Transcript
POSITIONAL RELEASE ThERAPY Assessmenr&r;-eannenr Dys/unction
of Musculoskeletal
POSITIONALRELEASE T Assessment&freatment of APY Musculoskeletal Dysfunction iHER 1George B. Roth, B.Se., D.C., N.D.
Kerry]' D'Arnbrogio, B.Se., P.T
Faculty, Department of Post-graduate and
PresIdent, Therapeutic ystems, Inc. Sarasota, Florida;
Continuing Education
Faculty, Dialogues in Contempornry Rehabilitation
Canadian Memorial Chiropractic College;
Hartford, Connecricucj
Director, Wellness Institute
Faculty, Northeast eminar.;
Toronto, Canada;
East Hampstead, New Hampshire;
President, Wellness Systems, Inc.
Director of Manual Thernpy, Upledger Insoitu,e
Caledon, Canada;
West Palm Beach, Florida
Industrial Injury Prevention Consulcant
wid... illustrations by
with phocographs by
] eanne Robertson
Stuart Hal/Jerin
an d
Matthew Wiley
with 256 illustrations with 342 photographs
�T� SI lOUIS
Baltimore
london
Boslon
Madrid
Carlsbad
Meltico City
Mosby Chicago
Singapore
Naples Syrlney
New York
Philadelphia
Portland
Tok.yo Toronto Wiesbaden
.,. A Times Mirror � Company
�.f1 \loshy Vice President and Publisher: Don L1dig Executive Editor: Martha Sasser Associate Develo/>mental Editor: Amy Dubm Develo/nnental Editor: Kellie White Project Manager: Dana Peick Project S/>eciaList: Cathenne Albright Designer: Amy Buxton Manufacturing Manager: Betty Rlchmoml COtler Art: Leonardo Da Vinci Copy right © 1997 by Mosby-Year Book, [nco A Mosby unprmt of Mmby, Inc. All rights reserved. No part of thi� publication may hy reproduced, stored m a retrieval system, or transmitted, in any form or by �my means, electronic, mechanical, photocoPYing, recordmg, or otherwise, without prior wntten permissH.lIl of the publisher. Permission to photocopy or reproduce solely for internal or personal use is permitted for lihranes or other use" regi;tered with the Copyright Clearance Center, provided ,hat the base fee of $4.00 per chapter pIlls $.10 per page" paId directly to the Copyright Clearance Center, 27 Congre" Street, Salem, MA 01970. This conscm doe� not extend to other kind.s of copymg, such as copymg for general distnbution, for advcrtising or promotional purposes, for creming new collected works, or for resale. Printed In the Umted States of America Comp<)sltion by Accu-Color, Inc. Pnnting/hinding by Maple V311 Moshy-Vear Book, Inc.
11830 Westlme Industrial Drive St. LOllIS, MlSsoun 63146 Library of Congress Cataloging.in·Publication Data D'Ambrogio, Kerry J. Positional release therapy: asses�ment and rrea[(nenr of musculoskeletal dysfunction
I Kerry J. D'Ambrogll>, George B.
Roth ;
with illustrations by Jeanne Rohertson. p.
em.
Includes bibliographIcal references and mdex. ISBN 0·8151·0096·5 I. Manipulation (Therapeutics) 2. Soft tissue mJunes. 3. Muscul,,;keletal system-Wounds amlmjunes. I. Roth, George B.
II. TItle IDNLM: I. Manipulation, Orthopedic-methods.
3. Soft TIssue Injuries-therapy. RZ341.D18 1997 616.7'062----Jc20
2. Pain-therapy.
WB 535 D I56p 19971
DNLM/DLC
for library of Congress
96·25538 ClP
98 99 00 01 I 9 8 7 6 5 4 3
About the Authors
KERRY J. D'AMBROGIO, B.Sc., P.T. Kerry D'Ambrogio, B.Sc., PT., graduated from the University of Toronto, Canada. He has studied in a great number of manual therapy and exercise cOllrses from around the world in the Osteopathic, Chiropractic, and Physical Therapy professions' This diverse back. ground provides Kerry with an integrated approach in the evaluation and treatment of musculoskeletal dysfunction and rehabilitation. Kerry has been actively involved in teaching seminars and speaking at research, physical therapy, and athletic therapy ccnven· [ions throughout Canada, the United States, Europe, Australia, and South America. He is the founder of Therapeutic Systems Incorporated (T.S.I.) and an international seminar company. He is the Director of the Manual Therapy Curriculum at the Upledger Institute, and he is also on faculty with Dialogues in Contempcrary Rehabilitation (D.C.R.) and Northeast seminar group. Kerry has contributed a chapter in a published manual therapy textbook and has been interviewed on radio [Q educate the public regarding manual therapy. Kerry currently practices and lives in Bradenton, Florida with his wife Jane and three children Carli, Cassi, and Blake.
GEORGE B. ROTH, B.Sc., D.C., N .D . George Roth is a Doctor of Chiropractic and a Naturopathic Physician based in the Toronto area. He has actively pursued the study of advanced musculoskeletal therapy with a number of innovators in the field and has contributed to the field through several inno· vation . He has publi hed articles in several journals and is on the faculty in the depart· ment of postgraduate and continuing education at the Canadian Memorial Chiropractic College. George has taught seminars through the Physical Medicine Research Foundation, the American Back Society, the University of Western Ontario (Department of Athletic Therapy). chiropractic. sports medicine. and physical therapy conventions and at numerous educational and clinical institutions throughout North America. He has been in practice since 1978 and is the founder of the Wellness Institute. He is also currently involved as a consultant to industry regarding injury prevention and rehabilitation and in the development of wellness programs. George lives with his wife and son in the Caledon countryside. north of Toronto.
v
Dedication
The authors would like to dedicate this book to Dr. Lawrence Jones, D.O., FA.A.O.
(1912-1996) for his pioneering discoveries in the field of musculoskeletal treatment and his contributions to the service of mankind. Dr. Jones spent over 40 years developing Strain�Counterstrain. During the process he gave his time, energy, and talent so that future generations of practitioners could enhance the care of their pariencs. His contribu.. tions have gained the respect and admiration of a broad spectrum of health professionals worldwide. Dr. Jones made it his life's work to share his knowledge for the benefit of others. We hope that our contribution [Q this continuing work will do his memory justice.
vi
Forewords
The body is a symphony of movement orchestrated by the
problem and practitioner B is using method B to treat the
natural oscillations of its component parts. The beat starts
same problem as he or she perceives it, and they are both
at the cellular {probably subcellular} level with the oscilla
successful in their outcome, then they must both be doing
tions of the individual cells. The organs, the heart, the
the same thing to the same thing, no maner what they say
lungs, the brain and spinal fluid, the gut, kidneys, liver, and
they are seeing or doing. I suspect that we are all treating
muscles all contribute their rhythm, pitch, and timbre, fir.;t
mechanical discords of the musculoskeletal system, inter�
to their organ system, and then to the orchestrated body.
ferences with the normal oscillations that we, somehow,
When it all functions together, it is a harmonic work of
may set right.
great complexity. When one of the players misses a beat it
George Roth and Kerry O'Ambrogio have put all these
can produce a discordant mess. The New York Academy of
thoughts together in an insightful book. They recognize the
Sciences has held conferences on the nature of biologic
oneness of the musculoskeletal system and have built on
rhythms and their dysfunctions and uses the terms dynamic
the work of others to devise a treatment method based on
diseases to describe the illnesses caused by these arrythmias.
scientific principles of nonlinear dynamic systems. If there
These are disorders of systems that can be described as a
is a musculoskeletal dysfunction, we may be able to facili�
breakdown of the control or coordinating mechanisms, in
tate the normal rhythms of the system by stopping the
which systems that normally oscillate stop oscillating or
orchestra, giving it a downbeat, and allowing the natural
begin to oscillate in new and unexpected ways.
oscillations, built into the structure, to get things back in
To many of us in the field of musculoskeletal medicine it
tune. This is the principle used in defibrillating a dysfunc
has become apparent that what we treat is usually not
tional heart by shocking it still, and it seems to be the prin
pathology in the classic Vercovian model, where each dis
ciple underlying positional release therapy.
ease has a verifiable tissue injury or biochemical disorder,
Positional release therapy is remarkably simple and is
but rather a perturbation of the normal rhythms of the mus
guided by the recognized diagnostic duo of somatic dysfunc tion (which is characterized as loss of joint play at the joint
culoskeletal system-a dynamic disease. New models that can explain both the static and dynamic mechanical fune,
level and similar tissue restrictions at each level studied)
tions of the body as an integrated whole are being devel
and tender points (which are unrelated to local inflamma
oped. In these models the body is a nonlinear, hierarchical,
tion or injury). These appear to be the diagnostic sine qua
structural system with every part functioning indepen#
non of dynamic diseases of the musculoskeletal system.
dently and as part of the whole, like instruments in a sym
Learning is made easy by this copiously illustrated book that
phony orchestra. How do we fix what is out of tune? Dynamic systems function nonlinearly. Linear processes,
is both a "how to" manual and a "why for" text. The mar�
once out of whack, tend to stay out of whack. Nonlinear
therapy, makes this a particularly important book. However,
processes tend to be self-correcting. A slight nudge may
as pointed out by George and Kerry, this is a book for all practitioner.; in the field of musculoskeletal medicine.
encourage a nonlinear process to correct itself. We take
riage of the two disciplines, chiropractic and physical
advantage of this when we jar a dysfunctional television set,
Because the technique is so simple, safe, and easy to learn,
scare away a hiccup, or defibrillate a heart. In the muscu� loskeletal system practitioners may treat similar problems
it can serve as an introduction to musculoskeletal tech�
with a variety of interventions. Joint manipulation of var�
niques for the less skilled and also as a valuable adjunct technique for the more experienced practitioner. It is a pow�
ious ilk, cranial manipulation, acupuncture, massage, exer�
erful tool that should be included in every clinician's bag.
cise, and so on all seem to work, in the right hands and at the right time, often for the same problem. John Mennell,
Stephen M. Levin, M.D., EA.C.S.
a pioneer in the field of musculoskeletal medicine, said that
Director, Potomac Back Center
if practitioner A is using method A to treat a perceived
Vienna, Virginia vii
viii
FOREWORDS
Positional release therapy is an extraordinary means of reducing hypertonicity, both protective muscle spasm and the spasticity of neurologic manifes[ation. Irs great achieve� ments are correction of joint hypomobiliry. improvement of articular balance (which is the normal relationship between twO articular surfaces throughout a full range of physiologic motion), elongation of the muscle fiber during relaxation, and increase in soft tissue flexibility secondary to reduced excessive sensory input into the central nervous system. Pain and disability may be remarkably reduced with this approach. Therapists and physicians can use Positional Release Thera/ry: Assessment arul Treatment of Musculoskelewl Dys function with almost every patient, in all fields of health
carc. Orthopedic patients enjoy improved function and decreased pain with increased motion. Chronic pain patients experience decreased discomfort, possibly less inflammation, and more functional movement. Neurologic patients, when this approach is slightly adapted to meet their unique requirements, attain positive gains in tone reduction with improved function in all aspects of activities of daily living. Positional release therapy is a comprehen� sive approach for all persons with stress�induced and dys� function�induced muscle fiber contraction. Dr. Lawrence Jones introduced the correction of muscu� 10 keletal dysfunction by correlating tender points with positions of comfort as described in his book Strain arul Counrersrrain. He based his findings on the theory that the treatment positions resulted in a reduction of neuronal activity within the myotatic reflex arc. Kerry D'Ambrogio and George Roth have extended and organized this approach and have included several new theories to account for the clinical manifestations. They have provided a total body scanning process for increased efficiency in practice management. Muscle and tissue references are listed, to provide a clear and pertinent anatomic and kine� siologic basis for treatment. The phomgraphs and illustra� tions are remarkably supportive for the study and practice of these techniques. Body mechanics, as it relates m the reduction of strain on the patient and the practitioner, are addressed in some detail.
Positional Release Therapy: Assessment arul Treatment of Musculoskelewl Dysfunction is an exceptional textbook that
addresses neuromusculoskeletal dysfunction in an effective and efficient manner. My belief is that their work will enhance our goal of improving health care through the use of manual therapy. My personal thanks are extended to Dr. Lawrence Jones for his landmark contribution of strain and counterstrain technique. My patients will be forever grateful. And my congratulations are extended to George Roth and Kerry D'Ambrogio for this valuable new book. Sharon Weiselfish, Ph.D., P.T. Co-partner, Regional Physical Therapy West Hartford, Plainville, and South Windsor, Connecticut Co�partner, Mobile Therapy Associates Glastonbury, Connecticut; Director, Dialogues in Contemporary Research (D.C.R.) Hartford, Connecticut
Acknowledgments
Many people over the years have helped to develop my
Thanks to Jane D'Ambrogio, B.A., B.Ed., Conrad
belief system wid1 regard [Q my healing and treatment
Penner, P.T., and Sharon Weiselfish, Ph.D., P.T., for editing
intervention philosophies. It is sometimes difficuh to say
chapters and for construccive advice and support.
where specific ideas originated because all these people
I would like to thank Dr. George Roth, D.C., for his
shared similar beliefs. I would like to acknowledge this out
patience and guidance. I've enjoyed the collaboration,
standing group of professionals for helping me put this book
friendship, and learning experiences in the writing of
together. It has been an honor to be associated with those
this book.
who are
M>
dedicated to haTing their knowledge, thoughts.
and ideas over the years:
A special thanks to Sharon Weiselfish, Ph.D.,P.T., for her friendship, contributions, incredible insight, and sup�
John Barnes, P.T., Jean Pierre Barral, D.O.,
pOTC. Sharon is an innovative thinker with her finest
Paul Chauffeur, D.O., Doug Freer, P.T.,
accomplishmel'Hs yet to come.
Dr. Dan Gleason, D.C., Phillip Greenman, D.O., Dr. Vladmir Janda, M.D., P.T., Dr. Lawrence Jones, D.O.,
Most of all, I'd like to thank Illy loving wife Jane and Illy family, who have provided me with the love and support
Dr. David Leaf, D.C., Goldie Lewis, PT.,
needed to write this book. They have comended with more
Frank Lowen, L.M.T., Edward Stiles, D.O.,
than anyone with regard to time spent and patience
Dr. Fritz Smith, D.O., John Upledger, D.O.,
required in ''''Titing this lxJok.
and Sharon Weiselfish, Ph.D., P.T. Thanks again to Doug Freer who originally inspired me.
Sincere thanks to all of YOll.
Kerry J. D'Amhrogio
I would like to thank Harold Schwartz, D.O., for helping
Working with Kerry has been stimulating, and I feel
to resolve my back pain and for opening me up to a new
that, despite occasional challenges, we have become better
way of looking at the body. Dr. Lawrence Jones inspired me
(riends and developed a greater respect for each other
through his down�[Q�earth comlllon sense and his humility,
through this collaboration. It can truly be said lhal the
and I hope that he would find this book a worthy testament
whole is greater than the sum of each of our parts.
to his goal of bringing these therapies to the world.
Several gifted practitioners, whom I can also call friends,
Last, but not least, I wish to thank my loving wife Deb orah and Illy son Joshua for their love and support. The
have been a continuing source of constructive criticism as
past 2 years has been a strain on them because of the long
positional release therapy has evolved over the years: Garry
hours I spent on this book, often hibernating away well
Lapenskie, P.T., Stephen Levin, M.D., EA.C.S., Iris Wev
into the night with my computer to write and edit the
ennan, P.T., Iris Marshall, M.D., Heather Hartsell, Ph.D.,
text. I cannot begin to express my gratitude for their
P.T., and
ecil Eaves, R.M.T., Ph.D. I am specifically
grateful to Garry Lapenskie, P.T., for his help in editing the
patience with their part�time husband and dad during rhis time.
manuscript. Stephen Levin, M.D., has been a continuing source of inspiration and a good friend.
George B. RDlh ix
x
ACKNOWlEOOMENTS
Kerry and George would both like to thank the following: Photographers Stuart Halperin and Matthew Wiley and
put in and an extra thanks to Robin and Mary-Ellen for the
illustrator Jeanne Robertson for their professionalism,
second photo shoot. Mosby staff Amy Dubin, Kellie White, Catherine
patience, and remarkable talentS. They have created an
Albright, and Martha Sasser for their advice, support, and
incredible visual learning experience for the reader. Models Mary-Ellen McKenna, N.D., Carol Fisher-Short,
patience with timelines.
R.M.T., and Robin Whale, D.C., for the long hours they
Preface
liThe magic is not in the medicine but in [he patient's body , in the vis medicacrix naturae, the. recuperative or self,correcnve energy of nature. \Vha( the treatment does is to stimulate nat, ural functions ar to remove what hinders them."
Miracles, C.S. Lewis, 1940 The purpose of this book is to provide the practitioner with a powerful set of tools to precisely and consistently resolve difficult cases of soft tissue injury and muscu loskeletal dysfunction. This text is an attempt [0 bring this information co the reader in a format that is concise, orderly, and user-friendly. We have formulated a system of assessment and treatment that can be easily learned and readily used to benefit patients. This material is appropriate for physical therapists, chiropractors, osteopaths, medical practitioners, occupational therapists. athletic trainers, and massage therapists. We acknowledge the pioneers in this field for their con tributions and view this (ext as a step coward a greater understanding of the complex nature of the human body. We 3re hopeful that this work will represent a measure of progress in the field of musculoskeletal therapy and enhance the clinical applicability of these powerful techniques. The basis of the treannen[ program described in this text can be traced to related practices in antiquity. In this cen· tury, positional release therapy (PRT) has evolved through the work of various clinicians, but the discovery of the clin· kal application of these principles is credited primarily to Dr. Lawrence H. Jones, D.O. His dedication to uncovering the basic principles of this form of therapy was a monu· mental achievement. Jones exemplifies the essence of Thomas Edison's definition: "Intelligence is perseverance in disguise." He is recognized as one of the great pioneers in the field of musculoskeletal therapy. Positional release therapy has had a powerful impact on both of us in terms of clinical success and patient accep· rance. In addition, our personal experience in dealing with our own painful conditions was instrumental in directing us to the development of this art. In George's case a severe, chronic condition of upper back pain developed subsequent to a motor vehicle acci-
dent that occured during childhood. The condition was exacerbated periodically on exertion. After becoming a chiropractor, George began seeking more effective and gentle methods of treatment, which eventually led him to study with several prominent osteopaths. He read an article by Jones that described counterstrain and subsequently met Dr. Harold Schwartz, D.O. (a student of jones), who was the head of the department of osteopathic medicine at a prominent teaching hospital. At about this time, George was experiencing an acute episode of his back condition that prevented him from sleeping in a recumbent position. It had proved resistant to several other modalities over the previous J months and was relieved by Schwartz in less than 10 minutes. This experience motivated him to begin a concerted quest to uncover the mysteries of this amazing therapy. He spent the next 5 years commuting between Toronto and Columbus in order to continue studying with Schwartz and eventually with jones. George then began assisting and coteaching with Jones and developed courses for chiroprac tors, physical therapists, and other practitioners throughout Canada. He also developed a specialized treatment table that was designed to facilitate the application of this form of therapy. While playing varsity football at the University of Western Ontario, Kerry D' Ambrogio experienced several recurring injuries to his groin, hip flexors, and right knee. These injuries plagued him during his 3 years at Western and limited his activity. As a result, he spent some time in the athletic injury clinic and received traditional therapy, which consisted of cold whirlpools, ultrasound, and stretching. While attending therapy Kerry observed other ath letes being treated, and this exposure sparked an interest in physical therapy. He decided to enter into studies at the Uni vetsity of Toronto to become a physical therapist. Throughout this period he continued to suffer from chronic pai.n. Kerry was first exposed to counterstrain by his professor, Doug Freer, and eventually attended a workship with jones. At the workship, Kerry discovered several severe tender points in his pelvic region and one on his right patellar tendon. Upon treatment, he experienced a dramatic xi
xii
PREFACE
improvement in the function of his pelvis, hip, and right
approach. The clinician is also encouraged to perform a
knee. Consequently. he was able to fully resume sports
number of reality checks to establish clinical indexes for
activities. This one treatment was able to accomplish morc
improved function. These can include standard orthopedic
than the countless previous therapy sessions. This extraoT'
and neurologic tests and specialized functional procedures.
dinary response motivated Kerry to pursue the study of
(See Chapter 7.)
countersrrain. He eventually assisted with Jones and then
The scanning evaluarion (SE), discussed in Chapter 5,
developed his own series of seminars so that he could share
and provided in its entirety in the Appendix, is designed to facilitate the cataloguing of the tender points. The SE pro
this technique with other professionals. Both of us had been exploring soft tissue skills over the
vides a system to organize assessment findings and serves as
past several years and found that our paths were inter'
a reference that quickly allows the practitioner [Q deter
seeting along synchronous lines as we pursued this knowl
mine a prioritized treatment program. This format can save
edge. We both became involved with teaching and writing
a great deal of time and provides an efficient method to
manuals for our seminars. When the idea to write a formal
track progress of the patient's condition and plan subse�
text was presented to George. he contacted Kerry, who,
quem treatments.
suprisingly, had been thinking of writing a book as well.
Jones coined the terms CDunrfTsrrain aml strain and coun�
The collaboration naturally evolved and was seen by both
terstrain (the latter being the title of his orginal text). Sev
of us as a unique opportunity co provide a greater degree of
eral authors, including Jones, have referred to the general
depth to the material and intergrate the concepts of chiro�
therapeutic approach as release by positioning and posi�
practic, osteopathy, and physical therapy.
tional release therapy. We feel that the term positional
We have attempted to provide a theoretical and histor ical perspective for positional release therapy. This founda
release therapy best describes this form of therapy in its broader. generic sense.
tion is intended to support the clinical experience and pro
With respect to the terminology used in the treatment
vide a level of confidence in the rationale for these
section, we have endeavored to keep this as simple as pos
techniques. An awareness and understanding of the under
sible while attempting to maintain a degree of structural
lying principles and context of a therapeutic model can
relevance. In certain cases, the terminology as coined by
play an important role in sustaining the perseverance
Jones is used; however, every attempt was made to correlate
required to develop the skills necessary for its application.
the treatment approach to the anatomic tissues involved.
The reader is provided with criteria for deciding whether
In a few instances, a positional reference is used where this
it is appropriate to lItilize PRT as a treatment modality.
has been determined to be the most logical format. Abbre
With the numerous emerging therapies available
the stu..
viations have been assigned for each treatment; these con�
dent of musculoskeletal therapy, we felt that is was neces�
sist of two to four letters plus numeral designations. For
[Q
sary to provide a "road map" in order to plot a course of
those trained in the Jones method, a cross-reference with
appropriate treatment. It should be noted that PRT is nor a
PRT terminology is provided (see the Appendix). There is
panacea and is best utilized within a complementary range of
also a cross�reference in the Appendix that correlates mus
therapeutic options as indicated for each individual patient.
cles and other tissues with the appropriate PRT treatment.
An outline of genenll treatment principles and rules is presented to provide a framework for consistent application
This can be used to quickly locate a particular treatment according to the involved tissue.
of the procedures. These guidelines have been established
Modifications of treatment positions and changes in ter
during the past 30 to 40 years and can serve to increase effi
minology are intended to improve the efficiency of treat�
ciency and save the therapist from repeating much of the
ment and simplify the recording and communication of
trial and error that was involved in the evolution of this
clinical findings. These changes should not detract from
PREFACE
pre\'iou� discoveries but \\fill hopefully serve to continue the development of this art ami science. Evolution is a pro' cess of building on previously established foundations. The descnption of the pomt locations and treatment procedures represents the core of this text. The underlying principle In the design of the illustration!'; and photographs has heen to c1e;uly portray the location of the tender pOInts, rhe anatomic structures Involved, and the general ptlSltion of treatment. The treatment section is divided into upper quadrant and lower quadrant sections. Each region of the body (cranium, cervical spine, thoracic spine, upper limb, etc.) b prefaced by an introduction to its clmicai rei, evance and general guidelines for the application of PRT. Each region is also headed by anatomic illustrations out, lining the general location of the most common tender fXllnt:,. Each lender point or group of tender points has a separate page that consists of'1 photograph and illustrmion With the speCific point location, detailed phorographs of
XIII
the treatment positions, anu written descriptions of the location of the tender points and the position ofrreatll'lent. Chapter 7 provides a realistic clinical context to rhe application of PRT. Strategies to help refine the techniques and optimize results arc provided, as well as mO<.!tfications for dealing with special clinical challenges. This chapter addresses the subtleties of the aTl of application of PRT skills. Potential pItfalls and questions related to clmical issues are also aJdressed. We hope that this text will msplTe the reader to look at musculoskeleml disorders in new way�. The mhercnt, self# healing potential of the body deserves our respect and sup port in the spirit of primwn no nocere (first do no harm). We believe thm positional release therapy is an approach that embraces this ideal and is truly powerful In its gentleness. We are hopeful that this wnrk will be of value to you, the practitioner. The relief of pain anti the improved function of your patients will be the ultimate measure of our success.
Contents Chapter 1
Origins of Positional Release Therapy,
I
Chapter 2 The Rationale for Positional Release Therapy,
7
Chapter 3 Therapeutic Decisions, Chapter 4 Clinical P rinciples,
19
27
Chapter 5 Positional Release Therapy Scanning Evaluation,
35
Chapter 6 Treatment P rocedures,
39
Chapter 7 The Use of Positional Release Therapy in Clinical P ractice,
Chapter 8 New Horizons, Appendix, Glossary,
22I
227
231
251
xv
POSITIONAL RELEASE ThERAPY Assessmen t&frealmenf of Musc,.loskeletal D,sfunction
1 Origins of Positional Release Therapy Body Positioning
1
Tender Points
2
Indirect Technique
2
History of Counterstrain
4
Recent Advances
5
Summary
5
The purpose of this chapter is to trace the development of positional release therapy (PRT) and put it into historical perspective. Positional release therapy is an indirect rech# niquci it places the body into a position of greatest comfort and employs tender points to identify and monitor rhe
A
lesion. Because PRT appears to be an effective modality, it must be based on certain general principles that have a sound physiologic basis. Several of the characteristics of PRT, which may be shared with other therapeutic models, can be identified. These include the use of body positioning, the use of tender points to identify the lesion and to monitor the therapeutic intervention, and an indirect approach with re peer to tissue resistance.
, BODY POSITIONING Body posture and the relative position of body partS has
B
been a subject of intense speculation and research throughout history. From yoga to the martial arts to rhe study of body language, the arrangement of the parts of the human body has been deemed to have a certain mental, physical, and spiritual significance. Several forms of yoga. a discipline with over 5000 years of history, include the phys ical practice of positioning the body to enhance function
Fig. I-I
Yoga pos(!(res. A,
Bow. B, Plough.
and release tension.1? These positions put certain parts of the body under stretch while other parts are placed in a
therapy. somi. core stabilization, functional technic, and
position of relaxation (Fig. I-I). The benefits of this form of exercise to relieve musculoskeletal pain are widely
counterstrain (Fig. I �Z).· These practices share a common#
accepted, and they are used successfully by a substantial
ment and posture with the general condition of the body.
ality in that they recognize the relationship of body move#
number of people.lo,n Modern derivations of this ancient art may be seen in the practices of Feldenkrais. bioenergetic
'References 1,7.9,10,11,15,17.
2
CHAPTER I
Origins of Positional Release Therapy
Bioenergefic exercises. (Modified from Lowen A. Lowen L: way 10 vibrant h�hh: a manual o(tHotnergelk exercises. New York, 19704. Harper & Row.)
Fig. 1-2 The
Several authors, both modern and ancient, elaborate on the "energetic" properties of postures and body positions.3 0.31.3 5 Some of these phenomena have been noted regularly by practitioners of PRT as part of the release process, which is disclissed in later chapters. The mechanism responsible for these effects is unknown.
'TENDER POINTS Acupuncture points have been used therapeutically for at least 5000 years. TI1CSC points correlate closely with many of those "discovered" by subsequent investigators (Fig. 1-3).36 References in the western literature to the presence of pal; pable tender points (TPs) within muscle date back to 1843. Froriep described his so-called Muskelschwiele, or muscle callus, which referred to the tender points in muscle that were found to be associated with rheumatic conditions. In 1876 the Swedish investigatOr Helleday described tender points and nodules in cases of chronic myositis. In 1904 Gowers introduced the term fibrositis to describe the pal pable nodule, which he felt was as ociated with the fibrous elements of the musculoskeletal system. Postmortem studies by Schade, which were reported in Germany in 1919, demonstrated thickened nodules in muscle, which served to confirm that these histOlogic changes evolved into lesions that were independent of ongoing proximal neurologic excitation.]] In the 1930s Chapman' discovered a system of
reflexes that he associated with the functioning of the lym phatic system (Fig. 1-4). He found that direct treatment of these reflex tender areas resulted in improved circulation and lymphatic drainage . Resolution of the underlying con dition, whether visceral or musculoskeletal, reduced [he tenderness of these areas. These reflexes have been described as gangliform contractions within the deep fascia that are about the size of a pea. More recently, Travell and Simons33 have systematized the mapping and direct treat ment of TPs in their two-volume series, M)'ofascial Pain and Dysfunction. Jonesl� reported on his discovery of tender points associated with musculoskeletal dysfunction as early as 1964. T he recognition of the tender point, or trigger point, as an important pathophysiologic indicator of musculoskeletal dysfunction has also been elaborated by Rosomoff.21·24 Bosey! states that acupuncture points are situated in pal pable deprcssions--cupules-under which lie fibrous cones containing neurovascular formations associated with con centrations of free nerve endings, Golgi endings, and Pacini corpuscles. Melzack and associates19 contend that there are no major differences between tender points, trigger points, acupuncture points, or other reflex tender areas that have been described by different investigacors. The varying effects reported with the use of different tender points may lie in their relative location with respect to underlying tis sues. ChaitOw3 points out that so-called spontaneous sensi tive points arise as the result of trauma or musculoskeletal dysfunction. The Chinese refer to these points as Ah Shi points in their writings dating back to the Tang dynasty (618-907 AD). Chaito\\A insists that these are identical to the points used by Jones. In summary, tender points have been recognized for thousands of years as having diagnostic and therapeutic sig nificance. Various investigatOrs have rediscovered these points and have applied a range o( therapeutic interven tions CO influence them. In general, any therapy that is able to reduce the tenderness of these tissues appears to have a beneficial effect on the health of the individual. Jonesli was the first clinician to associate body position with a reduc tion in sensitivity of these tender points.
