tension perceived by the medial head compared with the lateral head . In addition
to all of the collagenous cross-bridges, which have affected the elasticity of the
muscle, there is also the problem of changes in viscosity of the muscle (intrafusal
and extrafusal fibers) and all the surrounding connective tissue (see Chapter 3,
"Histology and Biomechanics of Myofascia," for a review of viscoelasticity). These
changes in viscosity and elasticity contribute to an afferent information mismatch,
when compared with the conditions under which most tasks are learned.
skeletal muscle, either close to or within the adventitia of arterioles and venules. 12
Von During and Andres specifically found Group IV endings in the adventitia of
small veins and even in the lymphatic vessels. 13
The research on the reflexive effects of Group III and IV muscle afferents has
concentrated primarily on their effects on ventilation and circulation. In that
realm, they have been found to have some very powerful effects on both systems.
On the sensory input side of the reflex equation, the III and IV afferents respond
to mechanical, chemical, and thermal stimuli. On the output side of the equation,
the responses appear to be related not only to systemic changes in respiration and
cardiac output but also to local changes in muscle blood flow. The for mer has been
well documented in the cardiorespiratory literature and the latter in literature re-
viewed in Chapter 4, "Histopathology of Myofascia and Physiology of Myofascial
Manipulation." 14
Considering the therapeutic techniques presented in this book and their in-
dications, it is worthwhile to discuss mechanisms of stimulation of the Group III
and IV receptors in a general sense, as they relate to myofascial technique. First,
Group III and IV receptors respond to both mechanical stimulation and muscu-
lar contraction. The mechanical stimulation most often used in research is that
of non-noxious probing. 15 The basic conclusions have shown that more force is
required to stimulate the receptive fields of Group III and IV afferents than is re-
quired for muscle spindles and GTOs. Group III and IV receptors are even differ-
entially sensitive to mechanical stimulation. 14 The second and third mechanisms
are related to chemoreception and a sensitizing effect of chemicals to mechanical
stimulation. These are considered in the following paragraphs.
Non-noxious probing will stimulate a majority of Group III receptors,
with noxious probing generating explosive bursts of impulses from many more
Group III receptors. In contrast, almost all Group IV receptors require a noxious
level of probing, and then only a few bursts of impulses will occur. The level of
probing (non-noxious and noxious) referred to in these studies exceeds the level of
stimulus required by muscle spindles and GTOs by several orders of magnitude,
making the forces very similar to those applied in even some of the gentlest tech-
niques presented in this book.
Approximately half of the Group III receptors respond immediately with a vig-
orous increase in afferent discharge during muscular contraction. The remaining
half tend to respond as the exercise session progresses (i.e., after > 30 seconds of
isometric contraction or rhythmical contraction). This finding indicates that about
half of the receptors may be more chemically sensitive rather than mechanically
sensitive. Unlike the Group III receptors, Group IV receptors tend to rarely dis-
charge with muscle contraction in the early stages. As the contraction progresses
and is maintained, however, the frequency of their discharge increases. This find-
ing would also support a primarily chemoreceptive role for the Group IV receptors.
Other studies regarding the chemoreceptive properties of these two recep-
tors have been perf armed with a wide variety of drugs, including papaverine,
104 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
Nociceptors
Nerve fibers that are selectively responsive to stimuli that may potentially dam-
age tissue or to stimuli from actual tissue damage are called nociceptors. They fall
into three major categories - mechanical, thermal, and polymodal - depending
on the form of stimulus required. These three categories can be further classified
according to their afferent nerve fibers. The thermal and mechanical stimuli are
transmitted via Aofibers and the polymodal stimuli via the C fibers. Aofibers
are thinly myelinated fibers that conduct impulses at 5- 30 m/second. C fibers are
unmyelinated fibers that carry impulses at 0.5- 2 m/second.
Neuromechanical Aspects of Myofascial Pathology and Manipulation 105
Source: H.L. Fields, Pain, p. 32, © 1987.Reproduced with permission of the McGraw -Hill Companies.
Basics of M ot or Contr ol
The spinal cord, brainstem, and cerebral cortex achieve motor control through
hierarchical and sometimes parallel processes. Each has its own independent level
of control, and each interacts with the others to accomplish full motor control.
Figure 5.6 displays a relatively simple diagram of the motor system. 23 The fol-
lowing sections emphasize the "sensory consequences of movement upon move-
ment" component of the model in Figure 5.6. Furthermore, some discussion is
included about the influence of myofascial pathology on the sensory consequences
of movement.
106 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
Cerebral cortex
Motor areas
Tha lamus
., Basal ,-.
)
'
ganglia
. Brain
', Cerebellum
" stem
Muscle
'
Sensory
receptors
Figure 5.6 Motor system levels of control. Source:Reprinted with permission from E. R. Kandel et al.,
eds., Principlesof Neural Science,3rd ed., pp. 533- 547, © 1991, McGraw-Hill Companies.
bone can occur in connective tissue patho logy. Such connections could alter the
MSR to either a heightened or a lowered level of activity, depending on the stimu-
lus applied to them. In the case of pathomechanical cross-bridge formation, such
an increase in the sensitivity of the MSR would alter the spinal-level mechanisms
of muscle tone regulation. Juli and Janda hypothesized that these changes would
result in an increase of dynamic muscle tone in the agonist muscle .11 With changes
in dynamic muscle tone and subsequent changes in movement patterns, the me-
chanical stresses would be different on the system, resulting in connective tissue
remodeling in response to Wolff's law.
Consider, for example, a patient, 3 weeks status after distal third femoral frac-
ture with an intramedullary rod, supine, with the lower leg hanging over the end
of a treatment mat and the knee in flexion. With the scarring that occurs, there
will be adhesions between the vastus lateralis, rectus femoris, and vastus interme-
dius. Each of these muscles has a resting tone. If the adhesions have formed in such
a way that they differentially affect the rate of change of length in the muscles as
they slide together and against each other, however, sensory mismatch will occur.
Accompanying this sensory mismatch will be a differential MSR response among
the three muscles that was not present before the scarring occurred. This example
of the impact of connective tissue pathology on the MSR is only one of many pos-
sible scenarios. Likewise, this example illustrates the impact of such a pathome-
chanical situation on the MSR. Multiple other interactions are possible, a few of
which are presented in the following section.
inhibitory input from several descending pathways. All of these combined inhib-
itory and excitatory inputs have major implications for fine motor control. The
GTOs and the other inputs to the Group l b inhibitory interneurons provide for
fine control of exploratory behaviors where the amount of force being generated is
critical. Therefore, the implication for these receptors' importance when learning
to perform manual therapy is obvious. 24
In addition to the implications for fine control and control in exploratory
behaviors, there are ramifications for patients and their motor control. The most
conspicuous example of problems with the GTO is tendinitis. In the case of Achil-
les tendinitis, an inflammation of the musculotendinous junction would result
in interfascicular edema inside the tendon. This edema changes the viscoelastic
properties of the musculotendinous junction, resulting in a change in the tension
on the braided collagen fibers that surround GTOs. Besides the change in the me-
chanics of the GTO, the chemical makeup of the GTO also undergoes ambient
change. With greater concentrations of bradykinin and cyclooxygenase metabo-
lites (by-products of inflammation), it is possible that the sensitivity of the GTO is
increased in the same way that the sensitivity of Group III and IV muscle afferents
is altered by these agents. If the GTO sensitivity were increased by inflammation
by-products, then the increased GTO firing rates would further inhibit the agonist
and facilitate the antagonist and, thereby, interfere with normal motor control and
movement patterns.
Joint Receptors
As previously described, joint receptors come in a variety of shapes, sizes, func-
tional characteristics, and locations in the joints. Discussion is restricted here to
the Golgi-Mazzoni and the ligamentous free nerve endings because they are the
most superficial of the joint receptors and are the most easily stimulated in the
practice of myofascial manipulation. The Golgi-Mazzoni receptors are similar to
GTOs and exhibit very similar effects on motor control at a reflex level. In like
manner, the free nerve endings transmit information to the spinal cord and syn-
apse on Group lb inhibitory interneurons. Both of these joint receptors are rapidly
adapting receptors and are also known to be essentially silent in immobile joints.
They are stimulated most at the extreme ranges of motion. Therefore, from a func-
tional viewpoint, the surface of a joint capsule in which the receptors are located
dictates which muscles are the agonists and which are the antagonists. In the case
of the posterior capsule of the knee, rapid knee extension would result in an in-
hibitory effect on the quadriceps at the end of range, whereas rapid knee flexion
would stimulate the joint receptors in the anterior capsule and cause inhibition of
the hamstrings at the extreme of knee flexion.
An example of the inhibitory properties of an abnormal stimulus to joint re-
ceptors was provided by Kennedy and colleagues. In their classic paper of 1982,
they demonstrated that an effusion (60 cc) of the knee would result in a 30%- 50%
decrement in the electrical activity of the quadriceps, as measured by the Hoffman
Neuromechanical As pects of Myofa scial Pathology and Manipulation 109
reflex, with the greatest inhibition occurring in the vastus medialis. Although they
did not distinguish the particular types of receptors, they were able to show that
the receptors in proximity to the joint cavity itself were very important. Under
the conditions of effusion, the quadriceps were inhibited; however, when a local
anesthetic was added to the effusion, the inhibition all but disappeared. 25 Clini-
cally, these findings add even further motivation for the therapist to control joint
effusion and, failing that, to make conservative recommendations for strenuous
activity of the lower extremity. If such a small joint effusion can inhibit the quad-
riceps, then failure to control the effusion could lead to serious injury from inhibi-
tion of the surrounding musculature. One can only assume that similar findings
would be seen in other diarthrodial joints with similar muscular inhibition. Such
findings clearly demonstrate that a mechanical stress on the rapidly adapting re-
ceptors, such as the Pacinian corpuscles, is (most likely) inhibitory to quadricep
motor units. Indeed, these findings offer compelling evidence that in the presence
of edema or bleeding following thrust manipulation procedures, there would be a
reflex inhibition of musculature surrounding that joint or related to that joint neu-
rologically. The findings of Kennedy et al. are consistent with findings reported in
prior and subsequent literature, confirming that joint receptors are more sensitive
to extremes of range. The mechanical stress placed on the joint capsule served to
stimulate the joint receptors in the same manner as extremes of range of motion
would.
Nociception
The influence of pain on movement and control, brought on by peripheral stimula-
tion, is probably the most obvious sign of change in movement control. The initial
response to acute pain from mechanical or thermal stimuli is transmitted to the
nervous system via AS fibers, which are myelinated, rapidly conducting fibers. The
withdrawal reflex seen in even spinalized animals is very fast. The response to pain
of a more polymodal nature, such as that mediated by inflammation by-products
and other neuroactive agents, is typically more complicated.
Polymodal pain is carried on C fibers, which are slowly conducting fibers.
Polymodal pain, most likely because of its continuing nature, also has the char-
acteristic of inducing some type of behavioral response. This response may be at a
spinal level or virtually any other level of the nervous system. The responses can
vary from obvious muscle guarding in the surrounding musculature to inhibition
of a muscle. The aim of both muscle guarding and muscle inhibition is to decrease
the movement that leads to pain.
One misconception that has been propagated from one author to the next is
the "pain - spasm - pain" cycle. Unfortunately, as Walsh 1 and Simons and Mense 32
eloquently point out, this hypothesis is based on a misunderstanding of the in-
volved motor reflexes. The original hypothesis stated that pain increased y -motor
neuron activity, which would stimulate or increase the sensitivity of the muscle
spindle and result in an increased a-motor neuron activity and muscle contrac-
tion. The major problem with this theory is the fact that muscle pain does not re-
sult in increased EMG activity. Furthermore, the timing and intensity of the EMG
activity does not correlate with the reported levels of pain.
These findings related to nociception present a contradiction to the practitio-
ner of manual therapy and any acute observer of posture and movement. It is rela-
tively easy to identify muscle asymmetries in bulk as well as in muscular activity
during movement. If muscular pain and the apparent increases in muscle tone are
not caused by spasm, then what produces the increase in muscle tone? This ques-
tion is actually twofold : First, what does pain have to do with increased muscle
tone? Second, what is muscle tone/spasm? The following sections explain some of
the thinking regarding these topics.
Muscle Tone
Muscle tone has long been associated with muscular contraction; however, it is
actually more complex than just a contraction. Certainly, a typical muscle con-
traction or level of muscle tone, explained according to the sliding filament theory,
cannot occur without an electrical action potential. In the case of muscle spasm
or "normal" resting muscle tone, an action potential is not typically discernible
via electromyography; therefore, it must entail more than just an electrogenic ac-
tivation of the actomyosin complex. Simons and Mense have offered an excellent
112 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
Muscle tone
(general tone)
Figure 5. 7 Muscle tone. Source:Adapted from Understanding and Measurement of Muscle Tone as Re-
lated to Clinical Muscle Pain, Pain, No. 75 (pp. 1- 17) by D. G. Simons and S. Mense with permission of
W. B. Saunders Company,© 1998. This figure has been reproduced with permission of the International As-
sociation for the Study of Pain© (!ASP©). The figure may not be reproduced for any other purpose without
permission.
review of muscle tone and its relation to clinical muscle pain. 32 In it, they divide
muscle tone into two types: electrogenic tone and viscoelastic tone (Figure 5.7).
sulfated version of GAGs, which account for the tissue cohesiveness. Another fluid
component of myofascial tissue is actin. Although actin certainly makes up a large
complement of muscle itself, it is also abundantly present in noncontractile fluid
and serves cell motility and intracellular structure functions. This protein is actu-
ally fluid in its purified form and, much like syrup, will form strings when picked
up on a glass rod or other stirring device.
The GAGs, actin, and myosin all contribute to the viscoelasticity of myofascial
tissue. Unlike elasticity, the stiffness of viscoelasticity is velocity dependent. Also,
it is worthy of note that unlike the velocity dependence of spasticity, the relation-
ship between viscoelasticity and velocity of movement is purely mechanical. The
mechanical viscoelasticity characteristic and the structural elasticity of the struc-
tural proteins combine to make up the specific tone of a muscle that is unrelated
to contractile activity.
Viscoelasticity of muscle, or viscoelastic tone, affects movement and postural
control The sensory mechanisms that produce the sensation(s) from the musculo-
skeletal system that prompt mammals to stretch after remaining still are relatively
undefined . Concerning posture, there are mechanical properties of muscle (largely
unexplored until recently) that tend to support a resting stiffness of muscles in
posturally supported humans that is unrelated to EMG activity, with the exception
of occasional corrective bursts of activity. The properties of myofascial tissues that
prompt the stretching behavior and account for maintenance of static balance,
however, have been the subject of an abundance of study, resulting in a focus on
the property of thixotropy.
Thixotropy
Defined
Thixotropy, from the Greek words thixis (touch) and tropos (turning or change-
able), is a term that is new to many people across the spectrum of clinicians who
use manual therapeutics. It is not, however, new to physiologists involved in the
study of muscle and tissue mechanics. Thixotropy describes a state of stiffness of
a fluid that is dependent on the history of movement. A number of common sub-
stances exhibit thixotropy. Tomato catsup is probably the most common. After
sitting in the bottle, catsup becomes very stiff and difficult to get out of the bottle.
With just a little stirring, however, the stiffness decreases substantially. 40
Thixotropy is a physical property of muscle and other tissues and not a re-
sponse to some neurophysiological event. The mere act of moving a substance with
thixotropic properties will result in a reduction of stiffness. The reverse is also true:
if a thixotropic substance remains still for a given period of time (which varies
depending on the substance), the substance will become stiffer.
To measure thixotropy, physiologists have used torque motors with very small
torques of approximately 0.1 newton meters (Nm). Under conditions of a sinusoi-
dal motion of the wrist, the amplitude of a motion of the wrist is about 0.02 radians
Neuromechanical Aspects of Myofasc ial Pathology and Manipulation 115
may also destabilize the T-tubules enough to result in a higher calcium concen-
tration within myofibrils. This would result in a larger number of cross-bridges
being formed between the myosin heads and troponin, which would increase the
stiffness (i.e., thixotropy). Such an increase in cross-bridges would decrease the
pliability of muscle in the immediately surrounding muscle tissue. This phenom-
enon would explain why deep massage is beneficial for increasing the pliability of
the muscle around trigger points. According to the pain-spasm-pain cycle, deep
massage of a myofascial trigger point should increase the pain, thereby increas-
ing the spasm, which causes even more pain. This does not always occur in prac-
tice; in fact, many practitioners can testify that deep massage can "decrease the
spasm."
I have reviewed the basic receptor anatomy and physiology for most of the
somatosensory system, with the exception of the vestibular system. I have also
reviewed some of the interactions of the somatosensory system with the motor
output system, with particular emphasis on that portion related to the myofas-
cial system. I now turn to the direct application of this physiology and biophysics
background .
arm associated with parallel skin stretching, passive movement, and active move-
ment. 31 They demonstrated the same highly correlated activity in a variety of tasks,
including reaction time tasks, holding tasks, and active movement of the arm. The
shortened range of skin produced very little activity in tactile receptors of the
axilla and upper arm. This is in contrast to movements into shoulder flexion or
shoulder flexion with abduction, which increased the activity. 46 Furthermore, the
greater the stretch in either amplitude or movement, the greater the firing rate of
phasic (rapidly adapting) receptors (e.g., Pacinian corpuscles).
These findings are completely logical and intuitive when considered in con-
junction with the human postural phenomena observed by clinicians. Consider a
patient 3 - 4 weeks following a cholecystectomy via a left upper quadrant incision
rather than a laparoscopic procedure. A phasic stimulus of skin receptors during
erect sitting or right shoulder flexion would be perceived as a "greater than rest-
ing or normal position" burst of activity. In that case, the patient would return to
a position that was more in line with resting position. If a mechanical restriction
resulted in an abnormal phasic stimulus or tonic stimulus, then the interpretation
by the system would be that the patient was in a stretched position when, in fact,
the position might be neutral. Consequently, the patient would tend to move into
a position that decreases the firing activity of the phasic and/or tonic receptors.
This position is then perceived, via the skin receptive fields, as normal, and further
shortening of the superficial fascia occurs. This faulty receptor activity and the
position sense activity it provides soon become the basis for postural perception.
Historically, the theoretical basis for such behavior has been pain avoidance.
Certainly, pain avoidance behavior is a reasonable and patent argument in the
early stages, but after several weeks of healing, the pain disappears. What remains
is the new position sense reference from skin and superficial fascia receptors.
