Positional Release Therapy

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. 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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