, INDIRECT TECHNIQUE The histOry of therapeutic intervention to affect structures can be broadly divided into direct and indi# reet techniques. Direct techniques involve force being applied against a resistance barrier, such as stretching, joint mobilization, and muscle energy.S,lO Indirect techniques employ the application of (orce away from a resistance barrier, that is, in the direction of greatest ease. Indirect therapies, including PRT, have evolved in various forms and share cerrain common characteristics and under lying principles. In 1943 Sutherland" introduced the concept of manip ulation of cranial StrUCtures. His technique to treat cra-
Origins of Positional Release Theral'Y
//'� ( AJ
K27
----;�---_.
;;� '�
6110 6111
I
J
J
-+---j�H
619
6147 6148 6149
�'
6150
B
'J
� K10
3
618
-
A
I
{
\
61 23 61 25
CflAPTER
---..
�
�
�
_ 61 53 61 54
\
6160
K3
fig. I·]
�
W �
61 67
Acupullcture lJOim5 related [0 A, the kidney meridian; and B, rhe blMder meridian.
nial lesions was to follow the motion of the skull in the direction in which it moved most freely. By placing pres· sure on the bones of the head in the direction of greatest ease, he found that the tissues spontaneously relaxed and allowed (or a normalization of structural alignment and function. In the late 19405 Hooverl! introduced functional [echnic. He found that when a body part or joint was placed in a position of dynamic recityrocal balance, in which all tensions were equal. the body would spontaneously release the restrictions associated with the lesion. During that period. the prevailing view of musculoskeletal assessment stressed the position and morphology of body parts. Hoover empha sizcd the impormnce of "listening" [Q the tissues, which refers to the process of carefully observing, through palpa tion, the patterns of tension within the tissues and paying attention [Q their functional characteristics and structure. He introduced the concept of functional diagnosis, which takes into account the range of motion and tissuc play within the structures being assessed.
Hoover advocated a treatment protocol that was respectful of the wisdom of the tissues and the inherent interaction of the neuromuscular, myofascial, and articular components. The technique involves movement toward least resistance and greatest comfort and relies on the response of tissues under the palpating hand of the practi# tianer. This dynamic neutral position attempts to reproduce a balance of tensions, which is ncar the anatomic neutral position for the joint, within its traumatically induced range. A series of tissue changes may occur during the posi# tioning that are perceived by the practitioner. The practj# tianer attempts to follow this evolving pattern until the body spontaneously achieves a state of resolution and the treatment is complete.11 Joncsl5 found that specific positions were able to reduce the sensitivity of tender points. Once located, the tender point is maintained wim the palpating finger at a sub# threshold pressure. The patient is then passively placed in a position that reduces the tension under the palpating finger and causes a subjective reduction in tenderness as reported by
4
CHAPTER I
Fig. 1-4
Origins of Positional Release Therapy
Chapman s reflexes. I
(Modified from Chaltow L: Sofi tISsue manipulation, Rochener,
Vt, 1988.
Healing Aru
Press.)
the patient.l; This "specific" position is, nevertheless, fine�
sleep for more than a few minutes was impossible. Jones
tuned throughout the treannent period (90 seconds), mllch in
decided that finding a comfortable position that would
the way that Hoover follows the lesion in his technique. Chaitow' also alludes to the possibility that a therapeutic
allow the patient to sleep would at least provide some tern, porary relief and some much,needed rest. After much trial
effect is exerted by maintaining contact with the tender point.
and error, they found a comfortable position. jones propped
In 1963 Rumney" described the basis for reestablish ing normal spinal motion as "inherent corrective forces of
the patient in this unusual, looking folded position with sev,
the body-if the patient is properly positioned, his own
eral pillows and left him to rest. Upon his return some time later, Jones suggested that the patient memorize the posi,
natural forces may reStore normal motion co an area." Other
tion in order to reproduce it when going to bed that night.
clinicians have used an indirect method co treat muscu�
.The patient was then slowly taken out of the position and
loskeletal dysfunction by having patients actively position
instructed to stand up. Much to the amazement of the
themselves through various ranges of morion under the
patient and Jones. the patient stood erect and with drasti,
guidance of the practitioner and while being monitored for maximal ease by palpation.B•JS
cally reduced pain. In the words of jones, "the patient was delighted and I was dumbfounded!""·ll
, HISTORY Of (OUNTERSTRAIN
This discovery emphasized the value of the position of comfort. Jones found that by maintaining these positions for varying periods of time, lasting improvement would often
In 1954 Lawrence H. Jones, an osteopath with almost 20
be the result. He initially held the position for 20 minutes
years of experience, was called on by a patient who had
and gradually found that 90 seconds was the minimal
been suffering with low back pain of 2 months' duration
threshold for optimal correction of the lesion.
that had nOt responded to chiropractic care. The patient
As jones pursued the possible applications of this new dis
displayed an apparent psoas spasm with resultant antalgic
covery, which he referred to as counterstrain, he noted that
posture. Jones was determined that he could succeed where
many of the painful conditions that he was able to alleviate
others had failed. However, after several sessions with no
were
improvement, he was ready to admit defeat in the face of
points. The traditional approach to lesions of the spine was to
this resistant case. The patiem was in so much pain that
assess and treat on the basis of tender areas in the paraspinal
assoc
iated with the presence of acutely painful tender
Origins of Positional Release Therapy tissues. These points, after positioning of the patient, became decidedly reduced in tenderness and remained so even after the treatment was concluded. Thus an important diagnostic dimension was added to this fonn of therapy. In many instances of back and neck pain, however, no tender point could be found in the area of the pain within the paraspinal tissues. Fate was once again to play a role. A patient who had been seeing Jones for low back pain was working in the garden when he was struck in the groin with a rake handle. In pain and fearing that he may have induced a hernia, he called on Jones. Jones examined the patient and assured him that no hernia was present. Jones then decided that the patient might as well stay and receive a treatment that was scheduled for later in the week. After the patient had been placed in the position for treatment of his low back, in which he was supine and flexed maximally at the hips, Jones decided to recheck the previously tender area in the groin. To his surprise, the tenderness was gone. This discovery answered the mystery of the missing tender points, and shortly thereafter Jones was able to uncover an array of anteriorly located tender points that were associ; ated with pain throughout the spine.1J He noted that approximately 30% to 50% of back pain was associated with these anterior tender points. With this latter discovery, much of the guesswork and trial and error in rhe application of therapy was eliminated. The use of tender points became a reliable indicator of the type of lesion being encountered, and therapeutic intervention could thus be instituted with increased confidence and reproducibility. Jones spent the better part of 30 years developing and documenting his dis coveries, which he first published in 1964.14 He later pro duced a bock entitled Strain and Counterstrain.15
, RECENT ADVANCES Positional release therapy owes its recent evolution to a number of clinicians and researchers. SchwartzI9 adapted several techniques to reduce practitioner strain. Shiowitz28 introduced the use of a facilitating force (compression, tor; sian, etc.) [Q enhance the effect of the positioning. Ramirez and othersll discovered a group of tender points on the pos; terior aspect of the sacrum that have significant connec· tions [Q the pelvic mechanism. Weiselfish34 outlined the specific application of positional release techniques for use with the neurologic patient. She found that the initial phase of release (neuromuscular) required a minimum of 3 minutes, and she also outlined protocols to locate key areas of involvement with this patient population. She, along with one of us (O'Ambrogio), outlined the twO phases of release: neuromuscular and myofascial. Brownl developed a system of exercise for the spine in which a pain·free range of motion is maintained. One of us (D'Ambrogio) devel· oped the scanning evaluation procedure to facilitate the effj· ciency and thoroughness of patient assessment,6 and one of us (Roth) has developed improved practitioner body mechanics to reduce strain and has correlated lesions with
CHAPTER I
5
specific anatomic structures. IS We have helped simplify the terminology used to describe lesions and systematized the educational program to help make the development of PRT skills more efficient. In the next chapter we will help to eStablish a physiologic basis for many of the clinical mani festations of musculoskeletal dysfunction.
, SUMMARY Positional release therapy has historical roots in antiquity. The three major characteristics (body positioning, the use of tender points, and the indirect nature of the therapy) can be individually traced to practices established over the past 5000 years. Connections can be made with the ancient dis· ciplines of yoga and acupuncture and with the work of investigators over the course of the past twO centuries. The correlation of different systems that use tender points sug· gesrs a common mechanism for the development of these lesions. Significant contributions to the development of this art and science have been made by Jones12•1J.16 and others. Positional release therapy is being continually advanced and developed through the contributions of many clinicians and researchers.
References I. 2. 3. 4.
5. 6. 7. 8. 9. 10. I!. 12. 13. 14. 15. 16. 17. 18. 19. 20.
21.
Brown CW: Change in disc nearmem saves hockey star, Backlmer )(Inl.I992. Bosey J: The morphology of acupuncture points. Acupunc Electother
Res ),79,1984. Chaitow L: Sofllimu! manipulation. Rochester, Vl, 1988. Healing Arts Press. ChaitOw L: The acupunclUre rreannem of pain, Wellingborough, 1976,Thorsons. Chapman F. Owens C: Introduction 10 and endocrine inteT1Jreuwon of Chapman's reflexes. self-published. O'Ambrogio K: Strain/counterstrain (course syllabus), Palm Beach Gardens, 1992,Upledger Insmure. Fcldcnkmis M: Awareness through I7lOt.IeTlltn!: health exercises fCJr pe T sonaigrowlh, New York, 1972, Harper & Row. Greenman PE: Principles of manual m.edicine. Baltimore. 1989. Williams & Wilkins. HashImoto K: SOlai natural exercise, Oroville, Calif, 1981. George Ohsawa Macrobiotic Foundation. Hewitl J: The compiele yoga book , New York, 1977,Random House. Hoover HV: Funcrionallechnic, AAO Year Book 47.1958. Jones LH: FOOl nearment without hand tmuma.} Am Osteopath As"" 120481,1913. Jones LH: Missed anterior spinal lesions: a preliminary report. DO 6075, 1966. Jones LH: Spontaneous release by positioning. 00 4:109,1964. Jones LH: Strain and COU1l[CTStrain. Newark, Ohio, 1981. American Academy of Osteopathy. Jones LH: Str.tin and counterstrain lectures at Jones Institute, I99Z-1993. Lowen A, Lowen L: The way 10 vibranl health: a manual of bt'orner. gelic exercises. New York, 1974,Harper & Row. Maigue R: The concept of painlessness and opposite mmion in spinal manipularions, Am} Phys Med 44:55,1965. Melmck R. Stillwell DM. Fex EJ: Tngger points and acupuncture
points for pain: correlations and implications, Pain 3:3,1977. Mitchell FL, Moran PS, Pruzzo HA: An e,-oaluacion and treatment ml1IlIW of os/eopalhic muscle tnelD procedllres, Valley Park, Mo. 1979. Mitchell. Moran and Pruzw. Ramirez MA. Haman J. Wonh L: Low back pain: diagnosis by six newl�' discovered sacml tender points and treatment WIth counter strJ.in,} Am Osteopath Assoc 89:7,1989.
6 22. 23. 24.
25. 26.
27. 28. 29.
CHAPTER I
Origins of Positional Release Theral'Y
Ramnum M: Fundamtnwu of ;ioga, New York. 1972. l"\'u�I('J3y. R(\S(llUoff Hl: Do hcmlilh.-J UISC;. cause rain! elm} Pam 1:91. 1985. Rus(lmnf( HL. Fi�hb.Jm DA, Goldberg M, Stcdc·Rosomoff ICOII finding!> In ratlcntS with chronic Introc.:wble hcniJ!fl rilln of the m ..'Ck amI/or hack. Pam 37:279. 1989.
30. 31.
RI)[h GB: CounLm[Tlun: posifional release rhef'aJ1)' htudy �U1dc). T(lhlnto. 1992, Wdlnt-··" IruILlU(C. -.elf-published, Roth CiR: Tuw;!n.!" a umfu -J mndel u( mU!>I.:ull",kderal J�';,funC{Jon. .. Prc..c.:nteJ at Canao.'1n Chlwpmtlc A'<"\(Xliltlon ,1000,,1 ",cetmn. June. 1995. Rumney Ie: Siructumi Jlagno;'l� ltlonal rcle�. j Am O�[CoplJ(h Assex: 2,141.1990. Schwan: HR: The u...e of countersmun In an acutely illm-hmrnal population.} Am O�leopalh .A.5.mc 86:4B. 19H6.
31.
31.
H.
15. 36.
Schwarr: JS� HLmum L'TleTSO' .�'mcms. New York. 19&), l\muo. .. ">f�l: aguLJ.:. W('I1L'Tg)' mot't'1llc'fll tlnJ hlld'Y struclUTe, Snuth FF: lnn Adanta. 1986. HumallLc�. Sutherland WG: The cranL,ll huwl. } Am OSCt>j)palh AHf)( 2:348, 1944 Tnwcll JG. SLmon!) [X]: MyofrucidJ. t)(lln "oJ J'Y,fUIlCIIOIL rho: m,IW.'T I)oin! manual, f\lhLmore, 1983, WtlIL.lIn�& Willom,. Wei�l(i.'ih S; Manual lheratry far !he OTlho/Jidsc and neumk� panc11I emt�,,::mg SCTam and coun!rolTam lechmqLlf. Harrfmd. Conn. 1993,
RegLonal PhYMcal Therapy. �1f.pubIL"hcd. Woodroffc WOl,)lerron H, Mclean CJ: Acupuncllm� t'nI..>rg:V In h.:>allh and ducase· a IW'Ck'Ufal gUide fm a,d,."anceJ snulcrtLS. NurrhamplOmhLrl.'. En�lanJ, 1979. ThuN,\Ils.
2 The Rationale for Positional Release Therapy Somatic Dysfunction
7
A New Paradigm
7
The Tissues
8 9
Therapy in Somatic Dysfunction
10
Positional Release Therapy
This chapter establishes a ra[ional basis of understanding
ociceptors: Pain Pathways
12
Crossroads
13
Fascial Dysfunction: Connective
The Role of Positional Release
Treatment
10
Feedback The Facilitated Segment: Neural
The Significance of the Tender Point
P r opr iocep tor s: Neuromuscular
Tissue Connections Summary
14 15
10
have been supported by the advent of imaging devices such
for [he clinical phenomena associated with positional
as the x-ray and its modem derivations (CT scan, MRI).
release therapy (PRT). Somatic dysfunction is discussed in
The aim of therapies based on this model is to reshape the
the light of recem discoveries regarding the physiologic
stnlC(ure according to an architectural ideal. The assump#
properties of the variolls tissues of (he body. Several models
tion is that, by reestablishing the optimal physical relation�
of dysfunction are introduced within the context of their
ship between body parts, everything will be restored to per#
possible role in explaining the effects of PRT. Certain pre
fect working order. The
vailing doctrines may be challenged by the arguments pre
designed to remodel the components of the body and to
sented, and we hope (hat the reader will keep an open mind
relieve perceived structural stress within the system.
and judge these theories on their rational merit and on the
Stretching shortened tissue, vigorously exercising hypo#
basis of how they fit with clinical experience.
tonic muscles and surgically refashioning osseous and artic#
, SOMATIC DYSFUNCTION A NEW PARADIGM
aim of achieving this architectural ideal have had limited
Prevailing theories regarding the development of muscll�
therapeutic intervention is
ular components of the musculoskeleml system with the success. The belief that these procedures should work because they are consistent with this model of the body
loskelctal conditions are undergoing intense scrutiny.
encourages persistence, even though the objective results may contradict the underlying prernise.17•18,45 Unfortu
Patients and insurers are demanding effectiveness and reli�
nately, in many cases, the StruCture resists our efforts. The
ability in therapeutic intervention. If the underlying theory
result is often frustration (or the practitioner and torment
regarding the development of somatic dysfunction IS incon�
for the patient.
sistenr with clinical anu physiologic realities, therapeutic models based on these principles must be questioned.
The functional model of the musculoskeletal system holds that biomechanical discurbances are a manifesta#
The structural model of musculoskeletal dysfunction is
tion of the intrinsic properties of the tissues affected.])
associated with gross anatomic and postural deformations
The tissue changes may be the result of trauma or inflam#
and degenerative changes (scoliosis, disc degeneration,
mation and are seen as a direct expression of fundamental
oSteophytes, etc.). The presence of these physical anomalies
processes at the ultrastructural and biochemical levels.
are considered a direct cause of sympcoms. These theories
These changes, which are collectively referred to as somatic
7
8
CHAPTER 2
The RatiOlUlIe for Positional Release Therapy
dysfunction, may be expressed as reduced joint play; loss of tissue resilience, rone, or elasticity; temperature and trophic changesi and loss of overt range of motion and postural asymmetry. This model views the form of the body as an expression of its function. Posture is seen as an outward manifestation of the degree of balance within the tissues, and greater emphasis is placed on the interaction of all of the body parts during physiologic and nonphysiologic mmion. This model emphasizes the role of the soft tissues, especially the myofascial elements. A growing body of knowledge supports the premise that a large proportion of musculoskeletal pain and dysfunction arises from the myofascial elements as opposed ro neural or articular rissues.J8 Rosomoff and ochers35 have concluded that over 90% of all back pain may be myofascial in origin. In fact, they contend that one of the mOSt popular theories for [he origin of back pain, that of pressure on a nerve, as in disk degeneration or disk protrusion. would result in a so� called silent nerve. They state that "back pain must be con sidered to be a non,surgical problem, unrelated to neural compression." Pressure on a nerve results in reduced sensa� tion and motor function, not pain. This can easily be proven by the common experience of placing the arm on the back of a chair and noting how the arm "falls asleep." During this episode, there is a sensation of numbness and loss of mOtor control-not pain. Ir is only when the pressure is relieved that pain is experienced. along with the gradual return of motor function. Saal and othersJa have proposed that, when disks are injured or are in the process of degeneration, they release water and proteoglycans. This material undergoes biochem� ical transformation through glycosylation and is subsequently targeted by the immune system as a foreign substance. This results in the initiation of an inflammatory response. As the leakage of this Uforeign" protein into the epidural space continues, there may be a significant rise in the levels of phopholipase (a component of the arachadonic cascade), leading (Q the production of nociceptive chemical mediators and biochemically induced pain.Ja BrownS notes that disk herniations may be a "red herring" in many cases of thoracic pain and that, barring any significant indications of spinal cord compression, a conservative approach to relieving the myofasdal source of the pain is all that is required. Rosomoff and others)5 point out that, in most cases of musculoskeletal trauma, the accompanying soft tissue injury and the resulting release of inflammatory chemical media, tors produce the sensation of pain. Myofascial responses to injury result from an increased level of proinflammatory chemicals present because of the injury or from direct trauma to the tissues.49 In the latter case it is postulated that calcium is released from the disrupted muscle, which in tum combines with adenosine triphosphate to produce sustained contracture) Proprioceptive and neuromuscular responses are other potentially important mechanisms associated with somatic dysfunction. The sudden strain that accompanies many injuries engages the mYOtatic reflex arc.n.5) These
events may account for the development of myofascial trigger points, protective muscle spasm, reduced range of motion, and decreased muscle strength, which consistently accompany musculoskeletal injury. The effect of trauma to the fascial matrix is also a subject of much speculation. The discoveries of Levin27•29 may shed some light on this complex issue. He and others have demonstrated that the underlying structure of all organic tissue determines its responses to traumatic forces and may account for certain properties that can lead to persisting dysfunction. 19•36.51 PRT, and other functional therapies, do not alleviate or attempt to treat any tisslle pathology. The primary role of these therapies is to relieve the somatic dysfunction, which, according to Levin,29 is a nonlinear process. A nonlinear process is one that exerts an influence over a relatively brief period ohime. These processes tend to be functional rather than pathologic and respond rapidly to functional therapy. Functional restoration establishes an environment in which the linear healing process of the pathologic component of the injury may occur more efficiently. Musculoskeletal dysfunction therefore appears to origi nate and be maintained at the molecular and ultrastructural level within the tissues. The intrinsic properties of tissue and their inherent pathophysiologic response to trauma seem to be consistent with many of the external manifesta, tions associated with somatic dysfunction. It is imperative that we examine our beliefs and hypotheses so that we can accommodate this developing knowledge base within our working model of somatic dysfunction. Effective therapy must be congruent with these principles regarding the response of the body tissues to trauma. We will now examine PRT within the context of its influence on these properties of tissue.
THE TISSUES The body is composed of several major tissue types. For the purposes of this discllssion, with respect to musculoskeletal dysfunction, we will consider three main classes of tissue: muscle, fascia, and bone. Even though these tissues are con� sidered separately and are often discussed in isolation from each other in the literature, we should recognize that they are interconnected functionally. The kinetic chain theoryli and the rensegrity model of the body21-29 support the concept that the effects associated with somatic lesions are trans� mined throughout the organism. Restriction or dysfunction in one area or type of tissue can result in reactions and symptoms in other areas of the body. Effective muscu� loskeletal therapy, including PRT, should address the source of the dysfunction, and thus it is essential to have a thor, ough understanding of the physiology and pathophysiology of the somatic tissues. The muscular system, despite its massive proportions, is maintained in a subtle state of balance and coordination throughout a wide range of postures and activities. The
The Rarionnle fCYT Posirionni Release Therapy muscles are the source and the recipient of the greatest amount of neural activity in the body. This includes sensory and motor activity, vertical (conscious, cerebral) pathways, and auronomic activity in relation to the metabolic, vis� ceral, and circulatory demands required during muscular exertion. The muscles, according to Janda, are "at the cross� roads of afferent and efferent stimuli" and arc, in fact, "the most exposed part of the motor system."zz Range of motion, segmentally and globally, is largely dependent on the state of balance ohhe muscles that cross the involved joints, and restriction of motion may be directly auributed [Q abnor� maliries in the tone and activity of this system. The response of muscle to injury is protective muscle spasm, and this reflex is mediated by local propriocepcors and monosynaptic reflexes at the spinal level. The neuro� muscular reflexes involved in this response will be discussed in greater detail later in this chapter in the section on pro� prioceptors. Muscle is interwoven with collagenous and elastic fibers and therefore shares certain characteristics with fascial tissue. Fibrous tissue changes within the muscle may thus be a feature of posttraumatic dysfunction. The fascial system is a vaSt network of fibrous tissue that contains and supports muscles, viscera, and other tissues throughout the body. Injury or inflammation results in adhesive fibrogenesis, which may result in the loss of normal elasticity. According to Barnes! and Becker,] the collagenous matrix of the fascia is in a state of dynamic adaptation to changing conditions, including the effects of strain, trauma, and inflammatory processes. Fascia contains a higher percentage of inelastic collagen fibers than elastin fibers and thus plays an important role in limiting excessive motion and conmining inflammation and infection. Alter� ations in the electrochemical bonds between collagen fibers results in the formation of cross�linkages in response to chemical irritation related to inflammation, overstretch, or other mechanical influences. As these cross�linkages form, the elasticity of the fascia becomes reduced and the tissue alters from a sol to a gel state within the area of involve� ment. The net effect is the development of an area of restriction and reduced elasticity, or fascial tension . US Neural tension and visceral dysfunction have also been cited as separate foci of dysfunction.2,6 These lesions may represent specific manifestations of fascial tension within these tissues. Osseous Structures have long been ignored as active ele� ments in the pathophysiology of mu culoskeletal dysfunc tion. Recent evidence indicates that bone is much more plastic and responsive than had been previously appreci ated. Chauffour" states that fresh long bone has flexibility of up co 30 degrees before the induction of fracture. The collagenous matrix of bone and the periosteum exhibit characteristics similar to fascia elsewhere in the body. In an injury, bone is no less affected than any other component of the musculoskeletal system and will display persisting injury patterns depending on the nature of tile event. Many of the therapeutic modalities used for muscle and fascia
CHAPTER 2
9
may, theoretically, be applied (Q the osseous component of the dysfunction . IO,'ll
THE SIGNIFICANCE OF THE TENDER POINT Tender points may arise in any of the somatic tissues: muscle, fascia (including ligaments, tendons, articular cap� sule, synchondroses, and cranial sutures), periosteum, and bone. The tender points in positional release therapy are used primarily as diagnostic indicators of the location of the dysfunction. The diagnostic and therapeutic utilization of tender points is central to a wide range of therapies, including PRT.' An understanding of their pathophysiology and role in the etiology of somatic dysfunction will help us in pursuing our study of PRT. Myofascial pain syndrome (MPS) is defined by Travell and Simons" as follows: "localized musculoskeletal pain originating from a hyperirritable spot or trigger point (TrP) within a tallt band of skeletal muscle or muscle fascia." A thorough review of the literature with respect to MP reveals a decided lack of objective criteria for evaluating and treating this common condition. IS The tender point (TP) is palpable as a small (0.25 co 1 .0 em) nodule, usually located in the subcutaneous, muscular, or fascial tissues, There appears to be a close association between the tender points used in PRT and by Jones with the Ah Shi points as described in Chinese writings,S the neurolymphatic points as described by Chapman and Owens,9 and the neurovas� cular points described by Bennett.' (See Chapter I . ) The association o f myofascial trigger points or tender points with musculoskeletal dysfunction has been estab� lished by numerous authors.' Sedentary lifestyles and occu pational repetitiveness limit the number of muscles used on a regular basis. Therefore a relatively small percentage of our total muscle mass tends to be ovenvorked, while other muscles become atrophied and reduced in their ability to tolerate loads or strain, Postural stress, trauma, articular strain, and other mechanical factors may excessively load myofascial tissues, leading to the biochemical changes involved in the production of TPs. Tender points are most prevalent in mechanically stressed tissues, notably those subject to increased postural demands, such as the upper trapezius, the levator scapula, the suboccipitals. the psoas, and the quadratus lumborum.l0 On deeper palpation, the intrinsic muscles of the axial skeleton (the multifidus, rota� tOres, levator costorum, scalene, and intercostal muscles) are also often found to contain active TPs. The "weekend warrior" often strains the underused muscle groups and demands phasic responses from muscles which have adapted to a primarily tonic function. inflammarion caused by the initiating injury releases proinflammatory and vasoconstrictive chemical mediators such as histamine and prostaglandins. Acute or repetitive 'Refecences 8, 22, 3 1 , 35, 39, 4Z, 45, 48. 'References 15, ZO, 35, 41, 45, 46, 54·57. 58.
10
CHAPTER 2
The Ralionale for PoSItional Release Therapy
trauma may result In the rupturing of the sarcoplasmic
to 3 degrees." (See Chapter 4. ) It may be speculated that
reticulum. The ensumg £loot! of calcium ions Into rhe toter·
positionll1g heyond this Ideal range places the antagolllstic
stlrial compartment leads (0 uncontrolled actin anJ myosin
muscles or opposing fascial structures under increased 111
interaction and rhe development of the palpable taut bands
suetch, which
of muscle associated with myofascial Involvement. The
spillover, resulting in reactivation of the facilitated seg#
turn causes a proprioceptive/neural
result of these traumatic events is hypertonicity, inflamma·
ment. The iueal position is dNermll1cd subjectively by the
[ion, bchemia, anti an increascu concentration of mcrabol·
patient's perception of tenderness "nd objectively by the
ically active chemical mediators. This vicious cycle, which
reduction 111 palpable tone of the tender point. We refer to
will be further perpetuated by repetitive trauma, is thought
thIS change as the comfort zone (CZ). This mtrlnsic feed·
to be responsible for rhe maimenance of these hypcnrri·
back system assists In the diagnosis and treatment of mus#
tahle, constricted focal areas of inflammation (TPs) within
culoskeletal dysfunction and affords PRT a high level of
the tissues. Z J.4 1,1'1
reliahility within the c1l1lical setting.
