Therapeutic techniques Chapter 6 6.5.7 Self-mobilization of the while with her thumb and forefinger she takes hold extremity joints of the first phalanx or the first metacarpal bone. This technique can be used both for traction as Obviously, the patient can also perform self-mobi- well as for mobilization of metacarpophalangeal lization of peripheral joints, especially in the lower joints II–V and of the carpometacarpal joint of the extremities, because both hands are free. This pos- thumb. sibility has already been alluded to in Sections 6.1.2 and 6.1.3 for some patient categories. Only a few Self-mobilization of the elbow in a instances will therefore be outlined here. radial direction Self-applied traction of the The standing patient grasps the edge of the treat- carpal bones ment table, with her arm held vertically and stretched in supination so that her thumb lies par- The patient sits with her legs crossed and fixes her allel with the edge of the table. Her other hand forearm on her thigh. With her free hand she takes grasps her elbow from the ulnar side and produces hold of one carpal or metacarpal bone (depending mobilization there by gentle rhythmic springing or on which she wishes to treat) between her thumb by a fast shaking movement in a radial direction and forefinger and performs traction in a distal (see Figure 6.83). direction (see Figure 6.82). Self-applied traction at the shoulder Traction of the fingers Traction at the shoulder can also be performed as Using the little finger of her other hand the patient PIR over the padded back of a chair, provided that grasps the distal phalanx of the finger to be treated, the chair back is softly padded and supports the side Figure 6.82 • Self-applied traction of the carpal bones. Figure 6.83 • Self-mobilization of the elbow in a radial direction. 245
Manipulative Therapy longitudinal axis of the arm until the slack is taken up. She then resists her own traction, breathes in slowly, breath-holds, and then relaxes as she breathes out. This procedure can be repeated at least three times. Self-mobilization of the knee The patient is seated on a low chair or stool and stabilizes her slightly abducted leg on her foot, which is first in external rotation and then in inter- nal rotation. When the foot is in external rotation, the patient takes hold of her knee with her oppo- site hand placed medially, takes up the slack using light lateral pressure, and shakes her knee in a lat- eral direction (see Figure 6.84A). When her foot is in internal rotation, she takes hold of her knee with her hand on the same side placed laterally. After taking up the slack using pressure directed medi- ally, she performs shaking mobilization in a medial direction (see Figure 6.84B). Shaking should never be forceful but should be at a frequency that produces rapid, rhythmic, spon- taneous springing of the joint. 6.6 Post-isometric relaxation and reciprocal inhibition 6.6.1 Basic principles Figure 6.84 • Self-mobilization of the knee by shaking Post-isometric relaxation (PIR) techniques as well (A) laterally with the foot in external rotation, and (B) medially as reciprocal inhibition (RI) have already been with the foot in internal rotation. alluded to in the context of mobilization techniques in Section 6.1. The method forms a connecting link of the patient’s thorax and not the axilla. Using her between therapy and rehabilitation: it is simulta- non-lesioned hand, the patient takes hold of her neously the specific therapy for muscle spasms, other forearm and applies light traction along the especially of TrPs, but always presupposes activity on the part of the patient. All the techniques pre- sented in this section have been selected because they may also serve as self-treatment methods. It has already been mentioned that Mitchell et al (1979) use muscle facilitation and inhibition in their muscle energy technique for joint mobiliza- tion. Nothing was therefore more logical than to use the method in muscle dysfunctions. However, this is at variance with what Mitchell et al originally wrote: ‘When isometrics are used for joint mobi- lization, maximal contractions are not desirable since they tighten, or freeze, the joints. Moderate 246
Therapeutic techniques Chapter 6 contractions are much more appropriate for joint relaxation is used alone, the contraction and relaxa- mobilization … However, when a muscle or its fas- tion phases should each last for 20 seconds. This cia must be stretched, powerful isometric contrac- approach can be used as self-treatment right from tions are useful …’ the outset. When combining PIR with inhalation and exhalation, it is important that both inhalation Experience indicates, however, that the use of and exhalation should be of sufficient duration, if a minimum of force during isometric contraction possible 10 seconds or longer. To achieve this it is is also much more advantageous in the treatment recommended that once inhalation (and sometimes of TrPs. Therefore, as for relaxation, we proceed also exhalation) has ended, the patient should as follows: the muscle is first stretched only as far breath-hold to slow the respiratory rhythm. as is possible without meeting any resistance. In the (extreme) position thus gained, the patient is PIR is routinely combined with RI. For this instructed to resist with a minimum of force and there are two options: one involves the tech- (in the case of the muscles of the trunk) usually nique developed by Ivanichev (1997) in which the to breathe in. This resistance is held for 5–10 sec- patient performs a forceful movement of maximal onds, after which the patient is told to let go and excursion in the direction into which relaxation is breathe out slowly. After a brief wait, the practi- intended. In the other option, the patient makes a tioner will sense that the muscle is de-contracting movement using only a minimum of force against or lengthening, thus allowing a new end position to rhythmic repetitive resistance from the practitioner. be reached. This phenomenon can be utilized for as Maximal forces are also undesirable here because long as the muscle continues to lengthen purely due they can easily lead to a ‘duel’ between patient and to the patient’s own relaxation. This phase may last practitioner in which the practitioner may actually for 10 seconds, but also for longer than 30 seconds. come off worse. Rhythmic repetitive resistance The process should never be cut short because it achieves the same inhibiton as one-off maximal is crucial for the therapeutic effect. If relaxation resistance. proves to be unsatisfactory after the isometric ten- sion phase, the isometric phase can be prolonged, The effect of treatment can be ascertained not sometimes to as much as half a minute. However, if only in the muscle (TrP) treated, but also at its good relaxation is achieved at the first attempt, the attachment point as well as at the attachment isometric phase may be shortened. The procedure points of ligaments which transmit the tension. can be repeated depending on how well the patient Often the discomfort in question will be referred relaxes. If relaxation is good, the practitioner will pain, which has a tendency to react favorably. TrPs sense how the tension ‘melts away’ so to speak. that are significant for the pathogenesis also give rise to chain reaction patterns (see Section 4.20) It is not possible for the practitioner to relax the involving multiple TrPs and movement restrictions, patient; this is something that the patient must do. and hence treatment can have a significant distant In this process the muscle also stretches effect. (spontaneously). As soon as the muscle is being stretched by the practitioner, it is no longer The method is also highly specific: in broad, fan- legitimate to call it relaxation (PIR). shaped muscles the forces need to be directed pre- cisely at the muscle bundles that harbor TrPs, and Wherever possible, PIR should be enhanced by also at the attachment point that belongs with the methods that utilize inhalation and exhalation, muscle bundle, for example where the attachment direction of gaze, and gravity for resistance (as point of the pectoralis muscle to a rib is painful. advocated by Zbojan (1984)). At this point we Hence one common reason for failure is insufficient would reiterate what has already been said concern- specificity. This method is inappropriate where ing the combination of mobilization techniques. there is no increased muscle tension (e.g. at pain- Instructions that determine direction (e.g. of gaze, ful hypotonic pain points in the fibromyalgia syn- pressure) should precede breathing instructions, so drome). The same naturally applies in situations as to prolong the process. When gravity-induced where the treated TrP itself is a secondary phenom- enon and its cause remains untreated. With regard to the theory underlying this physi- ologically highly effective method of muscle relax- ation, it is suspected that what we are dealing with here is not simple Sherrington-type inhibition. 247