Another hypothesis concerning the continued behavior of avoiding elonga-
tion is that of alteration in motor programs (motor memories) to fit the new and
dysfunctional behavior. Considering the amount of practice required to change
a very well-learned motor program, this is not likely. Consider, for example, at-
tempting to change one's signature. It is possible, but on a practical level, it is not
probable owing to the huge volume (millions of repetitions) of practice required.
It is likely this new position sense stimulus acts to inhibit the very muscles that
would elongate the skin's rapidly and slowly adapting receptors. Similar inhibition
is also seen in the Golgi tendon organ and Golgi-Mazzoni type joint receptors.
Such a postulate is based on the findings of numerous investigators of the
inhibitory influences of GTOs and joint receptors on motor output. It is also in
agreement with Janda's model of altered muscle function and motor performance
resulting from "inadequate proprioceptive stimuli," which is probably more cor-
rectly stated as inappropriate or mismatched proprioceptive stimuli. 31 One excep-
tion is noted, which is that the logic described cannot validly be applied to the Bin-
degewebsmassage type of stroke or the skin rolling. This is because their goals and
physiology are not directly connected to the evidence supplied by Cohen et al. 31
Neuromechanical As pects of Myofa scial Pathology and Manipulation 119
Diaphragmatic Techniques
Techniques for correcting restrictions in the diaphragm and inferior border of the
rib cage are important in helping patients who are having difficulty with postural
reeducation. The techniques progress from a gentle stretching of the superficial to
middle layer restrictions just inferior to the anterior rib cage, to those that involve
120 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
grasping the inferior portion of the rib cage, in a seated position, and stretching
it superiorly and anteriorly while asking the patient to sit up straighter and inhale
deeply (shown in Chapter 8, Figures 8.54 through 8.57).
Diaphragmatic techniques address restrictions that are very deep in the tho-
racic and abdominal cavities. Although directly addressing restrictions in the tho-
racic cavity is not possible, it is possible to affect restrictions in the mediastinum
by stretching the diaphragm and deep fascia of the abdomen and diaphragm. Such
restrictions can lead to or be the result of multiple postural problems, such as for-
ward head, protracted shoulders, and a general slumped posture in sitting.
The pathomechanics of slumped posture and forward head are fairly well un-
derstood. With an increasingly forward-head posture comes a tendency for the ribs
and sternum to move inferiorly and posteriorly. This leads to a shortening of the
connective tissue in the abdomen and the thorax. With decreasing length comes
a tendency for increased afferent activity from the tension receptors (e.g., GTOs,
Ruffini endings, Pacinian corpuscles). An increase in tension on these receptors,
especially on the GTOs, of the central tendon of the diaphragm has been shown to
elicit a complex inhibitory effect on the external intercostals and the diaphragm. so
All of this inhibitory activity results in a reduction in lung volume. Over time, as
lung capacity is diminished by these inhibitory processes, the connective tissue
would remodel to its new length, resulting in a new "set" for the normal tension on
the tendon. The manipulation techniques described herein allow for a lengthening
of the diaphragm along its anterior borders, with a resultant, postulated reduction
in the inhibitory activity of the GTOs.
The pathology of such adhesions and, more important, the changes in in-
tramuscular pressure caused by them relate to influences of thixotropy and the
Group III and IV afferents. Adhesions of such a nature can lead to a local irrita-
tion of the muscle and a destabilization of the cell membrane adequate to cause
a release of calcium into the myofibrils. This release of calcium will result in the
formation of cross-bridges without benefit of an action potential and increased
thixotropic resistance to stretch. Increases in intramuscular pressure have been di-
rectly associated with increased afferent action potentials of the Group III and IV
afferents coming from the arterioles, venules, and connective tissue in proximity
to these structures. Such afferent activity results in cardiovascular and pulmonary
changes on a systemic level and an autonomic response of increased blood flow at
a local level.
The treatment techniques themselves also have direct effects on the thixot-
ropy of the system and the Group III and IV afferents. The muscle play motion of
the muscle would provide a mechanical stimulus to aid in decreasing the thixo-
tropic resistance to motion. Next, the technique would have direct effects on the
Group III afferents, with resultant changes in local blood flow, in addition to sys-
temic cardiovascular and pulmonary effects. The changes in thixotropy engen-
dered by the techniques most likely also extend to changing the outflow from the
muscle spindles themselves, with all the cascade of effects from them.
Conclusion
Much of the material presented in the early sections of this chapter may appear
to be weighted heavily toward basic science. It is highly probable, however, that
a significant part of benefit derived from the techniques is neurophysiological in
origin because of the rapidity of the effects and the relatively longer period of time
required for remodeling. A number of these techniques can be viewed as methods
to prepare the patient to be able to move in a manner that will lead to more func-
tional remodeling of collagen.
Practitioners should certainly apply the science and neurophysiology where
valid, but they should also exercise caution when extending their explanation too
far afield from the intent of the science. Furthermore, the practitioner should re-
member that many manual techniques appear to have no rational explanation but
consistently appear to benefit patients. Consequently, the practitioner should use
the science for explanation, when possible, while continuing to use the art of man-
ual therapy to heal and investigating the explanations for the effects seen.
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36. DiMauro S, Tsujino S. Non-lysosomal glycogenoses. In: AG Engel, C Franzini-Armstrong,
eds. Myology. 2nd ed, vol 2. McGraw-Hill; 1994:1554-1576.
37. Simons DG, Hong CZ, Simons LS. Prevalence of spontaneous electrical activity at trigger
spots and control sites in rabbit muscle. JMusculoskelet Pain. 1995;3:35-48.
38. Elert J, Dahlqvist SR, Almay B, Eisemann M. Muscle endurance, muscle tension and personal-
ity traits in patients with muscle or joint pain: a pilot study. JRheumatol. 1993;20:1550-1556.
39. Ivanichev GA. Painful Muscle Hypertonus (in Russian). Kazan: Kazan University Press; 1990.
40. Proske U, Morgan DL, Gregory JE. Thixotropy in skeletal muscle and in muscle spindles: a
review. ProgNeurobiol. 1993;41:705- 721.
41. Walsh EG. Muscles,Masses and Motion: 1he Physiologyof Normality, Hypotonicity, Spasticity
and Rigidity. New York: Cambridge University Press; 1992.
42. Campbell KS, Lakie M. A cross-bridge mechanism can explain the thixotropic short-range
elastic component of relaxed frog skeletal muscle. JPhysiol. 1998;510:941- 962.
43. Hill DK. Tension due to interaction between the sliding filaments in resting striated muscle:
the effect of stimulation.! Physiol. 1968;199:637-684.
44. Mutungi G, Ranatunga KW. The viscous, viscoelastic and elastic characteristics of resting fast
and slow mammalian (rat) muscle fibres. JPhysiol. 1996;496:827-836.
45. Linke WA, Bartoo ML, lvemeyer M, Bolla ck GH. Limits of titin extension in single cardiac
myofibrils. JMuse Res CellMotil. 1996;17:425-438.
46. Simons DG. Clinical and etiological update on myofascial pain due to trigger points. JMuscu-
loskelet Pain. 1996;4:93-121.
47. Walsh EG, Wright GW. Postural thixotropy at the human hip. Q JExp Physiol.
1988;73:369- 37 7.
48. Bogduk N, Macintosh JE. The applied anatomy of the thoracolumbar fascia. Spine.
1984;9:164-170.
49. Bednar DA, Orr FW, Simon GT. Observations on the pathomorphology of the thoracolumbar
fascia in chronic mechanical back pain: a microscopic study. Spine. 1995;20:1161-1164.
50. Yahia L, Rhalmi S, Newman N, Isler M. Sensory innervation of human thoracolumbar fascia:
an immunohistochemical study. Acta Orthop Scand. 1992;63:195-197.
Muscle Pain Syndromes
Jan Dommerholt and Robert W. Stanborough
Muscle pain is a common feature of both acute and chronic pain problems and
affects people of all ages, although chronic muscle pain is less common in younger
populations. 1- 3 Patients with muscle pain are frequently referred to physical thera-
pists for evaluation and treatment ; therefore, physical therapists need to under-
stand the nature of pain and of muscle pain in particular. Clinicians need to be
familiar with the mechanisms of referred pain, peripheral and central sensitiza-
tion, and the best evidence-informed treatment options. 4 •5 Depending on the diag-
nosis, myofascial manipulation may or may not be a part of the patient's rehabilita-
tion program.
Muscle pain is experienced as an aching, diffuse, and difficult-to-localize pain,
which often features referred pain into deep somatic tissues. 3 It can be either tran-
sient, as in delayed onset of muscle soreness, 6 or more persistent .7 Parameters for
the treatment of persistent pain are not included in the American Physical Therapy
Association's "Guide to Physical Therapy Practice," 8 and relatively few physical
therapists have expressed special interest in chronic pain ,9 perhaps because of
lack of understanding. Unfortunately, one study suggested that 96% of orthopedic
physical therapists preferred not to treat patients with chronic pain problems. 10
Although physical therapists are well trained in addressing dysfunction, which
is often a source of pain, they are poorly represented in pain management societ-
ies, and few schools of physical therapy have adopted specific pain curricula for
physical therapists, as suggested by the International Association for the Study of
Pain. 9•11
Muscle pain is distinctly different from cutaneous pain and activates specific
cortical structures, including the anterior cingulate gyrus. 12- 14 Muscles feature
specialized muscle nociceptors, which are free nerve endings connected to the
central nervous system by thin myelinated (Group III) or unmyelinated (Group
IV) afferent fibers. 15 - 17 These nociceptors are particularly effective in inducing
neuroplastic changes in the spinal dorsal horn. 18 Under nonpathological circum-
stances, there is a dynamic balance between activation of dorsal horn neurons and
the descending inhibitory pain-modulating pathways, which are very effective in
inhibiting muscle pain. 19,20
125
126 SCIENTIFIC BASIS FOR MYO FASCIA L MAN IPULATION
healing according to the tissues' demands, and preventing further damage, result-
ing in delayed healing or excessive scar tissue. If healing is prolonged, what began
as a soft tissue mechanical dysfunction may develop into secondary myofascial
pain. Trigger points may develop and become the main source of pain, necessitat-
ing appropriate treatment.
Myofascial pain has been described as the most common diagnosis responsible for
chronic pain and disability, but it is also considered the most commonly missed
diagnosis. 22 •48 This may be due in part to the fact that physical therapy literature
rarely includes reference to trigger points. Several studies have shown that patients
with osteoarthritis, tension-type headaches, and migraines have more clinically
relevant trigger points than do healthy controls. 50 - 53 Although trigger points are
often associated with cervicogenic and tension-type headaches, not all headaches
feature trigger points. Nummular headache, for example, is a primary headache
disorder, characterized by mild to moderate and pressure-like pain circumscribed
to a single round or elliptical area of the head surface, but without active trigger
points in the neck and shoulder muscles. 54 - 56
The role of trigger points is adequately described in other studies and case
reports, including those of facet joint dysfunction, disc herniations, neck pain,
and postlaminectomy syndromes. 57- 60 Trigger points can also occur in associa-
tion with other medical conditions, ranging from nerve entrapments and myocar-
dial infarction to endometriosis, prostatitis, and interstitial cystitis. 61- 67 Although
trigger points are often missed and underdiagnosed, their presence does not ex-
clude other pertinent problems. Caution is therefore warranted, because clinicians
should not focus exclusively on trigger points. Although trigger points are recog-
nized as a source of pain, they are merely a symptom of an underlying dysfunc-
tion. Because trigger points are part of nearly every musculoskeletal pain problem,
it is debatable whether myofascial pain should be considered an actual syndrome. 5
Many recent studies seem to support the concept that a myofascial trigger point
is a manifestation of peripheral and central sensitization, 4 •68 •69 or it may indicate
an actual disease process of muscle rather than a poorly defined syndrome. 70 In
this context, there is no diagnostic or clinical benefit to the patient in making the
distinction between primary and secondary myofascial pain syndrome . The ex-
amination and treatment should be the same.
Diagnosis
The main criterion for the diagnosis of myofascial pain is the presence of an active
myofascial trigger point, an exquisitely sensitive region in a taut band of skeletal
muscle .71 Simons et al. define a trigger point as "a hyperirritable spot in skeletal
muscle that is associated with a hypersensitive palpable nodule in a taut band ." 32 (P 3l
Trigger points have been reported in all age groups except infants. 2 •72- 76 An active
trigger point produces symptoms, including local or referred pain or other pares-
thesia. A latent trigger point does not induce pain without being stimulated .32
Most patients complain of diffuse pain and are not aware that specific myo-
fascial trigger points may cause or contribute to their pain. The diagnosis of
myofascial pain is made by systematic palpation of taut bands and myofascial
trigger points, following a review of the patient's history, and by a thorough
musculoskeletal examination, including an assessment of posture and functional
movement patterns. 32 The patient's pain pattern and range-of-motion restrictions
130 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
Table 6.1 Criteria for Identifying a Myofascial usually point the clinician to the involved
Trigger Point muscles. The minimum acceptable criteria
Diagnostic criteria for trigger point diagnosis are the presence
1. Full stretch, limited by pain of a hyperirritable spot within a palpable
2. Taut band palpable taut band of a skeletal muscle, combined
3. Tender spot or nodule within a taut band
with the patient's recognition of the re-
4. Reproducible pain of patient's complaint
ferred pain elicited by the trigger point (Ta-
Confirmatory observations ble 6.1). These criteria, when applied by an
1. Local twitch response experienced therapist, have obtained good
2. Referred pain in the expected distribution of interexaminer reliability. 71 The presence of
that muscle
3. Endplate noise or spontaneous electrical
a local twitch response, referred pain, or
activity (SEA) demonstrated by an reproduction of the person's symptomatic
electromyographic study pain increases the certainty and specificity
Source: Alfven G. The pressure pain threshold (PPT) of the diagnosis of myofascial pain. A local
of certain muscles in children suffering from recurrent twitch response is a brief, involuntary con-
abdominal pain of non -organic origin: an algometric
study. Acta Paediatr. 1993;82:481- 483. traction of the taut band that can be seen,
Source: Simons D. Understanding effective treat- palpated, felt with the needle during trig-
ments of myofascial trigger points. J Bodyw Mov Ther. ger point injections or dry needling, and
2002;6:81- 88.
recorded electromyographically. It is me-
diated primarily through the spinal cord
without supraspinal influence_n -so The patient's body type and the specific muscle
involved will determine the ease of soliciting a local twitch response. The degree of
stimulation required to reproduce a patient's usual pain can also help determine
whether a trigger point should be considered active or latent. Active trigger points
have a lower pain threshold than that of latent trigger points.
The interrater reliability of the myofascial trigger point examination has been
studied by several authors. 71•81- 88 The reliable identification of trigger points re-
quires anatomical knowledge, adequate manual ability, training, and clinical prac-
tice. Older studies showing lack of interrater reliability were marked by a variety of
methodological problems, including a lack of identification of taut bands, inexpe-
rience of examiners in assessing muscle trigger points, incorrect positioning of the
patient or the examiner, incorrect palpation techniques, variation in the amount
of manual force exerted on the palpated point, and the duration of force applied.
One problem common to all interrater reliability studies is that the trigger point
criteria established by Simons et al. 32 have not been validated. 39- 41 Nevertheless,
Gerwin et al. established excellent interrater reliability for the five major features
of the trigger point: palpable taut band, tenderness, local twitch response, referred
pain, and reproduced pain. 71 They observed that individual features of the trig-
ger point are differentially represented in different muscles. For example, the lo-
cal twitch response was easier to obtain and, therefore, more commonly found in
the extensor digitorum communis than in the infraspinatus muscle. 71 Sciotti et
al. confirmed that clinicians can reliably identify latent trigger points in the tra-
pezius muscle, 87 whereas Bron et al. showed that experienced physical therapists
Muscle Pain Syndromes 131
can reach excellent reliability with palpation of trigger points in various shoulder
muscles. 81
In spite of these studies, recent systematic reviews of the reliability of the trig-
ger point diagnosis concluded that high-quality studies are still needed to confirm
the currently used clinical diagnostic criteria in different populations. 39- 4t,43The
taut band, trigger point, and local twitch response are objective criteria, identi-
fied solely by palpation, and do not require a verbal response from the patient.
Various authors have suggested methods to objectively quantify the amount of
pressure required to elicit a painful response from a trigger point using algometry
or palpometry; however, in clinical practice it remains difficult to determine the
distinguishing features of active and latent myofascial trigger points, because both
are painful with compression. 89·90 Pressure algometry is influenced by nociceptors
in the skin and subcutaneous tissues. 91 Chen et al. confirmed the presence of taut
bands with magnetic resonance elastography, 92·93whereas Sikdar et al. used ultra-
sound imaging and vibration sonoelastography to visualize taut bands and trig-
ger points. 94•95Previous efforts to visualize trigger points with sonography were
not successful. 96·97Gerwin and Duranleau showed local twitch responses with ul-
trasound .97Other authors have suggested that extracorporeal shockwave therapy
might help clinicians confirm the presence of trigger points, but few studies have
demonstrated its validity and utility .98- 101
Although Janda maintained that systematic palpation can differentiate be-
tween myofascial taut bands and general muscle spasms, 102electromyography is
now the gold standard to differentiate taut bands from contracted muscle fibers. 103
A taut band is an endogenous localized contracture within the muscle without
activation of the motor endplate. 104 Spasms can be defined as electromyographic
activity as the result of increased neuromuscular tone of the entire muscle and are
the result of nerve-initiated contractions. From a physiological perspective, the
term contracture is more appropriate than contraction when describing chronic
involuntary shortening of a muscle without electromyographic activity. In clinical
practice, the use of electromyography as a diagnostic tool is limited primarily to
research studies. 105- 107Surface electromyography can be used in the management
of trigger points especially to assess and treat abnormal tension and dysfunctional
movement patterns. 102·108·109
The diagnostic process must include the usual differential diagnostic consid-
erations and must rule out other pathological processes. For example, in the ex-
amination of a patient with knee pain, the clinician should consider radiculopathy,
ligamentous, meniscal, and capsular injuries; patellofemoral joint dysfunction;
bursitis; tendinitis; and arthritis. The clinician must also appreciate referred pain
patterns and the biomechanical implications of taut muscle bands and myofascial
trigger points in the quadriceps, hamstrings, gluteus maximus and iliotibial band,
adductors, and calf muscles. 110 After establishing an initial diagnosis of myofascial
pain, the clinician must determine whether any mechanical, systemic, or psycho-
logical perpetuating factors are contributing to the formation or persistence of
132 SCIENTIFIC BASIS FOR MYO FASCIA L MAN IPULATION
Clinical Characteristics
In clinical settings, patients with myofascial pain usually complain of diffuse pain
confined to one or more regions of the body, as opposed to complaints of wide-
spread pain, which often accompany fibromyalgia. In some instances, patients de-
scribe sharp pain over myofascial trigger points that they can easily identify . In
other cases, the pain complaint is related to referred pain from myofascial trigger
points, and patients have difficulty locating the source of pain. Taut bands and
myofascial trigger points can be identified upon palpation. Because some patients
perceive that clinicians do not take pain complaints seriously, they may be sur-
prised when a clinician elicits a familiar pain complaint by compressing myofas-
cial trigger points. Validating a pain complaint in this manner can be an impor-
tant step in establishing a therapeutic relationship.