Sensitization of nociceptive and mechanoreceptive
O'AmbroglO and Welselfish, in their lectures, descnbe
organs within the affected tissues appears to have a role In
twO major phases of the release phenomenon: the neuro#
mediating the formation TPs. Group I I I and IV nerve fibers
muscular phase, which lasts approxllnateiy 90 �econds, and
are sensitive to chemically active compounds such as
the myofascial phase, which may last for up ro 20 minutes.
prosraglam.lllls, kinins, hbtamine, and potassium. Micro#
WeisclfishSl further Mates that the neuromuscular pha'oC in
scopic examination of muscular TPs reveals the presence of
neurologic patients usually lasts for approxllnately 3 mlll#
mast cells (source of histamine) and platelets (source of
utes. (See Chapter I .) Clrmcally, several phenomena occur
serotonin). These prolnflammatllry suhstances may con#
during the pOSitioning. As one approaches the ez, (he tis#
tribute to the local hypersensluvity that activates the TPs
sues 111 the area of the tenuer POInt soften and become less
when mechanical deformation or direct pressure occurs.'o
tender. After a period of time, several other observations
The myofascial tis:,ues are, in essence, a continuous net#
may he noted. There IS often an II1crease II)
III
local tempera
work thar surrounds and penetrates all of the structures and
ture. Vibration and pulsation
organs of the body without IIlterruption. This can be com#
are also common findlllgs as the treatment progresses. The
the area of the tenuer point
pared wlrh a piece of woven fabric or a net. Any disruption,
breath may he observeJ to alter during the session,
pressure, or kink wlthm this net IS II1stantaneously trans#
becomll1g shallow and rapid, followed by several slow, Jeep
mitred to the entire structure and will create a distortion of
hreaths. This may occur several times during the treatment.
the previously symmetric architecwre.IU7,}.4 The tender
Fascial unwinding may he sensed extendtng from the area of
point may be conceived of as a focus of constriction of the
the tender point. The patient often reports several (ransient
myofascial tissues. These nodular focal points of tension
symptoms during: the course of the positionmg, includmg
(TPs) within the myofascial continuum may result 111 dis# tort ions
111
the biomechanical integrity of thiS matrix. I
They may also play a role
111
generating Irritable stlilluil,
which Illaintain the dysfunction via a facilitated segment (discussed later).
paresthesia. sensation of heat, fleeting pall1� in other areas of the lxxJy, headaches, emotional episodes, and ultimately, a sense of deep relaxation, The ohserved phenomena associated With somatic dys# function anJ the therapeutic effect of PRT may be explained hy several pathophysiological mechanisms: pro
H HE R OLE OF POSITIONAL R ELEASE T HERAPY IN S OMATIC D Y S F U NCTION
pnoceptlve systems, nOCiceptive pathways, the facilitated segment, and fascial dysfunction.
The role o f PRT in the resolution o f somatic dysfunction i s assessed within the context o f several o f the current theo#
PROPRIOCEPTORS: NEUROMUSCULAR FEEDBACK
ries of myofascial and neuromuscular pathophysiology. Each
In the 1 940s Denslowll and Korr!'U6 began investigating
of these pn.:lCesses may explain a certain aspect of the dys#
the role of neuromuscular feedhack sysrem> In the develop·
function, and a combination of effects may account for the
ment of somatic dysfunction. In functional technic, as
range of manifestations found in clinical practice.
uescribed hy HrK.wer, UI range of motion I� mOnitored for the degree of ease or billd. He describes a lesion as having an exceSSively resistant range of motion
POSITIONAL RELEASE THERAPY TREATMENT
111
one direction and
an excessively compliant range in another direction. These
Positional release therapy treatment is accomplisheu by
characteristics are nor ascribed to any pting dys' function in any other pan.
by compenS3nng for arca� of relative fixation. This results
The render poilU is a clinically recognized exprcs.o;ion
in excessive morton in regions of the hoJy that extend from
of somatic dysfunction and is used in PRT a� a diagnn'tlc
the focus of dysfunction. Excessl\'c force, Jue to strain or
indicator.
repetitive motion against thc restriction barrier, may cause
Several pathophysiologic mechanisms may he respon·
local mflammation amI pam. The mcreaseu mechanical
sible for the development of the c1mical manifesrations
deformation anJ strccch wlthu) these tissues may result in
associated
the release of pain-producing chemical mediacors. Thus
responses, mediated by monosynaptic reflexes and musculo· tendinous proprioceprors, can alter the length/tenSion rela#
pam may be exprc!lScJ within WiSUCS, which are, III fact,
with
somatic
dysfunction.
N curomuscular
secondary areas of Involvemem. The goal of treatment of
tionship of the muscular component of the dysfunction.
these hypermobile tissues (joints, ligaments, etc.) is [0
Tissue injury results in the release of proinflamm�ltory
CHAPTER 2
16
The Rationale far Posirional Release Therapy
chemical mediators. which in tum stimulate the pain recep� tors within the involved tissues. This further promotes the development and maintenance of protective muscle spasm and may result in a persisting dysfunction, which can become a focal point for reinjury and continuing pain. This cycle of events feeds inm the neurologic phenomenon referred to as the facilitated segment. Other, nonsomatic stimuli may also interact with this pathway and lead to a self#perpcruaring cycle of irritability. Fascial structures respond to trauma and the ensuing inflammatory process through the production of adhesive cross-fibers and fascial tension, which may impair mobility throughout rhe organism. The tensegrity model of organic tissue has given new insight into the nature of tissue interactions and a greater understanding of the pathophysiology of somatic dysfunction. Positional release therapy theoretically addresses neuro� muscular hyperirritability and muscular hypertonicity as mediated by the proprioceptive system. It also appears to reduce tissue tension, allowing for the resolution of the inflammatory response and the release of the electrochem� ical bonds associated with fascial restriction. Any tissue may be implicated in the pathophysiology of somatic dysfunc tion. The clinician should be guided by tissue response rather than by symptoms in the search for the underlying cause and treatment of the dysfunction.
References 1. 2. 3.
Barnes J : Myofascial release: the search far excellence, 1990, self.published. Barral JP: Visceral manilm/acion , Scanle, 1988, Eastland Press. Becker RF: The meaning of fascia.and fascial continuity, Osreopa,hic Ann, 1975:35·46.
4.
5. 6. 7. 8. 9. 10.
Bennett R: In Chapman's Reflexes. Martin R. editor:
Dynamics of correccion of abnannal function, Sierre Madre, alif, 1977, self·published.
Brown CW: Change in disc treatment saves hockey star. Back I.e, 7 ( 1 2 ) : 1 , 1992. Buder DS: Mobilisation of rhe nervous system, Melbourne. 1 99 1 , Churchill Livingstone. Caillet R: Sol' ,issue pain and disabiUry, Philadelphia, 1 980, Davis. Chaitow L: The aeulJuncture treatment of pain, We\lingbor� ough, 1976, Thorsons. Chapman F, Owens C: InCTocillCtion to and endocrine inlerpre� tation of chapman's reflexes, self�published. Chauffour P: Uen mechanique (mechanical link), Paris, 1 986, Maloine.
11.
Chauffour P: Lecrures (mechanical link}, Palm Beach, FL,
1 2.
Denslow JS, Korr 1M, Krems AB: Quanitative sHldies of chronic facilitation in human mo[Oneuron pool. Am J
1 994, 1995.
1 3. 14.
I S.
Phy.ioI 1 50:229, 1947. Dorman TA, editor: Prolotherapy in the lumbar spine and pelvis, Spine: "are o[ ,he AT! Review. 9(2), May 1995.
Gray G: Functional kinetic chain rehabilitation: overuse and inflammatory conditions and their management, Sports Medicine Updare, 1993.
Henriksson KG: Microscopic and biochemical changes in fobromyalgia, Proc I " 1m Symp MP May 1 989 (abstract).
16. 1 7.
lB. 19.
20.
21.
Hey LR. Helcwa A: Myofascial pain syndrome: a critical review of the literature, J Can Phys Assoc 46:28, 1994. Hey LR. Helewa A: TIle effects o( stretch and spray on women with myofascial pain syndrome: a pilot scudy, Phys iorher Can, 44:4, 1 992 (abstract). Hoover HV: Functional technic, MO Year Book 47, 1958 Imgber DE, Jamieson J: Cells as rensegrity stnlCtures: archi· tectuml regulation o( histodifferentiation by physical forcel: transduced over basement membrane. In Andersonn LL, Gahm CT. Kblom PE, editors: Gene expression during nannal and malignanc difierenciation, New York, 198;, Aca� demic Press. Jaeger B, Reeves JL: Quantification o( changes in myofas� cial lrigger point sensitivity with the pressure algometer fol lowing passive metch, !'ain 27(2):203, 1986. Janda V: Muscle and joint correlations. Proceedings. IV FINN, Prague, 1974, Rehabilitation Suppl 10- 1 1 , 1 54· 1 58, 1975.
Jones LH: Srrain and COIHucTSlrain, Newark, Ohio, 1 98 1 , American Academy o( Osteopathy. 23. Kalyan�Raman UP and mhers: Muscle pathology in pri� mary fibromyalgia syndrome: a light microscopic, histo� chemical and ultrastructural scudy, } Rheuma[01 2 :80B, 1984 24. Kanab R, Schaible HG. Schmidt RF: AC[iv3tion of fine anicular afferent units by bradykinin, Brain Res 327:8 1 , 22.
1985.
Korr 1M: Propriocepmrs and the behaviour of lesioned scg� ments, Osreopath Ann 2: 1 2, 1974. 26. Korr 1M: Proprioceptors and somatic dysfuncrion,} Am Osreopa,h A.!soc 74:638, 1975. 27. Levin SM: The icosohedron as the three�imensional finitl element in biomechanical supporr. Proceedings of the Society o( General Systems Research on Mental Images. Values and Reality, Philadelphirt, Society of General Sys tems Research, May 1986. 28. Levin, SM: The space truss as a mooel for cervical spine mechanics-a systems science concept. In Paterson JK, Burn L, editors: BClCk pain: an international review, Boston, 1990, Kluwer Academic. 29. Levin SM: The importance of soft tissue for structural sup port of the lxxIy, Spine: Stale of lhe an reviews. 9(2):357, 25.
1995. 30.
31.
Lowe JC: Treatment-resistant myofascial pain syndrome. Ir Hammer WI, editor: Functional sofr tissue examinaLion and treatment by manual methods, Gaithersburg, Md, 1991. Aspen. Melzack R . tillwell OM, Fex EJ: Trigger points and acupuncture points for pain: correlations and implications. Pain 3:3, 1977.
32. 33.
34. 35.
Mense S: Nervous outflow (rom skeleral muscle following chemical noxious stimlJlation , ) PhysioI 267:75, 1977. Paris SV: Manual therJpy: treat function not pain. In Michel TH, editor: Pain, New York, 1985, Churchill Livingstone. Rolf I: Rolfing, [he imegration of human scrucwre, New York, 1977, Harper & Row. Rosomoff HL and others: Physical findings in patients with chronic intractable benign pain of the neck and/or back, Pain 37:279, 1989.
Roth GB: Towards a unified model of musculoskeletal dys function. Presented at Canadian Chiropractic Association �1nnual mccting. June 1995. 37. Ruch TC: Pathophysiology of pain. In Ruch T, Patron HD editors: Physiology and biophysics: the brain and neural fWlc� ,ion, ed 2, Philadelphia, 1979, Saunde". 38. Saal JS and olhers: Biochemical evidence of inflammation iI discogenic lumbar radiculopathy: analysis of phospholipase
36.
The Rationale far Positional Release Therapy Al ac t i v i ty 10 human hcrniareJ Ji<,e, In ProceeJLng� of rhe Imcrnatinn<1i Soclcty for Study of the Lumhar Spine, Kyoto, J apan, 1989. 39. 40.
41.
42. 43.
44
45. 46. 47. 48 49.
Sarno JE, Mmd VI'", hack [XUll , New York, 1982, Berkley. SchmlJ, RF, KnlHkl KD, Schomberg ED, Dcr Eonfu" Kleon Kahhriger Muskelaffcrenten fluf den Mu�keltonus. In Bauer HJ anJ ", her" Therapoe der S"'�IIk, 1 98 1 , Veri,lg fur .nge wilnJte WI:>.!!Cn::.chafren. Munchen. ScuJd!. RA, Ewart NK, Tra�hel L The (reJrtnem of myo(iThClal trigger points with hellUm�neon and gallium. arsenide laser: a blmJcd, crossover trial, Pam 5(suppl):768, 1990 (a\Y.,tmct). Smith FF: Inner hridges: a guide w ('nerg)' mOl'emenl and body srructllTt.'. Adant!, .. 1986, Hunlratry, vol 5, New York, 1 983. Raven Press.
50.
51.
52.
53.
54. 55.
56.
57.
58.
CIiAPTER 2
17
Wall PD: Physlolo�lCal mechanisms mvolved In the pro duction and relief of pam. In Bonica J, Procacci P, Pagm CA. editors: Recent admnces in pam� pcuhophysiologrcal and clonical aspects, SpnngflclJ, III, 1974, Charb C TI,0m. Wang N . Butler JP, Imgber DE: Mechanotransduction across the cell surface and through the cytOskeleton, SCience 260, 1 1 24, 1993. Weinstein IN: A natomy and neurophYSiologic mecho.lOl!)ms of spinal pam. In Frymoyer JW, editor: The adult sl>me: prin, ciples and practice, New York, 1 99 1 , Raven Prcs�. Welsclf"h 5, Manual rherapy for the ormol>ltis, Am J Med 8U, 1 986. Wolfe F: FibroSitis, flbromyalgla and mll"Culoskeleral dis ease: the currenr status of the fibro:,tt1s syndrome, Arch Ph)s
Med Rehab 69'\27, 1 988. Wolfe F and others: The fibromyalgm and myofascial paUl syndromes: a preliminary study of tender POUlt'> and tngger POUlrs in persons wilh fibromyalgia, myofascial p. u n syn, d rome and 110 d isease, ) Rheuma,oI 1 9(6),944, 1 992. Wolfe F and others: Cnteria for fibromyalglth acute and chronic parients. With
ease. The therapISt should feel the tissues becoming relaxed.
chronic patients, there are w;ually several aretlS of long�
As long as these gUideltnes are followed, the nsk of harm to
standing dysfunction. Positional release therapy by Itself or
the patient will be mmimized.
in conjunction With other manual therapies can he used [0 reduce spasm, jOint hypomobility, and fascial rension. This
, WHICH CONDITIONS RESPOND BEST TO POSITIONAL RElEASE THE RAPY?
can result In improved postural alignment anu an Increase
As mentIOned earlier, PRT treats protective muscle spasm,
pain. This enables the patient to move much more easily
in functional mobility and flexibIlity In the spine, nbs, pelvis, and penpheral jomts. There is usually a decrease
10
fascial tension, and JOtnt hypomobility, which are usually the
and comfortably. At this point, mobility and Strength
result of a physical tnJury. Therefore any patient who has a
ening exercises can be adJed to further facilitatc changc
distmct, phYSical mechanism of tnJury wtll respond favorably
and to progress the patient to the next phase. This phase
to PRT. These mclude injuries resultmg from falls; improper
prepares the patient's boJy for movement.
lifting;
throwing; motor vehicle accidents; sudden, unex�
Phase Ill. Phase III deals with the restoration of hmc
peeted movements; and sports. The degree to which the
tionaI movement. Once the pauent has overcome (he
patient responds depends on the degree of dysfunction that
acute and srnlctural phase, he should be moving more
preceded the acute IIlJury.
easily with less dIscomfort and be ready to progress to a
Those patients whose pain commenced Insidiously with
more dynamic movement program. This Includes cardio�
no obvious immediate mechanism of mjury but who have a
vascular fitness (aerobics), strengthening (weIght lifting),
hIStory of trauma also tend to respond well to PRT. In these
and a continuation of flexibility and mobility exercises
Ca5C>, the pain may be the result of surpassing a physiologic
from phase II. The patient at this stage should not be ex
adaptive range. So-called repemlve strain injunes (RSls) may
penencing any sharp pain, although Jull pam may occur
result from excessIve challenge to the acccumulated muscular
with the healing process. The patient's range of motion
guarding, fascial tension, anti/or Jomt restrictions. Treatment
should be relatlvely pain free. The focus of therapy is on
directed to these background dysfunctions may allow for res
improving functional movement, strengthening muscles
olution of these rypes of conditions. Those patients who have
for structural support, and improving cardiovascular fitness.
had acute or chroniC pam that arose insidiously with no clear
Phase IV. Phase IV deals WIth nonnalozatlon of lIfe activ
mechanism of injury or history of trauma tend not to respond
Ities. It takes mto consideration the patient's lifestyle and
as well. Their dysfunctIons tend to be related to stress, visceral
goals. Is the patient able to continue with hiS work, actIv�
dysfunction, pathology (e.g., infections, tumours), or surgical
ities of daily living, and sports or recreational activities?
Intervention. Initial evaluation of the patient and subjective
Does he need retraining, lifesryle modification, or addI
findtng> should help identify these red flags. An appropriate
tional therapy? Appropriate refet evaluate for dys·
tiona1 release therapy has been found to benefit a WIde
functions In the patient's pelvis, sacrum, spine, and other
assortment of patients. Positional release therapy is pri�
sites and provide appropriate treatment. Often, this is
marily used
enough to realign the patient's body, decrease the pain, and
acute and Structural phases. It mu't be understood that PRT
III
the first two phases of rehabilitation, the
reJuce the excessive pressure or discomfon that the patient
does not change pathologic or surgical conditions. The
is experienCing. If pain or discomfort prevents these
therapist is not treating a "diagnosis." He is treating a
patients from exercising or walking, PRT can be used in
human being WIth dysfunctions. The alln of PRT is to
conjunction With other techniques such as mat exerCises,
remove restrictive barriers of movement m the body. This LS
and galt and balance training.
accomplished by decreasing protective muscle spasm, fascial tension, joint hypomobtlity,
NEUROLOGIC PATIENTS POSItional release therapy has been used successfully along with craniosacral therapy, muscle energy, and myofascial
pain,
and swelling and
increasing circulation and strength. As a result the patient begins to move more easily, with less pain and discomfort. he can then be progressed to phases III and IV, the well. ness and work reconditioning phases of rehabilitation.
Therapeutic Decisions
References I. 2.
l 4. 5.
6. 7.
Anderson DL: Muscle pain relief in 90 seconds: {he fold and hold method, Minnearoli�. 1995, Chronimed. Barnes J: Myofrucial release: the search JOT excellence, 1990, self-published.
Brown CYI/: The narural hl�tor'i of thorncic uisc degeneration, S()ine, (suppl) June 1992. O'Ambrogio K: StTain/colinrermam (course syllabus), Palm Beach Gardens. 1992, UpleJger In!olitutc. Gelb H: Killing pam WIthoUt presrnpuon, New York. 1980, Harper & Row. Jones LH: Strain and COltntmrrain, Newark. Ohio, 1981, American Academy of o..rcopadl)" levin SM: TIle !cosohedron llS the thrcc-dimcnsion;li finile clemcOi in hiomechanical support. Proceedings of the St.)Cicty
CHAPTER 3
zs
of Genern! Systems Research on Mcmal lma�cs, Valves and Reality, Philadelphia, Society o(Gcneral System.') RCSI..>arch, May 1986. 8.
Rosomoff HL and others: Physical findings In p3Ucnts with chronic Intractable benign pain of the nl.'1:k and/or hack. Pam,
9.
Saunders HO; Eva/Italian, {rcatment and prevention of musculoslwlawl disorders, Mmneapolis, 1989, Viki ng Press. Smith FF: Inll�>f bridge.s-a guUk 10 energy mOt-'t!meflf and body mucwre, Atlanta. 1986. Humanics New Age. UpleJgcr JE: CrlllniosacraI lherapy, Seattle, 1983,�tli1nd Pr�...... Weisclfish S: Manual therapy far the arcJwpedic and flt?urofogic patient emphasj�mg main and cOImlmrrain techniqcle. Harrfon.l. Conn, 1993, Regional Physical Thcmpy, self-published. Weis elfish S; Personal communication, 1995.
370279,1989.
10. 11. 12.
13.
4 C linical Principles What Is the Clinical Significance 28
of the Tender Point ?
28
Where Are the Tender Points?
What Is the Comfort Zone?
29
of Comfort
Points Be Palpated during the Assessment ?
Graded?
30
How Long Is the Position of
28
Comfort Maintained ?
How Is the Severity of Tenderness
30
The Immediate Posttreatment
28
Response
What Happens If the Patient Is
31
Frequency, Duration, and
28
Scheduling of Treatment
Preparing a Positional Release Therapy Treatment Plan
29
Achieving the Optimal Position
How Hard Should Tender
Unable to Communicate?
General Principles of Treatment
32
Summary
29
31
This chapter outlines the clinical significance of the tender
For example, in Fig. 4, I a patient develops symptoms in
point (TP), identifies where to find TPs, and explains how
his right knee as a result of running. The patient has a
ro grade the severity of their tenderness. It explains how to
hypomobile right 5,1 joint that is causing excessive prona,
prioritize these tcnder points in order [Q prepare a treatment
tion in the right foot and ankle. If there is prolonged
plan and explains the general rules and principles to follow
pronation during toe off this will result in internal rotation
when performing positional release therapy ( PRT). The fre
of the tibia and external rotation of the femur, causing a
quency, duration, and scheduling of trearmenrs are dis#
torque through the knee Over time this can lead to the
cussed. It is important to understand the general principles
development of symptoms in the right knee. If one were
so
that the treatment sessions will be as efficient as possible.
to treat only the symptoms the problem would persist.
Before beginning treatment, it is important to undcf#
Trearing globally first (Le., the hypmobile right 5-1 joint)
global and local treatment. The
would reduce the torque on the knee and reduce the
stand the difference between
scanning evaluation (SE) will reveal the most clinically sig·
chance of reoccurrence. After trearing the global dysfunc,
nificant lesions. There may be several significant lesions as
tion, the therapist may elect to treat the knee locally
the result of successive injuries, creating a layering effect of
for symptomatic relief.
the dysfunction pattem. This pattem of interrelated lesions is referred to as the global dysfunction.
I AGGRAVATING FACTORS I
Given the presence of several possible significant lesions within the global dysfunction, the practitioner must never, theless find a place to begin therapy. By comparing these lesions in a sequential manner, the practitioner will be able to determme the one or two dominant lesions, each of which is represented by a dominant tender point (DTP). The primary aim of therapy is to treat the global dysfunc tion via the DTPs because this pattern represents the source of the patient's symptoms.
ICAusel (e.g.. S-I hypomobility) Fig. 4·1
""r""
.
" �I
(e.g.. Knee pain and swelling)
Global
tlerSlloS
local treatment. 27
CHArTER 4
28
Clinical Priniciples
, WHAT Is THE CLIN ICAL SIGNIF ICANCE OF THE TENDER POINT?
•
-
A lender point may be defined as a remiC, tender, edema� mCll[S, fasc ia, or bone. I t can measure I
elll
�
acro&> or less,
Tension IS abo felt In the tissues surrounding the [cnJer#
Extremely sensitive
e Very sensitive
tOllS region that is located Jeep in muscles, tendons, "ga� With the most acute pOint being about 3 !TIm in diameter.
-
o
Fig. 4-2
-
-
Moderately sensitive No tenderness
System used [0 grade the �el't"TU:'l of lender POUlts.
ness. The tenLier poil)[ is usually four times as sensitive as normal tissue. S As mentioned
III
Chapters I and 2, the
tender pOints associated with PRT share common charac# tcrhrics and locations with trigger poinrs,R neurolympharic POIlHS, J neurovascular pOints, U and acupuncture (Ah Shi POints) · Most people feel that the tenJer point itself IS the
, H ow Is THE SEVE RITY OF TENDERNESS G RADED?
dysfunction. l lowever, it is only an outward manifestation
When evaluating the body fot tender pomb, a grtluing
of the reaction of the tisslies (() an underlying lesion.
:'::Iystem is necessary In order to measure the seventy of each
Patient!) orten find it IIHeresnng to learn that there I::' ten� ucrne:,::,
In i.l
body region thac is nO( obviously paln(ul for
them. They often have no palpable renJernes!'! in rhe area of pam.
point, In thb text, four clrcle� with various amounts of shading as shown
111
Fig. 4�2 are u"ied to graue the seventy
of the tender points. When palpating a patient who hl.ls an extremely sensl� [lve tender POll1t, there IS
�l
Visual Jump sign, and the
, WHERE ARE THE TENDER POINTS?
patient will express extreme sen�ulvity to touch. ThiS point
Tender poims are found throughout the body, anteriorly,
is shaJed (e). If the point is very tenJer hut there IS no Jump
is labeled extremely seruirit'e, and
111
the SE the entire circle
posteriorly, meJlally, and laterally. A diagram of these
SIgn, the point is IabeleJ very serulli.'e and only the top half
tender points i!'i ::,hown in the Appendix. As illustrated,
of the clTcle is fdled in (e). The pattent srates that the pOint
thc:,c lcnucr point!'i arc founu on muscle origin!'! or in5cr�
is very tenuer but does not flinch or jump away when TP
tions, within the muscle belly, over the ligaments, tendons,
is wuched.
fascia, and bone.
, H ow H ARD SHOULD TENDER POINTS B E PALPATED DURING T H E ASSESSME NT? When documentlllg the tender points, the tissue should
If the patient notices some tenderness of the point but there is no jump sign, it is labeled moderme anu only the bonom half of [he mcle IS (tIleJ
In
( � ). If there
IS no tenderness at all, the mcle " left hlank ( 0 ). The Scannll1g Evaluation
Rccordmg Sheer
I�
�hown
m
the AppenJix.
not be pressed so hard that tenderness on all the POllltS IS elicited. Likewise, If the touch IS toO light tender points may he misseJ. There is no suhstitute for clinical experi� ence and objective trial and error. We recommend that the
' W HAT HAPPENS IF THE PATIENT Is U NABLE TO COMMUNICATE?
practitioner find one tender point on the patient and then
The mabillty to directly communicate the severity of ten
uetermine how hnle pressure is required ro elicit the Jllmp
derness is a (ac£Or With certam neurologic patients and
siKn. A Jump sign is characterized by certain responses,
infmus, among others. Occasionally a Jump sign mtly he
such �lS a sudden Jerking motion, grabblllg of the therapist\
detected with palpation. If nm, other cues must be used.
hanu, a facial grimace, or the expression of a vocal exple�
Posture, range of motion, and tenSIOn In the muscle must he
tive. Through practice, the precise degree of pressure will
evaluMed and used as " gUIde. Wel'ellish has developeJ a
be learned. The depth of the ti"ue bemg palpated must
chart ro evaluate movement anu po�turtll restriclions assn�
also he considercJ. Deeper tissue requires more pressure
ciateu with tender point!'! to as.''i[st thempists treating these
than "iuperficial tissue, but It must be done gently and with
types of pattent>. (Sec p. 243
finesse. It IS Important to he firm when palpating, but
example of the postural pmhokineslologic l11odel'CI for
tI��ue mu�t he entered gently, and only necessary pre:,sure
determination of treatment.) For example, If a patient has a
III
the AppenJIX for an
mu�r he used to palpate through the layers of tissue. The
TIght protracted shoulJer, she Intght be able to horizontally
patient being evaluated should be taken into account.
adduct WIth ease hut finJ Jifficulty with horizontal abduc
Bahle"
tion. TenSion may abo be founu on palpation o( the right
chddren, athletes, anJ elJerly patients may
respond differently to touch. Patients' belief systems, how
pectoralis minor. In (hi:, Situation, hypertonicity of the right
much pam they are m, sI.... '{Itlln:t,)
An important point to note IS that as the patient is being placeJ IOtO the POe he sholllJ he pain free. If any palO " experienced while the patient is being JX1sItioned, it is not the correct position for him. For example, although an anterior tender point may Improve by flexing the patient, a posterior tender point may be stressed, which is morc sig nificant, thus reqUIring primary treatment. A thorough evaluation before treatment wdl reJuce the hkchhooJ of this occurring. Discomfort or other sen:;attons ariSing after
the left of the CZ on the diagram, into extension, will
the POC has been achieveJ (generally after 30 to 60 sec
induce increased tenderness and tension in the tissues. With
onds) are usually a parr of the normal release process and
movement further to the right of the comfort zone, into
tend to subside after another I to 3 minutes. It has been
flexion, an Increase In tenderness and tension in the tissues
found that having the patient take a deep breath in anu out
will agam he encoumcreJ. In the latter case, the response of
releases tension in the affecteu tissues. The use of either trac
the (i!)Sues may he the result of engaging the antagonist (for
tion or compression In small amounts may also help with the
example, the triceps), placing It IOto relative stretch and
complete resolution of the tender JX1int. Once the j:X)sltton
thus creatlllg an IIlcrease in proprioceptive stimulation that
is close to the comfort mne, It is important to make the
woulJ then fcoJ back to the agonist (hicep.) '
movements as small as IXlsslble to fine-tunc rhc posi{Jolllng.