Manipulative Therapy The latency periods are far too long for this. The response. Usually these are not just single points, patient is responding after all to verbal instruc- for which reason we do not recommend injecting tions. This is also the case with Kabat inhibition, local anesthetics. With needling it is possible to which is why a simple spinal reflex is hardly worth- ascertain with the needle still in situ that the TrP while considering. As described here, the effect of has been eradicated and is no longer painful. PIR may be due to the fact that: The following sections provide precise descrip- • when minimal force is used, only those muscle tions of techniques that can be used to diagnose and fibers contract that have a low stimulus treat functionally reversible TrPs in the individual threshold, as is the case in muscle TrPs muscles. • and consequently, we avoid the stretch reflex, 6.6.2 Muscles of the head which always comes into play with passive and neck stretching – even of a gentle variety. Masticatory muscles It may even happen that the patient experiences some pain during relaxation, even though the range Increased tension in the masticatory muscles is of movement increases during relaxation, for exam- present if the patient is unable to insert three ple during PIR in ligament pain. Despite this, the knuckles between the upper and lower rows of inci- pain disappears once PIR is complete. PIR impres- sors with mouth wide open. Tenderness of the tem- sively demonstrates how tension is associated with poromandibular joint (TMJ) is also routinely found pain, and relaxation with the absence of pain. on palpation. TrPs in the temporalis can be pal- pated in the temporal region, those in the masseter PIR is also comparable with the ‘spray and through the cheeks, those in the internal pterygoid stretch’ method of Travell (1952) but places behind the ramus of the mandible, and those in the greater emphasis solely on relaxation while refusing external pterygoid inside the mouth above the wis- to accept any stretching (even of a gentle variety). dom teeth. TrPs here are particularly common and The cold spray evidently causes transient inhibi- intensely painful. tion of the stretch reflex and therefore stretch is not an interfering factor here. Indeed, stretch is PIR to relax all of these muscles is performed as by no means an essential component of relaxation, follows: the patient is supine with her head at the as demonstrated by many techniques that utilize end of the treatment table. The practitioner fixes gravity, and in relaxation of the gluteus maximus the patient’s forehead with one hand and places her muscles (see Section 6.6.5). It has been found that other hand on the patient’s chin. She takes up the stretch need not necessarily occur at all; it serves slack by opening the patient’s mouth to a moderate rather as clinical proof of successful relaxation. degree (see Figure 6.85). The following respiratory synkinesis is then used: during (slow) exhalation Passive stretching is indicated in situations where the connective tissue element of the muscle is Figure 6.85 • PIR (RI) of the masticatory muscles. shortened, that is where the muscle sheaths – the connective tissues encasing the muscle bundles and fascia – are involved. PIR acts on the contractile elements in muscle. This effect has been documented in 351 muscle groups in 244 patients (Lewit & Simons 1984); an immediate analgesic effect was detected in 330 muscle groups, while no effect at all was recorded in 21 patients. As stated previously, some TrPs do not respond to methods that operate using reflex pathways, and also fail to respond when chain reaction patterns are treated. These would appear to be no longer functionally reversible. In such cases treatment then consists of traumatizing massage or needling in which it is important to ‘hit’ the maximally painful points and, where possible, also to produce a twitch 248
Therapeutic techniques Chapter 6 there is an automatic increase in resistance to mouth by shifting the thyroid cartilage from side to side; opening. At this point, however, the patient is told resistance is greater on the side where the digastri- to take a deep breath while energetically opening cus is tense. If tension is marked, then deviation of her mouth wide, as when yawning. The procedure is the cartilage to the tense side may even be visible, repeated two or three times. In this instance active as may a depression in the floor of the mouth on the mouth opening also provokes RI. tense side and a flattening on the other side. Self-treatment For PIR the patient should be supine; with one hand placed below the patient’s chin the prac- For self-treatment the patient sits at a table, with titioner should resist mouth opening while the one elbow on the table and the same hand support- thumb of her other hand is placed laterally against ing her forehead; the fingers of her other hand are the patient’s hyoid and palpates resistance (see resting on her lower incisors (see Figure 6.86). After Figure 6.87A). During the isometric phase the opening her mouth to take up the slack, she first breathes out; during deep inhalation she then opens her mouth as wide as possible. The hand at her fore- head should prevent anteflexion of her head, which would interfere with maximum mouth opening. However, her head should also not tilt backward. Digastricus The main antagonists of the masticatory muscles are the muscles at the floor of the mouth, principally the digastricus. Examination is most readily performed Figure 6.86 • PIR (RI) of the masticatory muscles Figure 6.87 • PIR of the digastricus: (A) treatment; (self-treatment). (B) self-treatment. 249
Manipulative Therapy patient opens her mouth against the resistance applied by the practitioner’s hand under her chin, breathes in, breath-holds, and then relaxes and breathes out. In this process the patient’s mouth will close and the practitioner will sense how lat- eral resistance at the hyoid subsides. It is therefore necessary prior to PIR to palpate the hyoid bone. While she must be able to feel the tension and relaxation, the practitioner must never poke about with her thumb at the hyoid. Self-treatment For self-treatment of the digastricus the patient is seated with one elbow supported on a table and her chin cupped in the same hand. The thumb of her other hand lies lateral to the hyoid on the tense side (see Figure 6.87B). Against the resistance of her chin against her hand, she opens her mouth, breathes in, breath-holds, and then relaxes while breathing out. The procedure is repeated two or three times. Mylohyoid If there is increased tension in the mylohyoid mus- Figure 6.88 • PIR of the external pterygoid: (A) treatment; cle at the floor of the mouth, the following self- (B) self-treatment. treatment method is indicated. The patient presses the tip of her tongue against her hard palate, breathes in, and lets her tongue drop back while breathing out. External pterygoid Short extensors of the craniocervical junction For specific treatment of the external pterygoid muscle the patient is supine with her mouth only Palpatory examination of these muscles is possible slightly open. From above, the practitioner places only with the patient supine and her head slightly both thumbs on the patient’s chin (see Figure raised. For treatment, the practitioner stands 6.88A). The patient is then told to push her chin behind the seated patient and places both thumbs forward and breathe in while the practitioner offers behind the patient’s head below the occiput, with resistance at the chin. She is next instructed to hold her fingers up over the zygomatic bones. The her breath, let go and then breathe out. patient is then told to look up and breathe in deeply as the practitioner resists the (automatic) retroflex- Self-treatment ion of the head (see Figure 6.89). Afterward the patient is instructed to hold her breath, look down, For self-treatment the patient places her thumbs and breathe out slowly. This must not produce on her chin (see Figure 6.88B). She then pushes anteflexion of the entire cervical spine but merely a her chin against the resistance of her thumbs and nodding movement. Consequently, the practitioner breathes in. After holding her breath, she relaxes as allows the patient’s supported head and upper body she breathes out. to drop slightly back and down without letting the 250