Myofascial pain may follow a sequence of events associated with postural
imbalances, leading to joint hypermobility or hypomobility and abnormal bio-
Muscle Pain Syndromes 133
In this situation , the normal , stable tripod support of the foot created by the first
and second metatarsal bones and the heel may not occur. Instead, in some indi-
viduals with such a foot configuration, weight is carried on a knife-edge from the
second metatarsal head to the heel, overloading the peroneus longus. Clinicians
may consider the use of orthotics to correct myofascial dysfunction of the peroneal
muscles. 128 Diagnostic callus formation occurs in these individuals in the areas of
abnormal loading - that is, under the second metatarsal head and on the medial
aspect of the foot at the great toe and first metatarsal head .
Abnormal postures can result in muscle imbalances, the formation of myo-
fascial trigger points in adaptively shortened or lengthened muscles, joint hypo-
mobility and hypermobility, and nerve compression. Forward-head posture is the
most common postural deviation in patients with chronic pain, including patients
with myofascial pain. 120 •122 •123 •129•130 The biomechanical and myofascial aspects of
the forward-head posture are fully discussed in Chapter 7, "Basic Evaluation of
the Myofascial System." The following are typical symptoms in this particular
.
scenario:
•!• Intermi ttent cervical, thoracic, or lumbar pain
•!• Unilateral or bilateral headaches, including migraine and tension-type
headaches
•!• Facial pain
•!• Myofascial trigger points in multiple muscle sites
•!• Upper extremity referred pain or paresthesia in the absence of neurological
findings
•!• Difficulty sitting for a long period of time, especially in deep, soft chairs or
bucket seats that accentuate forward-head posture
•!• Pain or ache on prolonged standing
•!• Decreased pain with rest or gentle movements
Fricton, a dentist who has specialized in myofascial pain, analyzed the most
common postural problems of patients with myofascial pain in the head and neck
regions. In addition to forward-head posture, patients presented with poor tongue
position, scoliosis, abnormal lumbar lordosis, and occlusal problems. 123
Several studies have shown that occupational groups with constrained work
postures and repetitive arm movements are at increased risk for developing myo-
fascial pain. 131•132 Work tasks with high repetition frequency and static muscle
loading may actually decrease the pain pressure threshold and result in allodynia
and hyperalgesia. 133 Constrained work postures may result in decreased circu-
lation and the release of nociceptive substances directly into muscle tissue. 134• 135
Awkward postures are common in the workplace and include excessive wrist flex-
ion and extension, ulnar and radial abduction, forearm supination and pronation,
extended reaches beyond the shoulder-reach envelope, and pinch grips that are
either too wide or too narrow. 136 •137 Particular occupational groups at increased
risk include musicians, data entry operators and typists, industrial workers, and
assembly line workers. 138- 144 Andersen et al. reported the onset of myofascial pain
Muscle Pain Syndromes 135
Sensory Dysfunction
Active myofascial trigger points not only feature local pain but also refer pain to
a distant site. Vecchiet and colleagues described a significant lowering of the pain
threshold over active trigger points, not only in the muscular tissue but also in
the overlying cutaneous and subcutaneous tissues, when measured by electrical
stimulation. With latent trigger points, the sensory changes did not involve the
cutaneous and subcutaneous tissues. In patients diagnosed with fibromyalgia, hy-
peralgesia was present in all three tissues, not only over fibromyalgia tender points
but also in other nonpainful regions. 149 - 151
Several studies support the observation that active and latent trigger points
show features of peripheral sensitization as well as neuroplastic changes within
the spinal dorsal horn. 4 •152 •153 Ge et al. demonstrated that nociceptive stimulation
of latent myofascial trigger points with glutamate injections increased the occur-
rence of local muscle cramps. Nearly 93% of subjects developed muscle cramps fol-
lowing glutamate injection into latent trigger points but not into the non-trigger
point regions. Injections with isotonic saline did not produce any muscle cramps
in latent trigger points or in normal muscle tissue. The authors suggested that la-
tent trigger points may feature a focal increase in sensitivity. 154 The presence of al-
lodynia or non-nociceptive hypersensitivity at latent trigger points was confirmed
by Li et al. 155 Eleven healthy volunteers were injected with hypertonic saline, glu-
tamate, or isotonic saline into a latent trigger point. Painful injections in trigger
points induced a higher pain score than did painful injections in normal muscle
tissue. Latent trigger points with a higher pain score produced more referred pain
than did latent trigger points with a lower pain score. 155 In another study, stimu-
lation of active trigger points in the upper trapezius or levator scapulae muscles
produced contralateral local twitch responses in the same muscle in 61.5% of the
subjects, whereas stimulation of latent trigger points did not produce any contra-
lateral local twitch responses. 156 These studies of latent and active trigger points
seem to suggest that the sensitivity of latent and active trigger points may represent
a gradual spectrum. More active trigger points seem to present with more features
of peripheral and central sensitization.
136 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
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Mus cle Pain Syndromes 137
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a C6 radiculopath y. Source:Reprinted with permission from Mediclip, Manual Medicine 2, version l.Oa.,
Williams & Wilkins.
not always experience pain but may feel other referred paresthesia , such as burn-
ing or tingling sensations. 32·37·159- 164 Referred paresthesia may also mimic or be
responsible for other pain problems, such as tinnitus, tension-type headaches, and
migraines. 70·153·161·165Mechanically stimulating an active trigger point may repro-
duce a patient's symptoms, either immediately or after a delay of up to 15 seconds.
Mechanical stimulation can consist of manual pressure, needling of the trigger
point, movement of the involved body region, and postural strains, such as for-
ward-head posture or pressure on the gluteal muscles in sitting . Pain following
pressure stimulation is probably due to the simultaneous activation of cutaneous
and muscle nociceptors. 166 Even physiological muscle tone at rest may stimulate
an active trigger point, indicative of hypersensitivity of the nervous system. Nor-
mally, skeletal muscle nociceptors require intense stimulation and do not respond
to moderate local pressure, contractions, or muscle stretches. 167·168It is important
to note that referred pain is not specific to myofascial trigger points; however, it is
more common and much easier to elicit over trigger points. 169Normal muscle tis-
sue and other body tissues, such as skin, fascia, zygapophyseal joints, and internal
organs, may also refer pain to distant regions, making referred pain elicited by
stimulation of a tender location a nonspecific finding. 170- 176
It is important that clinicians be familiar with the referred pain patterns of
trigger points. During the history taking, clinicians will be directed to the involved
muscles based on the location of the subjective pain complaint. For example, when
patients complain of pain or paresthesia down the arm, the clinician should not
only consider possible nerve root involvement but also immediately consider trig-
ger points in the scalene muscles; the shoulder muscles, including the rotator
cuff muscles and the pectoralis minor muscle 177- 181; and the arm muscles. 146•182,183
Knowledge of referred pain patterns is also relevant for the development of a treat-
ment plan. Treatment of trigger points in the infraspinatus muscle can inactivate
trigger points in the anterior deltoid and wrist extensors. 184 Trigger points in the
masseter muscle can be treated by deactivating trigger points in the trapezius mus-
cle.185General facial pain can be due to trigger points in the sternocleidomastoid,
masseter, temporalis, or trapezius muscles, 185- 191whereas pain down the leg could
originate in the gluteal muscles. 178
phenomena. 193 Zhang et al. noted an attenuated skin blood flow response after
painful stimulation of latent trigger points compared with normal muscle tissue ,
indicating increased sympathetic vasoconstriction at the location of latent trigger
points. 194 Increasing sympathetic flow via breath-holding also raised the electrical
activity of trigger points. 195 Sympathetic hyperactivity at trigger points was con-
firmed by Ge et al.192 In their study of patients with unilateral shoulder pain , they
observed that an increased sympathetic outflow to muscles decreased the pressure
pain threshold following mechanical stimulation of trigger points. An increase
of intrathoracic pressure increased local and referred pain intensities. 192 Psycho-
logical arousal or stress significantly increased the electrical activity of myofascial
trigger points , whereas autogenic relaxation and the administration of the sympa-
thetic blocking agent phentolamine reduced the activit y, which seems to indicate
that trigger points are indeed associated with the autonomic nervous system. 196 - 199
Pathogenesis
Research has advanced the study of myofascial trigger points considerably. Hu-
man and animal studies have confirmed that trigger points have a specific electri-
cal discharge , as Weeks and Travell established in 1957.105 - 107, 199 - 210 The electrical
activity is a local phenomenon , which is not mediated through the spine or supra-
spinal influences. 203 Simons and colleagues reported action potentials of 10-50
µV and intermittent biphasic spikes of 100-600 µV, and they established that the
electrical activity of trigger points is in fact endplate noise resulting from an exces-
sive release of acetylcholine at the motor endplate. 101,209 ,210 In 1956, Liley described
the spontaneous electrical activity that occurs at the motor endplate ,211 which was
confirmed in 1970 by Wiederholt. 212 Endplate noise is an indication of the irrita-
bility of trigger points 107 but is also an expression of sympathetic dysfunction. 195
Several researchers have explored the effect of therapeutic interventions on end-
plate noise . For example , laser treatments to trigger points in the biceps femoris of
rabbits reduced the endplate noise significantly in one study. 105
A motor endplate is the synapse between the terminal ends of motor neurons
and skeletal muscle. The terminal branches of a single motor neuron end in multi-
ple presynaptic boutons. 213 For an understanding of the role of the motor endplate
in the pathogenesis of trigger points , a brief review of normal muscle physiology
is required .214
the receptor opens a ligand-gated cation channel, which in turn facilitates a so-
dium (Na+) influx and a potassium (K+)efflux across the muscle cell membrane.
Each single quantum of acetylcholine depolarizes the postsynaptic cell and triggers
a miniature endplate potential. A sufficient number of miniature endplate poten-
tials will produce a depolarization and an action potential, which travels along the
T-tubules, triggers the dihydropyridine and ryanodine receptors in the sarcoplas-
mic reticulum, and causes a release of Ca 2+ from the sarcoplasmic reticulum.
Ca 2+triggers a shift in position of tropomyosin in the muscle sarcomere, which
exposes the myosin-actin binding sites, leading to the formation of cross-bridges
and muscle contractions. The release of cross-bridges is dependent on adenosine
triphosphate. Other proteins, including titin, nebulin, troponin, tropomodu-
lin, and desmin, also play significant roles. Titin is the largest known vertebrate
protein and connects myosin filaments to the Z-line with cross-links to other
sarcomeres. Titin is also linked to actin via its so-called PEVK segment, which
is thought to limit the degree of muscle contraction, because myosin filaments
are caught against this "viscous bumper." The myosin filaments, therefore, are
somewhat comparable to a drag net. 215- 219One interesting feature of titin is that
during sarcomere contractions, titin filaments are folded into a sticky gel on the
Z-line, which unfolds into a springlike structure during muscle elongation. 215·216•219
Nebulin inhibits cross-bridge formation until actin is activated by Ca 2+. Nebulin
is linked to desmin and myopalladin and contributes to cytoskeletal stability and
integrity. 220-224
Autonomic Aspects
The etiology of the autonomic aspects of trigger points has not been fully explored.
Based on studies of the impact of psychological arousal on the electrical activity
of trigger points, Hubbard suggested that myofascial trigger points may be due to
dysfunctional muscle spindles, 197 an opinion shared by Partanen and colleagues
as recently as 2009.298 •299 They maintained that the endplate spikes are action po-
tentials of intrafusal muscle fibers and that the "active spots" are in fact muscle
spindles. Simons et al. refuted this, however, by demonstrating that the spike po-
tentials are propagated by extrafusal muscle fibers and not by intrafusal fibers. 27
Liley showed, as early as 1956, that the spontaneous electrical activity is a conse-
quence of the release of acetylcholine at motor endplates. 211
Direct connections between the sympathetic nervous system and muscle fi-
bers have been established and may be critical for future studies. 300 - 302 In 1981,
Barker and Saito demonstrated that some extrafusal muscle fibers are autonomi-
cally innervated. 303 Ljung et al. demonstrated that the extensor carpi radialis bre-
vis muscle is supplied with heterogeneously distributed sympathetic and sensory
innervations in relation to small blood vessels. 304 Viscero-autonomic afferent input
may also trigger point formation via viscero-somatic reflexes.240 The research by
Shah and colleagues found increased levels of norepinephrine and serotonin in the
Mus cle Pain Syndromes 145
immediate milieu of active trigger points, which may be associated with increased
autonomic activity in the motor endplate of trigger points. 227•228 Intramuscular
injections of the a-adrenergic antagonist phentolamine decreased endplate noise
from trigger spots in rabbits, whereas the acetylcholine antagonist curare had no
impact. 199 Injections of serotonin antagonists also reduced pain levels significantly
when compared to injections of anesthetics. 305 •306 Gerwin et al. suggested that
a- and /3-adrenergic receptors at the motor endplate may provide a possible mech-
anism for autonomic interactions, 255 which in rodents increased the release of ace-
tylcholine after stimulation. 307
physical therapy practice. In spring 2009, the Executive Committee of the Ameri-
can Academy of Orthopaedic Manual Physical Therapy endorsed the practice of
physical therapy dry needling. Despite the widespread acceptance and the body of
research documenting its efficacy, the American Physical Therapy Association has
not yet endorsed dry needling by physical therapists but does not find the practice
inconsistent with its "Guide to Physical Therapy Practice." 8
The underlying mechanisms of physical therapy dry needling are still not en-
tirely understood. Physical therapy dry needling can change the chemical environ-
ment of trigger points and may restore normal functioning of acetylcholinesterase
and the acetylcholine receptors as part of muscle regenerative processes. 227•228 •311•312
Superficial physical therapy dry needling, which involves placing a needle into the
tissues overlying a trigger point at a depth of no more than 5-10 mm, may involve
stimulation of Aofibers when the needle is manipulated, release oxytocin, acti-
vate mechanoreceptors coupled with C-fiber afferents, or stimulate the anterior
cingulate cortex. 13•297•313 - 317 It is likely that physical therapy dry needling directed
at myofascial trigger points involves central pain mechanisms, but to date there is
no direct evidence. Hui et al. reported specific changes in the limbic system and
subcortical gray structures following acupuncture needling. 318
Several other studies have implicated the limbic system. 319 - 322 Takeshige and
colleagues confirmed that treatment of acupuncture and nonacupuncture points
involved the descending inhibitory system. 323 •324 Research of the mechanisms of
physical therapy dry needling techniques is still in the beginning stages.
No form of myofascial trigger point treatment should be offered as a stand-
alone intervention. Clinicians should avoid learning and using physical therapy
dry needling, or any other type of treatment, as a quick trick. Physical therapy
dry needling, as well as manual myofascial trigger point release, is better imple-
mented as one part of a comprehensive management plan. Although some patients
may express initial reluctance regarding physical therapy dry needling, many will
be encouraged to learn that the techniques can inhibit nociceptive input, often
within a few treatment sessions. Any intervention that causes extreme anxiety for
a patient, however, may not be the preferred initial choice of treatment. 153•325 - 333
Several studies support using soft tissue manipulation techniques either instead
of or in conjunction with physical therapy dry needling. 44 •334 - 341 The practitioner
must evaluate and, when indicated, treat both soft tissue and joint dysfunctions. 60
The intratissue and intertissue mobility of the functional unit must be evaluated
and treated as well.
In states that prevent the use of physical therapy dry needling, other interven-
tions may be used. Effective soft tissue techniques include myofascial manipula-
tion, massage therapy techniques, sustained pressure over the myofascial trigger
point, trigger point release with a microstimulation applicator, stretch and spray
techniques combined with postisometric relaxation, or muscle energy/hold - relax
techniques. 44, 334- 340
A trigger point release involves sustained pressure applied to the myofascial
trigger point using a flat palpation or pincer grip while the patient performs gentle
Muscle Pain Syndromes 147
Fibromyalgia
Definition
Fibromyalgia, initially labeled fibrositis, was believed to be a connective tissue dis-
order and type of muscular rheumatism. 368 The term fibromyalgia was later in-
troduced when it became increasingly apparent that no inflammation ("itis") was
°
associated with the connective tissue, only pain ("algia").369 •37 Fibromyalgia syn-
drome (FMS) is often diagnosed by using inclusion criteria set forth by the Ameri-
can College of Rheumatology (ACR).48 Although the word fibromyalgia is sugges-
tive of a musculoskeletal syndrome limited to fibrous and muscular tissues, it is
now defined as a medical condition, characterized and defined by the hallmark
of chronic widespread nonarticular musculoskeletal pain. 371 It is a diffuse central
nervous system disorder with pain and dysfunctional sensory processing. 26 It af-
fects nearly 2% of the U.S. population, occurs in women 10 times more frequently
than in men (3.4% female vs. 0. 5% male), and is usually diagnosed between ages 20
and 50 but has been observed in both younger and older individuals. 372 Annual
treatment costs in 1996 averaged $2,275.00 per patient. 373
Diagnosis
FMS is an idiopathic, chronic condition characterized by widespread, diffuse pain,
including above and/or below the waist and on the right and/or left sides of the
body, as well as multiple tender points. 48 •374- 376 In 1990, the ACR defined fibromy-
algia using two classification criteria. These criteria have since become readily ac-
cepted as diagnostic, even though their validity and reliability for clinical practice
have not been established. 25 •48 The first is a history of chronic, widespread, diffuse
pain lasting longer than 3 months, and the second is pain elicited in at least 11 of
18 identifiable but arbitrarily selected tender points using a palpatory force of 4 kg
per unit area. 48 The tender points sites include the following nine paired locations
(Figure 6.3):
Occiput:Bilateral, at the suboccipital muscle insertions
Low cervical:Bilateral, at the anterior aspects of the intertransverse spaces at
C5- C7: under 5 cm
Trapezius: Bilateral, at the midpoint of the upper border
Supraspinatus: Bilateral, at origins, above the scapula spine near the medial
border
Second rib: Bilateral, at the second costochondral junctions, just lateral to the
junctions on upper surfaces
150 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
A third complaint often noted but not part of the classification criteria is sleep
disturbance, with patients reporting fatigue even after waking. 3n - 379
A proper diagnosis is most important when examining patients with symp-
toms commonly attributed to FMS. Physicians who still rely solely on a simplistic
Insertion of
the subocci pital
Under the muscle
lower sternomastoid
muscle
~
.....