' ACHIEVING THE O PTIMAL POSITION OF COMFORT Achieving the optimal POC IS rhe ultimate goal of trear�
, H ow LONG Is THE POSITION OF COMFORT MAINTAINED?
mcn[ anJ the one that requires the greatest uegrce of e1in,
Once the patient IS i n a poSition of comfort, the difficult
ical finesse. ThiS will uctermmc rhe ultimate success of the
phase of the treatment is over. Now It is a walttng game.
therapeutic intervention. The comfort zone is specific and
According to Jones, 90 seconds is sufficient for release of
is uifferent for each of the treatment I�)sitions. As the pTac,
tension In the muscle tissue, and this has been backed up by
ririoncr treat.s [he panel)( amJ 3ncmprs co £inJ rhe comfon zone, the lISC of fine movements will he necessary as the CZ
and D'Ambrogio, there are two phases to the release of the
30 years of chmcal experience.' According to Weiselfish 111
is approached, In order [0 avoid missing the small range of
tender points. The first phase is a length-tension changc
motion In which It appear.;. The signals that tn<.i1carc that the optimal CZ has been attamed mcluue a dramatic
the muscle tissue It�lf, which takes approxl1ll<1tely 90 sec onds for routine orthopedic paticnts. Weiselfi�h has found
reuucrinn in tenucrncss anu a Significant, palpable soft,
that the change in the length-tenSion relationship with the
cnmg of the tissues in the area of the tender point. A posi,
muscle Will take approximately J minutes with neurologic patients '" Whde in the POC the patient may be surprISed
tion will be reached at which there is no tenderness and the tissue IS completely softened around the palpating
that the point is no longer tenJer anJ will frequently a.k If
finger. The response of the tender point can vary from
the therapist is still on the same I'omt. The seconJ phase of
patient to patient. Some patients have easily ueteeted
treatmcnt is a fascial release component and may take any
comfort zones; in others the response will be mOfe difficult
where from 5 to 20 minutes to resolve. Times vary from
to (l')cermin. When tT)"lI1g to shut off a tender point, the
patient to patient depending on the dysfunction.
key is perseverance. It IS Impormnt to remember that it IS essential, while moving the patient's htxJy Into the treatment pOSition, [0
Therefore in answering the lIlitial question, "How long do we hold a patient
III
the position of comforc?" the answer
" "The patient's hoJy will tell you." This approach to [X>si-
CliniC1l1 Principles
ClIAPTER 4
31
tiona I release was referred to by such pioneers as Hoover as
I t is extremely important to explain to all patients that
early as the 1 940,. (See Chapter I . ) While the patient is in
there may be some increased soreness. It may be explained
the comfort zone, the tissues are being palpated for a release
as a natural part of the body's healing process and the soft
phenomenon.7.? The release phenomenon, which can be felt by both the patient and the therapist, signifies a normaliza
warned of the possibility of soreness, confidence in the ther�
tion of the tissues. The therapist monitors for relaxation
apist may be diminished.
tissue reorganization taking place. If the patient is not
and softening in the tissues. pulsation. vibration, heat, and changes in perspiration. Changes in breathing rhythm, heart rate, and eye motor activit), may also be detected. These responses occur during the treatment, and once these
, F REQUENCY, D U RATION, AND SCHEDULING Of TREATMENT
changes cease the treatment is over and the patient often
It i s important t o b e thorough o n the initial evaluation
experiences a deep sense of relaxation. The therapist can
because this will save much time and frustration later on. If
help the patient feel these sensations by identifying them as
the patient has several areas of dysfunction, that is, has had
they occur. The patient may also experience some achiness,
surgeries, fractures, mOtor vehicle accidents, or pain that is
paresthesia. Reassure the patient that these sensa�
chronic in nature, an evaluation without treatment is rec·
{ions are transitory, tending to dissipate within a minute or
ommended during the first visit. This is both to save time
two, and are usually followed by a further release of tension.
and to minimize sensory overload because the examination
pain,
or
Each patient will be different, and the patient's body will
itself may temporarily activate several of the dysfunctions.
dictate how long the patient needs to be in the JX,lsition of
After an evaluation, a treatment plan is prepared for future
comfort. While the patient is in the POC, it is up [Q the
sessions. If the patient does not possess multiple dysfunc�
practitioner to monitor for the release phenomenon. If
tions (for example, if the injury is acute or involves a spe�
there is pain while getting into the position of comfort, that
cific mechanism of injury), treatment may begin immedi�
is a contraindication for that position.
atcly after evaluation. It is recommended that a thorough
HHE IMMEDIATE POSTTREATME NT RESPONSE
on the initial visit.
It is important [Q mention that once the point has been
patient's body, and the aim is to treat dysfunction. Pain is
PRT scanning evaluation of the patient's body be performed Remember, tender points represent dysfunctions in the
fully released the body must return to a neutral position
the end result of dysfunction. If only the painful areas are
slowly especially for the first 1 5' of motion. It is hypothe
examined, the treatment will not be as effe ctive or efficient.
sized that the ballistic proprioceptors will be reengaged by
The goal is not to treat all the patient's tender points bur to
returning [Q neutral too quickly. This may result in the
use the general rules and principles to help find the most
reestablishment of the protective muscle spasm. After
dominant point in the patient's body, treat it, and then
returning to neutral, the tender point must be rechecked.
move on to the next most dominant point.
DUring this entire process, the therapist's finger should
Positional release therapy treatment differs from that
remain over the tender point. This point should be either
described by Jones and other practitioners. With conven
fully eliminated or at least 70% improved.' There should
tional counterstrain and other forms of positional release, a
also be immediate changes in the patient's pain level,
patient with shoulder pain is treated using the same general
posture, muscle tension, joint mobility, and biomechan�
rules and principles. Therapy is mainly localized to that
ical movement. After treating this point, the other signif�
upper quadrant, and six to eight points might be treated for
icant points noted in the screening evaluation should be
a total of 90 seconds each. With global PRT sessions, only
rechecked. Some of the other points will be found to
one to three points are usually treated. The goal is to spend
have been completely released or significantly reduced
more time on evaluation and less time on treatment. If the
in severity. Then, using the general rules and principles,
most dominant point of the body is located and treated, a
the practitioner should decide which is the next most
majority of the other tender points (which may be adapta
severe point to be treated, and then the whole process
tions to the dominant lesion) will often be eliminated. The
is repeated.
dominant point may be located anywhere in the body, often
After the treatment, the patient will feel a sense of relax�
remote from the area of symptoms. To achieve maximal
at ion in that area. She will often find that she is able to
benefit, both a muscular release and a fascial release should
move more easily and with less discomfort. In the next 24 to 48 hours, clinical experience has
be obtained. This can take from 5 to 1 0 minutes and occa� sionally up to 20 minutes in the position of comfort. Each
demonstrated that approximately 40% of patients feel some
patient is different, and the release phenomenon mUSt be
increased soreness. This soreness may be found not only in
felt. By persisting until a complete release is achieved, much
the region treated but also in areas remote from the treat�
time and needless treatment will be saved because many of
ment area. For example, if the sacmm was treated, the
the secondary tender points will be eliminated. The patient
patient might experience some pain in his neck or shoulder
may not come in for another manual therapy session for
for the next few days.
another week or longer. During that time. the patient may
CIIAPTER 4
32
Clinical Prinicip/e,
be seen twO to three times per week for local PRT sessions,
continues to monitor the tender POInt the entire
which are held for 90 seconds, exercise therapy, the appli
time. It should be monitored for a decrease In tension
cation of modalities, correctIOn of body mechanics,
and tenderness. ThIS feedback IS necessary III orJer to
ergonomic education, and orher forms of supportive care.
assist in the fine tunmg required to locate the precise
n,. goal with PRT is to help decrease pain, muscular hyper
comfort zone.
tolllciry, fascial tension, and jomt hypomobility and to
4. Maintain contact on the tender point while in the
encourage the parienr to take an active role in recovery.
position of comfort. The tender point should be
Clinically it has been found that it is better to perform
monitored thmughout the treatment. Attention In
manual therapy once a week and use the other Jays for exer
should be given to the changes takmg place
cise, moJaliries, and education, This allows the patient's
area of the TP, such as pulsation, heat release, vibra�
the
body to adapt to the changes made during the manual
tion, unwinding, and the release m rhe patient's body
therapy session. It has been found c1mically that approxi
that indicates when treatment is lwer. Once the treat�
mately 40% of patient, wlil experience a degree of soreness
ment is over, contact should be maintained [0 be cer�
for a few days following the treatment. For thiS reason,
tam that the same spot that was evaluateJ before
modality and movement therapies may he beneficial during
treatment is being reevaluated. When patient!) notice
the remainder of the week follOWing mitial treatment. (This
that the point IS no longer tender, they will often a�k,
usually only occurs after the first onc or two visits.) When
"Are you sure you are on the same poind"
the patient returns for the next manual therapy session In
5. Hold the position of comfort until a complete
one week to ten days, a re-evaluation should be performed
release is felt. The position of comfort is held as long
USing the general rules anu principles to find the next most
as necessary to obtain a complete release in the body
dominant lesion and treat it if necessary. In the Scanning Evaluation Recordmg Sheet (see
( i .e., a sense of relaxation in the muscle, a decrease in the heat emitted, an elimination of achiness, cessa�
p. 232) there are five circles, which represent five treatment
tion of pulsation, vihratlon, or unwinding taking
days. The�e five circles represent each of the manual
place in the tissue, and a relaxation ofthc hreathing).
therapy days. If PRT has not made any significant changes
If the patient is removed from the position of comfort
in three to five visits, there may be another system involved
too S<.)()n, the results will be more short term and the
or It Inay he a red flag for a fracture, dislocation, tom tissue,
tender POint may reappear and reqUire further treat�
infection, malignancy, or emotional stress. The patient
mcnt. It is llTIportant to remember that when treating
should then be reexamined. It is important to understand
globally, the POe i, usually held longer (e.g., 5 · 10
that PRT is not a panacea.
min) and will have a more profound effect on the body. Local treatments are u,ually helJ for approxI
SUMMARY There arc nine Important points to remember when per� formmg PRT: I . Scan the body, grade the severity of the tender
points, and record the findings. 2. Follow the general rules. It " Important that the
mately 90 seconds. 6. Return to neutral slowl y It is Important to memion .
that once a tender point has been treated �ucces.!)fully, the patient's body muM be returned 1O neutral slowly. The first 1 5° is the most important range. If the patient is taken out of the comfort :onc roo quickly, the ballistic propnoceptors may then be reengaged
therapist treat the most severe tender pOInt first
and the protective muscle spasm can return. These
regardless of where the pain IS. Remember that the
tissues are often connected to a faci htated segment,
tender pomt represents the patienc's dysfunction. The
which renders them more vulnerahle to reinjury and
aim is to treat that dysfunction. Pain is a result of dys�
to the reestablishment of mflammation and spasm.
function. Once the tender pomt is treated and move�
(See Chapter 2.) 7. Recheck the tender point and use other reality
ment " re>tored, the pam will eventually subside. The second most Ilnportant rule is to treat proximal to
checks after treatment. After succe�sfully treating a
distal. If there are two equal tender points, treat prox;
tender point, it IS unportant for the thcrapiM and the
Imally before distally. This often e1unmates most of
patient to note what change.!) have taken place. The
the distal tender points. With several areas of extreme
patient may he eXCited that there is a significant
sensitivity, treat the area with the greatest number of
reduction
TP's first. Lastly treat the tender point in the middle
not be enough. It is important to have several reality
of a row of equally tender pomts. By following these
checks. A reality check is finding a pOSItiOn, move
simple niles, the efficiency and effectiveness of treat�
ment, or specific jOll"lt, fascial, or muscle evaluation
ment will be enhanced.
that IS objective, can be measured, and WIll reproduce
3 . Monitor the tender point while finding the position
III
tenderness. However, this by itself may
the patient's pain or complalllt. For example, a low
of comfort. It is important that while placing the
back patient might have limitation
patient into the poSition of comfort, the therapist
left side hending In the quarter range, which might
III
extension and
Clinical Principles
CHAPTER 4
33
increase the pain to 9 out of 10. A knee patient may
9. Treat only once per week, and allow the body to
have limitation in knee flexion to approximately 30°
adapt to the treatment. Use PRT to remove barriers
with pain at 8 out of 10. A shoulder patient may have
to movement, which w i l l allow the patient to
limitations of abduction to 60° and external rotation
progress with activities of daily living and a func�
(Q 30° with
tiona I rehabilitation program.
9 out of 1 0 pain rating on bmh at the end
of rhe available range. Afrer treating with PRT, it is important (Q recheck these movements (Q see if the patient is functionally moving better with less dis�
References I.
comfort. If these changes are not demonstrable, the treatment may nO( have addressed a primary lesion. These tests are an important source of feedback and can help the practitioner determine the future direc� tion of the tre3nnent program. They are also useful in encouraging the patient and engaging her coopera� tion in the recovery process.
8. Warn the patient of possible reactions and to avoid strenuous activity after treatment. The patient who is forewarned of the possible reactions to treatment will not only cooperate with the therapy program, but will also gain an appreciation for the power of this apparently simple and painless technique. The avoid ance of Strenuous activity for 24 (Q 48 hours after treatment will help ensure a more efficient recovery and reduce unnecessary discomfort. Failure to warn the patient may result in a loss of confidence in and cooperation with the rehabilitation program.
Bennett R: In Chapman's Reflexes. In Martin R, ediror:
Dynamics
of c:oTTccLion of abnormal function, Sierre Madre,Calif, 1977, self·
2. J. 4. 5.
6. 7. 8. 9. 10.
published. Chaitow L: The acupuncwre eTeatmenr of pain . Wellingboroll�h, 1976. Thorsons. Chapman F. Owens C: fnLf'OducLion to and endocnne mrerprewuon of Chapman's reflexes. self·publtshcd. O'Ambroglo K: S(T(un/counrersLTam (course syllabus), Palm Beach Gardens, 1992, Upledger Institute. Jones LH: SeTaln and coumt!wrain, Newark. Ohio, 1981, American Academy of Osreopathy. O'Connor J. Bevsky 0: AcupuncLure: a com/1l'ehensit1e rext. Seattle, 1988, Easdand Press. Smith FF: fnner bridges-a guide to energy move-men! and bod] struc· fIIre, A tlanta , 1986, Humanics New Age.
Travell JG, Simons lXi: M]ofascial pain and d]sfunction: w. trigger /X>IIlL manual, Baltimore. 1983, Williams & Wilkms.
Upledger JE: CT"allio.sacrai Ute:ralry , Seattle, 1983, Easlianu Press. Weiselftsh 5: Manual therapy for Uu.> orLhopedic and JU!ltroLugic patient emphasivng SeTaln and cOllllterseTain rechniqlU? Hartford, Conn, 1993. Regional Physical Therapy, self·published.
5 Positional Release Therapy Scanning Evaluation Purpose of the Scanning
35
Evaluation How to Prepare a Treatment Plan
37
Case Study I
37
Case Study 2
38
Summary
38
The Scanning Evaluation (SE) outlined in this chapter
tender point (DTP), and the treatment plan can then
was designed by one of us (D'Ambrogio). The SE record
be implemented.
ing sheet and tender point body chartS in the Appendix
The SE should be considered an assessment tool [0 work
are very simple co use and are cross�refcrenced with
in conjunction with the normal battery of orthopedic and
6, the treatment section of this book. These
ncurologic rests (range of motion, strength testing. nerve
can be photocopied and used to assist in the evaluation
conduction, pain questionnaires, etc.). Because this book
of patients.
deals mainly with positional release therapy (PRT), these
WURPOIE OF THE SCANNING EVALUATION
already adequately covered in sevcral other books.
The purpose of the SE is to evaluate the entire body for
PRT techniques, treatments will be much morc effective
tender points (TPs) and to prioritize rhem according to
and efficient. Several patients may have the same com�
their severity. In this context the TPs represent muscu�
plaint (e.g., knee pain, shoulder pain, or low back pain) but
loskelctal dysfunction. As in most other techniques, treat
the source of the condition, as revealed by the SE, may be
Chapter
other evaluation methods will not be reviewed. They are If time is taken [0 understand and implement the SE and
ment is the easy part. The difficult question is, "Where
different for each. No twO patients are the same, no matter
does one begin treating?" The SE, if used properly, will pro
how similar their presentations may be. The PRT scanning
vide a clear, visual representation of the location of the
evaluation will precisely reveal the source of rhe dysfunc�
dysfunctions that are contributing to the sympmffiS. I n
tion through to DTP. By identifying the location of the key
Chapter 4, the term
render point was defined, and a n expla
dysfunctions (which may have different locations than the
nation was given of where and how [0 find these points.
perceived pain) and treating restrictive muscular and fascial
The prioritization of the TPs using the general rules and
barriers, the pain will begin to subside. As we continue to
principlcs was also discussed. By recording the severity of
use the SE, we may begin [0 reexamine our thoughts about
rhe tender points in the SE, the practitioner will have crc�
the body, where pain originates, and how dysfunction and
ated an organized chart of the most significant tender
pain interact. Let us now look at the SE recording sheet in
points,
categorized
detail. If you turn to the Appendix you will see a full view
according to their clinical significance. This information
of the SE. You can refer back to the SE as we break it down
will allow the practitioner [0 dctermine the dominant
into its components and explain step by step the nuts and
which can
then
be specifically
35
36
Positional Release Therapy Scanning E.aluation
HAPTER 5
bolts of how to record tender points, prioritize your findings using the general rules, and prepare a treatment plan.
Positional Release Therapy Scanning Evaluation Pauem's Name Da!es '
_______
Practitioner
____ _
_ 2_3_4_5 _
If an extremely sensitive tender point is found equally on both points, fill in the circle and do not put any lines under neath (e). If an extremely sensitive tender point is found on both sides, but the right side appears more tender, draw slashing lines to the left and the right and place a crossing line through the one on the right. If the point is extremely
o Extremely senSitive 0 very 0 moderate 0 no tenderness \ nghr I left + most sensuive 0 rrcatmem
sensitive on the right but only moderately or very sensitive on the left, it is recorded in the same manner.
At the [OP of the scanning evaluation, fill in the patient's and practitioner's name. We have included five treatment dates. These five treatment dates correspond [0 the five cir·
When a point is treated during a session, place a small dot
cles that you see beside each of the number> and abbrevia
over the filled-in circle (,o). It is important to identify which
tions of the treatment names. For example, no.
40 in Chapter 6, Section IV, Anterior Thoracic Spine, looks like this:
point was treated so that the effects of those treatments can be observed during reevaluation of the patient at subse, quent sessions. Finding and treating the most severe tender
40. AT I
point often results in the elimination of many of the sec
00000
ondary tender points. which may have been adapting around The five circles are used to help us evaluate the extent of the dysfunction for each area of [he body. The circles should be filled in with a pen or pencil appropriately
the primary dysfunction. This procedure is what affords PRT such a high degree of efficiency and effectiveness. There are approximately
2 1 0 points, and each point has
a number, an abbreviation, and five circles to the right.
as follows:
During the initial evaluation, palpate the patient's body for e ·Vcry
e.Exuemely sensitive
Q·Modernte
O-No tenderness
tender points and record them on the recording sheet. Use the key given at the beginning of this section to grade the
The key is lIsed to record the severity of the tender
tender poims. On the initial evaluation, fill in only the first
points. If a point is palpated and there is an observable
circle of each number. If there is no tenderness, leave the
jump sign
(wherein the patient responds with a jerking
point blank (0). In the example below, it is found that no.
motion, pulling away from the contact, with facial grimace
40, ATI, is the most severe tender point. the recording
or vocal expletive), label that point
would appear as follows:
exrremely sensitive and
fill in the whole circle (e). If the patient feels that the point is very tender but does not have the jump sign, the
IV.
point is .ery ,ender and the top part of the circle is filled in
( e ) . If the patient has no jump sign and feels only a mod
40. AT!
erate amount of tenderness, the point is
41. AT2
moderately semi,
li.e and the bottom part of the circle is filled in ("). If the patient experiences no tenderness whatsoever, the point is left blank (0).
Anterior Thoracic Spine
eoooo
[po 85]
iJ. AT; ecoco
46. AT)00000
SO. ATtOOOOOO
QOOOO
H. ATS00000
47. AT8 QOOOO
SI ATiI 00000
4l. ATJ eooco
45. AT600000
48. AT9
52. ATI200000
Once the therapist has identified the DTP from the
After recording the severity of the tender point by filling
SE using the general rules and principles, [he position of
in the circle, its location is noted. If, for example, a central
treatment should be looked up in Chapter
point is found on the superior aspect of the manubrium and
page reference is provided in the SE recording sheet in
it is extremely tender, the circle for no.
40, ATI, is marked
6. The exact
brackets to the right of the section heading that is cross ref
as follows: e. However, if a tender point is found on either
erenced with Chapter
side of the body (for example, no.
ATI. If you look to [he right of [he heading IV Anterior
170, MK), the following
Thoracic Spine you will see the page reference (p.
keys are used to label it properly:
\ Right
/ Left
+
Most sensitive
6. In this example the DTP is no. 40
0
YOll tum to p.
Treated
85). If 85 you will see an illustration of all the ante,
rior thoracic tender point . If you rum the page over and look up No.
40, which is found on p. 86, you will see:
- A sketch of the involved anatomy with the TP super-
For example:
imposed on it
1 70. MK,
1 70. MK,
This means that the extremely sensitive
- A photograph of the location of the TP
tender point is found on the medial
- A description of how to find the location of the TP
aspect of the lef[ knee.
- A photo of how to perform the treatment
This means that the extremely sensitive
- A description of how to position the patient in the
tender point is found on the medial aspect of the right knee.
treatment
PositiolUll Release Therafry Scanning Evaluation
CHAPTER
37
5
As you can see the SE is very user friendly and will assist
AT4 and ATIO were moderately sensitive. AT7 was treated
you in the planning and implementation of YOUT treatments.
during the first visit. As a result of the treatment, we 3re left
Therefore onc can quickly appreciate the simplicity of
with AT! extremely sensitive and AT7 and AT12 very sen
the scanning evaluation. First u e the Tender Point Body
sitive. AT I was treated during the second visit, and, as a
Chart showing all of the tender points as a guide. Then
result, all the points were resolved.
record the tender points on the SE recording sheet, using
There are a total of five circles, representing five treat�
the keys given on p. 232 to grade the severity. Then use the
ment days. Normally this is sufficient to eliminate all of the
general rules and principles from (Chapter 4) to prioritize
tender points. The scanning evaluation will also help iden#
the tender points. Once the tender points that require treat�
tify any red flags. For example, if a tender point persists in
ment have been located, refer to the page number for the
being extremely sensitive after each visit and PRT does not
6). In the treat#
seem to be shutting off that point, there may be another
ment section, you will find a sketch of that particular part of
point in the body which is also extremely sensitive that
the body, with the dysfunction indicated by name, a descrip
must be treated before this. There may also be a pathologic
tion of the location of the tender point, and the position of
condition or visceral disorder causing this dysfunction. This
corresponding treatment section (Chapter
treatmenc. Any necessary clinical nQ[es are also included. A
is explained in greater detail in Chapter 7, which will iden�
photograph demonstrating the most common position of
tify different treatment strategies.
treatment is also provided to help visualize the correct pro�
If the time is taken to do a full evaluation of the patient
cedure. Therefore the scanning evaluation, when combined
on the first visit, a clear picture will form showing the loc 3 and 7.
was affecting the muscles of his right lower extremity. This can be explained from the facilitated segment model dis� cussed in Chapter
Case Swdy 2
2.
____________ _
Patient: Female in her early rhirries. Diagnosis: Medial collateral ligament strain, second degree, left knee.
Mechanism of injury: One wcek prior, patient fell and twisted her knee whilc skiing.
Weight-bearing status: Weight bearing as rolerarcd with crutches and knee immobilizer.
Range of motion: Extcnsion I 0$, knec flexion 30·. Pain evaluation: Patient is in consmnt pain that varies in �
intensity. Most of the time she feels a lot of soreness and s[iff� ncss, approximately 5/10. It can get as high as 10/10 with sudden movemcnt and movement beyond her available range.
Palpation: Swelling, heat, and rendemess noted on the medial aspect of the knec. On specific PRT evaluation, the dominalu point was found to be the gluteus minimlls, which is
1 cm lateral to d,C anterior inferior iliac spine. This point lics at the origin of thc rectus femoris Illuscle.
Treatment: The gluteus minimus tender point was treated for approximately 6 minures. As a result, knec extension was incrcilsed from �10- to �4· and knee flexion from 30- to 128-. This patient was able to get functional range of morion within the next 3 days and was able to tolerate full weight bearing without crutches or the knee immobilizer. Her therapy lasted anorher 3 weeks because she had some ligamentous damage, which gradually healed.
6 Treatment Procedures I.
UPPER QUADRANT
II.
Cranium
43
Cervical Spine
64
Anterior Cervical Spine Anterior Medial Cervical
LOWER QUADRANT 143
Lumbar Spine, Pelvis, and Hip Anterior Lumbar Spine
144
65
Anterior Pelvis and Hip
150
74
Posterior Lumbar Spine
159
Posterior Pelvis and Hip
166
Posterior Sacrum
174
Lateral First Cervical
75
Posterior Cervical Spine
77
Lower Limb
181
85
Knee
182
Anterior and Medial Ribs
90
Ankle
193
Posterior Thoracic Spine
95
Foot
204
Thoracic Spine and Rib Cage Anterior Thoracic
pine
Posterior Ribs
84
100
Upper Limb
104
Shoulder
105
Elbow
126
Wrist and Hand
/33
Thumb
/38
Fingers
139
This chapter is divkled into twO sections. Section I covers
of the body arc headed by a drawing of the pertinent
the positional release thcrapy (PRT) assessment and treat
anatomy of the area showing the common tender points
ment program for the upper half of the body: the cranium,
associated with that area. These subsections include the
the cervical spine, the thoracic spine and rib cage, and the
anterior cervical spine, the posterior cervical spine, the
upper limb. Section II deals with the same topics for the
anterior thoracic spine, the knee, the shoulder, and
so
on.
11Imb�lr spine, pelvis, hip, sacrum, and lower limb. A scan#
Each treatment is associated with one or morc tender
ning evaluation (SE) for the entire body can be found in
points and is displayed on a single page. The treatment
the Appendix. The SE may be used once the student has
name is given with the appropriate abbreviation and the
mastered PRT for the whole body. In this chapter, separate
area of anatomy considered as being treated by that position
SEs are provided for sections I and II, to allow the begin
of comfort (POe). This page includes a smaller drawing
ning student to be able to concentrate on one section at a
indicating the location of the specific tenuer points under
time or SO a local treatment may be perfonned, (or example.
consideration. A photograph or photographs demonstrate
for an acute injury.
the commonly used techniques, and the text describes the
Each major region of the body is introduced by a discus sion of some of the clinical and functional considerations for the area of the body in queStion. This includes a per
techniques in detail, with variations that may be used in special circumstances or as preference dictates. Note that tender points not directly over the tissue of
spective on pertinent functional anatomy, typical clinical
involvement, which may be considered
manifes[ations. and special treatment considerations.
because they may be somewhat distant from the area of dys
Within each section the reader will find that separate areas
function, are designated with an asterisk
reflex
points
(*). 39
40
CHAPTER 6
Trearmenl Procedures
In the AppendIx. the reader will find an anatomic cross reference that can help detennine which treatment may be most pertinent to a given area of the body. There is also a cross reference of PRT termmology wIth that given by Jones· No text can hope to replace educational workshops. We encourage you [0 pursue the further development of your skills and to experiment with the technique and modify it (() the needs of the presenting condition and to the greatest advantage of your patient.
, DIAGNOSIS AND TREATMENT PROTOCOLS The diagnosis of soft tissue involvement IS based on sev# eral objective and subjective criteria. A careful hiStory, Including a clarification of any trauma or repetitive strain ac[tvincs, is essential. It is important to differenriare 1"101"1# musculoskeletal factors, such as viscerosomatic reflexes, malignancy, infectious processes, and psychologic involve· ment. Postural and structural asymmetry are significant mdicators of mvoluntary antalgic stratcgies (0 reduce irri· tability of involved tissues. In general, an individual will adopt a posture that mmimizes tension or loading of hyper tonic or Inflamed tissue."/) Range-of-mollon (ROM) assess ment wtll heIr confirm and localIZe the Involvement of flexors, extensors, roratofS, latcral flexors, or related liga. ments and fascia.lo Local tissue changes (tension, tex(Ure, temperature, tenderness) and reduced joim play are also nared because these may indicate underlYing dysfunction. I\ The tender point is a discrete. localized. hyperirritable region associated wnh thc dysfunction and is used as a monimr durmg (fearment.ZI It is recommended that the user follow the outlined (featment positions as closely as poSSible because they have been carefully assessed over many years and have been determmed to be efficacious in a large percentage of cases.
Once attempted, the user may then wish to adapt the tech. nique to the needs of the individual if It is found that the prescribed method is less than satisfactory. The scanning evaluation will help the practitioner prioritizc the (feat· ment program.1 We suggest that the practitioner use the fol· lowing protocol for the most efficient use of thIS text: l. Scan the paticm's body for tendcr points and record them appropriately on the scanning evaluation. 2. Determme the most dominant tender pomt (DTP) using the general rules and prinCiples. 3. Look up the appropriate treatment for the DTP. The page reference is provided m the scanning evaluation. 4. Treat accordmg to the deSCription provided 10 the treatment section in Chapter 6. Treatment consists of precise positionmg of the body part or joint in order to maximally relax the involved tis· sues. The descriptions of the poSitions of comfort are pre· sented in their gross form. The ideal position is achieved through the use of micromovemenrs, or fine·tuning.8 This typically reduces the subjective tenderness and objective finnness of the associated tender point. Careful attention to the subtle changes occuring in the area of the tender point is necessary m order to obtam thc opomal release. Once this Ideal position IS achieved. It IS held for a period of no less than 90 seconds. During the pOSItioning. whIch may last for 5 minutes or more, further softening, relaxation, pul. sation, vibration, or unwinding of the tissues is often noted. The position 109 is followed by a passive return of the body part or jOlllt to an anatomically neutral poSition. Reevaluation may then be carried out to confirm the em· cacy of the therapeutic intervention. This approach will suffice for the majority of cases and will provide valuable experience m the development of the �kills necessary to refine this art.
I UPPER PRT
QUADRANT
Upper Quadrant Evaluation Practitioner
Patient's name
•
; Extremely sensitive
\ - Right I.