Therapeutic techniques Chapter 6 Figure 6.89 • Treatment of TrPs in the short extensors of the craniocervical junction: (A) resistance with upward gaze; (B) forward nod with downward gaze. head fall forward. The procedure is repeated from the newly gained position. For RI the patient is asked to nod her head for- ward as the practitioner offers rhythmic repetitive resistance. Self-treatment Figure 6.90 • Self-treatment of TrPs in the short extensors of the craniocervical junction: (A) resistance with upward For self-treatment the seated patient stabilizes her gaze; (B) forward nod with downward gaze during occiput from below with her fingers and her zygo- retroflexion. matic bones from above with her thumbs. Using both hands she makes a slight nodding movement superior angle of the shoulder blade and on the lat- to take up the slack (see Figure 6.90A). She then eral surface of the spinous process of the axis. looks up and breathes in, holds her breath, then leans back against the back rest of the chair, looks For treatment, the patient is supine with her head down, breathes out, and gives a forward nod while at the top end of the treatment table and the elbow doing so (see Figure 6.90B). of her flexed arm raised beyond her head. The prac- titioner exerts pressure on the patient’s shoulder Levator scapulae The typical TrP lies in the angle between neck and shoulder. Further pain points are located at the 251
Manipulative Therapy blade by pressing in a caudal direction against the is being treated and slowly breathe in, then to hold elbow, fixing the elbow in this position with the thigh her breath, let go and breathe out. During the ensu- in order to take up the slack in the levator scapu- ing relaxation the practitioner moves the patient’s lae. Using both hands the practitioner moves the head to the opposite side until light resistance is again patient’s head to the opposite side until light resist- encountered. The procedure is repeated. ance is encountered. This is felt sooner on the side of increased tension than on the other side. The practi- If, as is not infrequently the case, the patient tioner then simultaneously raises the patient’s head a cannot raise her arm as the above technique little and turns it to the same side (see Figure 6.91A). requires, then the practitioner may employ the The patient is instructed to look toward the side that method described by Sachse, which can also be used to test for muscle shortening. With the patient supine, the practitioner uses the palm of one hand to draw the patient’s shoulder caudally so as to fix it and positions her fingertips at the attachment of the levator scapulae at the superior angle of the shoulder blade. She places her other hand round the patient’s neck, raises the head into anteflex- ion, and produces side-bending above C4 to the opposite side until she feels tension at the muscle attachment point (see Figure 6.91B). The patient is then instructed to look toward the side of the tense muscle and breathe in slowly, hold her breath, then let go and breathe out. The procedure is repeated. Upper part of the trapezius Painful TrPs can be readily palpated along the entire length of the upper part of the trapezius. For treat- ment (and for examination), the patient is supine: the practitioner fixes the patient’s shoulder from above with one hand, while side-bending the head and neck with her other hand to take up the slack (see Figure 6.92). She then instructs the patient Figure 6.91 • Examination and PIR of TrPs in the levator Figure 6.92 • Examination and PIR of the upper part of scapulae (A) with fixation of the shoulder blade via the the trapezius. patient’s elbow pushed caudally by the practitioner’s thigh, and (B) with fixation of the shoulder using Sachse’s method. 252
Therapeutic techniques Chapter 6 to look in the direction of the stabilizing hand and breathe in slowly, then breath-hold, let go and breathe out. During relaxation the practitioner takes the patient’s head further into side-bending until the slack is taken up again, and the procedure is repeated. For RI the patient exerts pressure with her head toward the side of the tense muscle while the prac- titioner offers rhythmic repetitive resistance. Self-treatment For self-treatment of both the levator scapulae and the upper part of the trapezius, gravity-induced PIR is most effective. The patient sits against a low chair back with both arms hanging down over and behind it, to ensure as upright a posture as possible. In this position she looks up, raises her shoulders, breathes in (see Figure 6.93A), holds her breath and looks down, lets her arms drop, and breathes out slowly (see Figure 6.93B). This procedure is repeated several times. For RI the patient exerts downward pressure with both arms toward the floor. Scalenes While tension of the scalenes causes minimal direct Figure 6.93 • PIR of the levator scapulae and the pain, it is of great clinical significance. As a rule the trapezius: (A) with shoulders raised, looking up, and scalenes are involved in tension of the other upper breathing in; (B) with shoulders relaxed, looking down, fixators of the shoulder girdle; they play a decisive and breathing out. role specifically in the faulty clavicular breath- ing pattern that is characterized by lifting of the be examined (treated), and with one hand fixing the thorax during inhalation. Tension in the scalenes upper ribs on the same side. With her other hand leads to tension in the pectorals with pain points she tilts the patient’s head (turned to the opposite in the region of the sternocostal joints. This is often accompanied by a sensation of tightness that subsides after the scalenes have been treated. In restriction dysfunction of the first rib the scalenes develop reflex tension and this is one contributing cause of the thoracic outlet syndrome (see Section 7.5.2). The site of the typical TrP in the scalenes corresponds to Erb’s point and usually responds to PIR. Tension in the scalenes causes restriction of retroflexion of the rotated head to the opposite side. If there is marked cervical lordosis, tension of the scalenes may even restrict side-bending of the head, simulating increased tension in the trapezius. For examination, as for treatment, the practi- tioner stands behind the seated patient, using her body to support the patient’s shoulder on the side to 253
Manipulative Therapy Figure 6.94 • Examination and PIR of the scalenes. side) slightly backward so as to take up the slack (see Figure 6.95 • Self-treatment of the scalenes: (A) with head Figure 6.94). The patient is then told to look up and raised, looking up, and breathing in; (B) with head on the to the side and to breathe in. As the patient breathes treatment table, looking down, and breathing out. in, the practitioner offers powerful resistance with her hand placed on the patient’s ribs, while her other hand at the side of the patient’s head offers only minimal resistance. As the patient breathes out, she looks to the opposite side and allows her head to drop into retroflexion. Considerable relaxation gen- erally occurs spontaneously with the result that it is rarely necessary to repeat the procedure. Self-treatment pain point at the transverse process of the atlas; painful attachment points may be detected medi- Self-treatment of the scalenes is possible provided ally at the clavicle and at the mastoid process. that the faulty clavicular breathing pattern char- The muscle develops TrPs in response to most dis- acterized by thoracic lifting is not being treated turbances involving the head, neck, and even the simultaneously. For this the patient lies on her cervicothoracic region, and it is a good indicator of side, raising her head from the padded cover of the untreated dysfunctions in this whole territory. treatment table, and breathes in slowly (see Figure 6.95A). She then holds her breath, allows her head To treat this condition, use is made of gravity- to sink back (under gravity) to the treatment table induced PIR and respiratory synkinesis. The patient while breathing out, and then repeats the exercise lies supine, with her head rotated and resting over (see Figure 6.95B). the edge of the treatment table, so that her chin and mastoid process are (gently) supported by the For RI the patient exerts strong pressure with edge of the table. In this position the patient is told her head against the padded cover. to look up at her forehead and to breathe in slowly and deeply. As she does this the sternocleidomastoid Sternocleidomastoid muscle automatically contracts, causing the patient’s head to lift slightly with a side-nod (see Figure TrPs are almost invariably detected (using a pincer 6.96A). After holding her breath, the patient looks grip) along the course of this muscle in dysfunctions toward her chin and breathes out slowly, causing the of both the cervical region and the orofacial region; sternocleidomastoid to relax and her head to be low- these are associated with pain that is referred to ered (see Figure 6.96B). The act of looking up and the cranium and face. There is frequently also a down facilitates inhalation and exhalation, and the 254