•
-
l'
\
,,_ ·'
Origin of the Mid upper
Near the supraspinatus trapezius muscle
second costochondral muscle
junction
2 cm distal
to the lateral
epicondyle l
I
,
I
Upper outer
quadrant of
At the prominence
the buttock
of the greater I At the \
trochanter medial
lat pad
of the
knee
1'
Figure 6.3 Fibrom yalgia tender points. Source:Reprinted with permission. D. L. Goldenberg. Diagnos-
tic and Therapeutic Challenges ofFibrom yalgia, Hospital Practices1989, Vol. 24, No. 9A, p. 39. © 1989
McGra w-Hill Companies. Illustration by Laura Dupre y.
Muscle Pain Syndromes 151
tender point count will not be able to distinguish FMS from other chronic wide-
spread pain syndromes with similar symptoms, such as hypothyroidism, disturbed
sleep, growth hormone deficiency, metabolic insufficiencies, myofascial pain, my-
algias secondary to medication use, irritable bowel syndrome, nonulcer dyspepsia,
esophageal dysmotility, parasitic infestations, myoadenylate deaminase deficiency,
chronic prostatitis, vulvodynia, rheumatic and infectious diseases, psychological
diagnoses, hypermobility syndrome, and whiplash syndrome, among others. 25 •380
Tenderness assessed by the tender point count does not distinguish FMS from
other pain syndromes but may be an indication of allodynia, hyperalgesia, or pe-
ripheral and central sensitization. 381- 383 When a diagnosis of FMS is seen as an end
point rather than an opportunity to explore what may be causing the widespread
pain and associated symptoms, the established medical differential diagnostic
process is not applied. Although the FMS criteria state that the diagnosis is one of
inclusion, which should be made irrespective of other diagnoses, common sense
dictates that a physician would need to exclude other possible diagnoses to make a
diagnosis of FMS. In other words, FMS is actually a diagnosis of exclusion. 25 The
widespread nature of FMS is not sufficient to make the diagnosis. Using a tender
point count to establish the widespread nature of a particular pain problem may
lead to many false positives. 384 - 386 Localized musculoskeletal pain is relatively rare
and usually coexists with pain in other body regions.
Patients diagnosed with FMS commonly present with considerable comor-
bidities, including headaches, 48•387 anxiety and depression, 374 •388 - 391 irritable bowel
syndrome, 377•392 •393 and a number of other ailments, making the differential diag-
nosis extremely difficult when using the established classification criteria alone.
This is especially true when considering the extent to which symptoms overlap
with those of chronic fatigue syndrome and other chronic pain conditions. Both
FMS and chronic fatigue syndrome share symptoms of muscle pain, sleep distur-
bance, fatigue, cognitive dysfunction, abdominal pain, muscle weakness, reduced
activity, and migratory arthralgias. 378•394 Both are chronic pain disorders believed
to have an underlying central nervous system abnormality, although some chemi-
cal differences have been shown. Immunological dysregulations, such as the ab-
normal 2'-5' oligoadenylate (2-SA) synthetase/RNase L pathway, have been de-
tected in patients with chronic fatigue syndrome, but never in those diagnosed
with FMS.394•395 Patients with chronic fatigue syndrome also show significantly
lower blood perfusion in the brainstem compared with controls. 394 Of most inter-
est is the difference in levels of substance P. Those diagnosed with FMS or FMS and
chronic fatigue syndrome combined have elevated levels of substance P, whereas
those diagnosed with chronic fatigue syndrome alone do not. 394, 396
Although not yet definitive, new diagnostic methods involving the nervous
system seem promising. In the meantime, the sole use of the 1990 ACR classifi-
cation criteria has been challenged and no longer appears to be an acceptable or
reliable diagnostic method. 25•375 The criteria have several significant limitations,
which may explain why fewer health care providers currently use them in clinical
152 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
practice compared to a decade ago. 375 As a response to its limitations and because
so many patients failed to satisfy the 1990 classification criteria, the ACR has pro-
vided a provisional, updated case definition and diagnostic criteria that do not
require a tender point examination. 397
Wolfe et al. examined 829 patients previously diagnosed with FMS as part
of a two-phase multicenter study. 397 During the first phase, data were collected
from both patients and physicians for the purpose of developing questionnaires.
Patients were asked to complete a regional pain scale (renamed the Widespread
Pain Index [WPI]), a categorical scale for symptoms, a visual analog scale, and the
Health Assessment Questionnaire II functional disability scale, as well as to iden -
tifyprelisted symptoms experienced within the last 3 months. In the second phase,
participating physicians were asked to examine patients using the ACR tender
point count and to complete categorical scales for pain, fatigue, sleep disturbance,
cognitive symptoms, waking unrefreshed, and overall (global) severity using the
same categorical scoring as the patients. Physicians were also asked to indicate
whether patients complained of muscle pain, irritable bowel syndrome, fatigue,
cognitive problems, muscle weakness, headache, abdominal pain or cramps, par-
esthesias, dizziness, sleep problems, depression, constipation, diarrhea, interstitial
cystitis, anxiety, and muscle tenderness. Using a similar list of symptoms, physi-
cians were asked to categorize patients as having "few or no somatic symptoms,"
"a moderate number of symptoms," or a "great deal of symptoms." Using the data
collected, Wolfe et al. created a symptom severity scale to be used in conjunction
with the WPI during the examination process. 397
According to the updated criteria, listed in Table 6.2, a patient may be di-
agnosed with FMS if the following three conditions are met: (1) WPI score > 7
and symptom severity scale score > 5 or WPI score = 3 -6 and symptom sever-
ity scale score > 9; (2) symptoms have been present at a similar level for at least
3 months; and (3) the patient does not have a disorder that would otherwise ex-
plain the pain.
The provisional diagnostic criteria presented are not meant to replace the 1990
ACR classification criteria but were designed to supplement them. By addressing
the limitations of the tender point examination, the provisional criteria improve
the 1990 classification sensitivity. The provisional criteria also, for the first time,
enable recording of current and past symptom severity as these change through
the course of the patient's life.
Pathogenesis
During the past decade, the research regarding pain syndromes has expanded
considerably. The purpose of this book, however, is to provide sufficient back-
ground, research, and management for those soft tissue dysfunctions that best re-
spond to myofascial manipulation. Although FMS is no longer considered a soft
tissue or mechanical dysfunction, 25 •398 such patients are continually being referred
to physical therapists. As musculoskeletal specialists, physical therapists need to
Muscle Pain Syndromes 153
Ascertainment
(1) WPI: note the number of areas in which the patient has had pain over the last week. In how
many areas has the patient had pain? Score will be between O and 19.
Shoulder girdle, left Hip (buttock, trochanter). left Jaw. left Upper back
Shoulder girdle, right Hip (buttock, trochanter). right Jaw. right Lower back
Upper arm. left Upper leg, left Chest Neck
Upper arm. right Upper leg, right Abdomen
Lower arm. left Lower leg, left
Lower arm. right Lower leg, right
(2) SS scale score:
Fatigue
Waking unrefreshed
Cognitive symptoms
For each of the 3 symptoms above, indicate the level of severity over the past week using the
following scale:
0 = no problem
1 = slight or mild problems. generally mild or intermittent
2 = moderate, considerable problems. often present and/or at a moderate level
3 = severe: pervasive, continuous, life-disturbing problems
Considering somatic symptoms in general. indicate whether the patient has:•
0 = no symptoms
1 = few symptoms
2 = a moderate number of symptoms
3 = a great deal of symptoms
The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed,
cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score
is between O and 12.
*Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking
or remembering problem, muscle weakness, headaches, pain/cramps in the abdomen, numbness/tingling, diz-
ziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness , chest pain, blurred
vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud 's phenomenon, hives/welts, ringing in ears , vomit -
ing, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash,
sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder
spasms.
Note . Reprinted from Wolfe F, Clauw DJ, Fitzcharles MA, et al. "The American College of Rheumatology Prelimi -
nary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity." Arthritis Care and Research.
2010;62:607,with permission of John Wiley & Sons, Inc.
understand the current thinking about FMS to be able to provide the best evi-
dence-informed treatment.
The most widely accepted pathogenic models regarding FMS point to abnor-
malities in central nervous system sensory processing. The term central sensitiza-
tion is appearing more often in the literature to describe FMS. FMS is commonly
154 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
Management of Fibromyalgia
Individuals with FMS typically do not respond to treatments otherwise effective
in treating damaged or inflamed tissues (i.e., ice, nonsteroidal anti-inflammatory
drugs, steroid injections, or surgical procedures). The management plan typi-
cally includes pharmacological and nonpharmacological interventions. Pharma-
cological therapies may include medications such as antidepressants, analgesics,
muscle relaxants, anticonvulsants, and others. 407 Nonpharmacological therapies
may include aerobic and strengthening exercise, massage, chiropractic manipu-
lation, cognitive-behavioral therapy, sleep hygiene, and a number of alternative
therapies.
Pharmacological Management
The U.S. Food and Drug Administration has approved pregabalin, duloxetine,
and milnacipran for treating FMS, although these drugs do not necessarily dem-
onstrate acceptable efficacy for the majority of patients. 430Nevertheless, several
studies offer support for the administration of these medications for patients with
FMS to reduce overall pain levels, the number of tender points, stiffness, and fa-
tigue.374•43
1-438Nonsteroidal anti-inflammatory medications are often used but
have limited effectiveness. 439Tricyclic antidepressants, such as amitriptyline, have
been studied extensively because of their ability to block the reuptake of serotonin
or norepinephrine. They are effective in reducing pain and fatigue and improving
sleep but have resulted in problems with tolerability. 440-442Cyclobenzaprine, when
used at bedtime, has been shown to improve sleep and to reduce pain. 443-447 Selec-
tive serotonin reuptake inhibitors, such as fluoxetine, paroxetine, and citalopram,
have not been as effective as would be expected but do provide relief for some
patients. 431
•448-450Tramadol, a central-acting nonopioid analgesic with limited
opioid activity, has been shown to reduce pain as much as 20% when compared
with a placebo, especially when combined with acetaminophen. 451 •452Opioids are
commonly used in the management of patients with FMS, in spite of limited re-
search. 380The number of medications and their effects far exceed the limitations
and purpose of this text. It should be noted that no single medication has been
labeled as "the" drug of choice for patients with FMS, and no cure currently exists.
However, physical therapists and other clinicians should at least be familiar with
the names, indications, effects, and common side effects of some of the more com-
monly prescribed medications used in treating persons with FMS.
Nonpharmacological Management
Nonpharmacological therapies include exercise, massage, cognitive-behavioral
therapy, and a number of alternative therapies. Acupuncture, 453-456massage, 457and
osteopathic or chiropractic manipulation 458•459provide some short-term reduction
in pain, but the quality of the methodology of such studies is not strong. Exercise
is the most relevant intervention for the physical therapist. As with any referral,
156 SCIENTIFIC BASIS FOR M YOFASCIAL MAN IPULATION
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180 SCIENTIFIC BASIS FOR MYOFASCIAL MAN IPULATION
The principal focus of this chapter is the evaluation of the myofascial system. Myo-
fascial assessment, however, represents only one aspect of the total biomechanical
evaluation of the spine, and the results of any myofascial evaluation should always
be correlated with other findings to assess accurately the functional (or dysfunc-
tional) status of the spine and extremities. For that reason, this chapter will neces-
sarily ref er to other aspects of the biomechanical evaluation.
Dysfunction is defined by Dorland's Illustrated Medical Dictionary, 31st Edition,
as a "disturbance, impairment, or abnormality of the functioning of an organ." 1
More specifically, somatic dysfunction can be defined as "impaired or altered func-
tion of related components of the somatic system. Somatic dysfunction is a state of
altered mechanics, palpable changes of integrity, increased or decreased mobility
and autonomic changes." 2 A therapist diagnoses dysfunction in the same man-
ner as a physician diagnoses pathology: through correlation of findings. When a
physician is looking for pathology in relation to low-back pain, the diagnosis is not
made based on radiology or physical examination alone. In the case of discogenic
pathology, for example, the physician uses the history, physical examination, ra-
diological findings, and electromyograms (EMGs) to determine if true discogenic
radiculopathy exists. If the patient has a magnetic resonance image (MRI) with
a positive finding for discogenic lesion, in the absence of any other finding, the
herniation may not be the cause of the pain and dysfunction. The physician who
diagnoses discogenic pathology on the basis of MRI alone would be premature in
making the diagnosis. If, however, the patient is experiencing low-back pain; has
referred pain in the lower extremity; and has diminished reflexes, selective muscle
weakness, and positive EMG and MRI results, the findings together definitively
correlate for discogenic pathology.
The physical therapist diagnoses significant dysfunction in the same way.
All findings from the history, visual, palpatory, and movement examinations are
correlated to determine dysfunction. Postural asymmetry caused by a leg-length
discrepancy, without the existence of other indicators, may not be dysfunctional.
183
184 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
History
Cyriax stated that the patient's history is of great importance, especially in spinal
conditions. 3 Most clinicians have a standardized routine questionnaire and his-
torical format, but several key questions should always be asked when looking for
myofascial-type pain syndromes.
1. What is the quality of the pain? Myofascial pain is usually dull and aching, as well
as poorly localized. If the patient is reporting specific, sharp pain, which is easily repro -
duced, specific pathology may exist rather than a myofascial -type syndrome.
2. How is the patient sleeping at night? One of the critical factors in myofascial pain
is the disturbed sleep pattern. Typically, the patient will report difficulty going to sleep
and frequent awakenings during the night. Patients usually report feeling unrefreshed and
fatigued in the morning.
3. What pattern does the pain follow during the day? A typical daytime pattern for
myofascial pain is increased stiffness and pain in the early morning, with a slight drop -off
in symptoms at mid -morning, and with the pain remaining somewhat constant through -
out the day. Increased activity usually aggravates the condition, but the symptoms remain
regional and diffuse.
4. Can a position of comfort or relief be identified? Patients should be able to identify
a position of relief, even if only temporary, where pain may be decreased by minimizing
stresses through the contractile tissues. In the case of active trigger points, the position of
relief is often an alternating pattern of contracting and resting the muscle in a midrange
position.
Basic Evaluation of the Myofasc ial System 185
Observation of Posture
The patient should be viewed from anterior, posterior, and lateral angles to en-
sure accurate assessment (Figures 7.1 through 7.3). In integrating the myofascial
-..-
-=-
Figure 7 .1 Postural examination: anterior view. Figure 7 .2 Postural examination: posterior view.
186 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
•!• Maintenance of joints and soft tissues in shortened range, leading to restric -
tion of joint capsules and loss of proprioception
•!• Elevation of the first rib by increased scalene activity
•!• Anterior and posterior restriction of the first rib articulations
•!• Tendency toward thoracic outlet symptomatology
•!• Increased thoracic kyphosis with decreased lumbar lordosis
•!• Increased activity of the accessory respiratory muscles due to poor diaphrag -
matic breathing and poor expansion of the lower rib cage
Phasic Tonic
long us colli upper trapezius
deep neck flexors levator scapulae
Tonic Phasic
pectoralis group low/mid trapezius
rhomboids
Phasic
abdominals
erector spinae
quadratus lumborum
Tonic
iliopsoas Phasic
gluteal group
phasic gluteus medius and maximus - and the anterior - postural hip flexors (ilio-
psoas, rectus femoris) and phasic abdominals. The patient presents with a forward
pelvic tilt, increased lumbar lordosis, and slightly flexed hips (Figure 7.5). Altered
patterns of hip extension are often seen in ambulation, with compensatory exten-
sion of the lumbar spine.7•10
The layered syndrome is observed in the posterior view. From top to bottom,
an alternating pattern adaptation can be seen in the tonic and phasic muscles, in-
cluding the tonic upper trapezius/levator scapulae, phasic mid- and low trapezius,
tonic thoracolumbar erectors, phasic gluteus medius/maximus, and tonic ham-
strings (Figures 7.6 and 7.7).
Janda suggested that treatment should first focus on restoring proper length
to the tonic muscles before strengthening the phasic. 11 He based this on Sher-
rington's law of reciprocal inhibition. Although not confirming Sherrington's law,
researchers have shown that the deep cervical musculature becomes inhibited in
the presence of neck pain, 12•13 while superficial flexors of the cervical spine (i.e., the
190 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
postural
: uppertrapezlus
levatorscapulae
Phasjc: infraspinatus
mid/lowtrapezius
mombolds
Postural: erector
splnae
Phaslc: glutealgroup
Postural: hamstrings
Cervical Spine
In the forward-head posture, the cervical lordosis is decreased, as is the straight-
line distance between the occiput and the cervicothoracic junction. This rela-
tionship places the cervical erector spinae in a shortened position, which over a
Basic Evaluation of the Myofascial System 191
Thoracic Spine
In the forward-head posture, there is an
increased kyphosis of the thoracic spine.
The straight-line distance between the
manubrium and the umbilicus, as well
as the straight-line distance between gle-
nohumeral joints, is decreased. This places
Figure 7.7 Layered syndrome: lateral view. the pectoralis major and minor, along with
the upper trapezius, in a shortened position.
In the myofascial system, the pectoralis ma-
jor and minor muscles respond to dysfunction by tightening, as does the upper
trapezius. The middle and lower trapezius and rhomboid muscles weaken in re-
sponse to dysfunction, which further facilitates the thoracic dysfunction. Once
again, antagonistic muscle groups respond in opposite ways to facilitate the same
dysfunction. As noted, the anterior of the diaphragm, which, in turn, facilitates
the upper thoracic accessory breathing muscles, further compounds the problem.