OM 0CC PSB LAM SH
; Most sensitive
-
No tenderness
0; Treatment
00000 00000 00000 00000 00000
6. 7. B. 9. 10.
DG MPT LPT MAS MAX
NAS SO FR SAG LSB
00000 00000 00000 00000 00000
16. 17. lB. 19.
AT PT TPA TPP
00000 00000 00000 00000 00000
00000 00000 00000
26. AC7 27. ACB 2B. AMC
00000 00000 00000
29. LCI 30. LC 30. LC
00000 00000 00000
00000 00000 00000
37. PC6 3B. PC7 39. PCB
00000 00000 00000
00000 00000 00000
46. AT7 47. ATB 4B. AT9
00000 00000 00000
49. ATlO 50. AT lI 51. AT l2
00000 00000 00000
00000 00000 00000 00000 00000
62. 63. 64. 65. 66.
00000 00000 00000 00000 00000
67. MRB 6B. MR 9 69. MRIO
00000 00000 00000 00000 00000
00000 00000 00000
76. PT7 77. PTB 7B. PT9
00000 00000 00000
79. PT lO BO. PTlI B1. PT l2
00000 00000 00000
00000 00000 00000 00000 00000
II. 12. 13. 14. IS.
00000 00000 00000
23. AC4 24. AC5 25. AC6
-
-
00000 00000 00000
34. PC3 35. PC4 36. PC5
00000 00000 00000
00000 00000 00000
43. AT4 44. AT5 45. AT6
Anterior Ribs. Medial Ribs (pages 90-94)
52. 53. 54. 55. 56. VI.
+
/ - Left
o
AnteriorThoracic Spine (pages 85-89)
40. AT l 41. ATZ 42. AT3 V.
" - Moderately sensitive
Posterior Cervical Spine (pages 77-83)
31. PCI-F 32. PCI-E 33. PC2 IV.
�
Anterior. Medial. Lateral Cervical Spine (pages 65-76)
20. ACI 21. AC2 22. AC3 111.
e Very sensitive
5
4
Cranium (pages 43-63)
I. 2. 3. 4. 5. II.
J
2
Dates
ARI AR2 AR3 AR4 AR5
00000 00000 00000 00000 00000
57. 5B. 59. 60. 61.
AR6 AR7 ARB AR9 ARlO
MR3 MR4 MR5 MR6 MR7
PostenorThoracic Spine (pages 95-99)
70. PTI 71. PT2 72. PT3
00000 00000 00000
73. PT4 74. PT5 75. PT6
41
Vll.
Posterior Ribs (pages 100·103)
82. PRI 83. PR2 84. PR3 Vlli.
Shoulder (pages
94. 95. 96. 97. 98. IX.
TRA SC L AAC SSL BLH
Elbow (pages
114. LEP liS. MEP x.
85. PR4 86. PR5 87. PR6
00000 00000 00000
88. PR7 89. PR8 90. PR9
00000 00000 00000
91. PRIO 92. PRII 93. PRI2
00000 00000 00000
105·125)
00000 00000 00000 00000 00000
99. 100. 101. 102. 103.
SUB SER MHU BSH PMA
00000 00000 00000 00000 00000
104. 105. 106. 107. 108.
PMI LD PAC SSM MSC
00000 00000 00000 00000 00000
109. 110. Ill. 112. 113.
ISS ISM lSI TMA TMI
00000 00000 00000 00000 00000
00000 00000
118. MCD 119. LCD
00000 00000
120. M O L 121. LOL
00000 00000
00000 00000
126. CMI 127. PIN
00000 00000
128. D I N 129. IP
00000 00000
126·132) 00000 00000
Wrist & Hand (pages
122. CFT 123. CET
42
00000 00000 00000
116. RHS 117. RHP
133·137)
00000 00000
124. PWR 125. DWR
C RANIUM , CRANIAL DVSFUNGION It is not within the scope of this text to delineate an exhaus# [lve treatise on the complex functional anammy of the era, mum. TI1.C reader �houkl refer to the resources listed in the Appendix (0 obtain training In thi� important and clini# cally relevant region. It is recommended that an anatomy text and the drawings at the beginning of this section be reviewed In order (0 familiarize oneself with the basic anaromlC relationships. For many practitioners. cranial lesions may present ehal, lenges 111 terms of diagnosis and treatment. Mobility and motihty (self,actuared movement) within the cranium has now been well established, although it is not fully accepted 10 all circles. Sutherland," Upledger," and others have useJ various mcrhoJs of diagnosis and [rcarmenr [Q nor' malize the function of this important area of the body. Cra· nial function may have il significant bearing on the circula· tion of the cerehrospinal fluid (CSF) to the central nervous sy�rem and thu:, on the functioning of the entire nervous system.!l Dysfunctions caused by injuries, including birth trauma and persisting lesions resulting from childhooJ inJUries, .,;� (posterior belly)
¥f----f- Medial
pterygoid
S<' Nasal bone
Temporal bone
=-_- AT
_----,IF--
_ -. -__
OCCipital bone
Zygomatic bone :;;;o���-;f'-1i:.: Maxi la
r1
AT
This tender point is located in the anterior fibers of the temporalis muscle approxi mately 2 em (0.8 in.) posterior and lateral to the orbit of the eye and superior to the zygomatic arch. Pressure is applied medially.
The patient is supine. The therapist is on the side of the tender point and grasps the frontal bone with one hand and applies a force around an AP axis toward the tender point. The heel of the other hand is placed under the zygomatic bone. and pressure is exerted in a cephalad direction.
Treatment Procedures
CHAPTER 6
61
1 7. Posterior Temporalis (PT)
TPA
Parietal bone
AT MAS
-,
,
Occipital bone
Frontal bone Sphenoid bone -¥<{:'�:V Nasal bone ;���-::.-:r�L Zygomatic bone Maxilla ...,
Temporal bone PT
,
�,
1
-?
Mastoid process
- MPT l
Location of Tender Point
•
Position of Treatment
PT
Mandible
This tender point is located in the posterior fibers of the temporalis muscle approxi mately 3 cm ( 1 .2 in.) anterior to the external auditory meatus superior to the zygo matic arch. Pressure is applied medially.
The patient is supine. The therapist is on the side of the tender point. grasps the parietal bone with one hand. and applies a force to rotate the skull around an AP axis toward the tender point. The heel of the other hand is placed under the zygo matic bone. and pressure is applied in a cephalad direction.
Note:
AT and PT are treated using a similar technique.
62
CHAPTER 6
Treatmem Procedures
CRANIUM
1 8. Temporoparietal ( Anterior) (TPA)
Parietal bone
Frontal bone Sphenoid bone
Temporal bone
_ _ .::---
MAS .�!':: - - - DG
OCCipital bone
�;:;;;��-.:/'-1s: Zygomatic bone
(i
Maxil a
-
-
1
location of Tender Point
Position of Treatment
(Unilateral tenderness)
1
Position of Treatment
(Bilateral tenderness)
This tender point is located cephalad to the ear, on or just above the temporopari etal suture. Pressure is applied medially.
The patient lies on the unaffected side with a small roll under the opposite zygo matic area. The therapist sits near the head of the patient, grasps the parietal bone with the fingers, and pulls the parietal bone cephalad and medially away from the tender point side. Alternatively, the therapist may stand and apply the force with the heel of the hand. Counterpressure is applied with the other hand in a medial direc tion on the mastoid process on the same side as the tender paint. The patient is supine with the therapist seated at the head of the table. The therapist grasps the patient's cranium on both sides, just cephalad to the temporoparietal suture on the parietal bones. A medial pressure is applied bilaterally (see bottom right photo on p. 57).
Treaonem PmcedHre.�
CIIAPTER 6
63
1 9. Temporoparietal ( Posterior) (TPP)
TPA PT AT
SH
Location of Tender Point
•
Position of Treatment
(Unilateral tenderness) •
Temporal bone TPP
OCCipital bone
;
<
Frontal bone Sphenoid bone Nasal bone Zygomatic bone Maxil a
MAS ,
•
Parietal bone
Position of Treatment
(Bi lateral tenderness)
, MPT
Mandible
This tender point is located at the junction of the lambdoid the temporoparietal sutures approximately 3 cm ( 1 .2 in.) posterior to the external auditory meatus, in a depression on the skull. Pressure is applied medially.
The patient lies on the unaffected side with a small roll under the opposite zygo matic area. The therapist applies a force superior to the tender point, on the parietal bone, in a cephalad and medial direction in order to rotate the skull away from the tender point side. Counterpressure is applied medially on the ipsilateral mastoid pro cess with the other hand. The patient lies supine with the therapist at the head of the table. The therapist applies bilateral compression with the palms on both sides of the skull posterior to the ears (see bottom right photo on p. 57).
C E RVI C A L S P I N E be traced to dennatomal patterns associated with the nerve
, CERVICAL DYSFUNGION
rOOt distribution of the brachial plexus.
Bipedal posture has afforded human beings numerous evolu, tionary advantages, including an increased range of visual surveillance of the surroundings and an improved ability to manipuitnc the materials in the environment. However, the raised center of gravity also causes greater translational forces and resultant trauma to the poswral supportive tissues. The head and neck are particularly vulnerable to horizontal forces, which can be induced by falls or blows to the body.
To locate specific segments of the cervical spine, the fol lowing list of landmarks may be a helpful guide: C I : Transverse process just inferior to mastoid process and posterior to the earlobe. CZ: Spinous process is located approximately 1 . 5 to Z cm (0.6 to 0.8 in.) inferior to the midline of the occiput. This is a wide, bifid spinous process. C3: Located at the level of the hyoid anteriorly. On
The relatively large mass of the head is a source of significant
extension, spinous process remains palpable.
inertial force in the event of trauma to the cervical region.
C4: Located at the level of the superior border of the
The bane of modem existence, the automobile, provides unique opportunities for especially severe trauma to rhe rela,
thyroid cartilage anteriorly. On extension, spinolls process is not palpable.
tively delicate supportive elements of the cervical spine.
C5: Located at the level of the inferior border of the
Parnspinai muscles in the anterior, posterior, and lateral com,
thyroid cartilage anteriorly. Spinous process
partmcntsj the suboccipital musculature; the paravertebral, capsular, and ligamentous elements; and the superficial fascia may be variously compromised depending on the direction
remains palpable on extension. C6: Located at the level of the cricoid cartilage anteri orly. Spinous process is easily palpable on extension and is often bifid.
and magnitude of the displacing forces .l1 It appears that the deep, intrinsic tissues related to the
C7: Prominent bifid spinous process. To differentiate
intervertebral segment arc the particular focus of persisting
from T I , perform cervical extension. The C7
dysfunction, and it is [Q this level that therapeutic interest is
spinous moves anteriorly Inore than T I . J,I'1
directed. I The multifidus and rotatores posteriorly, the scalenes anteriorly and laterally, the longus capitis and longus colli anteriorly, and the suboccipitals are the active tissues
, TREATMENT
that have the greatest scgmental motor and sensory effect on
Positioning of the cervical spine involves using the tcnder
the cervic..1 1 spine, I I Palpation of the tender points on the
point as a fulcrum about which all of the componenr move�
posterior, infcrior aspect of the spinous processes may ncccs�
ments {flexion, extension, rotation, and lateral flexion} are
sitate slight flexion of the neck, and both sides of the bifid
focused. Treatment of anterior lesions consists of precise
proccs> should be examined.
flexion of the cervical spine ar the level of the tender point.
Clinical expressions of cervical dysfunction include neck
With scalene involvement, the addition of contralateral
pain, restriction of cervical motion, upper limb symptoms
rotation and a variable amounr of lateral flexion are also
(pain, paresthesia, paresis), upper thoracic pain, headaches,
induced. Posterior dysfunction may involve the posterior
dysphagia, nonproductive cough, vertigo, and tinnitus. The
suboccipitals, multifidus, or rota[Qres. These are treated
neck seems especially prone to stress�related responses and
using varying degrees of extension and often the addition of
patients who arc anxious should be evaluated for psychologic
rotation and lateral flexion away from the tender point side.
factors.16 Headache patterns, according to Jones,9 follow a
Occipital flexion, by retracting the patient's mandible,
segJ1'lental pattern,
should be maintained throughom any positions involving
with C 1 , 2 associatcd with frontal
headache, C3,4 with lateral head pain, C4 with occipital
cervical extension. The sternocleidomastoid may need to be
pain, and C5 with whole head pain. Joncs9 also points out
pushed laterally or medially in order to palpate the anterior
that dysfunction at the level of C3 is often
assoc
iated with
earache, tinnitus, or vcrtigo.9 Upper limb involvement may
64
tender points. The patient's neck should be relaxed during palpation and treatment.
ANT E RI O R C E R V I C A L S P I N E
Anterior View
AC I
Lateral View
Tender Points
Anteri or Cervi cal S p i n e 20. Anterior First Cervical ( AC l )
TPA TPP SH
location of
l
Tender Point
l
Position of Treatment
66
Rectus Capitis Anterior
Coronal suture Parietal bone �---.�.c Frontal bone Temporal bone Sphenoid bone ...... "" Nasal bone Lambdoidal J t--"d-- Lacrimal bone suture �;;;��-.::;f'-1'1::: Maxi Zygomatic bone Occipital bone la r1
_--....---
MAS
"-;��'1__+----""""""_'+-- AC I
Mental foramen ZygomatiC Mandible arch
This tender point is located on the posterior aspect of the ascending ramus of the mandible approximately I cm (0.4 in.) superior to the angle of the mandible. Pres sure is applied anteriorly.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the sides of the patient's head and rotates the head markedly away from the tender point side. Fine-tuning may include slight cervical flexion, extension, or lateral flexion.
Treac:ment PrOCedt�Tes
2 1 . Anterior Second Cervical (AC 2 )
ACl AC4 --e ACS --e AC6 --e
AMC
•
Position of Treatment
capitis -1-1"-1...dl lb�� Sternocleido mastoid Middle scalene
�'-AC7 --ACe Tender Point
Longus Colli
Rectus capitis anterior Rectus capitis lateralis
AC2
Location of
67
CHAPTER 6
AC2
Clavicle First rib Second rib
This tender point is located on the anterior surface of the tip of the transverse pro cess of C2. This is located approximately I em (04 in.) inferior to the tip of the mas toid process. Pressure is applied posteromedially.
The patient is supine with the therapist sitting at the head of the table. The therapist grasps the sides of the patient's head and rotates the head markedly away from the tender point side. This treatment is similar to that for AC I except that slightly more flexion is used.
CHAPTER 6
68
Trearment Procedures
Antenor Cervical Spine
2 2 . Anterior Third Cervical ( AC3 )
Longus Capitis, Longus Colli Rectus capitis anterior
Rectus capitis lateral is
;'l���������
AC2
LOngUs capitis --\-' \'!LC/!'f"fi., � ":::' C I ..-I n-:;, " C2 C3 Sternocleido mastoid C4 ACJ WIr!Ii��CO;S Longus Colli . 1It::,::Ii>!
ACJ AC4 -ACS
__
AC6 __
Clavicle
Posterior scalene O-AC7 - -AC8
1
1
Location of Tender Point
Position of Treatment
First rib Second rib
This tender point is located on the anterior surface of the tip of the transverse pro cess of C3 at the level of the hyoid. This area may usually be found directly posterior to the angle of the mandible. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and produces marked flexion to the level of C3, rota tion away from the tender point side, and lateral flexion away from or toward the tender point side. Note:
The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures
23. Anterior Fourth Cervical ( AC4)
CHAPTER 6
69
Scalenus Ant., Longus Capitis,
Longus Colli Rectus capitis anterior
---\�������::r��
Rectus capitis lateralis AC2
Longus fl'lj���,y' capitis -;-�..c:;
AC3
Sternocleido mastoid
AC4 ___ ACS ___
Middle scalene Anterior sCailene_
AC6 ___
Posterior scalene
Location of Tender Point
Position of Treatment
First rib Second rib
This tender point is located on the anterior surface of the tip of the transverse pro cess of C4 at the level of the superior border of the thyroid cartilage. This area is usually found just inferior and posterior to the angle of the mandible. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and produces moderate cervical flexion to the level of C4 (cervical extension may be required for this segment), rotation, and lateral flexion away from the tender point side. Note:
The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.
CHAPTER 6
70
Treatment Procedures
Antenor Cervical Spine
24. Anterior Fifth Cervical ( AC5 )
Scalenus Ant., Longus Capitis,
Longus Colli Rectus capitis anterior
AC2
capitis -i-'�a
AC3 AC4 _
AMC
fJs>_�
Sternocleido· mastoid
ACS _ Middle scalene
AC6 _
Posterior scalene
Clavicle First rib Second rib
O-AC7 --ACe
",
l
Location of Tender Point
Position of Treatment
This tender point is located on the anterior surface of the tip of the transverse pro cess of CS at the level of the inferior border of the thyroid cartilage. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and produces cervical flexion down to the level of the tender point and rotation and lateral flexion away from the tender point side. Note:
The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures
25. Anterior Sixth Cervical ( AC6)
71
CIIAPTER 6
Scalenus Ant., Longus Colli Kectus capltJs anterior
AC2
capitis -""t-\"I...c.:'Dt��� Y.
AC3 _ AC4
AMC
Sternocleido mastoid
AC5 Middle scalene Anterior ,c.,lon.,_
AC6 _
Posterior scalene
First rib Second rib
::'-AC7 - -ACe l
Location of Tender Point
•
Position of Treatment
This tender point is located on the anterior surface of the tip of the transverse pro cess of C6 at the level of the cricoid cartilage. Pressure is applied posteromedially.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and produces cervical flexion down to the level of the tender point and rotation and lateral flexion away from the tender point side.
Note:
The therapist may support the head on the therapist's forearm by passing it under the head from the non-tender point side and resting the palm of the hand on the patient's anterior shoulder on the tender point side.
72
CHAPTER 6
Treatment Procedures
Anterior Cervical Spine
26. Anterior Seventh Cervical ( AC 7 )
Sternocleidomastoid Rectus capitis anterior
Rectus capitis lateralis AC2
Longus capitis -1-fl.":;flil�"'r::;' �
AC3 AC4
AMC
ACS __ AC6
Sternocleido mastoid
;:;::!�- Longus Colli AC7
__
Clavicle First rib Second rib - -ACS
l
Location of Tender Point
Position of Treatment
This tender point is located on the posterior superior surface of the clavicle approx imately 3 cm ( 1 .2 in.) lateral to the medial head of the clavicle. Pressure is applied anteriorly and inferiorly.
The patient lies supine with the therapist sitting at the head of the table. The thera pist supports the patient's midcervical area and markedly flexes and laterally flexes the cervical spine toward the tender point side, rotating the cervical spine slightly away from the tender point side.
Treatmenr Procedures
27. Anterior Eighth Cervical (AC8)
CHAPTER 6
73
Sternohyoid, Omohyoid
Rectus capitis Basilar part of anterior occipital bone Rectus capitis lateralis AC2
Longus capitis -"i-��'JJ
AC3 AC4 _
AMC
AC5 _
,,�.....::;;:)
Sternocleido mastoid Middle scalene Anterior swlene_
AC6 _
Posterior scalene
First rib Second rib
--Ace
'1
l
location of Tender Point
Position of Treatment
This tender point is located on the medial surface of the proximal head of the clav icle. Pressure is applied laterally.
The patient lies supine with the therapist at the head of the table. The therapist grasps the patient's head and flexes the cervical spine slightly, laterally flexes slightly away from the tender point side, and rotates markedly away from the tender point side.
CHAPTER 6
74
Treatment Procedures
A N TERIOR MEDIAL CERVICAL
28. Anterior Medial Cervical ( AMC )
Longus Colli, Infrahyoid
Rectus capitis Basilar part of anterior occipital bone Rectus capitis lateralis
AC2
Longus capitis -i-'�C4
AC3 AC4 __
Sternocleido· mastoid
ACS __
Middle scalene
AC6 __
Posterior scalene
WJ.iIl:::;?�- Longus Colli
AMC
Clavicle First rib Second rib
O-AC7 • Ace _ _ _ .....I Location of Tender Point
l
Position of Treatment
These tender points are found along the lateral aspect of the trachea. The trachea is pushed slightly to the side to palpate the point. Pressure is applied posteriorly.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and markedly flexes the neck while adding slight side bending toward and rotation away from the tender point side.
Treatment Procedures
CHAPTER 6
75
LATERAL CERVICAL
29. Lateral First Cervical (Le I )
LC I----'
•
location of Tender Point
i
Position of Treatment
...-+
- MAS
-
=· --cl AC I
Rectus Capitis Lateralis
•
- - . MPT
This tender point is located on the lateral aspect of the transverse process of C I . Pressure is applied medially.
The patient is supine with the therapist sitting at the table. The therapist grasps the patient's head and laterally flexes the head toward or away from the tender point side depending on the response of the tissues.
Trearmem Procedures
CHAPTER 6
76
LATERAL CERVICAL
30. Lateral Cervical ( LC2�6)
Scalenus Medius
LCI
LC2 LC3
SH
ce'·--Cl ACI
l
Location of Tender Point
Position of Treatment
•
- - - LPT MAS --. MPT
C4
cs
C6
LC4 LCS LC6
These tender points are located on the lateral aspect of the articular processes of the cervical vertebrae. Pressure is applied medially.
The patient is supine with the therapist at the head of the table. The therapist grasps the patient's head and side bends the head and neck toward or away from the tender point side depending on the response of the tissues. Flexion, extension, or rotation may be needed to fine-tune the position.
P 0 S T E RI O R C E R V I C A L S P I N E Tender
Points
Posterior Rectus minor capitis Posterior major PC 2
::S;���
Transverse process of C I
PC3 PC4
PC6 PC7 PCB
���,,", -/
:\''"it't---f- :Superior
�
'- '-_ Inferior
-rl-�i]�
)
Obi��us capitis
)
Lon�us Rotatores BrevIs cervicis
==::����:-�
Le�tor
77
Posteri o r Cervi cal S p i n e 3 1 . Posterior First Cervical-Flexion (PC 1 ,F) Rectus Capitis Anterior
PCI PCI-t--_
PCI-E
• .. PC6 • PC7
___ pca -Location of
Tender Point
1
Position of Treatment
78
•
•
•
•
•
This tender point is located on the base of the skull on the medial side of the inser tion of the semispinalis capitis approximately 3 cm ( 1 .2 in.) inferior to the posterior occipital protuberance. Pressure is applied laterally and superiorly.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head by putting one hand on the occiput and pulling in a cephalad direction and the other hand on the frontal bone pushing caudad. This will create marked occipital flexion. Fine-tuning may include slight side bending toward and rotation away from the tender point side.
Treatment Procedures
HAPTER 6
79
32. Posterior First Cervical-Extension ( PC l �E) Obliquus Capitis Superior
PCI
PC I -E
PC I -E -_--' PC2 ---
PC6---- PC7
•
•
•
•
•
.----. PC8 -
Location of Tender Point
Position of Treatment
•
This tender point is located on a flat portion of the occipital bone approximately I to 1.5 em (0.4 to 0.6 in.) medial to the mastoid process. Pressure is applied in a cephalad direction.
The patient lies supine with the head resting on the table. The therapist sits at the head of the table. The therapist then places the hand under the patient's head with the fingers pointing caudally. With pressure from the heel of the hand, the therapist pushes caudally on the head in such a manner as to induce a local extension of the occiput on C I . The therapist can also add moderate rotation and slight side bending away from the tender point side to fine-tune.
Note:
One hand may be used to palpate the tender point and to apply caudal pres sure on the top of the posterior aspect of the head; the other hand is posi tioned on the frontal bone to assist the movement (not shown).
80
CHAPTER 6
Treatment Procedures
Postenor Cervical Spine
3 3 . Posterior Second Cervical ( PC 2 )
Rectus Capitis Posterior
Major/Minor
1,.-;;...--r PC2
PC I -F
....
PCI-E-----.; PC3
PC6
. . . _ .. . • • --
-
PC7 -
-
l
l
� Pce------
Location of Tender Point
Position of ' Treatment
•
This tender point is located on the base of the skull on the lateral side of the inser tion of the semispinalis capitis. Pressure is applied medially and superiorly. Another tender point may be found on the superior surface of the spinous process of C2. Pressure is applied inferiorly.
The patient lies supine with the head resting on the table. The therapist sits at the head of the table. The therapist then places the hand under the patient's head with the fingers pointing caudally. With pressure from the heel of the hand, the therapist pushes caudally on the head in such a manner as to induce a local extension of the occiput on C I . The therapist can also add moderate rotation and slight side bending away from the tender point side to fine-tune. Note:
One hand may be used to palpate the tender point and to apply caudal pres sure on the top of the posterior aspect of the head; the other hand is posi tioned on the frontal bone to assist the movement (not shown).
Treatment Procedures
CHAPTER 6
34. Posterior Third Cervical ( PC3 ) Rotatores, Multifidus, Interspinalis
PCI-F PC I-E--_-.:
J...-- PC3
PC6---- PC7
•
___
•
•
•
•
•
pca--
Location of Tender Point
l
Position of Treatment
This tender point is located on the inferior surface of the spinous process of C2 (pressure applied superiorly) or on the articular process of C3 (pressure applied anteriorly). Slight flexion may be needed to allow the tender point to be accessible.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and extends the cervical spine to the level of C3 and laterally flexes and rotates it away from the tender point side. This lesion may require flexion, in which case the treatment is identical to that for AC3.
81
82
CHAPTER 6
Treatment Procedures
Posterior Cervical Spine
3 5 �3 8. Posterior Fourth, Fifth, Sixth, and Seventh Cervical (PC4� 7 ) Rotatores, M u ltifidus, Interspinalis
• -.. PC6-• PC7 ____ pcs--
l
Location of Tender Point
Position of Treatment
PC4 PC5 PC6 •
•
•
•
��r_
�
��� ------�I --: �t:2 PC7 ----:;:;��� -
�
-
•
This tender point is located on the inferior surface of the spinous process of verte brae above (pressure applied superiorly) or on the articular process of the involved vertebral segment (pressure applied anteriorly). Slight flexion may be needed to allow the tender point to be accessible.
The patient lies supine with the therapist sitting at the head of the table. The thera pist grasps the patient's head and extends it moderately and laterally flexes and rotates it away from the tender point side. Extension is increased progressively as one treats progressively caudal lesions.
Trearmenr Procedures
39. Posterior Eighth Cervical (PCB)
CHAPTER 6
83
Levator Costorum
PCI-F PCI-E-_-.: PC3 ---:-
PC6-----
•
•
---. . . ___
PC7 -
•
PCB
pcslocation of Tender Point
1
Position of Treatment
The therapist palpates anterior to the upper portion of the trapezius to locate the upper border of the first rib_ The tender point is found by palpating medially toward the base of the neck until the transverse process of C7 is encountered and then moving onto the posterosuperior surface of the transverse process_ Pressure is applied anteriorly on the posterior surface of the transverse process of C7_
The patient lies supine with the therapist Sitting at the head of the table. The thera pist grasps the patient's head and induces marked lateral flexion and slight rotation away from the tender point side along with slight cervical extension.
THO R ACIC S PIN E AN D RIB C AG E HHORACIC DYSFUNCTION The thoracic spine and rib cage contain no less than 84 syn;
syndrome, carpal tunnel-like syndrome, and respiratory and
ovial joints. They form a protective housing for several vital
cardiovascular dysfunction. It is important to assess for and
organs. are the site of the origin of the sympathetic nervous
treat any significant thoracic lesions when there is upper
system, and are an important structural link with the upper
limb involvement. In general. treatment of the thoracic
limb. Although gross motion of the thoracic spine is limited
spine and rib cage may be determined by postural distortion,
by the presence of the ribs, physiologic and nonphysiologic
if present. Therefore a hyperkyphotic upper back will usu
mocion arc crucial [0 the respiratory, cardiovascular. and
ally be treated in flexion, and a hypokyphotic ;pine will
digestive organs. Trauma. postinfectious visceral adhesive
usually be treated in extension.2J The rules of priority, as
pathology, and surgical intervention are possible causes of
detennined by the scanning evaluation and by the applica
local lesions.7 Assessment of spinal and rib mmion may be
tion of the rules of treatment, will ultimately dC[ermine
useful in determining the site of clinically significant areas
where and how to treat.
of fixation. Posterior tender points may be found on the spinous pro; cesses, in the paraspinal musculature, on the transverse pro
HREATMENT
cesses, over the rib heads, or on the posterior angles of the
Posterior lesions are treated in extension, and head and
ribs. Anterior tender points are usually found on the ante
shoulder position is used to localize the release of the
rior aspect of the ternum, over the sternocostal joints, on
involved tissues at the level of the dysfunction. From
the anterior angles of the ribs, or on the anterolateral mar
appearances, it may seem, in some cases, that the area being
gins of the ribs. The tender points on the sternum are
treated is under stretch; however, review of the pertinent
reflexly related to the anterior aspect of the thoracic spine,
anatomy will clarify the rationale used. Through its myofas
which is of course inaccessible to direct palpation.
cial connections to the rib cage, the ipsilateral arm, when
As a guide to palpation, it should be noted that T2 is
elevated, causes the ribs to elevate, which in turn elevates
usually located at the level of the superior, medial angle of
the lower attachments of the levator costOTUm or multifidus
the scapula, TJ at the level of the spine of the scapula, and
toward their insertions on the lamina of the vertebrae one
T7 at the level of the inferior border of the scapula. The
or twO segments above.17 Anterior lesions are treated with
eleventh rib is usually found at the level of the iliac crest.J·" Clinical manifestations of thoracic dysfunction include back pain, neck pain, shoulder and arm pain, thoracic outlet
84
varying degrees of flexion with the addition of rotation or lateral flexion to fine-tune the position.