Therapeutic techniques Chapter 6 attachment point pain around the che-gu point well known to acupuncturists. Its relaxation is important in the setting of reflex therapy. For treatment by PIR, the practitioner abducts the patient’s thumb to engage the barrier. The patient is then instructed to adduct her thumb as the practitioner resists with minimal force and to let go after 5–10 seconds (see Figure 6.97A). The procedure is repeated. This is followed by RI in which either the patient performs maximum abduction herself or the prac- titioner (or the patient herself) offers rhythmic repetitive resistance to abduction. Self-treatment The patient uses her other hand to resist adduction (see Figure 6.97B). Figure 6.96 • Gravity-induced PIR of the sternocleidomastoid: (A) with head turned to the side, the patient looks up at her forehead and breathes in, automatically contracting the sternocleidomastoid; (B) she looks down at her chin and breathes out, relaxing the sternocleidomastoid, and letting her head drop. contraction and relaxation of the sternocleidomastoid occurs in the context of respiratory synkinesis. The patient repeats the exercise several times. This technique serves not only to relax the sternoc leidomastoid muscle. It is also a very effec- tive self-mobilization technique for movement restriction at the atlanto-occipital joint because it encourages side-nodding. In the exceptional cases where respiratory synkinesis is insufficient, the patient may also deliberately raise her head slightly. 6.6.3 Muscles of the upper extremity Adductor pollicis Figure 6.97 • PIR of the adductor pollicis: (A) the practitioner uses her fingers to resist adduction of the The attachment point for this muscle is at the thumb; (B) self-treatment. second metacarpal. The TrP in this muscle causes 255
Manipulative Therapy Radial epicondylopathy Alongside movement restriction at the elbow, TrPs may be present in the supinator, the forearm exten- sors, and the biceps and triceps brachii. The presence of a TrP in the supinator is con- firmed by restricted pronation compared with the non-lesioned side. For treatment, the patient should be seated in front of the practitioner or supine. The practitioner places one hand laterally to fix the patient’s elbow, which is flexed at right angles. With her other hand she takes the patient’s forearm at the wrist into pronation to take up the slack (see Figure 6.98A). She then instructs the patient to resist with minimal force in the direction of supina- tion, holding this for 5–10 seconds and then letting go. As the patient breathes out, pronation should increase markedly. The procedure is repeated from the newly gained pronation position. For RI rhythmic repetitive resistance is offered against pronation performed by the patient. Self-treatment The procedure for this is self-evident but care must be taken to ensure that the patient keeps her elbow against her trunk and does not move it forward away from her body (see Figure 6.98B). For RI the patient forcefully performs maximal pronation resisted by her other hand. Finger and hand extensors TrPs in the finger and hand extensors cause move- Figure 6.98 • PIR of the supinator muscle: (A) treatment ment restriction, which can be tested very accu- and testing for TrPs; (B) self-treatment. rately by approximating the patient’s fingertips as far as possible toward the palmar aspect of her fore- Self-treatment arm, and comparing with the fingers of the other hand (see Figure 6.99A). This test involves simul- Here, too, the procedure for self-treatment is taneous flexion of the wrist and fingers. The TrPs obvious. The main difference is that the patient can be readily palpated in the forearm. For PIR the mainly places her thenar eminence over the fin- practitioner places her thenar eminence or fingers gertips of the hand being treated and uses her over the back of the patient’s hand and fingertips, so fingers to flex the wrist of the treated hand (see as to approximate them to the forearm; the result Figure 6.99B). can be measured by using the fingers of her other hand. The slack is taken up in this way. The patient next resists the pressure of the practitioner’s hand for 5–10 seconds and then lets go. During relaxation there is a measurable increase in flexion. For RI the patient flexes her fingers while the practitioner offers rhythmic repetitive resistance against flexion. 256
Therapeutic techniques Chapter 6 Biceps brachii When TrPs are present in the biceps brachii it will be found that extension at the elbow is somewhat restricted. Treatment involves gravity-induced PIR. The seated patient supports her extended elbow on one knee, then bends the elbow a little and holds her forearm slightly raised for 20 seconds (see Fig- ure 6.100A). She then allows her forearm to drop back to its original position and relaxes for 20 sec- onds (see Figure 6.100B). The exercise can be repeated two or three times. For RI the simplest method is to perform maxi- mal active extension at the elbow. Figure 6.99 • PIR of tensed finger and hand extensors: (A) examination and treatment; (B) self-treatment. The patient can also perform RI by rhythmically Figure 6.100 • Treatment of TrPs in the biceps and repetitively resisting the flexion of the treated brachii: (A) with the forearm slightly raised; (B) during hand. relaxation the forearm rests in extension on the patient’s knee. 257
Manipulative Therapy Triceps brachii When TrPs are present in the biceps brachii they are also routinely found in its antagonist, the triceps brachii. According to Krobot (1994), primary TrPs in the triceps brachii cause axillary pain. They can be palpated in the long head of the triceps close to the axilla and the patient reports pain on extension of the elbow joint under pressure (e.g. when doing press-ups). Treatment involves gravity-induced PIR. The patient is seated and raises her arm vertically, flexes it at the elbow, and places her hand on the top of her head. She then lifts her forearm a little and holds it there for 20 seconds (see Figure 6.101A). Afterward she lets it fall again to her head and relaxes for 20 seconds (see Figure 6.101B). The exercise can be repeated two or three times. For RI the patient exerts forceful pressure with her hand on her cranium. Ulnar epicondylopathy In this condition TrPs are present in the digital flexor muscles on the ulnar side. For treatment, the patient is seated in front of the practitioner with elbow fully flexed and forearm in supination. The practitioner takes hold of the patient’s dorsiflexed hand from the radial edge and supports the back of the hand with her thumb. The patient’s hand is then taken into dorsiflexion and pronation to take up the slack (see Figure 6.102A). The patient resists with light pressure toward flexion and supi- nation. After 5–10 seconds she relaxes in the direc- tion of pronation and dorsiflexion. The procedure can be repeated two or three times. For RI the patient exerts pressure toward prona- tion while the practitioner offers rhythmic repeti- tive resistance into supination. Self-treatment Figure 6.101 • Treatment of the triceps brachii: (A) with forearm slightly raised; (B) during relaxation the patient’s With the hand to be treated in the same position hand rests on her head. as above, the patient places the fingers of her other hand on the palm of her dorsiflexed hand from the Supraspinatus ulnar side, while supporting the back of the hand with her thumb. She takes up the slack into supi- TrPs in the supraspinatus muscle are found in the nation and dorsiflexion and then offers isometric fossa supraspinata. On abduction against resist- resistance in the direction of pronation and flexion ance the patient typically feels pain at the greater (see Figure 6.102B). After 5–10 seconds she relaxes and dorsiflexion and supination are amplified. This exercise is repeated three times. 258
Therapeutic techniques Chapter 6 Figure 6.103 • PIR of the supraspinatus: (A) examination and treatment; (B) self-treatment. Figure 6.102 • PIR of the hand and finger flexors: Figure 6.103A). In this position she tells the patient (A) examination and treatment; (B) self-treatment. to exert slight counterpressure into abduction while breathing in, and then to relax as she breathes out, causing adduction to increase. The procedure is repeated from the newly gained position. For self- treatment the patient does exactly the same, using her own hand (see Figure 6.103B). For RI the patient exerts forceful adduction of her arm resisted by her other hand. tubercle. For treatment, the practitioner stands Infraspinatus behind the patient and supports her. She brings the patient’s flexed arm medially into adduction The infraspinatus is a common source of shoulder in front of her chest, to take up the slack (see pain. TrPs here are palpated in the fossa infraspinata. 259