Table 7.2 summarizes these changes.
Lumbar Spine
In the lumbar spine, two situations commonly exist. The first, excessive lumbar
lordosis, can be correlated to dysfunctional muscle groups (lower crossed syn-
drome). The increased lumbar lordosis includes a tightening of the lumbar erector
192 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
spinae, psoas muscle groups, iliacus, and tensor fasciae latae. The antagonistic
groups, which include the abdominals and the gluteus maximus, weaken, further
facilitating the dysfunction. Corresponding
Table 7.3 Lumbar /Lumbopelvic Agonist/ joint dysfunction includes hypomobility of
Antagonist Relationships
the lumbar segments, with tightening of the
Tonic (postural) Phasic posterior structures (Tables 7.3 and 7.4).
lliopsoas/tensor fasciae Gluteus maximus The other scenario, in which there
latae
is a loss of lumbar lordosis, pits the ham-
Hamstrings Quadriceps
strings and posterior hip structures against
Hip adductors Gluteus medius
the erector spinae as antagonistic groups
Gastrocnemius-soleus Dorsiflexors
(layered syndrome). This situation is more
Erector spinae Abdominals
common in men with early to moderate
Basic Evaluation of the Myofascial System 193
Table 7.4 Muscle Agonist/Antagonist Groups of the LumbopelvicArea and Resulting Dysfunction
Response to
Muscle group Action dysfunction Results of dysfunction
lliopsoas • Hip flexi on Tightens • Restricted hip extension
• Assists in external • Tight anterior hip capsule
rotation & adduction • Increased lumbar lordosis
• Backward bending of • Decreased posterior
the lumbar spine rotation of ilium
• Restricted hip extension,
external rotation &
adduction
Tensor fasciae • Anterior rotation of ilium Tightens • Decreased posterior
latae • Hip flexion, internal rotation of ilium
rotation, abduction • Restricted hip extension,
• Backward bending of external rotation &
lumbar spine adduction
• Assists knee flexion • Contributes to increased
lumbar lordosis
Gluteus maximus • Hip extension Weakens • Loss of hip extension
• Posterior rotation of • Decreased posterior
ilium rotation of ilium
Hip adductors • Hip adduction Tightens • Restricted hip abduction
• Assists hip flexion • Restricted posterior
• Anterior rotation of ilium rotation of ilium
Gluteus medius • Hip abduction Weakens • Limited hip abduction
• Hip internal rotation • Loss of lateral hip
(anterior fibers) stabilization
• Hip external rotation
(posterior fibers)
Erector spinae • Extension of spine Tightens • Increased lumbar lordosis
Abdominals • Flexion of spine Weakens • Anterior pelvis tilt
• Increased lumbar lordosis
degenerative joint disease of the lumbar spine. The tightness in the hamstrings
and posterior capsule of the hips pulls the spine into forward flexion, holding the
erector spinae in a lengthened position, leading to progressive weakness. The cor-
responding dysfunction is usually joint hypermobility with eventual instability of
the lumbar spine.
When evaluating posture, the clinician should consider these myofascial re-
lationships and how they correlate to structure. These findings may then be cor-
related to the remainder of the evaluation.
Palpatory Examination
Once posture and active movements are assessed, the clinician may begin to esti-
mate where the significant dysfunctions exist. The palpatory examination reveals
yet more information that may be correlated to previous findings and offers a clear
picture of possible goals and treatment approaches.
The palpatory examination includes, but is not necessarily limited to, the fol-
lowing: (1) palpation of the myofascial structures in the form of layer palpation,
(2) palpation of joint structures, and (3) assessment of passive segmental mobility.
Palpation of myofascial structures is primarily emphasized here, including layer
palpation and passive mobility of muscles and fascial mobility.
Layer Palpation
Layer palpation is a systematic method of assessing the mobility and condition of
the myofascial structures, starting from the most superficial structures and pro-
gressing into the deepest palpable structures. Layer palpation is extremely impor-
tant, especially because a common error in both assessment and treatment is to
press through the superficial tissues and delve into the deeper structures without
consideration of possible superficial tissue adaptations. The tissues that can be pal-
pated include the skin, subcutaneous fascia, blood vessels, muscle sheaths, muscle
bellies, musculotendinous junctions, tendons, deep fascia, ligaments, bone, and
joint spaces.
The clinician should be able to palpate in depth the location of the structures
during the palpatory examination. Developing layer palpation requires training of
both tactile and visual senses. The development of tactile skills includes the ability
to detect tissue texture abnormalities and tissue resistance, taking into consider-
ation how tissues at one level of depth differ from the surrounding tissues at the
same depth or on the contralateral side. Table 7.5 lists contrasting terms that are
helpful in describing results from layer palpation.
196 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
superficial-deep acute-chronic
compressible-rigid painful-non pai nfu I
moist-dry circumscribed-diffuse
soft-hard rough-smooth
hypermobile-hypomobile thick-thin
For practical purposes, the layer palpation format may be categorized into su-
perficial and deep palpation (Table 7.6). The superficial palpatory examination in-
cludes assessment of tissue temperature and moisture, as well as use of light touch
to determine the extensibility and integrity of the superficial connective tissues.
Tissue rolling is an important part of layer palpation, because it gives the clinician
information about the extensibility of the subcutaneous connective tissue (Fig-
ure 7.8). In tissue rolling, the skin and superficial connective tissue are lifted up,
away from the deeper tissues. Both the extensibility of the tissues and its integrity
can be palpated .
The deep palpatory examination includes compression, a perpendicular pal-
pation through layers of tissue, and shear. Shear is movement of the tissues be-
tween layers, also moving perpendicular to the tissue. The palpable structures are
muscle sheaths, muscle bellies, tendons, myotendinous junctions, tenoperiosteal
junctions, joint capsules, and the deep periosteal layers of tissue . Tissue texture
abnormalities and restrictions are noted in the deeper tissues. Transverse muscle
play is an effective assessment tool for determining the mobility of a muscle or
muscle group within the enveloping fascial sheath. In muscle play, the muscle is
"bent" in order to assess the transverse flexibility of the muscle . This concept is
discussed in greater depth in Chapter 8, "Atlas of Therapeutic Techniques."
Once the evaluation is completed, the findings are correlated to define the spe-
cific dysfunction, and treatment is initiated accordingly. Reevaluation should take
place before, during, and after a treatment for the purpose of treatment modifica-
tions, to provide optimal outcomes and to accommodate for changes made .
Basic Evaluation of the Myofasc ial System 197
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Atlas of Therapeutic Techniques
Robert I. Cantu, Alan J. Grodin, and Robert W. Stanborough
199
200 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Myofascial restrictions, on the other hand, are not as predictable because they can
occur outside the realm of specific joint arthrokinematics. Restrictions of the su-
perficial fascia, a loose irregular connective tissue, for example, may occur in many
planes and in many different and unpredictable directions. The treatment is based
on localizing the restriction and moving into the direction of restriction, regard-
less of whether the direction follows the arthrokinematics of the nearby joint.
Herein lies one of the problems with myofascial manipulation: Treatment has
a tendency to become subjective and abstract. The danger of losing credibility is
higher than in joint manipulation, because treatment is based on "what the thera-
pist is feeling." There is no doubt that "good hands" and an "intuitive mind" are of
great value in manual therapy, specifically in myofascial manipulation. A balance
should exist, however, between scientific scrutiny and clinical intuition. Treatment
that relies heavily on one while deemphasizing the other will not be balanced and,
therefore, will not be as effective. This text represents myofascial manipulation
in a biomechanical and kinesiological sense, respecting and integrating nearby
joint arthrokinematics as much as possible. In this way, myofascial manipulation
is represented in the most concrete empirical form possible, without negating the
intuitive aspects of the treatment technique.
Sequencing of treatment: The sequence in which technique is applied will
generally make the difference between success and failure. There are two impor-
tant questions: Where in the entire treatment scheme does myofascial manipula-
tion fit? And how does the clinician sequence individual myofascial technique for
optimal results? Each patient is different, and each clinician will determine the
sequence of treatment on an individual basis; however, the guidelines discussed
below may be helpful in deciding treatment sequencing for individual patients. A
general scheme of treatment follows.
1.Myofascial manipulation of involved and regional areas associated with local in-
volvement. With joint manipulation, treatment often focuses on individual joints being
moved in specific directions. Myofascial manipulation, however, initially focuses on
larger areas or regions of treatment. Individual joint restrictions often have significant
myofascial components. Passive segmental mobility of individual joints may change with
regional treatment of myofascia because the tissue may cross one or more joints. Releas-
ing myofascial tissues prior to joint manipulation also allows joint manipulation to be
performed with less force application. If the myofascial component of the restriction is
first released, the mechanical restriction of the joint can more easily and more specifically
be assessed and treated. The general progression of myofascial manipulation considers the
following factors:
a. Direct beforeindirect technique. For the most part, all the techniques described
in this text are direct in nature. In other words, the techniques locate the restriction and
move into the direction of the restriction. The concept is that the shortest distance be-
tween any two points is a straight line, and the shortest distance through a restriction is
directly through the restriction. If the changes cannot be made with direct technique be-
cause of pain, autonomic responses, or severity of the restriction, then indirect technique
maybe used.
At las of Therapeutic Techniques 201
Positioning of patient and therapist: The therapist needs to keep in mind two
important concepts related to positioning. First, to achieve maximal therapeutic
effect, both patient and therapist should be situated in the most efficient positions
possible . This concept may seem elementary, yet it is often forgotten in the day-
to-day treatment of patients. Any inefficiency in the therapist's application of the
treatment is transferred to the patient. The patient senses this inefficiency in the
manual technique and is unable to relax fully.
202 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Care and protection of hands: The hands are the primary treatment modality
for the manual therapist and do not come with a replacement guarantee. Because
of the significant and repetitive stresses that the hands withstand, great care should
be taken to use them properly, in the most effective and efficient way possible. If a
manual therapist works on 15 patients a day, 5 days per week, the therapist is lay-
ing hands on more than 3,700 bodies per year. Those numbers accumulate over the
course of a career. The hands are very durable body parts; however, the principles
of Wolff's law (good stress/bad stress) apply to patient and therapist, bone and
soft tissue alike . Practicing correct application of technique and following proper
hand-care procedures are essential for ensuring longevity of the manual thera-
pist's career. The following are some suggestions for hand care.
1. Whenever possible, use techniques that do not hyperflex or hyperextend any joints.
Suggested techniques include the chisel grip (Figure 8.1), octopus grip (Figure 8.2), and
half-chisel grip (Figure 8.3). End -range maneuvers will only accelerate joint hypermobil-
ity problems, leading to early arthritic changes. The thumbs, when used together, should
support each other and should be aligned with the metacarpals, which in turn should be
aligned with the radius. When used individually, the thumb and proximal interphalangeal
At las of Therapeutic Techn iques 203
(PIP) joint of the index finger can be used together to form a very stable contact surface
(Figures 8.2 and 8.4).
2. Adapt for size difference between therapist and patient . If the patient is large, and
the desired depth of penetration is not practical, the therapist should not use the fingers or
204 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
thumb. The fists and elbows are excellent alternat ives. The the rapist can palpate with the
fingers but should treat with the elbows or fists.
3. Wash hands in cold water after each patient treatment . If the the rapist experiences
any inflammat ion in the hands du ring a pat ient treatment, the cold water may act as a
At las of Therapeutic Techn iques 205
cryotherapy/anti -inflammatory treatment. Using warm water 15- 20 times per day may
have a cumulative inflammatory effect, whereas use of cold water may slow down the
process.
4. Protect the hands during off-hours. When gardening or performing any type of
work that may be hard on the hands, the therapist should wear gloves. Manual therapists
actually incur more microtrauma to their hands during off-hours, when the hands should
be getting much -needed rest.
5. Use of lubricant. A small amount of lubricant should be used, especially in tech -
niques involving longer stroking. The amount of lubricant should be just enough to de-
crease noxious skin friction, but not enough to cause slipping of the hand on the body.
A certain amount of traction on the skin is necessary for appropriate delivery of the
technique.
Execution: The therapist places the stabilizing hand on the patient to gen-
tly stabilize the subcutaneous connective tissue. The manipulating hand is placed
gently on the patient, with the pisiform being the axis of motion for the tech-
nique. Starting with the elbow of the manipulating hand close to the body, the
therapist moves it from the body, bringing the fingers away from the stabilizing
hand in a sweeping motion. Then the therapist lifts the manipulating hand and
repeats the stroke. The technique is repeated at a deliberate pace, moving about
an area of the spine as indicated by restrictions. The technique is superficial, ap-
plied only to the superficial, subcutaneous connective tissue. The technique is
generally comfortable and, at worst, should be only mildly uncomfortable. The
goal of this technique is to quiet the autonomic system, not to create mechanical
changes.
Figure 8.9 Long axis distraction of superficial connective tissue: stroke initiation.
Figure 8.10 Long axis distraction of superficial connective tissue: stroke completion.
Figure 8.11 Long axis distraction of superficial connective tissue: stroke from above.
reached. A lateral elongation force is then applied, as the elbow and fore arm slide
laterally and around the body. Most of the pressure is at the elbow and the proxi-
mal one-third of the ulna. The rest of the forearm and hand are merely resting on
the patient, in a relaxed position, as the technique is executed. Deeper pressure
At las of Therapeutic Techn iques 211
may be gradually applied to the muscular and periosteal levels as the subcutaneous
fascia releases and as patient tolerance dictates.
skin and subcutaneous tissue. Generally, the skin is rolled from caudal to cephalic,
but other directions such as medial to lateral or diagonals can be pursued . One
can imagine balancing a drop of water on the lifted portion of the skin as the roll
is applied. When a restriction is encountered, the rolling can be stopped, and a
gentle posterior stretch or oscillation can be applied . (Although the figures show
skin rolling in the region of the back, the technique may be applied anywhere in
the body where restrictions are found in the superficial subcutaneous connective
tissue.)
Figure 8.17 Long axis laminar release: stroke completion with distraction.
214 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
along the groove may be identified. These lesions are manifestations of local in-
creases in muscle tone, reflexive muscle guarding, or connective tissue thicken-
ings. The lesions may be results of acute inflammation or may be remnants of older
trauma, holding patterns, or chronic fibrotic changes. The movement of the hands
may be stopped at any time to apply localized, sustained pressure over the lesions.
,,
\
\.
----10
0
Figure 8.18 Muscle play of erector spinae: force distribution. Force applied through the thumbs "bends"
the muscle.
At las of Therapeutic Techniques 215
bending the hose is one way to accomplish this goal. For the technique, the tips of
the thumbs are placed on the lateral border of the erector spinae, while the thumbs
remain positioned so they are in line with the radius of the forearms. This ensures
that forces are distributed throughout the arm and are not localized in the inter-
phalangeal, metacarpophalangeal, or carpometacarpal joints. (Having the thumbs
in any other position will quickly produce fatigue.) The pads of the index fingers
are placed lightly over the medial border of the erector spinae. The palms of the
hands are resting lightly over the lateral aspect of the patient's body (Figures 8.19
and 8.20).
Execution: This technique is performed in an oscillatory manner using a
medial-lateral force, initially applied through palms of the hands, producing an
oscillatory movement through patient's body at each spinal segment. This rhythm
will vary from patient to patient and will also depend on the patient's general state
of relaxation. Moving too quickly or slowly will result in either a log-rolling type
of motion or a motion that is out of resonance. Once a satisfactory rhythm and
excursion are attained, the thumbs, which are contacting the lateral border of the
erector spinae, begin to create the bending force in synchrony with the rhythm
of the rest of the body. The primary force is now at the thumbs, with the palms
retaining a degree of force to maintain the oscillation. The "power" portion of
the stroke is from lateral to medial with the thumbs; the index fingers are merely
monitoring the position of the hand on the erector spinae. To ensure that a bend-
ing movement is being executed (as opposed to only a medial-lateral movement),
the elbows must move from a position away from the body to a position toward the
body during the power portion of the stroke. In other words, the elbows are held
away from the body at the initiation of the stroke (shoulder abduction) and are
moved toward the body during the stroke (shoulder adduction).
If a restriction is identified in a medial-to-lateral direction, the hand position
is changed or reversed. The therapist must, therefore, move to the other side of the
table to perform the technique so the thumbs are contacting the medial border
of the erector spinae. The "power" portion of the stroke is still delivered through
the thumbs, but now in a medial-to-lateral direction. Different levels of the erec-
tor spinae may be treated simply by moving the hands in a cephalic or caudal
direction, being sure that the thumbs contact the lateral borders of the erector
.
sp1nae.
Hands: The top hand is placed over the iliac crest to "anchor" the pelvis. The
bottom hand is crossed over the top hand and placed over the erector spinae mus-
cle mass as close to the lumbosacral junction as possible. The table should be low
to allow for the use of the therapist's body weight.
Execution: A small amount of lubrication is used. The palm of the bottom
hand pushes into the erector spinae muscle group and slides slowly and firmly in
a cephalic direction. This technique is deep, but the therapist uses the entire heel
of the hand to create a strong but diffuse technique. During the technique, the top
hand remains anchored onto the iliac crest, allowing for a moderate distraction of
the lumbar area.
Figure 8.22 Bony clearing of the iliac crest: bilateral hand support.
border of the iliac crest laterally and at moderate depth. A small amount of lubri-
cant should be used to avoid skin irritation.
In the second part of the technique, the "power grip" shown in Figure 8.4 is
used to gain further depth. Again starting as medially as possible, the therapist
At las of Therapeutic Techniques 219
scours along the superior border of the iliac crest, using the reinforced thumb and
PIP joints as the contact on the patient. This technique should be used for thera-
pists with hypermobility in the metacarpophalangeal or other joints of the digits.
being above the middle fingers. The fifth digits are also "dummy" in that they do
not participate in actually manipulating tissue.
Execution: The therapist places the fingers over the border of the iliac crest
and applies a posterior-anterior force through the fingers (Figures 8.25 and 8.26).
A very slight extension of the fingers occurs during the power portion of the stroke
as the fingers deliver a repetitive stroke in an oscillatory manner. By correctly ap-
plying the force, the fingers will slide off the border of the ilium into the connec-
tive tissue. When the fingers are withdrawn posteriorly in preparation for the next
stroke, they move back on the border of the ilium. Contact with the patient is
never broken during the repetitive application of the technique, except to move to
other areas of the iliac crest. The crest may and should be manipulated from the
most lateral palpable aspect to the most medial palpable aspect, because the entire
border of the iliac crest is susceptible and vulnerable to myofascial restrictions.