AN T E RIO R THO R AeI C S PIN E Tender
Points
Upper Anterior Thoracic Region
Lower Anterior Thoracic Region 85
Anterior Thoracic Spine 40,42. Anterior First, Second, and Third Thoracic (ATl,3) Internal Intercostal, Sternothyroid ..
ATI
Internal intercostals Transversus thoracis External intercostals
Location of
l
Tender Point
(All)
Location of Tender Point
(An)
l
Location of Tender Point
(All)
l
Position of Treatment
ATl
This tender point is located on the superior surface of the suprasternal notch. Pres sure is applied inferiorly.
This tender point is located on the anterior surface of the manubrium. Pressure is applied posteriorly.
This tender point is located on the anterior surface of the sternum on or just infe rior to the sternomanubrial joint. Pressure is applied posteriorly.
The patient sits in front of the therapist with knees flexed and hands on top of the head. A pillow may be used between the patient and therapist for comfort. The ther apist places his or her arms around the patient and under the patient's axillae. The patient leans back toward the therapist, and the therapist allows the patient to slump into marked flexion down to the level of the tender point. The patient's trunk is folded over the tender point. Fine-tuning is accomplished with the addition of rota tion or lateral flexion. Note:
86
ATl
AT 1-6 may be performed in the supine or lateral recumbent positions with minor modifications.
Treatment Procedures
87
CHAPTER 6
43A5. Anterior Fourth, Fifth, and Sixth Thoracic (AT4,6) Internal Intercostal
ATI An AT3
AT4 ATS AT6
AT7
location of Tender Point
Internal intercostals Transversus thoracis External intercostals
AT4 ATS AT6
This tender point is located on the anterior surface of the sternum at the level of the fourth interspace. Pressure is applied posteriorly.
(AT4) location of Tender Point
This tender point is located on the anterior surface of the sternum at the level of the fifth interspace. Pressure is applied posteriorly.
(ATS)
1
location of Tender Point
This tender point is located on the anterior surface of the sternum at the level of the sixth interspace. Pressure is applied posteriorly.
(AT6)
1
Position of Treatment
The patient is seated in front of the therapist with the knees flexed and the arms extended off the back of the table. A pillow may be used between the patient and the therapist for comfort. The patient leans back toward the therapist. The therapist places pressure on the patient's upper back to create thoracic flexion down to the level of the tender point. The flexion is progressively increased as the level of treat ment proceeds caudally. Local flexion may be augmented by grasping one or both of the patient's arms and applying caudal traction and internal rotation or by having the patient clasp his or her hands behind the therapist's knee. Fine-tuning is accomplished with the addition of rotation or lateral flexion (see photo above left). The photo above right illustrates an alternate, lateral recumbent position.
88
CHAPTER 6
Treacment Procedures
Anterior Thoracic Spme
46�48. Anterior Seventh, Eighth, and Ninth Thoracic (AT7 �9) Diaphragm, Diaphragmatic Crura
ATI
l
Location of Tender Point (AT1)
Location of Tender Point (AT8) l
Location of Tender Point (AT9)
l
Position of Treatment
This tender point is located on the inferior, posterior surface of the costochondral portion of the seventh rib (pressure applied anteriorly and superiorly), approximately I cm (0.4 in.) inferior to the xyphoid process and I cm (0.4 in.) lateral to the mid line. Pressure is applied posteriorly. This tender point is located approximately 3 to 4 cm (1.2 to 1.6 in.) inferior to the xyphoid process and 1.5 cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly. This tender point is located approximately and 1.5 cm (0.6 in.) late .
1.5 cm (0.6 in.) superior to the umbilicus
Assume, for the purposes of illustration, that the tender point is on the right side. The patient sits in front of the therapist with the therapist's left foot on the table to the left side of the patient. The patient rests his or her legs on the table with the knees pointing to the left while the left arm rests on the therapist's left thigh. The therapist flexes the patient's trunk down to the level of the tender point and side bends the trunk to the right by translating it to the left. The therapist then rotates the patient's trunk to the left by having the patient bring the right arm across the body and grasp the left wrist. Note:
A physical therapy ball or chair may be used to support the arm for AT 7-9.
Treacmem Procedures
CHAPTER 6
89
49,51. Anterior Tenth, Eleventh, and Twelfth Thoracic (ATI0,12) Psoas, Iliacus
::-;Jr+- AT7
'-�F-f- AT8 An
ATI
ATiO ATII
location of Tender Point
This tender point is located approximately 1.5 cm (0.6 in.) caudal to the umbilicus and I .S cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlO) 1
location of Tender Point
This tender point is located approximately 4 cm (1.6 in.) caudal to the umbilicus and 2 cm (0.8 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlI)
1
location of Tender Point
This tender point is located on the inner table of the crest of the ilium at the midax illary line. Pressure is applied caudally and laterally.
(ATl2)
1
Position of Treatment
The patient is supine and the therapist stands on the tender point side. The head of the table may be raised or a pillow may be placed under the patient's pelvis. The patient's hips are markedly flexed and may be rested on the therapist's upraised thigh. The thighs are rotated toward the tender point side, and lateral flexion may be toward or away from the side of the tender point.
Note:
Treatments for AT I 0-12 are similar, with slight variation in fine-tuning. A phys ical therapy ball may be used to support the legs. AT7-9 may be performed in the supine or lateral recumbent position.
AN T E RIO R AN D
M E D I A L RIB S
Tender Points
��� ----1t
AR2 AR3--....w�...
ARS -�_ AR6-� . ...._-AR7---\,e ARB ----'Ie'___� AR9 --�,.::.; ARlO
--1�i;,:L..._i==k����1).J Anterior Rib Cage
Posterior view of anterior chest wall Relationship of tender points
90
MR3-IO
Anterior, Medial Ribs 52. Anterior First Rib (ARl) ARI
:::---..
AR2 __ AR3_ AR4-.-. ARS AR6 AR7 ARB AR9 ARlO
ARI • • •
•
Location of Tender Point
l
Position of Treatment
Scalenus Anterior, Scalenus Medius
MR3-IO
Internal intercostals Transversus thoracis External intercostals
This tender point is located on the first costal cartilage immediately inferior to the proximal head of the clavicle. Pressure is applied posteriorly.
The patient may be supine or sitting. The therapist grasps the head and places the patient's neck in slight flexion, marked lateral flexion toward the tender point, and slight rotation (usually toward the tender point) to fine-tune the position.
91
92
Treatment Procedures
CHAPTER 6
Antenor Medial Ribs
53. Anterior Second Rib (AR2)
Scalenus Posterior
AR I :::::----..
AR2 __
AR3_ AR4-. AR5 AR6 AR7 ARB AR9 ARlO
l
Location of Tender Point
Position of Treatment
• •
MR3-IO
Internal intercostals Transversus thoracis External intercostals
This tender point may be found in two locations. One is on the superior surface of the second rib inferior to the clavicle on the midclavicular line (pressure is applied inferiorly and posteriorly). Another tender point may be found on the lateral aspect of the second rib high in the medial axilla (pressure is applied medially).
The patient may be supine or sitting. The therapist grasps the head and places the patient's neck in slight flexion, marked lateral flexion toward the tender pOint, and slight rotation (usually toward the tender point) to fine-tune the position.
Treamlenr Procedllres
CHAPTER 6
93
54,61. Anterior Third through Tenth Ribs (AR3,lO) Internal Intercostal
ARI _____ � AR2 __ AR3_ AR4_ • MR3·IO ARS- • • AR6 : AR7 • AR8 • AR9 • ARlO
l
Location of Tender Point
l
Position of Treatment
������;;[2�r -AR3 to::::;S:;Q, :; c AR4 """"f�3� ���l -ARS
Internal intercosta Is T thoracis External intercostals""-..�":>---7 ransversus>
AR6 � tJL """ -AR7 ' AR8 ctf'-AR9 \."'l \''-f-- ISM TMI '-+-ISI TMA
J?:�"" �
LD
Posterior Shoulder Region
105
Shoulder 94. Trapezius (TRA) SCl
Trapezius (Upper Fibers)
TRA
MC
TRA
BlH
BSH PMI
Subclavius
?
Deltoid Pectoralis minor (cut)
•
PMA --• SER
•
Biceps brachii
{
+4J-h/...jf.4- \
long head
Short head Serratus anterior
l
Location of
These tender points are located along the middle portion of the upper fibers of the
Tender Point
trapezius. Pressure is applied by pinching the muscle between the thumb and fingers.
Position of
The patient is supine with the therapist standing on the side of the tender point. The
Treatment
patient's head is laterally flexed toward the tender point side. The therapist grasps the patient's forearm and abducts the shoulder to approximately 90° and adds slight flexion or extension to fine-tune.
106
Treatment Procedures
CHAPTER 6
107
95. Subclavius (SCL) SCl
TRA
AAe BLH
BSH
PMI
�
SCL
/
Deltoid
---
• SER
�
Pectoralis minor (cut)
•
PMA
Subclavius
Subscapularis
•
Biceps brachii
-\,1HHJICt
ong head
Short head
Serratus anterior
"I
l
Location of Tender Point
This tender point is located on the undersurface of the middle portion of the clav icle. Pressure is applied superiorly and somewhat posteriorly.
Position of
I . The patient is supine and the therapist stands on the opposite side of the tender
Treatment
point. The therapist adducts the arm obliquely across the body approximately 30· and adds slight traction caudally. (See photo above left.) 2. The patient is lateral recumbent with the tender point on the superior side. The therapist stands behind the patient and places the affected arm in slight extension behind the patient's back. Pressure is applied to the affected shoulder to cause it to be adducted in the transverse plane. R etraction or protraction and flexion or extension are added for fine-tuning. (See photo above right.)
108
Trearmenr Procedures
CHAPTER 6
Shoulder
96. Anterior Acromioclavicular (AAC) Pectoralis Minor SCL
Anterior Deltoid,
TRA
AAC AAC
BLH
BSH PMI
7
Deltoid
• PMA
--•
SER
l
l
Location of Tender Point
Position of Treatment
�
Pectoralis (cut)
minor
•
Biceps brachii
-+-\f-IHJR-
ong head
Short head
This tender point is located on the anterior aspect of the acromioclavicular joint near the distal end of the clavicle. Pressure is applied posteriorly.
I . The patient is supine. The therapist stands on the opposite side of the tender point and grasps the patient's affected arm above the wrist. The therapist then slightly flexes and adducts the arm obliquely across the body at an angle of approximately 30° and adds a moderate amount of caudal traction in the direc tion of the opposite ilium. 2. The patient is supine and the therapist stands on the side of the tender point. The therapist grasps the affected forearm and flexes the arm to approximately 90° and fine-tunes with slight adduction and internal rotation.
Treatment Procedures
97. Supraspinatus Lateral (SSL)
SSL
CHAPTER 6
109
Supraspinatus Tendon
----
h;:"-"1-+-Teres major
l
l
Location of
These tender points are located on the superior vertebral angle of the scapula and
Tender Point
along the medial border of the scapula. Pressure is applied caudally, laterally, or both.
Position of
I . The patient is prone and the therapist stands on the side of the tender point. The
Treatment
affected arm is grasped above the wrist, extended 20° to 30°, internally rotated, and tractioned caudally. 2. The patient is prone and the therapist stands on the side of the tender point. The patient's forearm is flexed at the elbow and the hand is placed under the affected shoulder. The therapist pushes the lateral aspect of the inferior angle of the scapula medially and cephalad. 3. The patient is supine. The therapist flexes the shoulder to approximately I 10° to 120° with the elbow flexed and fine-tunes the position with internal or external rotation.
Treatment Procedures
109. Infraspinatus Superior (ISS)
�:;;- PAC ·-.. -.- 155 •
----� ISM 151 • •_-;:==:, TMI __-+ --' e-#-----,,- LD
CHAPTER 6
121
Infraspinatus (Superior Fibers)
���,---- Levator scapulae Supraspinatus rf�������i��� Infraspinatus
-
l
l
Location of Tender Point
Position of Treatment
Teres minor ;.4-+-- Teres major
This tender point is located along the inferior border of the spine of the scapula. Pressure is applied anteriorly.
The patient is supine and the therapist is on the side of the tender point. The thera pist grasps the forearm and flexes the shoulder to approximately 90° to 100° with moderate horizontal abduction and slight external rotation.
CHAPTER 6
122
Treannent Procedures
Shoulder
1 1o. Infraspinatus Middle (ISM)
Infraspinatus (Middle Fibers)
55M PAC 1\---- Levator scapulae Supraspinatus Infraspinatus
-----0-155 • •----� I S M _--;==3151 •
TMI
'--r-'T -- MA
Mf---L- D
Location of Tender Point
l
Position of Treatment
ISM
-++-\L--..
Teres minor 04'--+-T - eres major
This tender point is located in the upper portion of the infraspinous fossa. Pressure is applied anteriorly.
The patient is supine and the therapist stands on the side of the tender pOint. The therapist grasps the forearm and flexes the shoulder to approximately I 100 to 1200 with moderate horizontal abduction and slight external rotation.
Treatment Procedures
111. Infraspinatus Inferior (lSI)
H�-{
l
Location of Tender Point
• • •
ISS ISM
Infraspinatus (Inferior Fibers)
Levator scapulae Supraspinatus Infraspinatus
1TMS 51 TMA LD
123
CiIAI'TER 6
Teres minor IS
Teres major
This tender point is located in the central or lower portion of the infraspinous fossa. Pressure is applied anteriorly.
Position of
The patient is supine and the therapist stands on the side of the tender point. The
Treatment
therapist grasps the forearm, flexes the shoulder to approximately 1300 to 1400, and fine-tunes with slight abduction/adduction and internal/external rotation.
Treatment Procedures
CHAPTER 6
124 Shoulder
1 12. Teres Major (TMA)
1\---- Levator scapulae
··---� 155 --- 15M -- 151 ••• --TMI
••
--,
Supraspinatus Infraspinatus
--
-
Teres minor TMA -t-t--<.\
�1-/-- Teres major
latissimus dorsi
l
location of Tender Point
l
Position of Treatment
This tender point is located along the lateral aspect of the inferior angle of the scapula. Pressure is applied anteromedially.
The patient sits in front of the therapist. The therapist grasps the patient's forearm, bends the arm at the elbow, and produces marked internal rotation, adduction, and slight extension (hammerlock position). Internal rotation may be augmented by pulling the forearm posteriorly.
Treatment Procedures
CHAPTER 6
125
113. Teres Minor (T MI) SSM PAC
E:8�'l-- Levator scapulae
........-
.e---�ISS e-----.-ISM _---..) lSI
Infraspinatus
ee---TMI
TMA H-- LD
e--...r--
Teres minor
TMI
;4--l---- Teres major
dorsi
Location of Tender Point
This tender point is located on the upper third of the lateral border of the scapula or along the posterior, inferior border of the axilla. Pressure is applied anteriorly, medially, or both.
Position of Treatment
The patient sits in front of the therapist. The therapist grasps the involved forearm, which is bent at the elbow. The shoulder is extended to approximately 30°, adducted, and markedly externally rotated.
E L BO W
Tender Points
LEP -'"
MEP
LCD --H-.... 1fII.<--- MCD RHS. RHP --t'<'\.\
MOL----I,� u)--- LOL
126
Elbow 1 14. Lateral Epicondyle (LEP)
"I
This tender point is located on the supracondylar ridge superior to the lateral epi
Location of
condyle. Pressure is applied medially.
Tender Point
RHS RHP
LEP __ -.II
1
_
__
Position of Treatment
lE P ---, ,.«1
Treatment is directed to the first thoracic segment or the first rib. (AT I . PT I .AR I . PR I). Check for tender points in these areas and treat according to the general rules. Monitor the LEP tender point during and after the treatment.
127
118
CHAPTER 6
Treatment Procedures
Elbow
1 1S. Medial Epicondyle (MEP) l
Location of Tender Point
This tender point is located on the supracondylar ridge superior to the medial epi condyle. Pressure is applied laterally.
LEP ___.. RHS RHP __ _
l
MEP
Position of
Treatment is directed to the fourth thoracic segment or the fourth rib. (AT4. PT4.
Treatment
AR4. PR4. MR4). Check for tender points in these areas and treat according to the general rules. Monitor the MEP tender point during and after the treatment.
Treatment Procedures
1 16. Radial Head Supinator (RHS)
CHAPTER 6
129
Supinator
Brachialis
LEP RHP
___I.
RHS
_
__
RHS
Supinar.or """",�!}Y
Pronator teres
j Pronator ____�� quadratus 1.
(��..u
l
l
� Location of Tender Point
This tender point is located on the anterior surface of the proximal head of the radius. Pressure is applied posteriorly.
Position of
The patient may be seated or supine. The therapist grasps the patient's forearm and
Treatment
elbow, markedly supinates the forearm, and mildly extends the elbow. Abduction (valgus) is used to fine-tune the position.
130
CHAPTER 6
Treatment Procedures
Elbow
117. Radial Head Pronator (RHP)
Pronator Teres
�', ,
Brachialis
RHP
Supinator -""�g[
Pronator teres
Pronator ---f':�a quadratus
1
location of Tender Point
l
This tender point is located on the anterior surface of the proximal head of the radius. Pressure is applied posteriorly.
Position of
The patient is sitting or supine. The therapist grasps the forearm and elbow and pro
Treatment
duces marked pronation and flexion at the elbow with the dorsum of the patient's hand coming to rest on the patient's lateral trunk.
Treatment Procedures
CHAPTER 6
118, 119. Lateral/Medial Coronoid (MCDjLCD)
Brachialis
II
,,
,,
\
,
Brachialis
,, ,
RHS RHP
__ _
13 1
LCD
MCD
$upinator"""""Mi--M
Pronator teres
de Pronator , � quadratus -IT.--,� b
1
1
Location of Tender Point
J
a
These tender points are located on the medial and lateral aspects of the coronoid process of the ulna. Pressure is applied posteriorly.
Position of
The patient is sitting or supine. The therapist markedly flexes the elbow, pronates the
Treatment
forearm to turn the palm forward, and externally rotates the humerus.
CHAPTER 6
132
Treatmem Procedures
Elbow
120, 121. Lateral/Medial Olecranon (MOL/LOL)
Triceps
,,,I�/a+-1+-- Medial head Long head -++,1' II! ,n'. 4J4.-- Lateral head
Medial head -�t-;,
MC'L-����t.f.r-- LOL "IIl-l--- Anconeus
l
Tender Point
l
Position of
The patient is seated or supine. The therapist hyperextends and adducts (varus) or
Treatment
abducts (valgus) the elbow and adds slight supination to fine-tune.
Location of
These tender points are located on the lateral and medial aspect of the olecranon process. Pressure is applied medially or laterally.
W R 1 S T AND H AN 0
Anterior (Palmar) View
Tender Points
Posterior (Dorsal) View
133
Wrist and Hand 122. Common Flexor Tendon (CFT)
eFT
RHS RHP
__ _
Flexor carpi ---/-i,1,£., radialis
Common flexor tendon Palmaris longus
Opponens pollicis Abductor pollicis (cut)
�f--- Palmar aponeurosis
(cut) ,k�(/fJ.�:l!�interossei Palmar �
l
location of Tender Point
l
Position of Treatment
This tender point is located on the anterior medial aspect of the forearm, just distal to the medial epicondyle. Pressure is applied posterolaterally.
The patient is supine or seated. The therapist markedly palmar flexes the wrist with the greatest force being exerted on the hypothenar side. Pronation/supination and abduction/adduction are used to fine-tune the position.
134
Treatment Procedures
HAPTER 6
135
123. Common Extensor Tendon (CET)
"�_ ��; carpi I radialis _ longus Extensor carpi ulnaris
Extensor carpi radialis brevis
Extensor digitorum--lr:-.11�!t\"-Ir- Extensor pollicis longus
Extensor_-,..."., indicis
DIN
Extensor pollicis brevis
Interossei --O!§§�f:ti:t\Jn IP
1
1
Location of Tender Point
Position of Treatment
This tender point is located on the posterior lateral aspect of the forearm, just distal to the radial head. Pressure is applied anteromedialiy.
The patient is supine or seated. The therapist markedly extends the wrist, with the greatest force being exerted on the thenar side. Pronation/supination and abduc tion/adduction are used to fine-tune the position.
136
CHAPTER 6
Trearmem Procedures
Wnst and Hand
124. Palmar Wrist (PWR)
RHS RHP
__ _
Location of Tender Point
l
Wrist Flexors
These tender points are located along the palmar surface of the carpals. Pressure is applied posteriorly.
Position of
The therapist faces the dorsum of the patient's wrist. The therapist palmar flexes the
Treatment
wrist over the tender point. Fine-tuning is accomplished with siding, pronation or supination, and radial/ulnar deviation.
Treatment Procedures
125. Dorsal Wrist (DWR)
CHAPTER 6
137
Wrist Extensors
DIN
IP
1
Location of Tender Point
These tender points are located along the dorsal aspect of the wrist. Pressure is applied anteriorly.
Position of
The therapist doriflexes the wrist with slight side bending toward the tender point.
Treatment
Fine-tuning is accomplished with pronation or supination and radial/ulnar deviation.
138
CHAPTIR 6
Treatment PTocedltre�
Thumb
126. First Carpometacarpal (eMl) Flexor Pollicis Brevis, Opponens Pollicis
1
Location of Tender Point
Position of Treatment
This tender point is located in the thenar eminence on the palmar surface of the first metacarpal. Pressure is applied posterolaterally.
The therapist flexes (see photo above left) or opposes (see photo above right) the thumb over the tender point and fine-tunes the position with abduction/adduction and internal/external rotation.
Treatmenr Procedures
CHAPTER 6
139
Fingers
127. Palmar Interosseous (PIN)
Metacarpophalangeal Joints
MEP
eFT
_ RHS __
RHP
PIN
l
location of Tender Point
These tender points are located within the palm of the hand, on the medial and lat eral sides of the shafts of the metacarpals. Pressure is applied posteromedially or posterolaterally.
Position of
The therapist markedly flexes the fingers over the tender point with the addition of
Treatment
lateral flexion toward the tender point and rotation to fine-tune the position.
140
CHAPTER 6
Treatment Procedures
Fingers
128. Dorsal Interosseous (DIN)
Metacarpophalangeal Joints
DIN[
...._IP ...
l
Location of Tender Point
These tender points are located on the dorsum of the hand. on the medial and lat eral sides of the shafts of the metacarpals. Pressure is applied anteromedially or anterolaterally.
Position of
The therapist markedly extends the finger over the tender point with the addition of
Treatment
lateral flexion toward the tender point and rotation to fine-tune the position.
Note: The metacarpophalangeal joints may also be treated in a similar manner.
Treatment Procedures
129. Interphalangeal Joints (lP)
w
CHAPTER 6
141
Capsular Ligaments Leo
��. -'r.
eFT
'i
RHS __ _
tendon Flexor carpi radialis
RHP
�,..
flexor
MEP
OJ',
�
Common
Meo
.
Palmaris longus
Opponens
�"' ..
pollicis Abductor pollicis
carpi ulnaris Palmar
(cut)
-
•
PWR
,
"' .
•
PIN
..
}IP
- J \.�- IP .
l
Location of Tender Point
..-l._�
These tender points are located on the capsule to the proximal. middle. or distal interphalangeal joints. Pressure is applied over the tender point toward the center of the finger.
c+
Position of
The therapist folds the more distal phalanx over the tender point. and rotation and
Treatment
lateral flexion are added to fine-tune the position.
Note: The metacarpophalangeal joints may also be treated in a similar manner.
II
LOWER QUADRANT
PRT Lower Body Evaluation Patient's name
Practitioner
Dates
2
•. Extremely sensitive \ Xl.
e . Very sensitive
/-
- Right
�- Moderately sensitive +
Left
5
4
- Most sensitive
o
- No tenderness
(; - Treatment
Anterior Lumbar Spine (pages 144-149)
130_ All 131. ABL2 XlI.
00000 00000
132. AL2 133. AL3
00000 00000
134. AL4
00000 00000
140.SPB
00000 00000 00000
150.PL3-1
135. AL5
00000 00000
00000 00000
Anterior Pelvis & Hip (pages 150-158)
136.IL 137.GMI XIII.
00000 00000
138.SAR 139.TFL
141.IPB
00000 00000
142.LPB 143.ADD
00000 00000
Posterior Lumbar Spine (pages 159-165)
144.PLl 145.PL2 146.PL3 XIV.
00000 00000 00000
147.PL4 148.PL5 149.QL
151.PL4-1 152.UPL5
00000 00000 00000
153.LPL5
00000 00000 00000
160.GME
00000 00000
Posterior Pelvis & Hip (pages 166-173)
154.SSI 155.MSI XV.
00000 00000
156. lSI 157.GEM
00000 00000
158. PRM 159.PRL
00000 00000
161.ITB
Posterior Sacrum (pages 174·180)
162.PSI 163. PS2 XVI.
00000 00000
164.PS3 165.PS4
00000 00000
166.PS5
00000 00000 00000
174.PES
00000 00000 00000
I S4. FDL
00000 00000 00000 00000 00000 00000
200.PCN3
167.COX
00000 00000
Knee (pages 182-192)
168. PAT 169. PTE 170.MK XVII.
00000 00000 00000
171.LK 172.MH 173. LH
175.ACL 176.PCL
00000 00000 00000
177.POP
00000 00000 00000
00000 00000 00000
IS7. EDL
00000 00000 00000
00000 00000 00000 00000 00000 00000
206.PMTI
Ankle (pages 193-203)
17S. MAN 179.LAN 180.AAN XVlll.
00000 00000 00000
lSI. TAL 182.PAN 183.TBP
185.TBA 186.PER
Foot (pages 204-219)
ISS. MCA 189. LCA 190. PCA 191. DCB 192.PCB 193.DNV 142
3
00000 00000 00000 00000 00000 00000
194.PNV 195.DCNI 196.DCN2 197.DCN3 19S.PCNI 199.PCN2
201.DMTl 202.DMT2 203.DMT3 204.DMT4 205.DMT5
207.PMT2 208.PMTJ 209.PMT4 210.PMT5
00000 00000 00000 . 00000 00000 00000
LUMB A R S PINE, P E LV I S, AN D
H I P
, LUMBAR AND PELVIC DYSfUNCTION
and wei�ht�hearing mechanism and also as a hou..,mg for the
Low back pam " a lead 109 cause of dlSab,"ty and lost pro
pelVIC vIScera. Ir should be borne in mind that uterine,
ductivity in our IDCicry. The lumbar spine has been the sub�
ovarian, prostate, bladder, and lower howcl dysfunction or
jeer of extensive !-.tudy and a wide range of medical inter#
mflammation may have an Important heaTIng un the fllnc·
vemions. Modem unagmg methods arc able to detect
tion of the pelvis. These organs have direct contact With
structural abnormalities with great resolution. Surgical can ..
the mtTlnsic muscles and ligaments of the pclvi'l, notahly
oiuarcs are seiecreJ much more carefully, and many sur ..
the levator am and the piriformis.6•14
geons recognize th,n the detection of significant structural
Clinical manifestations of lumbar and pclvic involvc·
pathology is no guarantee of causation or a positive surgical
ment mclude low back pain, scoliosis, hip and lower lllnh
outcome.l It is gradually becommg accepted that myofascial
pain, bursitis, paresthesia, and numerous reflex visceral
dysfunction IS the cause of (he vast majority of painful can ..
symptoms, mcludmg cystitis, irTltable bowel syndrome, and
dltions of the low back anu that surgical procedures arc
dysmenorrhea.
11,e major focus of soft tissue therapy has been the pos
, TREATMENT
inappropriate in most cases. 16
terior musculature of the lumbar spine. These therapies have met With some degree of success. This type of mter� ventlon often recommends the
use
Posterior lumhar tender pomts are locatcd on thc spmous
of extension, which IS
proces-<;cs, m the paraspmal area, or on thc tips of the trans·
also an Importam part of the therapeutic approach 10 PRT
verse processes (attachment of the quadratus lumhorum). assoc
In certam ca�s. TI'lC diagnostic method used 10 PRT, how�
Accessory reflex tender points
ever, is precise 10 providmg ,iIrection to the use of extension
are al� located in the gluteal region. Postcrior Icsion� �lre
or
flexion dcpendmg on the presemation and the location
of the primary tender pomts.
treated
III
iateU with Ll, 4, and 5
extension, With the addition of rot to mduce
provides a powerful tool to address this common and often
lumber and pelvic movement.
overlooked cause of low back pain. Weight-bearing problems associated with abnormal
Pelvis and hip tender points are located antcriorly and postcTlorly on the pelViS, on the greater tnx:hantcr, or on
function of the feet may also have an Impact on the spine
the femur.
and pelv". The human foot dlStrtbutes weight throughout
Involved muscles, and the leg, are used for added leverage.