Manipulative Therapy Figure 6.104 • PIR of the infraspinatus. The patient’s that is the ‘frozen shoulder’ position. It appears that arm, abducted at right angles and flexed at the elbow, is there is indeed a close relationship between the in internal rotation: (A) with forearm slightly raised; (B) with subscapularis and frozen shoulder, and that TrPs in forearm lowered during relaxation. the subscapularis may accompany frozen shoulder from the outset through all its stages. For diagno- External rotation against resistance provokes pain sis it is necessary to palpate the TrPs directly. For at the attachment point with the greater tubercle. this, the patient is supine with her arm abducted Gravity-induced PIR is used both for treatment and at about 60°. In this position the practitioner takes self-treatment. The patient is supine with her arm in hold of the patient’s forearm and exerts light latero abduction over the side of the treatment table and her caudal traction along the axis of the patient’s arm. elbow bent at right angles so that her forearm points With the fingers of the other hand, the practitioner toward her hip (i.e. her shoulder is in internal rota- slips over the edge of teres major and latissimus tion). The effect of gravity causes the muscle slack to dorsi deep into the axilla on the ventral aspect of be taken up (see Figure 6.104A). The patient next lifts the shoulder blade to palpate the exquisitely tender her forearm about 2 cm, holding it in this position for TrPs of the subscapularis. about 20 seconds. She then relaxes for at least 20 sec- onds and lets her forearm drop (see Figure 6.104B). Frequently, however, the pain is not consistent From the newly gained position the procedure is with that of frozen shoulder where pain radiates repeated two or three times. The patient can perform as far as the wrist. The pain may simply be felt in this exercise as self-treatment several times a day. the shoulder, shoulder blade, or thorax; if this pain occurs on the left side, it may also present as car- For RI the patient exerts downward pressure diac pain or dyspnea with respiratory limitation with her hand. due to costal restrictions. These conditions are fre- quently associated with TrPs in the subscapularis. Subscapularis The subscapularis should therefore always be pal- pated in cases of pain of unknown origin involving If the subscapularis muscle goes into spasm (con- the shoulder and thorax. tracts), the result is adduction and internal rotation, Here, too, gravity-induced PIR is used for (self-) treatment, with the patient positioned as described for the infraspinatus (see above), the difference here being that her forearm is pointed cranially (see Figure 6.105A and B). However, it is likely that a patient with a frozen shoulder will not be able to abduct the arm at right angles and that external rotation will also be restricted. In such circum- stances the patient should abduct the arm just a little in order for there to be sufficient external rotation for gravity to enhance external rotation still further. It is necessary in such cases for the patient to perform the exercise while side-lying on the painful shoulder (see Figure 6.105C and D). For RI the patient exerts active pressure with her forearm into external rotation. Latissimus dorsi and teres major These two muscles constitute a functional unit. In combination with the pectoralis major they adduct the arm. On their own they permit retroflexion of the arm. They clearly play an important role in the synkinetic movement of the arms during walk- ing and also probably during trunk rotation. TrPs in 260
Therapeutic techniques Chapter 6 Figure 6.105 • PIR of the subscapularis: (A) with forearm slightly raised; (B) with forearm lowered during relaxation. Gravity- induced PIR of the subscapularis in frozen shoulder: (C) side-lying, with forearm slightly raised; (D) during relaxation. these muscles are palpated in the axilla and further drawn position of the shoulders. Beneath the clavi- down the back. Pain radiates from the shoulder cle the tendon protrudes on abduction like a ‘false down the ulnar aspect of the arm. clavicle’ and is tender to palpation. For examina- tion, with the patient supine, the practitioner brings For treatment, gravity-induced PIR is most practi- the patient’s arm as far as possible into abduction cal. The patient is side-lying, with her back close to in order to detect any shortening of the pectoralis the edge of the treatment table. The arm to be treated major (see Figure 6.107A). is abducted at 135° and flexed at the elbow (see Fig- ure 6.106A). The patient next takes her arm further Gravity-induced PIR is useful for treatment, into abduction, breathes in slowly, holds her breath, with the patient in the same position as for exami- then relaxes while breathing out and lets her arm nation. She relaxes her arm (which is abducted over fall against her head (see Figure 6.106B). For RI she the edge of the treatment table) until the slack is exerts pressure with her upper arm against her head. taken up. She then raises her arm about 2 cm and breathes in slowly, holds her breath, relaxes and 6.6.4 Muscles of the trunk breathes out slowly, while her arm sinks down again (see Figure 6.107B and C). The procedure is Pectoralis major repeated two or three times. Increased tension (TrPs) of the upper (subclavicular) For RI the patient exerts forceful pressure with part of the pectoralis major results in a forward- her arm toward the floor. Where the sternocostal part of the pectoralis major muscle is tense (TrPs), full elevation of the 261
Manipulative Therapy Figure 6.106 • PIR of the latissimus dorsi: (A) with upper arm raised; (B) with upper arm lowered to rest on head. arm is restricted and the tendon in the axilla is taut as Figure 6.107 • (A) Examining the subclavicular part of the well as tender to palpation. For the examination, the pectoralis major for shortening. (B) PIR of the pectoralis patient is supine. Placing her forearm on the patient’s major, with arm raised during inhalation. (C) Arm lowered sternum, the practitioner fixes the thorax from above, during exhalation. while with her other hand she brings the patient’s arm into maximum (oblique) elevation without applying any force and identifies any muscle shortening (ten- sion) (see Figure 6.108A). TrPs can be palpated here by a pincer movement beneath the axilla as the prac- titioner slips her fingers between the ribs and the flat pectoralis major, while her thumb palpates through the overlying skin, eliciting a twitch response. Gravity-induced PIR is useful for self-treatment. Like the practitioner previously, the patient per- forms the same elevation movement with her arm over the edge of the treatment table, then lifts her arm just a very little, breathes in slowly, holds her breath, and then relaxes slowly while breathing out (see Figure 6.108B and C). For RI the patient herself performs maximal forceful elevation. 262
Therapeutic techniques Chapter 6 Figure 6.109 • PIR targeted specifically at the muscle bundles of the pectoralis major that attach to the painful periosteal point. For treatment, the patient can be supine or side-lying. The practitioner brings the patient’s arm into abduction, producing contraction of the fiber bundle that is causing the painful pressure point. This tension must be palpated precisely (see Figure 6.109). Pectoralis minor Figure 6.108 • (A) Examining the sternocostal part of the Tension (TrPs) of the pectoralis minor manifests pectoralis major. (B) PIR of the pectoralis major, with arm itself as a pain point below the clavicle, corre- slightly raised. (C) Arm lowered during exhalation. sponding to the coracoid process, and as painful attachment points at the ribs. It further produces Painful attachment points forward-drawn shoulders and increases thoracic on the ribs kyphosis; moreover, it can be one contributing cause in the thoracic outlet syndrome (Hong & Simons 1993). For treatment (relaxation), we use gravity-in- duced PIR. The patient is supine close to the edge of the treatment table with her arm hanging down over the edge. She raises her shoulder while breath- ing in slowly (see Figure 6.110A), holds her breath, and then lets her arm drop while she breathes out and relaxes (see Figure 6.110B). The procedure is repeated three times. For RI the patient exerts pressure with her arm toward the floor. These pain points are found in the axillary line and Serratus anterior often in the vicinity of the sternocostal joints. They are commonly associated with thoracic pain, for In tension of the serratus anterior there are TrPs which differential diagnosis is essential. The struc- close to the costal attachment points. For examina- tures in question are attachment points of individ- tion, the patient is side-lying, with her underneath ual fiber bundles of pectoralis major (in the axillary leg (i.e. the leg on the treatment table) stretched line, serratus anterior). 263