The depth of penetration of the stroke is moderate and depends on patient toler-
ance. Although this may be a tender area for some, many patients will be restricted
in this area without experiencing any tenderness. The clinician should treat this
area based on objective findings in the evaluation and not merely on subjective
complaints.
A variation of this technique is to apply the same force, but contact 1 or
2 inches inferior to the border of the ilium and into the connective tissue. Force is
applied into the connective tissue of the ilium, manipulating the entire expanse of
the ilium, or at least palpating for restrictions. The fingers should manipulate the
deeper connective tissues and should not slide off the ilium.
Medial-Lateral Pull-Away
Purpose: The first purpose of this tech-
Figure 8.29 Bilateral sacral release. nique is autonomic or reflexive in nature.
As with other autonomic techniques, it de-
sensitizes the patient who is extremely acute
and gains entryway to deeper technique. As
the patient's condition allows or dictates,
deeper pressure is applied until the level of
the erector spinae is reached, changing the
emphasis of the technique from autonomic
to mechanical The erector spinae can be
gently manipulated from a medial to lateral
direction.
Patient position: Side-lying, with hips
and knees semiflexed. A pillow should be
placed between patient and therapist both
for biomechanical advantage and for mod-
esty. The patient is moved close to the edge
of the table until snug against the pillow.
Therapist position: Standing over pa-
tient, snug against pillow.
Hands: The hands are placed gently
over the patient. The therapist makes con-
tact with the whole hand, while the finger-
tips rest over the medial border of the lum-
Figure 8.30 Bilateral sacral release: contact.
bar erector spinae.
224 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
Execution: The stroke begins very gently at approximately the level of the
subcutaneous fascia and works from medial to lateral (Figure 8.31). Initially, the
pressure is evenly distributed throughout the hand. As the patient tolerates, more
pressure is exerted through the fingertips until a moderate to deep pressure is be-
ing consistently exerted.
metacarpophalangeal joint of the top hand can be placed on the quadratus lumbo-
rum as the bottom hand positions to hike the hip.
Executi on : The top hand is placed gently on the patient for support and to
minimize patient movement. The middle aspect of the forearm (ulnar surface) is
wedged into the groove between the 12th rib and the iliac crest (Figure 8.32). Light
to moderate pressure is placed down onto the muscle groups and sustained for a
period of time until a release of muscular tone is achieved or until it is obvious that
no change will be made. The forearm may be moved anterior and posterior (back
and forth), as the therapist flexes and extends the shoulder, making a very deliber-
ate "sawing" type of motion.
As an alternate technique, the therapist can use the bottom hand to contact
the greater trochanter and push it cephalically to "hike" the hip and create side-
bending in the lumbar spine (Figure 8.33). This is done to put the quadratus lum-
borum in a slackened position. Simultaneously, the first metacarpophalangeal of
the top hand makes contact with the quadratus, pushing firmly in a medial direc-
tion to access its deeper fibers for the purpose of tone reduction.
connective tissues and contractile tissues may become dysfunctional and exhibit
changes consistent with immobilization.
More specifically, this technique may be used to prepare for correction of lat-
eral shift conditions of more than 3 weeks' duration. As discussed in Chapter 3,
"Histology and Biomechanics of Myofascia," muscle decreases in length by losing
sarcomeres-the process takes approximately 3 weeks. Tissue held in a shortened
range for longer than 3 weeks has undergone contractural changes, which must be
addressed before shift correction can be attempted.
Finally, this technique may be used to decompress compressive lesions such
as nerve impingement syndromes. Aside from backward bending, side bending is
the least stressful movement on the disc, followed by, in increasing order of stress,
forward bending and rotation. In rehabilitation of discogenic lesions, the side-
bending elongation maneuver may decompress a nerve root by taking the disc
into the second-least-stressful maneuver.
Patient position: Side-lying.
Therapist position: Standing perpendicular to patient with pillow between
therapist and patient. The top forearm contacts the lateral thorax/rib cage, while
the bottom forearm is placed between the ilium and the greater trochanter.
Hands: The fingers contact the medial border of the erector spinae .
Execution: To localize forces in the lumbar area, the hips and knees are bent to
90° and the patient's feet are lowered off the table. Care must be taken while lower-
ing the feet off the table not to provoke any symptoms. Once the feet are off the
At las of Therapeutic Techniques 227
table, pressure is exerted in a cephalic direction with the top forearm and in a cau-
dal direction with the bottom forearm. At the same time, the fingers move from
medial to lateral on the erector spinae, strumming the tissues as they elongate. The
forearms are localizing most of the stretch on the quadratus. The hands are pri-
marily aiding this movement by gently releasing the erector spinae (Figure 8.34).
In this position, a gentle hold - relax technique may be performed by asking
the patient to gently push the ilium into the therapist's bottom forearm. The pa-
tient should not be allowed to remain with the legs off the table for more than
30 - 45 seconds, because the lever arms of the lower extremity are applying consid-
erable forces into the lumbar spine.
To diffuse the forces and provide a more general elongation of the lumbar and
thoracic spines, the therapist asks the patient to fully flex the shoulder and hold
the top of the treatment table. The legs are then lowered off the table, as previously
described . The forces may be applied through the arm - hand contacts described
above, or a traction - elongation force may be applied through the palms of the
hands, as shown in Figure 8.35. The therapist can apply an elongation of the lateral
connective tissue of the lumbar and thoracic spines and even into the connective
tissues of the shoulder girdle complex.
In some cases, where the quadratus lumborum has been hypertonic but not
necessarily shortened, it may be necessary to create more length in the quadratus
than possible with the previously described quadratus lumborum technique. To
create more length, the therapist rotates the patient's trunk to the Tl 2/Ll segment.
228 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
During this rotation, rib 12 is rotated away from the pelvis, allowing for lengthen-
ing of the more cephalic aspect of the quadratus lumborum. Once rotated, the legs
are placed off the table and a side-bending force is placed on the pelvis as previously
described (Figure 8.36). The top arm continues to side-bend at approximately 30°
At las of Therapeutic Techniques 229
off center. The therapist should not continue to rotate. The change in angle of the
side-bending provides a more aggressive stretch of the quadratus lumborum. Note
of caution: Discogenic lesions are a strong precaution here, because the rotation
could compromise a discogenic lesion.
0.,
restrictions, passive segmental mobility may be altered with this or any other myo-
fascial technique.
simultaneously flexed. The leg movement is executed through the therapist's hip
and pelvis. The therapist pulls the patient's knee toward the chest, causing hip flex-
ion, a posterior pelvic tilt, and consequently forward bending in the lumbar spine,
thereby decreasing the lumbar lordosis (Figure 8.40). This allows for elongation of
232 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
the posterior tissues coming from hip flexion as well as from the caudal stroking
of the therapist's bottom hand.
If a specific joint restriction is found, this technique may be somewhat lo-
calized to prepare the surrounding soft tissues prior to a joint manipulation. The
hip is first flexed to forward-bend the lumbar spine to the level of the restriction.
During this time the fingers are palpating between the spinous processes for the
forward-bending restriction. Once movement is felt at the appropriate level, the
hip is extended slightly to slacken the tissue at that level. The top stabilizing hand
is brought down to a position just cephalic to the restricted level. The bottom hand
is brought up to a level almost contacting the top hand. The therapist then strokes
over the erector spinae in a caudal direction the length of two to three segments
while the hip is flexed through a short arc of movement. This allows for tissue to
be elongated both by the hip flexion and by the caudal pull of the bottom hand.
Passive intervertebral mobility should be assessed prior to an appropriate number
of repetitions of this technique .
unilaterally starting at the mid-thoracic spine and progressing down to the sa-
crum (Figure 8.43).
If specific restrictions are located along the erector spinae, the patient may be
placed in a crouched static position while the therapist manipulates the restricted
At las of Therapeutic Techniques 235
.;
j
•
•
l
1 •
'..'
. •I
•
'
.• '• •
.. • •
'
•
'
•
• .. I
/I i'
\ I·, 1
I
/,'
- . ,I J fJ,il k t\:
Figure 8.47 Forward-bending laminar release: Figure 8.48 Lamina release: sitting, bending, and
sitting, bending initiation. rotation.
spine and moves in the caudal direction along the convexity created as the patient
moves segmentally into the diagonal plane. Again, the therapist manipulates the
erector spinae at the level of movement recruitment (Figure 8.48). If a movement
restriction and/or myofascial restriction is encountered, the patient may be asked
to stop, and the therapist may apply a sustained pressure.
This technique may also be applied to the cervical spine either bilaterally (Fig-
ure 8.49) or unilaterally as the therapist uses one hand to guide the patient's head
and neck, generally into a diagonal direction, and uses the other hand to stroke
down the cervical paravertebral muscles (Figure 8.50).
Contraindi cations: This technique should not be used with patients who have
discogenic backs or necks, because a loaded spine is being taken into forward
bending.
Figure 8.49 Forward-bending laminar release: Figure 8.50 Lamina release: seated upper
sitting, bilateral upper quadrant bending. quadrant.
the mid -lumbar joint manipulation. Decreasing myofascial restrictions not only
allows the patient to relax into rotation but also facilitates locking a specific joint
of the lumbar spine.
Patient position: Side-lying with pillow placed between therapist and
patient.
Therapist position: Standing facing patient at level of lumbar spine. The top
hand is placed over the patient's subclavicular-pectoral area, while the bottom
hand is placed over the mid-lumbar area. The patient's knee is placed in the ante-
rior portion of the therapist's hip.
Hands: The fingers of the bottom hand are placed on the medial aspect of the
erector spinae.
Execution: The lumbar spine is bent forward to a mid-range by flexing the
patient's hip and recruiting motion into the lumbar spine. The lumbar spine is
then rotated by pulling the patient's bottom arm until movement is recruited into
the lumbar spine. In the therapist position described above, the lumbar spine is
rotated from both contact points. The erector spinae muscles are simultaneously
stroked diagonally with the fingers, as the rotatory force is applied through the top
arm (Figure 8.51). The lumbar spine may be rotated close to end range but should
Atlas of Therapeutic Techniques 239
not be taken to the limit of motion. As relaxation and elongation are achieved, the
spine may be taken to end range to perform the joint manipulation.
Test Procedure
To determine if a lateral shear imbalance exists, the therapist stands behind the pa-
tient and passively moves the patient into a lateral shift position (Figure 8. 52). This
240 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
.... .
i I
••
~l-!\t • •
' is accomplished by placing one hand on the
L
\
I
\·\
•
ilium and the other hand on the acromion-
;
' '
' ' . '
•
shoulder girdle area. The therapist places
:l\·..: i
I force through the tissues by simultaneously
stabilizing the ilium in a lateral direction
. I' r'. .,
I : ), (i.e., in the transverse plane) while apply-
'{
ing downward pressure on the acromion-
shoulder girdle in a 45° diagonal direction.
The vector on the acromion-shoulder girdle
is a combination of lateral force (in the hori-
zontal plane) and compressive force. If the
patient's trunk moves easily to the right and
is restricted in movement to the left, the pa-
tient is restricted in left lateral shear.
The next step is determining whether
the restriction is merely postural or whether
a true myofascial restriction exists. To
make this determination, the therapist has
the patient lie prone in a neutral position,
and the therapist again tests lateral shear,
this time primarily from the pelvis. If the
Figure 8.52 Lateral shear examination. patient's pelvis moves easily to the left and
is restricted in movement to the right, the
patient is said to be restricted in left lateral
shear. Remember, movement of spine is always referred to in terms of the superior
vertebrae move on the inferior. The direction of the shear is always based on the
direction the vertebral movements in the same way. In standing, if the trunk is
restricted in movement to the left, a left lateral shear restriction exists. In the prone
position, a left lateral shear is re-created with ilial movement to the right, which
results in trunk motion to the left. If ilial movement to the right is restricted, the
restriction is still said to be in left lateral shift .
If a movement restriction exists when the patient stands but normalizes when
the patient is prone, the condition is not as significant and is usually more easily
treated. If a movement restriction exists when the patient is standing and remains
when the patient is prone, the condition has become more entrenched and can po-
tentially be more detrimental if left unchecked. Either way, treatment is necessary
to correct the dysfunction.
Diaphragm Release
Purpose: Diaphragm release techniques are designed to free up restrictions
in the anterior fascia just caudal to the rib cage and to manipulate the diaphragm.
In a forward-head, protracted-shoulder, slumped position, the anterior elements
collapse, thereby reducing diaphragmatic excursion, which can lead to increased
activity in the secondary accessory breathing muscles. Also, for the patient to per-
form postural reeducation techniques successfully and elongate the thoracic area,
the contracted area of the anterior chest and abdomen must be supple and mobile.
Any of these techniques can be used successfully to eliminate pain referred to the
shoulder via the diaphragm. Three techniques are shown, ranging from the least
aggressive to the most aggressive; the general progression should follow the pa-
tient's tolerance level.
242 EVAL UATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Position 1: Supine
Patient position: Supine, with knees and hips slightly flexed, supported by
bolster or pillow.
Therapist position: Standing or sitting at side of patient. The seated position is
biomechanically more advantageous for the therapist.
Hands: The therapist's top hand is placed over the bottom portion of the rib
cage. The bottom hand is placed at the anterior-medial border of the rib cage, just
lateral to the xiphoid process and in the connective tissue just inferior to the rib
cage (Figure 8.54).
Execution: The top hand gently pushes the connective tissue in a medial and
caudal direction in order to slacken the tissue just inferior to the rib cage. This
allows the fingers of the bottom hand to wrap underneath the rib cage (to patient
tolerance). The stroke is applied, following the border of the rib cage medial to
lateral (Figure 8.55). Care should be taken not to push into the floating ribs while
moving laterally with the stroke. In this position, only a superficial or moderate
level of penetration can be achieved .
Position 2: Side-Lying
Patient position: Side-lying, with hips and knees flexed to 90°.
Therapist position: Standing behind patient, pillow between therapist and pa-
tient for stability and barrier.
Hands: The hand position is similar to that described for Position 1. The top
hand is placed on the lower portion of the rib cage, while the bottom hand is placed
at the caudal border of the rib cage, just lateral to the xiphoid process .
Executi on : With the patient more flexed in side-lying, more slack is placed in
the superficial connective tissue. The first technique actually manipulates both the
connective tissue and the diaphragm. The second technique bypasses the super-
ficial connective tissue to engage the deeper connective tissue under the rib cage.
The therapist uses the top hand once again to move the connective tissue medially
and caudally, allowing the bottom hand to slide under the rib cage (Figure 8.56).
244 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Position 3: Sitting
Patient position: The beginning posi-
tion for this technique is the slumped sitting
posture. This puts the tissues in the greatest
amount of slack and allows the therapist
greater access to the tissues underneath the
rib cage. As the technique progresses, how-
ever, the therapist may ask the patient to as-
sume a more erect posture so the therapist
can manipulate the rib cage.
Therapist position: Standing behind
patient with pillow between therapist and
patient. The patient leans into the therapist
in a slumped position.
Hands: Whereas the previous tech-
niques are unilateral, this technique is bi-
lateral. Both hands slide underneath the
Figure 8.57 Diaphragm release: sitting. rib cage medially, just lateral to the xiphoid
process.
Execution: The manipulation is again
executed in a medial-to-lateral direction, with the patient in the slumped position.
At an appropriate time, the hands firmly grip the rib cage, and the patient is asked
to inhale deeply and attempt a more erect posture. The rib cage is manipulated
anteriorly (Figure 8.57).
Psoas Release
Purpose: Manipulation of the psoas muscle is clearly indicated when actual
shortening exists, which may create mobility problems into hip extension as well
as the lumbar spine, especially with forward-bent posture. In an axially extended
posture (flat-back posture), however, the psoas may be hypertonic in an effort to
increase lordosis or to guard a lesion, where axial flexion of the lumbar spine is
the primary dysfunction producing symptoms. In either case, a restriction may be
present or pain may be referred to the low back.
Patient position: Supine position, with hips and knees flexed approximately
30°-45 ° and supported on pillows or therapist's leg to put muscle in slackened
position (Figure 8.58). If the muscle does not exhibit enough slack, the hips may
be flexed to 90°, over the therapist's leg (Figure 8.59). This technique should be
performed on an adjustable-height table for optimal biomechanical advantage.
Therapist position: Standing at patient's side . If necessary, therapist places
one leg on the table; the patient's legs are then placed over the therapist's leg. The
At las of Therapeutic Techn iques 245
therapist may use his or her position to change the amount of hip flexion during
application of the technique.
Hands: The therapist uses fingertips to contact the psoas. The psoas is ap-
proached from a 45° angle as the hands are placed lateral to the rectus abdominus,
slightly inferior to the umbilicus.
246 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
Execution: Because the psoas is located along the lumbar vertebrae and corre-
sponding discs, a significant depth must be achieved through the abdomen. Care
must be taken to progress slowly into the appropriate depth, asking the patient
about the relative comfort of the technique. Ease of depth may be achieved by
sinking with every exhalation of the patient. As more depth is achieved through
the abdomen, "landing" on a more rigid structure indicates arrival onto the psoas.
The psoas will be more rigid than the soft tissue of the abdomen. The patient will
also report a different sensation, usually more noxious when the psoas is palpated,
especially if the psoas is dysfunctional. Proper location may be confirmed by ask-
ing the patient to slightly flex the hip, which will cause the muscle to fire into the
therapist's fingers.
Because longitudinal stroking of a muscle is generally less noxious than trans-
verse stroking, the psoas should be gently manipulated using a longitudinal stroke
at first. Only after longitudinal stroking has been applied should a transverse
stroke be attempted . Once the technique is terminated, the hands should be gradu-
ally removed from the abdomen. In some cases, the psoas may be more accessible
with the patient in a side-lying position. The therapist may use the thumbs to ac-
cess and release the psoas (Figure 8.60).
lliacus Release
Purpose: The iliacus muscle can be treated for limited extension of the hip
or as an extension of a psoas release. Even though the iliacus does not have an
At las of Therapeutic Tec hniques 247
p :,
Hands: The bottom hand grasps the quadriceps and femur distally, just proxi-
mal to the knee. The top hand grasps the quadriceps anywhere on the muscle belly
where a restriction is identified . The top hand palm is placed laterally over the
vastus lateralis.