Positioning reproduces the action of the
1[5 length, from heel [0 mc, by way of an energy·efficient
The sacral tender points were discovercd by MauTlce
longitudinal arch. It should be noted that humans are the
Ramirez, D.O., a brilliant osteopath whom one of us (Roth)
only 31l1mai that walks on its heels. Unfortunately, the ..uti·
met while both were studymg with Harold Schwanz,
ficial. hard, flat walkmg surfaces present in modern urban
D.O.," at an osteopathic hospital in Ohio. These lender
settings afford no support for this structure. am.! the detcri�
points are associated with the levator am, and lesions are
oration of the arches of the feet may, in time, destabilize the
treated by simply toggling the sacrum by compressmg ante·
biomechalllcal effiCiency of the entire pelvis and spine.2Q The pelvII is pre<:::..
GME
GME
__-. Ifh-TFL
ITS
l
i
Location of Tender Point
Position of Treatment
These tender points are located on a line approximately I em (0.4 in.) inferior to the iliac crest and 3 to 5 em ( 1. 2 to 2 in.) on either side of the midaxillary line. Pres sure is applied medially.
The patient lies prone, and the therapist stands on the same side as the tender point. The therapist extends and abducts the hip and supports the patient's leg on the therapist's thigh. The hip is pOSitioned in marked external rotation for tender points located posterior to the midaxillary line (see photo above left) and in internal rotation for those located anterior to the midaxillary line (see photo above right).
Treatment Procedures
CIIAPTER 6
173
161. Iliotibial Band (ITB)
GME ---... .. ....., .. "r-- TFL
hl---fjl- ITB
ITB
l
Location of Tender Point
l
Position of Treatment
These tender points are located on the iliotibial band along the lateral aspect of the thigh on the midaxillary line. Pressure is applied medially.
The patient may be supine or prone. The therapist stands on the side of the tender point, grasps the patient's leg, and produces marked hip abduction and slight hip flexion with internal or external rotation to fine-tune the position.
P 0 S T E R IO R
S AC RU M Tender
Points
�����----�- �2 ����;-----�-- �3 �4
Posterior View
Pubis
j
Puborecta lis Pubococcygeus Levator Ani Iliococcygeus Obturator internus
�=-----JT- Ischium
Piriformis Coccygeus Superior View
174
Posterior Sacrum 162. Posterior First Sacral (PS1 )
QL{
PS2 PS3 PS4 PSS
-
••
•-P1.1 • ••-Pll •• ••• •-P1.4 • ••-PLS
PU
Levator Ani Short posterior sacroiliac ligaments
PSI
s::s:/�
151 Long posterior sacroiliac ligament
Sacrotuberous ligament Sacrococcygeal ligaments
l
Location of Tender Point
l
Position of Treatment
Tendon of biceps femoris
This tender point is located in the sacral sulcus. medial and slightly superior to the PSIS. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the inferior lateral angle opposite the tender point side. resulting in rotation around an oblique axis.
175
176
CHAPTER 6
Trearment PrOCedtlTeS
Posterior Sacrum
163. Posterior Second Sacral (PS2)
QL{
-
Levator Ani
• • -Pl.1 • • • -PL2 • •• • •• • • ••-PlS
PlJ Pl.4
PS3 PS4 151
1
1
Location of Tender Point
Position of Treatment
This tender point is located on the midline of the sacrum between the first and second sacral tubercles. Pressure is applied anteriorly.
The patient is prone.The therapist applies an anterior pressure on the sacral apex in the midline. producing rotation around a transverse axis.
Treatment Procedures
164. Posterior Third Sacral (PS3) -
{
QL
PS2
-
CHAPTER 6
177
Levator Ani
•• •-PLI •• •P1.2 •• PLJ • • • -PL� • • • -PLS •
� PSS 151
"I
1
Location of Tender Point
Position of Treatment
This tender point is located in the midline of the sacrum between the second and third sacral tubercles. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the apex (or occasionally the base) of the sacrum in the midline. resulting in rotation around a transverse axis. Alternatively. the patient may be placed in sacral extension by raising the head end of the table and the foot end of the table or by using pillows to sup port the patient's trunk and lower limbs in extension. with the third sacral segment as the fulcrum.
CHAPTER 6
178
Treatment Procedures
Posterior Sacrum
165. Posterior Fourth Sacral (PS4)
QL{
PS2 PS3
Levator Ani
...-� ..
,- • • • -PLl - • • •Pl." - • •
• -PLS
PSS lSI
1
1
Location of Tender Point
Position of Treatment
This tender point is located in the midline of the sacrum just above the sacral hiatus. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the sacral base in the midline. producing rotation around a transverse axis.
Treatment Procedures
166. Posterior Fifth Sacral (PS5) -
{
QL
PS2 PSJ f>S.4
-
• • • • •
• • • • •
CIIAf'fER 6
179
Levator Ani
• -PI.I • -pu • -pu • -PL4 • -PLS
151
1
1
Location of Tender Point
Position of Treatment
This tender point is located approximately I cm (0.4 in.) superior and medial to the inferior lateral angle of the sacrum. Pressure is applied anteriorly.
The patient is prone. The therapist applies an anterior pressure on the sacral base on the side opposite the tender point, resulting in rotation around an oblique axis.
CHAPTER 6
180
Treatment Procedures
Posterior Sacrum
167. Coccyx (COX) Pubococcygeus, Sacrotuberous Lig., Sacrospinous Lig.
-
QL{
-
PS2 PS3 PS4 PSS 151
cox
l
l
location of Tender Point
Position of Treatment
This tender point is located on the inferior or lateral edges of the coccyx. Pressure is applied superiorly or medially.
The patient is prone. The therapist applies an anterior pressure on the sacral apex in the midline. Rotation or lateral flexion of the sacrum, usually toward the tender point side, may be added to fine-tune the position.
DMT2,3
7 The Use of Positi onal Release Therapy in Clinical Practice Can Po itional Release
How to Incorporate Positional
Therapy Address Repetitive
Release Therapy with
221
Other Modalitie The Use of Reality Checks
222
222
222
How Do You Treat
223
Any Suggestions When Working with Obese Patient ?
223
Regard to Ergonomics and
223
Does Positional Release
Sensations Occur during the Treatment while the Patient Is in a Position of Comfort?
225
What Activities Can the Patient Perform after a Positional Release Therapy
225
What Can Patients Do about Posttreatment Soreness?
225
Do You Offer Any Home
Therapy Specifically Treat Soft Tissue Damage?
224
Treatment Session?
Any Further Sugge tions with Proper Body Mechanics?
Has Pain? What Happens If Pain or Other
What Happens If a Tender Point
Conflicting Points?
What Happens If You Are Unable Points and Yet the Patient
Patients Regarding Positional
Does Not Shut Off?
224
to Locate Significant Tender
How Do You Communicate with Release Therapy?
Strain lnjurie ?
224
Programs to Your Patients? Summary
225 225
, How TO INCORPORATE POSITIONAL RElEASE THERAPY WITH OTHER MODALITIES
reduced in the first few visits so that the patient can progress with cardiovascular fitness, strengthening,
Positional release therapy helps normalize inappropriate
used for pain management and swelling or to help promote
mobility, and range#of,motion exercises. Modalities may be
proprioceptive activity and promotes the release of muscle
soft.tissue healing. Positional release therapy may not be
guarding and fascial tension, thus increasing soft tissue flex#
the primary treatment for all conditions, but it will help
ibiliry, improving joint mobility, decreasing pain, increasing
many patients overcome certain aspects of the dysfunction.
circulation, and decreasing swelling. By using PRT, the
Based on the evaluation and determination of the calise
patient's muscle, fascia, and articular components are struc#
of the dysfunction, other modalities may be introduced. In
rurally normalized to a point where the therapist can start
the case of persisting articular restriction, these may include
to implement a functional rehabilitation program. It is
manipulation, mobilization, or muscle energy. If the cranial
essential to perform a thorough reevaluation at each visit.
structures are not fully corrected or the dural tube is under
In most cases the patient's pain level will be dramatically
(ension, cranial osteopathy
or
craniosacral (herapy may be
221
222
CHAPTER 7
The Use of Positional Release Therapy in Clinical Practice
applied. With visceral or fascial involvement, the appro�
tion that either through various injuries sustained in the
priarc soft tissue technique is used. If the patient demon�
past or from the present injury, the tissues may have become
s[rares muscle weakness, a strengthening program should be
injured and are in a shortened, tense position. This can
instituted. Frequently, massage and general exercise pro�
result in the tissues being tender to the touch. If these tis,
grams can further release tight, overused muscles, ease fas#
sues (muscles, ligaments, etc.) become short and tense, they
cial tension, and help promote increased circulation.
will create joint stiffness and limit movement.
Modalities slich as ice, heat, and electrical stimulation can
Patients will realize that trauma obtained in the past can
aid in relaxing the patient and can help resolve inflamma�
result in accumulated restrictions throughout the body. To
rion, posureatment soreness, and other reactions.
explain areas of dysfunction that are remote from the per,
HHE USE OF REALITY CHECKS
a sweater or blouse, can be used. This demonstrates that fas,
Reali!y checks are orthopedic and functional tests used to
radiate from the source and thus cause strain in surrounding
confirm various Outcomes. These tests must be objective
"reas. (See Chapter 2, Fig. 2-4.)
ceived symptoms, the analogy of a pulled garment, such as cial restrictions, like fabric, can cause lines of tension to
and measurable. The pain scale from 0 to to may be used
Once the patient understands the purpose of the full,
(0 being no pain and 10 being the most severe) or a range
body evaluation, the therapist should proceed to explain
of,motion test (the patient lifts his arm over his head while
what the patient can expect during and after the treatment
the practitioner uses a goniometer to measure the range in
session. It is suggested that the therapist find a tender point
degrees). Joint hypomobility tests (spinal
to demonstrate the PRT technique and gently bring the
or
sacral spring
tests) and functional tests (doing a deep squat or going up
patient into and Ollt of the position of comfort. This shows
and down stairs) can also be used. If a patient has low back
the patient that the tenderness will disappear in the posi
pain, the range of motion should be evaluated in each of the
tion of comfort and demonstrates that the treatment is
three planes. If it is found that there is pain at *0 on left side
gentle and safe. It is important to explain that the patient
bending and extension at X range, these are two reality
may experience release phenomena consisting of pulsation,
checks that can be used to confirm the outcome of treat,
vibration, paresthesias, pain, or heat while in the position of
ment. Therefore when using PRT it is now possible to mon,
comfort. These sensations will dissipate when a release in
itor left side bending and extension after treatment to see if
the soft tissues is completed. The patient should be
there is a change in the pain level or range of motion. Thus
informed that there should be a significant reduction in
it is important to find two or three objective measurements
tenderness. The patient should be relaxed, more comfort,
throughout the treatment program. It is also important to
able, and able to move more freely. During the 24 to 48
make the patient aware of these reality checks because this
hours after the first treatment, approximately 40% of
will be helpful in motivating the patient as changes occur.
patients report some increased discomfort. Reassure the patient that this discomfort will disappear after a day or two
, How Do You COMMUNICATE WITH PATIENTS REGARDING POSITIONAL RELEASE THERAPY?
and that an improvement in the original symptoms will be
Communication is one of the most important aspects in
felt elsewhere. For example, if the sacrum is treated, the
noticed. It is helpful to advise the patient that the discom, fort may be felt directly in the area treated or that it may be
dealing with the public. On the first visit, it is crucial that
patient may feel discomfort in the sacrum, neck, shoulder,
the subjective evaluation of the painful areas be recorded. It
or other areas of the body.
should also be noted whether the pain is constant, periodic,
If these pretreatment discllssions are omitted, the proba,
or occasional. Have the patients grade pain from 0 to 10,
bility of future problems with the patient is extremely high.
with 0 being no pain and 10 being the most severe. What
Thus it is necessary to prepare the patient and make Sllre that
do they expect to get from therapy? As health care
he is aware of the different sensations he may experience.
providers, we must keep our patients focused on their own
When the practitioner clearly explains what is to be ex
goals. Also, they must decide what they are prepared to do
pected, the patient feels respected and included in the treat'
to obtain these goals. How will they know if they have
ment program. He appreciates that the technique is gentle
obtained their goals? What reality checks will be used? It
and that immediate results may be felr. The pariem values
must be made clear [Q patients how their bodies will move
the time taken, and this ensures satisfaction and confidence
and what they should feel. Some patients have no idea what
with both the practitioner and the rehabilitation program.
wellness feels like. Each patient's expected outcome of therapy should be discussed and recorded by the practi tioner to ensure that the goals will be met. It is important to discuss the rationale of PRT. The
'WHAT HAPPENS IF A TENDER POINT DOES NOT SHUT OFF?
patient must understand why a full,body evaluation is crit,
ClinicaHy, this has been found to be a rare occurrence. From
ical even when a specific site is so obviously painful. Men-
our experience, when a therapist is unable to shut off a
The Use of Positional Release Therapy in Clinical Practice
CIIAPTER 7
223
tender pOint, she must first establish if she is palpatmg the
tender TXllnt, The practitioner shllulJ he alert to this
exact location of the tcnder point. Some pomL'; aTC close
possibility if the tissues UO not responu as expected.
rogcrher. For example. the anterior third lumbar, which is on
Further ilwestigations or an appropnate referral may
the lateral aspect of the amerior mferior lilac spme. is In
he required.
close proximity [0 the [cm.lcr point for (he gluteus minnnus, which is I em lateral to the anterior inferior iliac spine. To treat an anterior
, How Do You TREAT CONFLICTING POINTS?
c,,1 hIp l1exlon of 90 Jegree, anJ siJe bent ,harply away
A paticnt who has experienced a whiplash rype of mJury, for
from the tender pom[ siJe (p. 148). To treat a gluteus
example. may have tender pOints
mmimus. only the involved hip is flexed [0 approximately
rior aspects llf the neck. The practitioner may find that an
DO degrees with 0 degrees of abduction and rmarion
attempt to treat the anterior lesion hy flexing the patient's
111
third lumbar.
the anteTlor and rx)stc�
(p. 152). In this situation, these two points are In close prox#
neck ll"'I
61.ARIO
PI f.'I1;£� o�
nr -{
�����1i0l;r-
60.AR9
,
5 1.ATI2
�
1t''
100.sER
I84.FDl
169.P TE
tp
-;
� �
10S.lD
Z -;
Plantar
Dorsal
Dorsal
Palmar
236
ApPENDIX
'ANATOMy/ POSITIONAL RELEASE THERAPY CRoss.REFERENCE Muscles are listed by name only; other tissues are specified (bone,joint,etc.).
Anatomic Reference
Positional Release Therapy Reference
Acromioclavicular joint Adductor hallucis Adductors Anconeus Anterior cruciate ligament Biceps Brachialis Coccygeus Common extensor tendon Common flexor [cndon Coracoacromial ligamenr Coron",1 suture Cuboid (bone) Cuneiform (bones) Deltoid anterior Deltoid ligament Diaphragm Digastric Dorsal calcaneocuboid ligament Dorsal cuneounavicular ligament Dorsal interossei Extensor digitorum longus
AAC, PAC PMTl ADD LOL,MOL ACL BLH, BSH LCD,MCD ISI,COX CET CFT AAC FR DCB, PCB DCN 1-3, PCN 1-3 AAC MAN AT7-9 DG DCB DCN 1-3 DIN, DMT2,3, DMT4,5 AAN, EDL DMT2,3, DMT4,5 AAN,DM T l PMT4,5 PCA, DMT2,3, DMT 4,5 FDL CMI FR SO PAN GEM MHU GME,SSI GMI,MSI LH MH IL, ALI IPB, LPL5 AL2-5, LPL5 ITB ISS,ISM,151 MRJ-IO ATI-6, AR3-10 IP PC3-7 PLI-5 PTI-12 LAM,acC LK
Extensor hallucis longus Flexor digiti minimi brevis Flexor digiwrum brevis Flexor digitorum longus Flexor pollicis brevis Frontal bone Frontonasal joint Gastrocnemius Gemelli Glenohumeral ligaments Gluteus medius Gluteus minimus Hamstrings, latcral Hamstrings, medial Iliacus IIiococcygeus Iliopsoas Iliotibial band Infraspinatus Intercostal, external Intercostal, internal Interphalangeal joints Interspinalis, cervical Interspinalis, lumbar Interspinalis, thoracic Lambdoid suture Lateral collateral ligament
Page 108,118 217 158 IJ2 190 110,114 131 169,180 135 134 108 57 208, 209 212,213 108 194 88 50 208 212 140,215,216
196,203,215,216 196,214 219 207,215,216 200 138 57 56 198 170 113 172, 167 152, 168 188 187 151, 145 156,165 147,165 173 121,122,123 94 86, 87, 93 141 81, 2 160 96 48,46 186
ApPENDIX
237
Page
Anatomic Reference
Positional Release Therapy Reference
Lateral pterygoid Latissimus dorsi Levator ani Levator cestaTum LevatOr scapula Longus capitis Longus colli Lumbricals (foor) Masseter Maxilla (bone) Medial collateral ligament Medial pterygoid Metacorpophalangeal joints Metatarsal (bones) Multifidus,cervical Multifidus,lumbar Multifidus,thoracic Nasal bones Navicular (bone) Obliquus capitis superior ObruramT extemus Occipital bone Occipimmasroid suture Opponens pollicis Palmar interossei Patellar retinaculum Patellar tendon Pectineus Pectoralis major Pectoralis minor Peroneus Peroneus tertius Piriformis Plantar calcaneocuboid ligament Plantar calcaneonavicular ligament Plantar cuneonavicular ligament Popliteus Posterior cruciate ligament PronatOr teres Psoas Pubococcygeus Quadratus femoris Quadratus lumborum
52 LPT LD 117 PSI-5 175 PC8, PRI-12 83,101 120 MSC 6 AC3-5 67,74 AC2-6, AMC 218 PMT2,3 53 MAS 54 MAX 185 MK 51 MPT 139,140 PIN,DIN 214,217 DMT,PMT 81 PC3-7 160, 162,163,164 P L l -5,PL3,PL4-1,UPL5 96 PTI-12 55,56 NAS,SO 210,211 DNV,PNV PCI-E 79 157 LPB 46,48 OCC,LAM 45 OM 138 CMI 139 PIN 183 PAT 184 PTE 157 LPB 115 PMA 116 PMI 195,202 LAN, PER 216 DMT4,5 171 PRM,PRL 209 PCB 211 PNV 213 PCN 192 POP 191 PCL 130 RHP 89,146 ATIO-12,ABLZ 180,ISS COX,SPB 170 GEM ATI2, QL, PL3-I, PL4-1, PT IO-12,UPL5, 89,161,162,163,99,164,103 PRI I ,12 207 PCA 183,184 PAT,PTE 66,78 ACI,PCI-F 75 LCI PC2 80 120 MSC 81 PC3-7 160,162, 163, 164 PLI-5, PL3,PL4-1,UPL5 96 P T I-12 164,165 UPL5,LPL5
Quadratus plantae Quadriceps femoris Rectus capitis anterior Rectus capitis lareralis Rectus capitis posterior Rhomboid Rotatores, cervical Rotatores,lumbar Rotatores,thoracic Sacroiliac ligaments
2,8
ApPENDIX
Anatomic Reference
Positional Release Therapy Reference
Sacrospinolls ligament Sacrotuberous ligament Sagirtal suture Sartorius Scalenus anterior Scalenus medius Scalenus posterior Serratus anterior Soleus Sphenobasilar suture Sternocleidomastoid Sternothyroid Stylohyoid Subclavius Subscapularis Supinator Supraspinatus Talocalcaneal joint Talofibular ligament Talonavicular ligament Temporalis Temporomandibular jOint Temporoparietal joint Tensor fascia law Tentorium cerehclli Teres major Teres minor Tibialis anterior TIbialis posterior Transversus [horae is Trapezius Triceps Wrist extensors Wrist flexors Zygomatic bone
cox COX,ISI SAG SAR AC4·6 LC2·6, ARI AR2,PRI SER PAN PSB, LSB AC7 ATI SH SCL SUB RHS SSM,SSL MCA, LCA, PCA LAN DNV MAS, AT, PT 00, MPT, LPT, MAS, MAX TPA,TPP TFL OM TMA TMI TAL,TBA TBP MR3·IO TRA LOL,MOL DWR PWR AT,PT
Page
180 180,169 58 153 69 76,91 92,101 112 198 47, 59 72 86 49 107 I II 129 119, 109 205,206, 207 195 210 53,60,61 50,51,52,53,54 62,63 154 45 124 125 197,201 199 94 \06 132 137 136 60,61
239
ApPENDIX
, STRAIN/COUNTERSTRAIN/POSITIONAL RELEASE THERAPY CROSS-REFERENCE Strain/Counterstrain Terminology
Positional Release Therapy Terminology
Abdominal second lumbar (Ab2L) Adductors (ADD) Anterior acromioclavicular (AAC) Anterior cruciate ligament (ACL) Anterior eighth cervical (A8C) Anterior eighth thoracic (A8T) Anterior eleventh thoracic (A II T) Anterior fifth cervical (A5C) Anterior fifth lumbar (A5L) Anterior fifth thoracic (A5T) Anterior first cervical (A I ) Anterior first lumbar (AI L) Anterior first rib (AIR) Anterior first thoracic (AI T) Anterior fourth cervical (A4C) Anterior fourth lumbar (A4L) Anterior fourth thoracic (A4T) Anterior lateral trochanter (ALT) Anterior medial trochanter (AMT) Anterior ninth thoracic (A9T) Anterior second cervical (A2C) Anterior second lumbar (A2L) Anterior second rib (A2R) Anterior second thoracic (A2T) Anterior seventh cervical (A 7C) Anterior seventh thoracic (A7T) Anterior sixth cervical (A6C) Anterior sixth thoracic (A6T) Anterior tenth thoracic (A lOT) Anterior third cervical (A3C) Anterior third lumbar (A3L) Anterior third thoracic (A3T) Anterior third to sixth rib (A3R-A6R) Anterior twelfth thoracic (A12T) Bursa (BUR) Coccyx Coronal (C) Cuboid (CUB) Dorsal cuboid (DCU) Dorsal fourth, fifth metatarsal (DM4,5) Dorsal metatarsal (DM) Dorsal metatarsal (DM) Dorsal wrist (DWR) Elevated first rib Elevated second to sixth ribs Extension ankle (EXA) Extension carpometacarpal (ECM) First carpometacarpal (CMI) Flexed ankle (FAN) Flexion calcaneus (FCA) Flexion medial calcaneus (FM
Abdominal second lumbar (ABL2) Adductors (ADD) Anterior acromioclavicular (AAC) Anterior cruciate ligament (ACL) Anterior eighth cervical (AC8) Anterior eighth thoracic (AT8) Anterior eleventh thoracic (ATI I ) Anterior fifth cervical (AC5) Anterior fifth lumbar (AL5) Anterior fifth thoracic (AT5) Anterior first cervical (ACI) Anterior first lumbar (AL l ) Anterior first rib (AR I ) Anterior first thoracic (ATI) Anterior fourth cervical (AC4) Anterior fourth lumbar (AL4) Anterior fourth thoracic (AT4) Sartorius (SAR)' Gluteus minimus (GMI)' Anterior ninth thoracic (AT9) Anterior second cervical (AC2) Anterior second lumbar (AL2) Anterior second rib (AR2) Anterior second thoracic (AT2) Anterior seventh cervical (AC7) Anterior seventh thoracic (AT7) Anterior sixth cervical (AC6) Anterior sixth thoracic (AT6) Anterior tenth thoracic (ATIO) Anterior third cervical (AC3) Anterior third lumbar (AU) Anterior third thoracic (AT3) Anterolateral third to tenth rib (AR3-10)' Anterior twelfth thoracic (ATI 2) Supraspinatus lateral (SSL)' Coccyx (COX) Sagittal suture (SAG)' Plantar cuboid (PCB)' Dorsal cuboid (DCB)" Dorsal fourth, fifth metatarsal (DMT4,5) Dorsal first metatarsal (DMTI)' Dorsal second, third metatarsal (DMT2,3) Dorsal wrist (DWR) Posterior first rib (PRI)' Posterior second to tenth ribs (PR2-10)' Posterior ankle (PAN)' Dorsal interossei (DIN)' First carpometacarpal (CM I) Anterior ankle (AAN)' Plantar calcaneus (PCA)' Tibialis posterior ( TBP)"
Page 146 158 108 190 73 88 89 70 149 87 66 145 91 86 69 14 87 153 152 88 67 147 92 86 72 88 71 87 89 68 148 86 93 89 109 180 58 209 208 216 214 215 IJ7 101 102 198 140 138 196 207 199
240
ApPENDIX
Strain/Countmtrain Terminology
Positional Release Therapy Terminology
Page
Frontal (F) Frozen Shoulder (F H) Gluteus medius (GM) Gluteus minimus (GMI) High flareout 51 (HFO-SI) High ilium-sacroiliac (HISI) High navicular (H.NAV) Iliacus (lL) Infraorbital (10) Inguinal ligament (lNG) Inion Interossei (lNT) Interspace rib (4 Int-6 Int) Lambdoid (L) Lateral (1C) Lateral ankle (LAN) Lateral ankle (LAN) Lateral calcaneus (LCA) Lateral canthus (LC) Lateral epicondyle (LEP) Lateral hamstring (LH) Lateral/medial coronoid (LCD/MCD) Lateral meniscus (LM) Lateral olecranon (LOL) Lateral trochanter (LT) Latissimus dorsi (LD) Long head of biceps (LH) Low ilium-flareout (LIFO) Low ilium-sacroiliac (L1SI) Lower pole fifth lumbar (LP5L) LTS2 Masseter (M) Medial ankle (MAN) Medial ankle (MAN) Medial calcaneus (MCA) Medial coracoid (MC) Medial epicondyle (MEP) Medial hamstring (MH) Medial meniscus (MM) Medial olecranon (MOL) Metatarsal Midpole sacroiliac (MPSI) MTS2 Nasal (N) Navicular (NAV) Occipitomastoid (OM) Patella (PAT) Patellar tendon (PTE) Pes anserinus (PES) Piriformis (PIR) Point on spine (POS) Posterior acromioclavicular (PAC) Posterior auricular (PA) Posterior cruciate ligament (PCR)
Frontal (FR)* Medial humerus (MHU)* Gluteus medius (GME)* Tensor fascia lata (TFL)* Inferior sacroiliac (151)* Superior sacroiliac ( 5 1)* Dorsal navicular (DNV)* Iliacus (lL) Maxilla (MAX)* Lateral pubis (LPB)* Posterior first cervical. flexion (PCI-F)* Palmar interossei (PIN)* Medial third to tenth rib (MRJ-IO)* Lambda (LAM)* Lateral first cervical (LCI) Lateral ankle (LAN) Peroneus (PER)* Lateral calcaneus (LCA) Anterior temporalis (AT)* Lateral epicondyle (LEP) Lateral hamstring (LH) Lateral/medial coronoid (LCD/MCD) Lateral knee (LK)* Lateral olecranon (LOL) Iliotibial band (lTB)* Latissimus dorsi (LD) Biceps long head (BLH)* Inferior pubis (lPB)* Superior pubis (SPB)* Lower posterior fifth lumbar (LPL5)* Infraspinatus superior (1 5 5)* Masseter (MA )* Medial ankle (MAN) Tibialis anterior (TBA)* Medial calcaneus (M A) Pectoralis minor (PMI)* Medial epicondyle (MEP) Medial hamstring (MH) Medial knee (MK)* Medial olecranon (MOL) Plantar metatarsal (PMTl-5)* Middle sacroiliac (MSI)* Medial scapula (MSC)** Na al (NAS)* Plantar navicular (PNV)* Occipitomastoid (OM) Patella (PAT) Patellar tendon (PTE) Pes anserinus (PES) Piriformis medial (PRM)* Infraspinatus middle (lSM)* Posterior acromioclavicular (PAC) Temporoparietal. post. (TPP)* Posterior cTuciate ligament (PeL)·
57 113 I7Z 154 169 167 210 151 54 157 78 139 94 48 75 195 202 206 60 127 18 131 186 132 173 117 110 156 155 165 III 53 194 ZOI 205 116 128 187 185 l3Z 217 168 120 55 211 45 183 184 189 171 122 liB 63 191
ApPENDIX
Strain/Counterstrain Terminology
Positional Release Therapy Terminology
Posterior eighth cervical (P8C) Posterior fifth to seventh cervical (P5C, P6C, P7C) Posterior fi"t cervical (PIC) Posterior fi"t, second lumbar (PI-2L) Posterior fi"t, second thoracic (PI-2T) Posterior fourth cervical (P4 ) Posterior fourth lumbar (P4L) Posterior medial trochanter (PMT) Posterior occipital (PO) Posterior sacrum I (P I) Posterior sacrum 2 (PS2) Posterior sacrum 3 (PS3) Posterior sacrum 4 (P 4) Posterior sacrum 5 (PS5) Posterior second cervical (P2C) Posterior sixth to ninth thoracic (P6-9T) Posterior tenth to twelfth thoracic (PIO-I 2T) Posterior third cervical (P3C) Posterior third lumbar (P3L) Posterior third to fifth thoracic (P3-5T) Posterolateral trochanter (PLT) Radial head (RAD) Radial head (RAD) Short head of biceps (SH) phenobasilar (SB) Sphenoid (SP) Squamosal (SQ) Stylohyoid (SH) Subclavius (SUBC) Subscapularis (SUB) Supraorbital (SO) Supraspinatus (SPI) Talus (TAL) Teres major (TM) Teres minor (TMI) Tracheal (TR) TS3 Upper pole fifth lumbar (UP5L) Wrist (WRI) Zygoma (Z)
Posterior eighth cervical (PC8) Posterior fifth to seventh cervical (PC5-7)
*Change In tennmoIOb'Y_
241
Page 83 82
Posterior first cervical, ext. (PCI-E)* Posterior first to fifth lumbar (PLI-5)** Posterior first, second thoracic (PTI-2) Posterior fourth cervical (PC4) Posterior fourth lumbar, iliac (PL4-1)* Gemelli (GEM)* Occipital (OCC)* Posterior sacrum I (PSI) Posterior sacrum 2 (PS2) Posterior sacrum 3 (PS3) Posterior sacrum 4 (PS4) Posterior sacrum 5 (PS5) Posterior second cervical (PC2) Posterior sixth to ninth thoracic (PT6-9)
79 160 96 82 163 170 46 175 176 177 178 179 80 98
Posterior tenth [Q twelfth thoracic (PTI 0-12) Posterior third cervical (PC3) Posterior third lumbar, iliac (PL3-I)* Posterior third to fifth thoracic (PT3-5) Piriformis lateral (PRL)* Radial head pronator (RHP)* Radial head supinator (RHS)* Biceps short head (B SH)* Posterior sphenobasilar (PSB)* L"eral sphenobasilar (LSB)* Temporoparietal, ant. (TPA)* Stylohyoid (SH) Subclavius (SCL)* Subscapularis (SUB) upraorbital (SO) Supraspinatus medial (SSM)* Talus (TAL) Teres Major (TMA)* Teres minor (TMI) Anterior medial cervical (AMC)* Infraspinatus inferior (ISI)* Upper posterior fifth lumbar (UPL5)* Palmar wrist (PWR)* Posterior temporal is (PT)*
99 81 162 97 171 130 129 114 47 59 62 49 107 III 56 119 197 124 125 74 123 164 136 61
242
ApPENDIX
'ApPLICATION OF STRAIN AND COUNTERSTRAIN (OR POSITIONAL RELEASE THERAPY) TO THE NEUROLOGIC PATIENT Adapted from Sharon Weiselfish, Ph .D., P.T.