Manipulative Therapy practitioner, the patient raises her arm, breathes in, holds her breath, and lets her arm fall again to take up the slack as she breathes out (see Figure 6.111B and C). For RI the patient exerts forceful pressure in the direction of extension. Diaphragm Figure 6.110 • PIR of the pectoralis minor: (A) shoulder For palpatory examination of the diaphragm the of the arm hanging down over the edge of the table, in the patient is seated in slight anteflexion and the prac- raised position; (B) shoulder lowered during relaxation. titioner stands behind him, supporting his trunk against her own. With the fingers of both hands out while her uppermost leg is bent at the hip to flexed, she performs palpation beneath the inferior stabilize the side-lying position. The practitioner costal arches from below and upward and moves brings the patient’s upper arm cranially into abduc- her fingers laterolaterally (see Figure 6.112). If TrPs tion with retroflexion to engage the barrier. With are present, marked resistance will be felt and the the thumb of her other hand she simultaneously patient will experience some pain. fixes the painful attachment point at the rib (see Figure 6.111A). The direction of abduction can PIR and RI are regularly effective. The patient be established accurately because, if the patient’s breathes in a little, then with mouth closed he arm is guided correctly, the tension is transmit- pinches his nose and tries to breathe in against iso- ted precisely to the location of the practitioner’s metric resistance. He holds this for 5–10 seconds thumb (pain point). As she breathes in, the patient and then breathes out slowly. He is able to last out offers resistance and after holding her breath she because he has breathed in a little to start with. relaxes as she breathes out. The procedure can be For repeats and for subsequent self-treatment the repeated. patient learns to perform isometric resistance not by pinching his nose, but by closing his glottis, as Self-treatment when pronouncing the consonant ‘K.’ After two or three repeats the patient performs RI by actively For self-treatment, gravity-induced PIR is useful. breathing out as far as possible. Adopting the same position as for treatment by the The method is so effective that any painful resistance that persists is not a TrP but in all prob- ability is attributable to the gall bladder, spleen, or stomach. The major clinical significance of these TrPs is that the diaphragm is one of the most important muscles in the deep stabilization system. It is the starting point for extensive chain reaction patterns and for pain that is referred particularly to the tho- racic and cervical regions and to the head. Exami- nation of the diaphragm is therefore recommended as a routine procedure. Despite its simplicity and effectiveness, TrP relaxation here is of secondary importance compared with active exercising and strengthening of the deep stabilization system as a whole, which is discussed in Section 6.8.7. Erector spinae Increased tension and TrPs are very frequent in all parts of the erector spinae because this muscle 264
Therapeutic techniques Chapter 6 Figure 6.111 • (A) Specific PIR of the tense serratus anterior with the slack taken up in the direction of the TrP at the rib. (B) Arm raised for self-treatment. (C) Arm lowered during relaxation. often also reacts in response to disturbances in any of this muscle on both sides. For this, the patient spinal segment. There is one simple gravity-induced is prone with her head hanging over the end of the technique that can be used along the entire course treatment table. She raises her head and breathes in (see Figure 6.113A), then holds her breath and, while breathing out, she relaxes into the starting position (see Figure 6.113B). If the patient lifts her head only a little, she then contracts and relaxes only the upper parts of the erector spinae; the higher she lifts her head, the further caudally the muscle is contracted. This procedure is repeated. Figure 6.112 • Palpation of the diaphragm. Thoracic region Generally, tension is detected predominantly on one side. In such cases it is more specific to treat with a combination of anteflexion, side-bending, and rota- tion. In the cervicothoracic and thoracic region, the practitioner stands behind the seated patient and fixes the shoulder or costal angle on the painful side with one hand, using the thumb of that hand 265
Manipulative Therapy Figure 6.114 • Treatment of the cervicothoracic and thoracic part of the erector spinae. Figure 6.113 • PIR of the erector spinae: (A) with head stands behind the patient, who is seated in slight raised; (B) with head lowered again during relaxation. kyphosis with hands clasped behind her neck. The practitioner threads one arm under the patient’s to fix the muscle paravertebrally just below the TrP. axilla to reach round to her shoulder on the side With her other hand she brings the patient’s head to be treated and tells the patient to look toward into anteflexion, side-bending, and rotation toward the non-lesioned side until the slack has been the opposite side until she has taken up the slack taken up in rotation (see Figure 6.115). She then (see Figure 6.114). Now the patient is instructed asks the patient to look toward the lesioned side to look toward the lesioned side and up, to breathe and to breathe in while she resists the patient’s in deeply (as the practitioner resists the automatic efforts to turn in this direction. The patient is then counterpressure), and then to hold her breath, look instructed to look as far as possible in the direction toward the non-lesioned side, and breathe out. This of the non-lesioned side and to breathe out, which procedure is repeated. results in an increase in rotation. This procedure is repeated. For RI the patient continues to look toward the non-lesioned side, while the practitioner rotates For RI the practitioner rhythmically and repeti- the patient’s head against resistance toward the tively resists rotation toward the non-lesioned side. restricted side. Lumbar region Thoracolumbar region Relaxation of the erector spinae in the lower lum- When treating the erector spinae in the lower tho- bar region is performed using gravity-induced PIR racic and upper lumbar region, the practitioner coupled with inhalation and exhalation. Because the position for this technique is identical to that used when mobilizing the lumbar spine into flexion (see Figure 6.35), this technique can also be used for self-mobilization of the lumbar spine into flexion. 266
Therapeutic techniques Chapter 6 Figure 6.115 • Examination and PIR of the thoracolumbar part of the erector spinae; simultaneously with rotation mobilization of the spinal column. The patient is side-lying in kyphosis, her under- Figure 6.116 • PIR of the lower lumbar erector spinae: neath leg flexed at the hip and knee, and her upper- (A) the leg hanging over the side of the table is slightly raised most leg hanging over the edge of the treatment during inhalation; (B) the leg is allowed to fall again during table, bringing her pelvis into a forward-tilted posi- relaxation and exhalation. tion. She looks up at the ceiling (i.e. she rotates her head and shoulder in the opposite direction anteflexion, and then into side-bending and rotation from that of the pelvis). In this position the patient so that the peak of the curve is at the level of the relaxes and the weight of her leg hanging down is painful TrP (which the patient will feel during ante- sufficient to take up the slack of her lumbar erec- flexion; see Figure 6.117). After taking up the slack, tor spinae (i.e. to bring the lumbar spine into ante- she looks in the opposite direction from rotation, flexion and rotation). The patient then lifts her breathes in slowly, and uses the hand placed on her hanging leg slightly, breathing in slowly (see Fig- head to resist automatic rotation in the direction of ure 6.116A), holds her breath, and then relaxes as her gaze. She holds her breath and then looks in the she breathes out, allowing her leg to fall again (see direction of mobilization and breathes out, taking Figure 6.116B). This procedure is repeated three her head and trunk into rotation, anteflexion, and times. This technique is also effective in the treat- side-bending as far as the (new) barrier. ment of pain at the spinous processes, in which case the more painful side must lie uppermost. TrPs in the horizontal part of the trapezius Self-treatment Here the typical pain point is medial to the supe- The following technique is effective for self-treat- rior angle of the scapula; it is characterized by a ment of the entire erector spinae (apart from the most caudal segment) while seated: with one hand on the top of her head, the patient brings her head and therefore her trunk first into a position of 267