Execution: Firmly grasping the distal aspect of the quadriceps with the bot-
tom hand, the top hand lifts and rolls the quadriceps over the femur and exerts
a shearing force through the quadriceps in a lateral-to-medial direction (Fig-
ure 8.67). The force is applied through the palm of the hand without sliding. The
technique is designed to move the muscle, not to slide over the muscle, which is
more of a massage technique. The technique is generally performed in a lateral-
to-medial direction because more restrictions seem to occur in the vastus late-
ralis, but it may also be applied in a medial-to-lateral direction by moving to the
patient's other side and shearing the quadriceps in a medial-to-lateral direction
(Figure 8.68). The technique may also be performed in diagonal planes if a restric-
tion occurs in that plane.
Alternately, both hands may be placed over the quadriceps to engage more
surface area but with the sacrifice of stabilization (Figure 8.69), or force can be ap-
plied through the tips of the thumbs to address a specific restriction, similar to the
erector spinae muscle play (Figure 8.70).
Some patients may not tolerate transverse muscle play of the quadriceps in
either a lateral-to-medial or a medial-to-lateral direction, even with light pressure.
In such cases, an anterior-to-posterior force is often tolerated (Figure 8.71), allow-
ing the therapist then to progress to the previous directions.
At las of Therapeutic Techn iques 251
The main difference between soft tissue manipulation and joint manipulation
is that in joint manipulation, arthrokinematic rules must be followed. In soft tissue
manipulation, restrictions may occur in any plane and at any depth, and manipu-
lation of the restriction does not depend on arthrokinematics.
252 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Figure 8 .69 Transverse muscle play of quadriceps: Figure 8 .70 Transverse musc le play of quadriceps:
bilatera l grip . using thumbs .
the therapist's axillary or pectoral area. (Female therapists should use a folded
towel as a mechanical barrier.)
Hands: The therapist either grasps the treatment table with one hand on either
side, thus "strapping" the patient to the table, or, for added stability, grasps the pa-
tient's leg with one hand and the opposite side of the table with the other hand.
Execution: With the patient in a firm grasp, the therapist asks the patient to
push the leg into the therapist's chest. The patient is then asked to release the con-
traction, and the therapist "takes up the slack," moving the hip into further flexion-
adduction (Figure 8.77). Occasionally, a patient will complain of anterior hip pain
while the technique is being executed. A possible explanation is that the anterior
capsule may be pinching with the extreme amount of flexion being applied to the
hip. If this occurs, the hip may be taken out of extreme flexion to emphasize the
technique's adduction component. The therapist stabilizes the pelvis at the ante-
rior superior iliac spine with the top hand. The leg is grasped with the bottom arm
and adducted with a slight external rotation component (Figure 8.78). The addi-
tion of external rotation and the increase in adduction will compensate for the loss
of flexion and regain the tissue tension lost with the loss of hip flexion.
Figure 8.78 Hold-relax stretch of hip: anterior superior iliac spine stabilization.
should make the anterior capsule taut, thereby making it less likely to be pinched
(Figure 8.79).
Patient position: Supine, with hip taken into 90° flexion, end-range external
rotation, and end-range adduction.
258 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
Longitudinal Stroking
Hands: Contact with the patient is made with a loose fist (i.e., with the meta-
carpophalangeal joints of the hand) (Figure 8.80), bilateral power grips (Fig-
ure 8.81), or a forearm (Figure 8.82). Contact is initiated on the distal aspect of the
hamstrings.
Execution: With the patient's leg relaxed over the therapist's shoulder, the
therapist applies firm pressure into the distal aspect of the hamstrings with the fist
or elbow. The therapist strokes the hamstrings longitudinally, in a distal-to-prox-
imal direction, to the insertion at the ischial tuberosity. If a restriction lies in the
proximal hamstring near the ischial tuberosity, the hip may be flexed beyond 90°.
If the therapist identifies a specific restriction, the elbow may be used to apply
a sustained pressure on the restriction. The stroke should be stopped when the re-
stricted area is reached. The pressure should be sustained for an appropriate period
until changes in the restriction are palpable or until it is obvious that no change is
going to occur.
Figure 8.80 Hamstring manipulation: loose fist Figure 8.8 1 Hamstring manipulation: bilateral
contact. power grip contact.
---
Figure 8.83 Hamstring manipulation: splayed Figure 8.84 Proximal hamstring stret ch.
hands.
into two basic categories: mid-belly injuries and proximal injuries. Proximal inju-
ries can be more serious, more recurrent, and more difficult to treat than mid-belly
lesions. The proximal injury can sometimes act similar to an epicondylitis, where
the injury is in the tenoperiosteal junction. By isolating a stretch to the proximal
hamstring, the therapist can more effectively aid in the remodeling of the proxi-
mal tissues.
Patient position: Supine, with leg resting on therapist's shoulder.
Therapist position: Standing on one leg, with other leg on treatment table.
Hands: The therapist places his or her hands around the patient's knee. This
will help to provide a traction force and control the amount of knee flexion.
Execution: The therapist first performs a straight -leg raise until the patient
feels a mild hamstring stretch. The patient is then asked to localize the stretch. If
the stretch is felt in the distal or mid-belly of the hamstring, the therapist allows
the patient's knee to bend slightly. Keeping the slight bend constant, the therapist
continues to flex the hip until the patient again feels the stretch. At this point,
the patient should feel the stretch more proximally because the distal aspect has
been slackened and the proximal aspect has been further stretched . The therapist
repeats the process, allowing the patient's knee to flex slightly more, and then flex-
ing the hip further. The process is repeated until the stretch is felt closest to the
origin at the ischial tuberosity (Figure 8.84). To further localize the stretch, a slight
At las of Therapeutic Techn iques 261
traction force can be placed on the leg while stretching. The traction serves to pull
slightly more on the origin of the muscle at the ischial tuberosity.
the technique goes through three different hand positions: (1) palm of the hand,
(2) elbow, and (3) PIP joints of both hands.
Execution:
(1) Using the palm of the hand: The therapist applies gentle pressure to the
piriformis muscle using the bony landmarks above. With the knee bent to 90°, the
hip is gently rotated externally to put the piriformis on slack (Figure 8.89). Pres-
sure is gently increased through the manipulating hand until the level of the piri-
formis is reached. A sustained pressure is applied, provided the pressure does not
create an increase in tone. As the piriformis relaxes, more pressure can be applied
progressively. If the piriformis releases, even partially, the patient's tolerance will
increase, allowing the next variation of the technique.
(2) Using the elbow: With the lower extremity extended, the same sustained
pressure may be applied to the piriformis using the elbow (Figure 8.90). The el-
bow allows for the application of more localized pressure. As the piriformis re-
leases and as the pain decreases, progressive pressure can be applied for further
inhibition.
(3) Using bilateral PIP joints: Finally, again with the lower extremity ex-
tended, the PIP joints of both hands may be used to apply even more localized
pressure (Figure 8.91). If the patient is able to tolerate it, a gentle oscillatory motion
created with wrist flexion-extension can be performed to further inhibit and me-
chanically manipulate the piriformis.
266 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
----
Remember, restrictions can occur in any direction or plane, and the technique
direction should be modified to treat the restriction adequately.
Figure 8.94 Transverse muscle play of ham- Figure 8.95 Transverse muscle play of hamstrings
strings: posterior-to-anterior pressure to lateral and adductor magnus: posterior-to-anterior pres-
tissues. sure to adductors.
the restriction. The clinician should be sensitive to restrictions and follow them
with the technique, because no arthrokinematic rules apply. The success of the
treatment often depends on whether the direction of application was properly
identified.
At las of Therapeutic Techn iques 271
I
l X
'
Figure 8.100 Bony clearing of the tibia: dumm y thumb.
At las of Therapeut ic Techn iques 273
Figure 8.101 Bony clearing of the tibia: prone, Figure 8.102 Bony clearing of the tibia: prone,
half -chisel grip . thenar eminence .
'
,,
\
Figure 8.105 Lateral elongation of peroneal Figure 8.106 Lateral elongation of peroneal tis-
tissue. sue: with movement.
or hip, and even into the low back. Once a maximal stretch is achieved, the patient
should be slowly retuned to the starting position. The technique may be repeated
two or three times. Treatment is based not on pain but rather on postural exami-
nation and functional limitations.
278 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
same can be done actively as the patient dorsiflexes in time with the proximal-to-
distal stroke.
Figure 8.112 Lateral elongation of upper thoracic area: stroke comp letion .
Figure 8.113 Lateral elongation of upper thoracic area: deep anterior technique.
Unilateral Posterior/Anterior
Articulation of First Rib
Purpose: This technique is essentially a
joint manipulation technique, but it blends
well with the lateral elongation and rib
techniques, especially if rib dysfunction is
present. With increased myofascial tone in
the subclavicular area, the upper thoracic
Figure 8.114 Lateral elongation of upper thoracic area, and the scalene muscles, joint me-
area: rib splaying.
chanics in the first rib can easily become
282 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
1 ....
-
Pectoralis Major
Patient position: Supine, with shoulder
flexed 90°-120 °.
Therapist position: Standing over pa-
tient at 45° angle. The therapist may place
a leg on the table to allow the patient's arm
to rest in a relaxed position (Figures 8.119
to 8.121).
Hands: The therapist's thumbs slide
underneath the pectoralis major, and the
Figure 8.119 Pectoralis major muscle play/pecto-
hands grasp the muscle firmly between the
ralis minor manipulation.
thumbs and fingers.
//
Figure 8.120 Pectoralis major and minor muscle play: close up.
286 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Pectoralis Minor
Hands: With one hand maintaining
the same position as described above, the
thumbs are moved posteriorly until in con-
tact with the pectoralis minor. The muscle
may be difficult to palpate, but if the ribs are
palpable, the muscle is being palpated.
Execution: The thumbs are pressed
onto the pectoralis minor, and a gentle
"cross-friction type" technique may be per-
formed. Care must be taken because the
Figure 8.121 Pectoralis major and minor mus cle pectoralis minor area is very tender even if
play: hand contact.
not dysfunctional.
Figure 8.122 Seated pectoral anterior fascial Figure 8.123 Seated pectoral anterior fascial
stretch: bilateral. stretch: unilateral.
Subscapularis
Purpose: The subscapularis is generally not an area reported by the patient to
be painful; however, the area may be significantly restricted and extremely ten-
der to palpation. Because the internal rotators are held in a shortened position
during the forward-head, protracted-shoulder posture, the subscapularis and the
surrounding myofascia become restricted, acting as barriers to efficient postural
reeducation.
Patient position: Supine, with shoulder flexed from 90° to 170°, depending on
the restriction and comfort level of patient.
Therapist position: Standing at head of table at 45° angle to patient. The thera-
pist holds the patient's arm close to the therapist's body to provide a slight traction
force.
Hands: The therapist may place hands on the patient in three different ways,
depending on how aggressively the therapist wishes to deliver the technique. The
therapist may use the palm of the hand, the thumb, or the fingertips, in order from
least aggressive to most aggressive.
Execution:
(1) Using the palm of the hand: The patient's arm, which is in some degree
of flexion, is gently distracted. The palm of the other hand is placed on the lateral
288 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
X
X
Figure 8.124 Subscapularis: half-chisel grip. Figure 8.125 Subscapularis: thenar eminence
contact.
border of the scapula, as close to the glenohumeral joint as possible. While placing
gentle distraction on the arm, the therapist uses the palm to stroke caudally and
toward the inferior angle of the scapula. If fascial restrictions exist, the stroke may
be lengthened to include the lateral fascial sheaths between the scapula and the
ilium (Figure 8.125).
(2) Using the thumb: In the same position, the therapist uses the thumb to
stroke caudally. Thumb placement is more specific; it should be located on the
anterior surface of the lateral border of the scapula. While distracting the arm, the
therapist moves the thumb caudally over the anterolateral border of the scapula
toward the inferior angle (Figure 8.124).
(3) Using the.fingertips: Specific restrictions, either in the lateral aspect of the
subscapularis or in the fascial sheath between the scapula and the thorax, may be
treated using the fingertips. The tips of the index, middle, and ring fingers palpate
the anterior surface of the lateral scapula and apply gentle pressure. Either sus-
tained pressure or a slow oscillatory movement can be used (Figure 8.125).
, Position 1: Supine
Patient position: Supine, with shoulder
flexed 120°-170 °.
Therapist position: Standing behind
patient, grasping patient's arm and provid-
ing distraction of arm.
Hands: The therapist places the entire
surface of the hand just below the patient's
nipple line. Male therapists treating fem ale
patients should carefully drape the patient
and should stay well below breast tissue.
Execution: As the arm is tractioned
into flexion, a traction force is applied to the
superficial fascia, first in the direction of the
umbilicus (Figure 8.126). The therapist may
change the direction of the force and direct
it more diagonally toward the contralateral
anterior superior iliac spine or into a more
cardinal plane direction toward the ipsilat-
eral anterior superior iliac spine. The shoul-
der should be in as much flexion as possible
to allow for maximal stretch of the connec-
Figure 8.126 Anterolateral fascial elongation. tive tissues. The use of skin lubricants for
this technique is discouraged.
Medial Border
Hands: The top hand is lightl y placed
on the shoulder, and the bottom hand is
placed just off the medial border of the
scapula, between the scapula and the tho-
. .
rac1c sp1nous processes.
Execution: With the top hand , the ther-
apist slightly retracts the patient's shoulder
to slacken the tissue. Meanwhile , the fingers
of the bottom hand stroke from cephalic to
caudal along the length of the medial bor-
der of the scapula (Figure 8.128).
Upper Border
Hands: The fingertips of both hands are
placed over the upper trapezius muscle me-
Figure 8.128 Scapular framing: medial border.
dially at the cervicothoracic junction.
At las of Therapeutic Techn iques 291
Figure 8.129 Scapular framing: upper border. Figure 8.130 Scapular framing: lateral border.
Execution: With firm pressure, the fingertips stroke the upper border of the
scapula and upper trapezius muscle from proximal to distal (i.e., from the cervi-
cothoracic junction to the glenohumeral joint). A gentle stretch is applied with the
palms of the hand as the scapula is stroked (Figure 8.129).
Lateral Border
Hands: The palm of the bottom hand is placed over the shoulder joint to sta-
bilize the area. The palm of the top hand is placed over the lateral border of the
scapula.
Execution: While the bottom hand is stabilizing the shoulder, the palm of
the top hand strokes the lateral border of the scapula caudally with firm pressure
(Figure 8.130). Specific finger pressure may be applied if trigger points or restric-
tions are found.
Executi on : Once the nodule within the band or myofascial trigger point is
identified, the therapist applies gentle compression into the muscle belly to elicit
the patient's symptoms (Figure 8.133). The patient is asked to contract and relax
by performing the muscle's action (in this case, external rotation) followed by a
294 EVAL UATION A ND TREATMENT OF THE MYOFASCIAL SYSTEM
moment of complete relaxation. The therapist maintains the force until the symp-
toms subside and the tissue is felt to relax, being careful not to exacerbate the
patient's pain. Once the myofascial trigger point has been released, the therapist
should follow up with a local myofascial release technique and a passive stretch.
(This method of palpation and treatment can be used on a number of other muscles.)
Scapular Manipulation
Pur pose: Once the scapular soft tissues have been prepared by using tech-
niques such as scapular framing, the scapula may be manipulated off the thoracic
cage. This allows for more aggressive stretching of the scapulothoracic myofascia.
Two variations of this technique can be performed .
Pati ent pos iti on : Side-lying, with a pillow between patient and therapist, and
patient's arm resting comfortably on the pillow.
Therapist pos iti on : Standing at patient's side.
Hand s: Two variations of this technique may be performed : (1) The top hand
grasps the shoulder joint anteriorly, while the fingers of the bottom hand slide onto
the undersurface of the scapula. (2) In the alternate technique, the bottom hand
slides under the arm and around the scapula until the fingers can slide onto the
scapula's undersurface (Figure 8.135). The top hand also contacts the scapula so
At las of Therapeutic Techniques 295
Figure 8.134 Myofascial trigger point release: pincer palpation (upper trapezius).
the fingers can slide onto the undersurface of the scapula. The shoulder and chest
of the therapist contact the patient's shoulder anteriorly for stability.
Executi on : Once the fingers of the bottom hand have grasped the medial bor-
der of the scapula, the therapist lifts the scapula and shoulder girdle complex off
296 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Figure 8.137 Upper extremity and posterior quadrant fascial elongation: initiation.
Figure 8.138 Upper extremity and posterior quadrant fascial elongation: completion.
adduction (Figure 8.137). As the tissues creep, the therapist should continue to
move the upper extremity, causing the patient to feel a stretch through the upper
extremity, into the shoulder complex, and eventually into the trunk (Figure 8.138).
The movement may be continued until the patient is fully rotated, but this is not
298 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
------
while using the top hand to retract the shoulder complex and rotate the thoracic
spine (Figure 8.140). The fingers act as a fulcrum of rotation for the thoracic spine
as they slide down the length of the thoracic spine. If the therapist feels segmental
restrictions as the technique is being performed, the stroke may be stopped and
the restricted segment may be oscillated into rotation.
Biceps Stretch
Purpose : The purpose of this technique
is to apply a focused stretch of the biceps
muscle .
Patient position: Supine, with shoulder
slightly off table. If a less aggressive version
of the technique is desired, the patient may
be placed in the side-lying position to ac-
complish a lighter version of the stretch.
Therapist position: Seated level with
patient's neck or shoulder.
Figure 8.141 Trans verse fascial stretch of the Hands: The top hand is placed over the
biceps. patient's shoulder at the acromion and cora-
coid process for stabilization and to prevent
the shoulder from lifting from the table. The bottom hand is placed on the distal
arm, just proximal to the wrist.
Execution: The therapist gently extends the patient's shoulder. At the same
time, the elbow is fully extended and the radioulnar joints are fully pronated.
About the time the patient begins to feel a stretch, a slight traction force may be
placed through the arm (Figure 8.142). The therapist should ask the patient to tell
when a moderate stretch is felt. Because of the long lever arm, it is difficult to tell
when the biceps muscle/tendon is in a plastic stretch. After a 5- to IO-second hold,
the arm is released, and the stretch may be repeated.
Forearm "Ironing"
Purpose: As described earlier in the chapter for the lumbar erector spinae, the
"ironing" techniques are useful to decrease underlying tone and move fluid within
the tissues. If an area is particularly tender, longitudinal stroking is always less
painful than cross-stroking. This technique is effective for a wide array of elbow,
forearm, wrist, or hand dysfunctions. Although not shown, the technique can also
be applied to the flexor and the extensor surfaces of the forearm.