I COMMON STRAIN AND COUNTERSTRAIN OR PRT TECHNIQUES FOR THE NEUROLOGIC PATIENT Upper Quadrant The muscles of the upper quadrant. which, when treated with strain and CQunrcrsrrain [Cch� niques, (or PRT) most efficiently affect spasticity, are as follows: SCS Terminology
PRT Terminology
Page
Anterior cervicals
AC
65-74
Lateral cervicals (scalenes)
LC
75,76
Anterior first thoracic
ATI
86
Elevated first rib
PRI
101
Second depressed rib
AR2
92
Pectoralis minor
PMI
116
Subscapularis
SUB
III
Latissimus dorsi (subluxed hemiplegic shoulder)
LD
117
Third depressed rib
AR3
93
Biceps
BLH, BSH
110,114
Lower Quadrant The muscles of the lower quadrant, which, when tceated with strain and coumerstrain tech� niques, (or PRT) most efficiently affect spasticity. are as follows: SCS Terminology
PRT Terminology
Page
Sacral tender points
PSI-PS5 COX
175-180
Quadratus lumborum
QL
161
Iliacus
IL
151
Piriformis
PRM,PRL
171
Adductor
ADD
158
Medial hamstrings
MH
187
Quadriceps
PAT
183
Gastrocnemius (extended ankle)
PAN
198
Medial ankle
MAN
194
Flexed calcaneus
PCA
207
Medial calcaneus
MCA
205
Talus
TAL
197
ApPENDIX
243
I I PATHOKINESIOLOGIC MODEl EXAMPLES I.
2.
3.
4.
5.
6. 7.
8.
9. 10. II. 12.
13. 14. IS.
I f the patient has a protracted shoulder girdle and there is a limitation in hori zontal abduction, it is assumed that the pectoralis minor is hypertonic with short' ened and contracted muscle fibers. The technique of a second depressed rib would be utilized to decrease the gamma gain of the pectoralis minor. I f the patient has an anteriorly displaced humeral head with an internally rotated shoulder joint and limitation in external rotation, the technique for subscapularis would be utilized. If the patient has a limitation in shoulder abduction and a depressed humeral he," or a caudal subluxation/dislocation of the glenohumeral joint, the techniques for the latissimus dorsi and the third depressed rib would be utilized. If the patient has an elevated shoulder girdle and there is a limitation 10 cervIcal side bending to the opposite side, the lateral cervical techniques would be utili zed, to decrease the gamma gain for the medial scalenes, which elevate the first rib. If the proximal head of the first rib is elevated, rib excursion with respiration is inhlb, ired. and lower cervical range of motion-especially rotation-is limited, the tech, nique for an elevated first rib {PRO can be utilized. I f the patient has a flexed elbow joint and a limitation in elbow extension, the technique for the biceps can be utilized. If the patient has a pronated forearm and a limitation of forearm supination, the pomts for the medial epicondyle can be utilized. Often the proximal radial head is displaced anterior, as a compensatory movement. The technIque for the rodial head (RHS, RHP) can be utilized. If the patient has an elevated pelvic girdle with a limitation of lumbar side bending to the opposite side, the technique for the quadratus lumborum (the anterior twelfth thoracic tender point) can be utilized. If the patient has a hip flexion tightness or contracture with a limitation of hip exten# sion, the technique for the iliacus can be utilized. If the patient has an adducted and internally rotated hip and there is a limitation of external rotation of the hip, the technique for the adductor can be utilized. If the patient has a flexion synergic pattern of spasticity at the knee and there IS a limitation of knee extension, the point for the medial hamstrmgs can be utilized. If the patient has an extensor synergic pattern of spasticity at the knee with a Iimlta# tion of flexion, the technique for the quadriceps (patella extenso,,) can be utilIZed. If the patient has an equinus posture with a plantar flexed foot and a limitation in dorsiflexion, the technique for the medial gastrocnemius (PAN) can be utilized. If the patient has an equinovarus foot posture with a limitation in eversion. the technique for the medial ankle and medial calcaneus can be utilized. If the patient has a clubfoot with an internal rotated and dropped talus, the tech nique for [he talus can be utilized.
244
ApPENDIX
'THE I MPORTANCE OF SOFT TISSUES FOR STRUCTURAL SUPPORT OF THE BODY Stephen M. Levin, M.D. from the Potomac Back Center Vienna, Vlrglnlil Reprint requests to: Stephen M. leYln. M.D. Director Poto�C Back Center 1 S77 Springh ill ROild Vienna. VA 22182
Most of us view the skeleton as rhe frame upon which the soft tissues are draped. The POS[� and�beam construction of a skyscraper is the favored model for the spinel! and is used for all biologic structures-the upright spine is regarded as the highest biomechanical achievement. The soft tissues are regarded as stabilizing "guy wires," similar to the curtain walls of steel framed buildings (Fig. I). Skyscrapers are immobile, rigidly hinged, high-energy--consuming, vertically oriented structures that depend on gravity to hold them together. The mechanical properties are New tonian, Hookian, and Iinear.4.S A skyscraper's flagpole or any weight that cantilevers off the building creates a bending moment in the column that produces instability. The building must be rigid to withstand even the weight of a flag blowing in the wind. The heavier or far; ther Out the cantilever, the stronger and more rigid the column must be (Fig. 2). A rigid column requires a heavy base to support the incumbent load. The weight of the structure pro; duces internal shear forces that are destabilizing and require energy just to keep the structure intact (Fig. 3).
FIG. I (left). Adult thoracolumbar ligamcmous spine, fixed m the base and {ree at top, under tier; tica/loading, and restramed (It midthoracic and midlumbarle�els in the antero/X)sterior plane. A, before loading. 8, during loading. C, stability failure occuring under a load of 2.04 kg. 0, /ateral view showing amerolX)sterior reSlrainr.s. (From Morris
B
A
0.9 Meters
JM. Mukolk Kl: Biomechanics of the lumbar spine. In Amer· iean Academy of Orthopaedic Surgeons: Adu of Orthotics: Blomechanical Principl es and Application. St. louis, Mosby,
1975: with permission.) 0.9 Meters
11
FIG. 2
(Above, left).
[J [J
Befuiing stresses in a beam. (From Gallleo: Discord e dlmonstnzioni matematiche lI'ltomo
due nuove sdenze. leiden. 1638.)
a
(Above, right). \Vhen simple coml}Tessitle load is apt>lied, bofh coml}Tessive wui shear sm�sses 1fI1L'if cxist on t>/anes that are oriemed obliquely fO fhe line of application to fhe load..
FIG, 3
SPINE: State of the Art Reviews-Vol. 9. Phil adel phia. Hilnley & 8elfus. Inc.
No.
2 May 1995 .
ApPENDIX
FIG. 4. A log of 200 kg Iocaced 40 em from the ful crum requires a muscle reacrion farce of 8 x 200 kg. The erectores spinae group can generate a farce of abow 200-400 kg, whc i h du! force Utal is necessary. There/ore, muscle power alone cannm. lift such a load, and another Slt/>(>OTting member is reqtlircd. (Courtesy of Serge Gr.tcovetsky, PhD.)
245
=
FIG. 6.
Bird
Skeleton.
(Courtesy of Califomia Aademy
of Sciences, San Francisco.)
�
+
""
FIG. 5.
.......... ,"
1
FIG. 7.
""
"'"
frame.
Loading a squlIre and a triangular (lnUS)
Balancing comtJTe5siw loads.
Biologic structures are mobile, flexibly hinged, low�energy-consuming, omnidirectional structures that can function in a gravity�free environment. The mechanical properties arc non� Newtonian, non-Hookian, and nonlinear. S If a human skeletal system functions as a lever, reaching ou[ a hand or casting a fly at the end of a rod is impossible. The calculated forces with such acts break bone, rip muscle, and deplete energy (Fig. 4). A post-and-beam cannot be lIsed to model the neck of a flamingo,the tail of a monkey, the wing of a bat,or rhe spine of a snake (Fig. 5). Because invertebrates do nOt have bones,there is no satisfactory model to adequately explain the structural intergrity of a worm. Post�and;beam modeling in biologic Structures could only apply in a perfectly balanced,rigidly hinged,upright spine (Fig. 6). Mobility is out of the equation. The forces needed to keep a column whose center of gravity is constantly changing and whose base is rapidly moving horizontally are overwhelming to contemplate. If we add that the column is composed of many rigid bodies that are hinged together by flexible,almost frictionless joints, the forces are incalculable.2 The complex can; tilevered beams of horizontal spines of quadrupeds and cervical spines in any vertebrate require tall,rigid masts for support1 that are not usually available. Since post�and;beam construction has limited use in biologic modeling, other structural models must be explored to determine if a marc widely applicable construct can be found. Thompsonli and,later,Gordon" use a truss system similar ro those used in bridges for modeling the quadruped spine. Trusses have clear advantages over the post�and;lintel construction of skyscrapers as a structural support system for biologic tissue. Trusses have flexible,even fric� tionless hinges with no bending moments about the joint. The support elements are either in tension or compression only. Loads applied at any point are distributed about the truss as ten; sian or compression (Fig. 7). In post-and-beam construction, the load is locally loaded and
246
ApPENDIX
A
c
B
D
A, tetrahedron, B, ocwhedron, (, icosahedron, (ension�vectored icosahedron tuirh compression ele� menrs wi!hin Ute tension shell. FIG. 8.
and D,
creates leverage. There are no levers in a truss, and the load is distributed throughout the structure. A truss is fully triangulated, inherently stable, and cannot be bem without pro� dueing large deformations of individual members. Since only trusses are inherently stable with freely moving hinges,it follows that any stable structure with freely moving hinges must be a truss. Vertebrates with flexible joints must therefore be constructed as tfusses. When the tension elements of a truss 8rc wires or ropes, the truss usually becomes uni# diredtional (see Fig. 7); the element that is under tension will be under compression when turned topsy�[Urvy. The tension elementS of the body (the soft tissues-fascia, muscles,liga; ments,and connective tissue) have largely been ignored as construction members of rhe body frame and have been viewed only as the motors. In loading a truss the elements rhat are in tension can be replaced by flexible materials such as ropes,wires, or in biologic systems,liga ments, muscles, and fascia. Therefore, the tension clements are an imegral part of rhe con struction and not just a secondary support. However, ropes and soft tissue can only function as tension elements, and most trusses constructed with tension members will only function when oriented in one direction. They could not function as mobile, omnidirectional struc; rures necessary for biologic functions. There is a class of trusses called censegrityJ structures that are omnidirectional so that the tension elements always function in tension regardless of the direction of applied force. A wire bicycle wheel is a familiar example of a tensegrity struc ture. The compression elements in tensegrity structures "float" in a tension network JUSt as the hub of a wire wheel is suspended in a tension network of spokes. To conceive of an evolutionary system construction of tensegrity trusses that can be used to model biologic organisms, we must find a tensegriry truss that can be linked in a hierar chical construction. It must start at the smallest subcellular component and must have the potential, like the beehive, to build itself. The structure would be an integrated tensegrity truss that evolved from infinitely smaller trusses that could be, like the beehive cell, both structurally independent and interdependent at the same time. This repetion of forms,like in a hologram, helps in visualizing the evolutionary progression of complex forms from simple ones. This holographic concept seems to apply to the truss model as well. Architect Buckminster FullerJ and sculptor Kenneth Snelsonu described the truss that fits these requirements,the tensegrity icosahedron. In this structure,the outer shell is under tcn sian, and the vertices are held apart by internal compression !istrutS" that seem to float in the tension network (Fig. 8). The tensegrity icosahedron is a naturally occurring, fully triangulated, three-dimensional truss. It is an omnidirectional, gravity-independent, flexibly hinged structure whose mechan ical behavior is nonlinear, non-Newtonian, and non-Hookian. Independently, Fuller and
ApPENDIX
FIG. 9.
FIG. 1 0.
247
The icosahedral slTUcture of a virus .
Indefinieely extensive array of tensegriry icosahedra. (From
Fuller RB: Synergetics. New York. Macmillan. 1975: with permission.)
Snelson use this truss [0 build complex structures. Fuller's familiar geodesic dome is an example, and Snelson 12 has used it for artistic sculptures that can be seen around the world. Ingber7.16 and colleagues use the icosahedron for modeling cell construction. Research is underway [Q use this structure in more complex tissue modeling, 16 Naturally occurring exam# pies that have already been recognized as icosahedra arc the self�genera[ing fullerenes (carbon 0 organic molecules),S viruses,17 clemrins,' cells, IS radiolari3,6 pollen grains, dandelion 6 balls. blowfish. and several other biologic structures· (Fig. 9). Icosahedra are stable even with frictionless hinges and, at the same time, can easily be altered in shape or stiffness merely by shortening or lengthening one or several tension ele ments. Icosahedra can be linked in an infinite variety of sizes or shapes in a modular or hierar chical pattern with the tension elemems (the muscles, ligaments, and fascia) forming a con tinuous interconnecting network and with the compression elements {the bones} suspended within that network (Fig. to). The structure would always maintain the characteristics of a single icosahedron. A shaft, such as a spine, may be built that is omnidirectional and can fune.. rion equally well in tension or compression with the intemal stresses always distributed in tension or compression. Because there are no bending moments within a tensegrity structure, they have the lowest energy COSts.
248
ApPENDIX
f'�iiCt��
___ shoulder
/
humerus
ulna
\
r
/'
elbow
radius
Fig. I I .
lco.ro arm.
FIG. 1 2.
E#C column. (Courtesy of Kenneth Snelson.)
Viewed as a model for the spine of human:, or nny vertehrate :-,pecics, the tl'llsion Ico�ahe# lIron space truss (Fig. II) with the hones acting
ilS
rhe compressive tdcmcnr� and the soft ris�
MIl'S as the tenSIOn elements will be swble in i,
tion of Comfort; Posture; Yoga
133, 1 34 Core swhdi:auon, I
c Calcaneus tender points lateral, 204, 206
lateral, 1 93 , 195
medial, 204, 205
medial, 193, 194
plantar, 204 , 207
Annulospiral endings, I I , I I , 1 2 Arachidonic acid, 1 2 Arm;
see
Elbow; Hand/wriSl; Shoulder
palpation of, 2 2 1 Common cxtcn:.or tcndon tender Common flexor tendon tender point,
flexor digitorum longus, 193, 200
tibialis, posterior, 193, 199
Comfort zone, 10, 29- 30, 32
point, 1 3 3 , /35
postures
anterior, 193, 1 96
tibialis, anterior, 1 93 , 20 I
second, 77, 80 third, 77, 8 1 Coccyx tender poinl, 174, 180
treating, 4 3
extensor Jigirorum longus, 193,
ralus, 1 93 , 197
first, 77-79
Chapman's reflexc�, 4
Birth injuries
tender points 0(, 1 93-203
posterior, 193, 198
posterior rendcr points of, 64, 77;83
fourth through sevcnth, 77, 82
1 14
dysfunction 0(, 1 8 1
peroneus, 193, 202
75-76
first, 65, 75
eighth, 77, 83
1 10
Bone [issue, 8, 9
203
lateral lender l'len"" 182, 1 9 1 CubniJ render points dorsal,204 , 208 plantar, 204, 209 Cumul.ulvc trauma lhsordcr. 224; see also Repetitive stram Injury Cuneiform tender pOints Jor"'�ll first through third,204, 2 1 2 plantar firS[ lhrough t1md,204, 2 1 3 Cupules,2
epIcondyle, medial, 1 26 , 1 28 olecranon, lateral/medIal, 126, 132
raJial head pronator, 1 26 , 1 30 raJlal hea" supinator, 1 26 , 1 29 EpIcondyle tender POints lateral, 1 26 , 1 27 meJial, 1 26, 1 28 Ergonomics,223-224 Evaluation of lower body form for, 142 scanning, 5, 35-38,232-233 of lIpper body fom) for, 41 Exercises; see also Bioenergetic exer# ci�es at home, 225 role of, 228 Extensor lJigitorum longus tender POint, 1 93 , 203 Extensor tendon tender point, common, 1 3 3 , 135 Extrafusal fibers, I I , I I
D
F
Devices ,"Slstive,22 1, 250 Diagnosis; see also Scannmg evaluation funcuonal. 3 protocol for, 40 Digastric tender point. 44, 50 Direct [cchni4ue. 2; see also Indirect technique Dominant tender POInt,27. 40; see abo Tender pOlllt:-. III '\C,mnmg evaluation, 36�37 Dynamic neutral position, 3 DynamIC recIprocal balance, 3 DY�(lInction; see also Mlisculo�keletal JY�(lInction; Somatic Jysfunc� lion; specific anatomic areas global,27
Facilitated segments, 1 3 , 11-14 Fascial matrix, effect of trauma on,8 Fascial system,8,9 Jysfunctlon of,14-15 tension of; see Fa�cial tt�n�ion Fascial teruion, 9 normalization of,20 patterns of,14, 1 5 Feldenkrais, I Fibrogenesl� aJhe�ive,9 Fingers; see Ham.l/wrist Flexor JigltOrum longus tender pOint,
E Elhow dy�function of,104 tender pOints of, 104, 126-132 coronOId, lateral/medial, 1 26 , 1 3 1 epIcondyle, lateral, 1 26, 1 27
193, 200
Flexor tendon tender POint common, 1 3 3 , 134 Flower spray endings, II, I I Foot dysfunction of, 1 8 1 tender points of, 1 8 1 , 204-2 1 9 calcaneus, lateral, 204, 206 calcaneus,medial,204, 205 calcaneus, plantar, 204, 207 cuboiJ, dorsal, 204, 208 cubOId,plantar, 204, 209 cuneiform, dorsal, fin:.t through tlmJ, 204, 2 1 2
cunciform,plantar, first through th"d, 204 , 2 1 3 mC{atarsab, dorsal, first through fifth, 204, 2 1 4-2 1 6 metatarsals,plantar, fir�t through ftfth, 204, 2 1 7·2 19 navicular, JONal, 204, 2 1 0 navicular, plantar, 204 , 2 1 1 Frontal tender pOint,44, 57 Functional diagnosis, Ji see also DiagnOSIs Functional techniC, 3
G Gamma bias, II Gamma effercnt neurons, I I Gemellt tenJer POlnl, 166, 1 70 Gcriatric patients treatmg, 23 Global dysfunction,27; see also Mus culoskelctal dysfunction; Somauc dys(ucnllon; specific anatomic areas
Global treatment, vs. local treatmem,27, 27 Glossary, 251-25 3 Glutcus medlu� tender [XHnt, 166, 172
Gluteus ml1llmU� tem.ler [XHnt, 150, 1 5 2 , 168,
Goigi tcndon organs, I I
H Hamstring render POlllts lateral, 182, 188 medIal, 182, 187 Hand/WrISt dysfunction of, 104 tender pOints of, 104, 133- 1 4 1 carpometacarpal,first, 1 3 3 , 138 common flexor tendon, 133 I
134
common extensor tendon, 1 3 3 , 135
mtero�colls, dorsal, 1 3 5 , 140 interosseous, palmar, 1 3 3 , 139 Interphalangeal JOInts, 1 33 , 141
WrI,t, dorsal, 1 3 3 , 1 3 7 WrISt, palmar, 1 3 3 , 136 Head; see Cranium
INDEX
J
High�gain servomechanism, I I Hip/pelvis anterior tender points oC 1 4 3 , 150-158
Joints; see also s/Jecific anatomic areas hypomobility of, 20
adductors, 150, 158
Jones neuromuscular model, I I , 1 2 , 1 2
iliacus, ISO, 1 5 1
Jump sign, 28, 36
Kinectic chain theory, 8, 1 4
sartorius, ISO, 153
Knee
gemelli, 1 66 , 1 70 gluteus medius, 1 66 , 1 72
fourth-iliac, 159, 163
upper fifth, 1 5 9 , 1 64
pubis, lateral, ISO, 157
1 66-173
1 5 9- 1 65
first through fifth, 159, 160
K
pubis, superior, ISO, 155
posterior tender points of, 1 4 3 ,
po�terior tender points 0(, 1 4 3 ,
lower fifth, 159, 165
152 pubis, inferior, ISO, 156
tensor fascia lata, 150, 154
dy,function of, 1 43
third-iliac, 159, 1 62
gluteus minimus, ISO,
dysfunction of, 1 4 3
M
dysfunction of, 1 8 1
Masseter tender point, 44, 53
[ender points of, 1 8 1 , 182-192
Maxilla tender point, 44, 54
cruciate ligament. amerior,
Mechanoreceptors. 1 0 Metatarsal tender points
182, 190 cruciate I igament, posterior,
dorsal, 204, 2 1 4- 2 1 6 first, 204, 2 1 4
182, 1 9 1
iliotibial band, 166, 1 73
hamstring, medial, 182, 187
fourth and fifth, 204 , 2 1 6
piriformis, lateral/medial, 166,
hamstring, lateral, 182, 188
second and third, 204, 2 1 5
171
lateral, 182, 186
plantar, 204, 2 1 7- 2 1 9
sacroiliac, inferior, 1 66, 1 69
medial, 182, 185
fifth, 204, 2 1 9
sacroiliac, middle, 1 66 , 1 68
patella, 182, 183
first, 204, 2 1 7
sacroliac, superior, 1 66 , 1 67 Humerus tender pain[ medial, lOS, 1 1 3
patellar tendon, 182, 184 pes anserinus, 182, 189 popliteus, 182, 192
L
1 73
The Importance of Sof' Tissues for Stnlctural Suppor, of ,he Body, 244-249
o(�l1lotion assessment normalization of, 20
joint, 20
I l iacus tender point, ISO, 1 5 1
second and third, 204 , 2 1 8 Mobiliry; see Hypomobility; Range Muscle spasm
Hypomobility
I l iotibial band tender point, 1 66,
protective, 1 9 Muscle spindles, I I , 1 I
L,mbda tender point, 44, 48
Muscular system, 8-9
Lmissimus dorsi tender point, 105,
Musculoskeletal dysfunction, 7,
1 17 Legs; see Ankle; Knee Lesion; see Facilitated segments; Injury limbs; see Lower limb; Upper limb Lower body
8- 1 0, 2 3 ; see also Global dysfunction; Soma[ic dys� function Myofascial Pain and Dysfunc,ion, 2 Myofascial pain syndrome. 9; see also Pain
Indirect technique, I , 2-4
evaluation form for, 1 42
Myofascial skeletal truSS, 1 4- 1 5
Inflammation
treatment of, 2 3 ; see also s/:>ecific
Myofa!lcial [issue, 1 0
due to injury, 9-10, 1 2 in somatic dysfunction, 8 Infraspinatus tender poinrs inferior, lOS, 1 23
anatomic areas Lower limb
N
dysfunction of, 1 8 1 tender points of, 2 3 , 1 8 1 , 182-
middle, lOS, 1 22
2 1 9; see also specific anatomic
Nasal [ender point , 44, 55
superior, 105 , I 2 1
areas
Navicular tender points
Injury mOtor vehicle, 2 3 tissue, 8- 10, 1 2 Interosseous tender points
Lumbar spine anterior tender points of, 1 43 , 144-149 abdominal second, 144, 146
dorsal, 1 33 , 140
fifth, 1 44 , 149
palmar, 1 33 , 139
first, 144, 1 45
I nterphalangeal joints tender points of, 133, 1 4 1 Intrafusal fibers, I I , 1 1
257
dorsal, 204, 2 1 0 plantar, 204, 2 1 1 Neck; see Cervical spine Neurologic pa[ients treating, 24, 242 Neurolymphatic points, 9; see also
second, 144, 1 47
Acupuncture points; Ah Shi
third, 2 2 3
points; Tender points; Trigger
third and fourth, 144, 1 4 8
poin[s
INDEX
258
Neurovascular poin[�. 9;
see also
Acupuncture points; Ah Shi points; Tender points; Trigger
optimal, 30
points
during treatment, 40;
see aLm spe, cific anatomic areas
NocicepmTs, 1 0 i n somatic dysfunction, 1 2� 1 3
Q
Popliteus tender point, 1 8 2 , 192 Position of comfort, 1 0
Quadratus lumborum tender point, 159, 1 6 1
for fascial dysfunction, 1 5
R
length of treatment in, 1 2 , 30�J I
Nonlinear process of positional release therapy, 8
Position of treatment;
see
Position of
comfort; Treatment procedures
Radial head pronator tender point,
Positional release therapy, I , 20
o
activity level following, 2 2 5 advances in, 5
1 26, 1 29
case srudies in, 37·38
Ohesity considerations in treatment, 2 2 3
Range,of�lllQ(ion assessment, 40
comfort zone in, 29·30, 30
Occipital tender point, 44, 46
contra indications for, 20�21
Occipitomastoid tender point. 44�45
cross�reference charts for, 236�241
Olecranon tender points
diagnosis protocol for, 40
lateral/medial, 1 26 , 1 3 2 O'teopathic positioning table, 250
effects of, 10· 1 5 , 20, 3 1 ergonomics in, 223·224 evaluation forms for, 4 1 ·42, 1 42
Osteoporosis treatment 0(, 23
as global treatment, 27, 27
p P�lin
anterior tender points of. 90, 9 1 ·93
origins of, 1 · 5
first, 90, 9 1
other modalities with, 2 2 1 ·222
second, 90, 92
effects of therapy on, 20
posttreatment reaction to, 3 1 ,
184 Pathokinesiologic determination
2 2 2 · 2 2 3 , 225 forms for, 232·233 tender poims in;
amputee, 24
see
third through tenth, 90, 93 medial tender points of, 90, 94 third through tenth, 90, 94 posterior tender points of, 1 00·103
scanning evaluation in, 35�38
eleventh and twelfth, 100, 103 first, 100, / 0 1
Tender points
treatment
second through tenth, 100, 102 Ruffini receptors, 1 0· 1 1
phases of, 2 1 · 22 plan, 3 1 · 3 3, 37·38, 40
for treatment, 243 Patients
treating, 24 Rib cage
224
patienr relationship in, 222
Patellar tendon tentler points, 182,
Cumulative trauma disorder Respiratory patients
dysfunction of, 84
back, 1 4 3
posttreatmCrH, 225
poims
Repetitive strain injuries, 2 1 ; see also
indications for, 1 0· 1 5, 22·24,
pain arising during, 225
Patella tentler points, 182, 183
Reality checks, 222
Reflex points, 39; see also Tender
home·based, 2 2 5
arising during treatment, 2 2 5
myofascial origins 0(, 8, 9, 1 2
1 26, 130 Radial head supinator tender point,
principles of, 29 procedures, 39·40;
anatomic areas
communication widl, 222
s
see also specific
Sacroiliac tender points
geriatric, 2 3
Positioning table, 250
inferior, 1 66 , 169
in mOtor vehicle accidcms, 2 3
Posnrearment, soreness, 222�223,
middle, 166, 168
225
neurologic, 242
superior, 1 66 , 167
obese, 223
Postural asymmetry, 40
pediatric. 23
Posture, I ;
with sports inj uries, 2 3�24
see also Body positioning;
Yoga postures
respiratory, 24
somatic dysfunction and, 8
Sacrulll posterior tender points of, 1 4 3 , 1 74·180 coccyx, 174, 180
Pectoralis major tender point, /05, I 15
Proprioceptors, 1 0· 1 2
fifth, 1 74 , 179
Pecroralis minor tender point, 105, 1 1 6
Protective muscle spasm, 1 9
first, 1 74 , 1 75
Pediatric patients
PRT;
neating, 2 3 Pelvis;
see Hip/pelvis
Peroneus