Manipulative Therapy Figure 6.117 • Self-treatment of the erector spinae, with the patient seated (see text). radiating pain pattern, and is encountered espe- Figure 6.118 • PIR of the horizontal part of the trapezius: cially in radicular syndromes and acute cervico (A) examination and treatment; (B) self-treatment. brachial pain in the upper extremity. For diagnosis, the practitioner takes up the slack in the muscle by bringing the scapula into maximal abduction: to do this she takes the patient’s upper arm as far as pos- sible toward the opposite shoulder, thus causing the muscle to protrude like a taut cord that is painful on snapping palpation. For treatment, the practitioner stands behind the seated patient and brings the patient’s elbow toward the opposite shoulder to take up the slack (see Figure 6.118A). She instructs the patient now to give slight counterpressure with the elbow against her hand and to breathe in, hold her breath, and then relax as she breathes out. The patient’s elbow will then come even closer to the opposite shoulder. This procedure is repeated two or three times. For RI the patient exerts pressure with her hand in the same position against the practitioner’s hand, which rhythmically and repetitively increases springing counterpressure. Self-treatment above (see Figure 6.118B). Gravity-induced PIR is especially helpful for self-treatment. The patient is For self-treatment the patient uses her own hand side-lying close to the edge of the treatment table in exactly the same way as the practitioner does and allows her uppermost arm to hang vertically 268
Therapeutic techniques Chapter 6 For RI the patient pushes her hand forcefully toward the floor. Quadratus lumborum Figure 6.119 • Self-treatment of the horizontal part of When trunk rotation is restricted, the quadra- the trapezius: (A) with the upper arm raised; (B) with arm tus lumborum is routinely found to harbor TrPs. hanging down during relaxation, and pushing it toward the These are palpated at the waist. The patient may floor for RI. be prone or supine for comparison of the two sides. However, it can be difficult here to distinguish the over the edge. The weight of her hanging arm pro- quadratus lumborum from the oblique abdomi- duces abduction of the shoulder blade and the slack nal muscles. For precise palpatory examination it is taken up (see Figure 6.119A). The patient then is better if the patient is side-lying. With one hand raises her hanging arm a little and breathes in, holds she holds the top end of the treatment table and her breath, relaxes as she breathes out, and lets her lets her uppermost leg hang down over the edge of arm drop again (see Figure 6.119B). the table behind her, so as to create as much room as possible for palpation between the iliac crest and the inferior costal arch. Using a pincer hold, the practitioner palpates by forefinger pressure caudally beneath the iliac crest and cranially beneath the inferior costal arch in the direction of the attach- ment points of the muscle. Tension in the quadratus lumborum can be treated both by gravity-induced PIR and using res- piratory synkinesis. The patient stands with her legs apart and relaxes into side-bending. If she is completely relaxed (her head must also be hang- ing sideways), looking up and breathing in slowly and deeply will be sufficient to raise her trunk (see Figure 6.120A). The patient then holds her breath, looks down, relaxes, breathes out slowly, and sinks to a (new) end position (see Figure 6.120B). This procedure is repeated two or three times. For RI, after the slack has been taken up, the patient actively pushes her downward-hanging arm toward the floor. Due to the chain reaction pattern linking the quadratus lumborum with the psoas major and erec- tor spinae muscles, relaxation of the quadratus lum- borum normalizes restricted rotation of the trunk. If this exercise is poorly tolerated, the patient can assume the same side-lying position as for examination, raising the leg while breathing in and letting it fall again beyond the edge of the treat- ment table while breathing out (see Figure 6.125). Rectus abdominis TrPs in the rectus abdominis may give rise to referred pain simulating visceral disease. They may also be associated with pain at the attachment 269
Manipulative Therapy points with the pubic symphysis, xiphoid process, and the adjacent parts of the costal arches. Exami- nation routinely reveals tenderness at the attach- ment points and it is also possible to diagnose the TrPs using rapid snapping palpation. Clinically, there is frequently a characteristic forward-drawn posture with tension of the neck and back muscles, as well as restriction of retroflexion that the patient experi- ences as low-back pain. For treatment (and self-treatment), gravity-in- duced PIR is most effective: the patient is supine with her buttocks resting at the end of the treat- ment table and her legs hanging over the edge. She rests the foot of the non-treated side on a low stool, and a pad is inserted under the buttock on the other side to tilt her pelvis slightly to one side. In this position she relaxes her freely hanging leg to take up the slack. She then lifts the knee of that leg a little and breathes in (see Figure 6.121A); afterward, as she breathes out and relaxes, she lets her leg fall again to a (new) end position (see Figure 6.121B). This procedure can be repeated twice. For RI the patient actively presses her hanging foot down toward the floor. If the intention is more to relax the upper part of the rectus abdominis, she should raise her head, hold this for about 20 sec- onds, and then let it sink back to the padded sur- face of the treatment table. For RI she can then press her head against the padded surface. This technique is not commonly used because TrPs in the rectus abdominis generally occur sec- ondarily as a result of movement restrictions involv- ing the fibula, the feet, and even the pelvic floor. 6.6.5 Muscles of the hip region Figure 6.120 • PIR of the quadratus lumborum: (A) looking Iliopsoas up during maximal inhalation; (B) looking down, relaxation and exhalation. Intensely painful TrPs are palpated through the abdominal wall: at the psoas major by parallel pres- sure from the side against the spinal column; and at the iliacus, parallel to the inguinal ligament, by pressure in the direction of the ilium. For treatment, we employ gravity-induced PIR. The patient is supine with his buttocks at the end of the treatment table. He flexes his non-lesioned leg at the knee and hip and, with his hands clasped around the tibial tuberosity, he draws the leg up toward his chest, thus fixing the pelvis. He then lifts the knee of his hanging, lesioned leg a few 270
Therapeutic techniques Chapter 6 Figure 6.121 • PIR of the rectus abdominis: (A) the Figure 6.122 • PIR of the iliopsoas: (A) with knee raised leg hanging freely over the edge of the table is raised during inhalation; (B) with knee lowered during relaxation during inhalation; (B) the leg is allowed to fall again during and exhalation, pushing it toward the floor for RI. relaxation, pushing it toward the floor for RI. Ligament pain (pelvic region) centimeters while breathing in (see Figure 6.122A), Where contraction of the ligaments in the pelvic holds his breath, and then lets it fall again as he region provokes pain, increased resistance and (on relaxes and breathes out (see Figure 6.122B). This range of motion measurement) restricted adduction procedure is repeated about three times. are invariably encountered on the side where pain is present. Of course, this resistance cannot derive For RI the patient exerts pressure in the direc- from the ligaments themselves and therefore can tion of his hanging foot toward the floor. only be of muscular origin. 271
Manipulative Therapy remain constant while his other hand performs PIR (see Figure 6.123B). For RI he can also rhythmically and repetitively resist adduction. Gluteus maximus and levator ani A tender or painful coccyx is generally attributable to attachment point pain due to increased tension in the caudal part of the gluteus maximus and TrPs in the levator ani. Treatment consists of PIR of the gluteus max- imus and levator ani. For this, the patient is prone, with his heels rotated outward to relax the but- tock muscles. Standing by the patient’s legs, the practitioner crosses her hands and places one hand on each buttock. As she exerts light pressure she will feel the increased muscle tension (see Figure 6.124A). She next tells the patient to clench his buttocks together with minimal force, to maintain this pressure for about ten seconds, and then to let go. During the protracted (!) relaxation phase the practitioner feels her hands going deeper as the ten- sion in the muscles diminishes. This procedure is repeated several times until it seems as if tension is no longer diminishing. The practitioner then checks to establish whether the coccyx is still painful. Figure 6.123 • PIR in ligament pain: (A) examination and Self-treatment treatment; (B) self-treatment. For self-treatment, the patient is supine with his For treatment, the practitioner flexes the two hands beneath his buttocks and his feet rotated patient’s knee and hip to the point where resistance, inward; gravity-induced PIR is also used (see Figure and simultaneously the pain response, are greatest 6.124B). The patient now tenses his gluteals a lit- on adduction. This technique applies equally for tle and holds this for 20 seconds before relaxing for the iliolumbar ligament and for the sacroiliac liga- 20 seconds. This procedure is repeated three to five ments. In this position the patient exerts light pres- times. sure against the practitioner’s examining hand and holds this for 5–10 seconds (see Figure 6.123A). A painful coccyx is caused by tendomyopathy of During the relaxation phase, the practitioner brings the gluteus maximus and levator ani muscles, and the patient’s thigh further into adduction provided post-isometric muscle relaxation therapy is con- that no resistance develops. In the process the sistent with the pathogenesis. Only in exceptional patient will generally experience some pain but this cases where there is no increased tension is there an is of no significance provided that the patient is still indication for the (standard) therapeutic approach able to relax. This procedure is repeated from the per rectum. newly gained position. 