Patient position: Supine or seated.
Therapist position: Standing or sitting at patient's side .
At las of Therapeutic Techn iques 301
Hand position: The inside hand of the therapist gently grasps the patient's
wrist and flexes it. The outside hand is positioned on the distal aspect of the fore-
arm, just proximal to the wrist.
Execution: Using a small amount of lubrication, the palm of the therapist's
hand bears down on the soft tissues and begins to stroke in a distal-to-proximal
direction, stopping at the elbow (Figure 8.143). The pressure is firm, but the hand
and fingers remain relaxed, so the technique feels firm but not painful. The thera-
pist should use some body weight to avoid the technique coming primarily from
the arm.
...
Execution: Starting distally, the therapist wedges between muscle groups with
the index and middle finger (or thumb), applying firm pressure. Using a small
amount of lubricant, the fingers slide proximally following the wedge created dis-
tally (Figure 8.144). Lack of a wedge or space between fibers may indicate fascial
At las of Therapeutic Techniques 303
adhesions. The therapist should identify and focus on these areas, working longi-
tudinally, from proximal to distal, until the fascia is freed up.
) Palmar Stretch
Purpose: The purpose of this technique
is to stretch the palmar fascia and the pal-
X mar surface of the hand.
Patient position: Supine or sitting.
Therapist position: Standing or sitting ,
facing palm of patient 's hand.
Hands: The hand position is very im -
portant in this technique. Both of the
therapist's little fingers are placed between
the patient's index and middle fingers. The
therapist's fingers are then interdigitated
through the patient's fingers, with the mid-
dle and ring fingers of the therapist in the
web space of the patient's hand. The thera-
fingers, open the patient's hand to create a stretch. At the same time, the thumbs
can be used to massage the palmar surface of the hand when the stretch is occur-
ring (Figure 8.146). If the elbow is flexed and the wrist is in neutral, the palmar
fascia will be localized. If the elbow and wrist are extended, the stretch will also
include the wrist flexor muscles.
Retinacular Stretch
Purpose: Related to the previous technique, the retinacular stretch is designed
to open the carpal tunnel in a medial-to-lateral direction and to increase the ex-
tensibility of the retinaculum.
Patient position: Supine or sitting.
Therapist position: Standing or sitting, facing palmar surface of patient's
hand.
Hands: The therapist's thenar eminences are placed over the patient's distal
forearm and wrist. The therapist's fingers are on the dorsal surface of the patient's
hand to apply counterpressure.
Execution: The therapist applies firm pressure into the patient's wrist and dis-
tal forearm with the thenar eminences as the fingers apply counterpressure on the
dorsal surface of the hand. A firm stretch is applied from midline outward to the
ulna and radius. As the therapist's hands separate, firm pressure is maintained for
maximal stretch (Figure 8.147).
At las of Therapeutic Techn iques 305
a dresser drawer that is stuck and cannot be opened . By closing the drawer, one
makes the drawer become free to open. This technique can be divided into two
specific components: (1) a general axial extension of the cervical spine and (2) a
specific axial extension at the occiput-atlas (OA) joint.
Patient position: Supine, with head flat on treatment table .
Therapist position: Sitting at head of table .
Hands: The palms of the hands cradle the base of the occiput while the fingers
contact the lower cervical paravertebral musculature (Figure 8.149).
Execution: The head and neck are brought into a straight axial flexion (mov-
ing the head directly toward the ceiling). The fingers are simultaneously stroking
the lower cervical paravertebrals in a medial-to-lateral direction (Figure 8.150).
With each repetition, the fingers are moved up a level until they are in contact with
the subcranial musculature.
At this point, the technique may be applied more specifically in the area of
the OA joint. The therapist again flexes the head and neck axially, while apply-
ing firm pressure at the OA joints bilaterally with the fingertips. The fingers are
no longer stroking in a medial-to-lateral direction but are maintaining the pres-
sure on the OA joints. The neck may be axially extended into a diagonal plane
to check for unilateral restrictions. If a unilateral OA restriction exists, the neck
may be axially flexed in the same diagonal plane in an attempt to free up the
restriction.
This technique may be used as a direct technique with patients who exhibit
an axially extended posture. Although this posture is seen less often than the for-
ward-head posture, the technique may be used to move the neck directly into the
restriction.
Position 2: Supine
Purpose: This technique is used to elongate the cervical myofascia.
Patient position: Supine.
Therapist position: Sitting at head of table.
Hands: One hand cradles the head at the occiput and brings the cervical spine
into a forward-bent position. The other hand makes contact with the cervical
308 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
paravertebral muscles, bilaterally, using the thumb on one side and the PIP joint of
the index finger on the other side.
Execution: One hand holds the neck statically in the forward-bent position
while the other hand strokes gently from approximately mid-cervical to cervico-
thoracic junction (Figure 8.151).
therefore, may be considered a muscle energy technique. The idea behind the tech-
nique is stabilization of the occiput and movement of the atlas. The patient is axi-
ally flexing and extending the neck while the occiput is held rigid.
Patient position: Supine.
Therapist position: Standing or sitting. The patient's head will be cradled by
the therapist's arm and shoulder.
Hands: As the therapist cradles the patient's head with one arm and shoulder,
the therapist uses the hand on that side to firmly grasp the occiput. The other hand
is placed over the hand grasping the occiput as additional reinforcement.
Execution: With the therapist firmly holding the head, the patient is asked to
axially flex and extend the neck gently (Figure 8.153). The head is not allowed to
move, so the neck is actually moving on the head. The atlas is allowed to translate
anteriorly and posteriorly on a nonmoving occiput. After several repetitions, the
patient is allowed to rest his or her head on the table, and the amount of resting
axial flexion is reassessed.
Masseter Manipulation
Purpose: Prior to any intraoral soft tissue manipulation of the temporoman-
dibular joint (TMJ), the clinician should always attempt extraoral soft tissue ma-
nipulation aimed at restoring mobility of the joint. This technique inhibits the
masseters, allowing for a more comfortable and increasingly functional opening
of the mandible. The functional opening may be significantly increased without
having to perform intraoral maneuvers.
310 EVALUATION AND TREATMENT OF THE MYOFASCIAL SYSTEM
Temporalis Manipulation
Purpose: As with the masseter, the
temporalis should be manipulated prior to
Figure 8.153 Manipulation of subcranial and any manipulation of the TMJ. This tech-
occiput-atlas myofascia.
nique inhibits the temporalis muscles and
therefore may allow for a more comfortable and increased opening of the man-
dible or decreased headache pain.
Patient position: Supine, with head flat on treatment table.
Therapist position: Sitting at head of table.
Hands: The finger pads of the index, middle, and ring fingers are placed on the
temporalis muscle bellies bilaterally.
Execution: Beginning with moderate pressure, the therapist makes small cir-
cular strokes with the hands, gradually increasing in size while manipulating with
a push-pull stroke (Figure 8.155). The push-pull stroke is created by flexing and
extending the fingers. The majority of the force is applied through the push (i.e.,
the finger extension). The therapist slowly and gently moves around the muscle
until the entire muscle is treated. After several strokes, the patient may be asked to
time opening of the mouth with the push stroke in an effort to further relax and
elongate the tissues.
Retro-Orbital Decompression
Purpose: Related to the previous technique, the purpose of this technique is
to stretch the retro-orbital fascia and the fascia around the nasal suture. This tech-
nique is especially indicated for patients with retro-orbital headaches and sinus
headaches.
Patient position: Supine.
Therapist position: Sitting at head of table.
Hands: The bottom hand gently cradles the base of the occiput. The palm of
the top hand makes contact with the frontal area, while the fingers are positioned
as follows: The index and ring finger are placed over the left and right orbital bones,
At las of Therapeutic Techniques 313
just inside the eyebrow, well away from the eyes, and the middle finger is placed
just over the nasal suture.
Execution: A gentle traction is applied through the occiput with the bot-
tom hand. The palm of the top hand places a mild traction over the frontal fas-
cia, while the fingers apply a fascial traction over the retro-orbital and nasal fas-
ciae (Figure 8.157). The therapist must be careful to make absolutely no contact
with the eyes. The fascial stretch is applied firmly with the pads of the fingers for
10-20 seconds.
on the SCM near the insertion at the mastoid process (Figure 8.158). The SCM is
gently stroked from cephalic to caudal. The SCM may also be cross-stroked at any
point along the muscle belly where trigger points, tender areas, or areas of hyper-
tonicity are encountered (Figure 8.159).
At las of Therapeutic Techn iques 315
References
1. Feldenkrais M. Advances ThroughMovement. New York:Harper & Row; 1972.
2. Rosenthal E. The Alexander technique: what it is and how it works. Med Prob/PerformArt.
1987;2:53- 57.
3. Dietze E, Schliack H, WolffA. A Manual of Reflexive Therapyof the ConnectiveTissues.Scarsdale,
NY: Sidney Simon; 1978.
4. Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Insufficient lumbopelvic
stability: a clinical, anatomical and biomechanical approach to "a-specific" low back pain. Man
1her. 1998;3:12-20.
5. Simons DG, Travell JG, Simons LS, Cummings BD.MyofascialPain and Dysfunction:1he Trig-
ger PointManual: Vol. 1. UpperHalf of Body, 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 1998.
Index
317
318 Index
Joint manipulation versus soft tissue manipulation, forward-bending laminar release, 230- 232
199-200 forward-bending laminar release - quadruped,
Joint mobilization, convex/concave rule for, 12 232- 235
Joint pain, 11 forward-bending laminar release- sitting, 236- 237
Junctional zones iliac crest release, 219- 221
biomechanics of, 59- 63 iliacus release, 246 - 248
biotensegrity of musculoskeletal system, 61- 63 "ironing" of erector spinae muscle group, 216- 217
connective tissue insertion to bone, 59- 61 L3 deep soft tissue manipulation, 229- 230
histology of, 58- 59 lateral sacral release, 221- 222
musculotendinous junctions, 58- 59 lateral shear correction, 239- 241
long axis distraction of superficial connective tis-
Kabat, Herman, 25 sue, 207- 209
Kaltenborn, Freddy, 12 long axis laminar release, 212- 214
Knott, Margaret, 25 longitudinal posterior hip release, 232
Kyphosis (humpback), 4- 6 lumbar myofascial roll, 237- 239
medial - lateral fascial elongation, 209- 211
L3 deep soft tissue manipulation, 229- 230 medial - lateral pull-away, 223- 224
Lange, M., 128 muscle play of erector spinae, 214- 216
Lateral elongation psoas release, 244- 246
of peroneal tissue, 274- 275 quadratus lateral erector spinae release, 224- 225,
of upper thoracic area, 279- 281 226
Lateral fascial distraction of tibia, 274 side-bending elongation quadratus stretch,
Lateral sacral release, 221- 222 225- 229
Lateral shear correction, 239- 241 therapeutic techniques, 205- 248
Lateral shear examination, 239- 240 tissue rolling, 196, 197, 211- 212
Layer palpation, 195-197 Lumbar/lumbopelvic area, muscle agonist/
Layered syndrome, 189, 190, 191 antagonist groups of, 192
LBP. See Low-back pain (LBP) Lumbopelvic area, muscle agonist/antagonist
"Legs carry trunk" model, 52 groups of, 192
Ligaments Lumbopelvic/lower quarter area
as dense regular connective tissue, 46- 47 bony clearing of tibia, 271- 274
function of, 47 cross-friction of gastrocnemius - soleus musculo-
insertion of, to bone, 59- 61 tendinous junction, 275- 276
Long axis distraction of superficial connective tis- cross-friction of piriformis insertion, 263- 264
sue, 207- 209 gluteal fasc ial plane manipulation, 262- 263
Long axis laminar release, 212- 214 greater trochanter rocking, 248- 249, 250
Longitudinal posterior hip release, 232 hamstring manipulation, 258- 259
Loose irregular connective tissue, 47- 48 hold - relax stretch of hip, 255- 258
Low-back pain (LBP) iliotibial band (1TB) paratrochanteric manipula-
causes of, 10 tion, 253- 255
exercise for, 13 ischial tuberosity cross-friction, 261
fibrotic process and decreasing mobility in con- lateral elongation of peroneal tissue, 274- 275
nective tissue, 73 lateral fascia l distraction of tibia, 274
incidence of, 13 lower extremity/posterior quadrant fascial elon-
Lower crossed syndrome, 188- 189 gation, 276- 277
Lower extremity/posterior quadrant fascial elonga- piriformis release in prone, 264- 266
tion, 276- 277 plantar fascia manipulation, 278- 279
Lubricant for hands, 205 proximal hamstring stretch, 259- 261
Lumbar myofascial roll, 237- 239 therapeutic techniques, 248- 279
Lumbar spine transverse muscle play of gastrocnemius - soleus,
bilateral sacral release, 222- 223 268- 270
bindegewebsmassage-type stroke, 205- 207 transverse muscle play of hamstrings, 267- 268
bony clearing of iliac crest, 217- 219 transverse muscle play of hamstrings and adduc-
diaphragm release, 241- 244 tor magnus: posterior-to-anterior pressure, 268
evaluation of, 191-193 transverse muscle play of quadriceps, 249- 252
322 Index
future considerations, 13-1 4 Pacinian corpuscles, 93, 95- 96, 101, 118, 119, 120
historical basis for, 3-1 0 Paget, Sir James, 7
mechanical approaches, 21- 25 Pain. See also Low-back pain (LBP); Muscle pain
modern theories and systems of, 17-28 syndromes
modern trend toward mobility and diagnosis of acute pain, 111
pathology, 10-13 cutaneous pain, 125
movement approaches to, 25- 28 nociception and nociceptors, 104-105, 111
physiology of, 80- 86 pain - spasm - pain cycle, 111, 113, 115-1 16
Myofascial pain dysfunction syndrome, 128 polymodal pain, 111
Myofascial pain syndrome. See also Evaluation of referred pain, 136-138, 253
myofascial system Widespread Pain Index (WPI), 152
autonomic aspects, 144- 145 Pain - spasm - pain cycle, 111,113, 115-11 6
autonomic dysfunction, 138- 139 Palmar stretch, 303- 304
clinical characteristics of, 132-139 Palmer, David Daniel, 9
definition of, 126, 128-129 Palpatory examination, 195- 197
diagnosis of, 129-132 Paravertebral muscles, elongation of, 305
management of, 145-149 Pare, Ambroise, 6
motor and mechanical dysfunction, 133-135 Paris, Stanley, 12
normal muscle contraction, 139-140 Paroxetine, 155
pathogenesis of, 139-145 Pathophysiology of soft tissue repair, 69- 72
peripheral and central sensitization, 142-144 Peckman, John, 24
physical therapy for, 145- 147 Pectoralis major muscle play/pectoralis minor ma-
referred pain, 136- 138, 253 nipulation, 285- 286
sensory dysfunction, 135-138 Periosteum, 47
taut bands and, 73, 131, 132 Peripheral neuropathy, 128
trigger point contractures, 140- 142 Peripheral sensitization, 142-144
Myofascial release, 24- 25 Peroneal tissue, lateral elongation of, 274- 275
Myofascial trigger point release (infraspinatur) flat Petrissage massage techniques, 21
palpation, 292- 294 Pharmacological management, of fibromyalgia
Myofascial trigger point release (upper trapezius) (FMS), 155
pincer palpation, 294 Physical therapy
Myofascial trigger points. See Trigger points for chronic pain, 125
Myofibroblasts, 35, 36, 48- 49, 72- 73 diagnosis and, 183-184
Myofilaments, 54- 56, 59 dry needling, 145-1 46
Myogelosis, 128 for myofascial pain syndrome, 145- 147
Myotendinous junction trigger point injections, 147- 148
biomechanics of, 59- 63 trigger point release, 146-1 47
biotensegrity of musculoskeletal system, 61- 63 Physical therapy dry needling, 145- 146
connective tissue insertion to bone, 59- 61 Physiology of myofascial manipulation
histology of, 58- 59 blood flow and temperature, 80- 82
collagen distribution, 85- 86
Neural mechanisms, 4 fibroblastic activity/collagen synthesis during
Nociception and nociceptors, 104- 105, 111, 125. See healing process, 83- 85
also Muscle pain syndromes; Pain metabolism, 82- 83
Nonthrust articulation, 12 reflexive (autonomic) effects, 83
Nontraumatized connective tissue, response of, to Piezoelectric effect, 50
immobilization, 74- 77 Piriformis
Nuclear bag fibers, 97 cross-friction of piriformis insertion, 263- 264
Nuclear bag spindles, 97 piriformis release in prone, 264- 266
Nuclear chain fibers, 97- 98 Plantar fascia manipulation, 278- 279
Plasma cells, 35
OA myofascia, manipulation of, 308- 309 Plasticity, of connective tissue, 50
Octopus grip, 202,203 PNF (proprioceptive neuromuscular facilitation), 25
Opioids, 155 Polymodal pain, 111. See also Pain
Osteopathic medicine, 8- 9, 155 Position sense, 109-110
324 Index
Upper crossed syndrome, 188, 189 Widespread Pain Index (WPI), 152
Upper extremity and posterior quadrant fascial Wolff's law, 45
elongation, 296- 298 Wounds. See also Histopathology
U.S. Food and Drug Administration, 155 definition of, 69
favorable healing conditions, 70
Vata-Pacini corpuscles, 119 fibroblastic phase of, 71- 72
Viscoelastic model of connective tissue, 41- 45 granulation phase of, 70- 71
Viscoelastic muscle tone, 113-114 healing phases of, 69- 72
Voss, Dorothy, 25 inflammation of, 70
maturation or remodeling phase of, 72
Ward, Robert, 24 scar formation, 77- 78
Washing ofhands, 204- 205 WPI. See Widespread Pain Index (WPI)
About the Authors
Robert I. Cantu, MMSc, PT, MTC, is regional manager for Physiotherapy Associ-
ates in Atlanta, Georgia. He is also an instructor at the University of St. Augustine
for Health Sciences, where he has taught in the area of myofascial manipulation
for the last 21 years.
Alan J.Grodin, PT, MTC, is senior vice president for Sovereign Rehabilitation in
Atlanta, Georgia. He is also an instructor at the University of St. Augustine, where
he has taught in the area of myofascial manipulation for the last 27 years.
327