6.6.6 Muscles of the lower For RI the patient offers resistance into abduction extremity against the rhythmic repetitive pressure on his thigh. Self-treatment Hip abductors For self-treatment, the patient uses the hand on Tenderness at the greater trochanter is due princi- the same side to ensure that hip and knee flexion pally to tension of the hip abductors, primarily the 272
Therapeutic techniques Chapter 6 treatment table, with his underneath leg flexed at the knee and hip and his uppermost leg hanging over the end of the table in adduction. The patient lifts his leg horizontally (see Figure 6.125A), holds for 20 seconds, and then relaxes for a further 20 seconds (see Figure 6.125B). This procedure is repeated two or three times. This technique also relaxes the quadratus lumborum at the same time. For RI the patient exerts forceful pressure with his leg against the padded cover of the treatment table and practices this exercise daily. It may be helpful to adopt an even more pre- cise procedure here: if the TrPs are located pri- marily in the gluteus medius, the uppermost leg should perform the exercise in extension. How- ever, if the TrPs are primarily in the tensor fasciae latae, the uppermost leg should be flexed a little at the hip. Figure 6.124 • PIR of the gluteus maximus for a tender and painful coccyx: (A) examination; (B) self-treatment. gluteus medius and the tensor fasciae latae. Active Figure 6.125 • PIR of the hip abductors (this technique abduction is then also frequently painful. However, can also be used for PIR of the quadratus lumborum): the same pain points are also found in osteoarthri- (A) with uppermost leg raised; (B) with leg lowered during tis of the hip. When TrPs are present in the gluteus relaxation, pushing it toward the floor for RI. medius (palpated using a pincer grip), the inferior margin of the iliac crest is also tender. TrPs in the tensor fasciae latae are palpated just above the greater trochanter and pain points are also found simultaneously along the course of the fascia lata on the lateral aspect of the thigh. Gravity-induced PIR is used to treat these mus- cles. The patient is side-lying at the end of the 273
Manipulative Therapy Hip adductors As in osteoarthritis of the hip, Patrick’s sign is posi- tive and the attachment points at the pubic sym- physis and pes anserinus are painful, causing the patient also to experience knee pain. TrPs can be palpated in all the muscles belonging to the hip adductor group. The adductors are closely associ- ated with diseases of the hip, they may give rise to pain that is referred to the pelvis, and they are often coupled with TrPs in the pelvic floor. The position for Patrick’s test is used for exami- nation and to take up the slack: the patient is supine and flexes one leg at the knee and hip so that his heel is touching the medial aspect of his other out- stretched leg just below the knee. Gravity-induced PIR is used for treatment. After taking up the slack, the patient raises his knee a little for about 20 sec- onds (see Figure 6.126A) and then lets it fall again while he relaxes (see Figure 6.126B). After a fur- ther 20 seconds, this procedure is repeated two or three times from the newly gained position. For RI the simplest option is maximal active abduction. The ischiocrural group of muscles The basic function of the ischiocrural group of mus- Figure 6.126 • PIR of the (short) hip adductors: (A) with cles is to fix the pelvis in an upright position. These thigh raised; (B) relaxation, pushing it against the table for RI. muscles extend the hip and flex the knee. TrPs can be palpated along the course of these muscles and nerve stretch test. Tension in the muscle is therefore produce pain in the thigh and at the muscle attach- generally increased in dysfunction of the L4 segment ment points, especially at the ischial tuberosity. and in the L4 radicular syndrome. For treatment (and self-treatment), the patient For treatment and self-treatment, we use gravity- is prone with his pelvis at the end of the treat- induced PIR. The patient is supine with one leg out- ment table so that both legs hang down (his feet stretched so that the lower leg hangs over the edge may even be resting on the floor). The gravity-in- of the treatment table. Flexing his non-lesioned duced technique is used for PIR. The patient raises leg at the hip and knee, he draws it up toward his one outstretched leg a little from the floor (see trunk using his hands, which are clasped round the Figure 6.127A), holds for 20 seconds, and then lets tibial tuberosity. The patient then extends the knee it sink back to the floor as he relaxes (see Figure of the leg to be treated and holds it for 20 seconds 6.127B). After a further 20 seconds, this procedure is repeated two or three times. For RI the patient exerts forceful pressure with his foot against the floor. Rectus femoris To examine for TrPs, the practitioner uses pincer palpation along the course of the rectus femoris; the diagnosis is usually made by applying the femoral 274
Therapeutic techniques Chapter 6 Figure 6.128 • PIR of the rectus femoris: (A) with knee extended and raised; (B) relaxation with knee flexed. Figure 6.127 • PIR of the ischiocrural muscle group: For treatment, the patient is prone: he flexes his (A) with one leg raised; (B) relaxation with foot resting on knee at right angles on the side to be treated and the floor, and pushing it against the floor for RI. allows his lower leg to fall outward. He then turns on to his side so that his lower leg is lying horizon- (see Figure 6.128A); he next relaxes and allows it to tal on the treatment table. The patient now raises drop back down for 20 seconds (see Figure 6.128B). his foot and lower leg by about 2 cm (see Figure This procedure is repeated two or three times. 6.129A), holds this position for 20 seconds, then lets them drop back down to the table surface (see For RI he flexes his knee powerfully in the same Figure 6.129B) and relaxes in that position for a position. further 20 seconds. This procedure is repeated three times. Piriformis For RI the patient exerts forceful pressure with The TrP in the piriformis muscle is palpated as pain- his lower leg against the padded surface of the ful resistance above and medial to the greater tro- treatment table. chanter. Given this location, it is hardly surprising that spontaneous discomfort here causes the patient Biceps femoris to complain of ‘hip pain’ and is an obstacle to sleep- ing on the painful side at night. This TrP is generally Pain at the fibular head is the result of TrPs in the linked with dysfunction of the motion segment L4/ biceps femoris. For treatment, the practitioner L5 and with the L5 radicular syndrome. stands at the foot end of the treatment table on the patient’s non-painful side. The patient is supine. 275
Manipulative Therapy Figure 6.129 • PIR of the piriformis: (A) with lower leg raised; (B) relaxation with lower leg resting on the padded surface of the treatment table, and pushing it against the table for RI. With her right hand the practitioner grasps the Figure 6.130 • PIR of the biceps femoris for tenderness f1300 patient’s right foot (or with her left hand his left of the fibular head: (A) examination and treatment; (B) self- foot), with her thumb at his heel and her little fin- treatment. ger at his little toe, so as to rotate his foot inward. She then raises the patient’s stretched leg, bringing forward with his free foot and bends his knee, pro- it simultaneously into internal rotation and adduc- ducing an increase in the inward rotation of the tion to take up the slack (see Figure 6.130A). In this foot and in the tension of the ischiocrural muscles position the practitioner tells the patient to exert light pressure with his foot into external rotation against her resistance and to hold this for 5–10 sec- onds. During the subsequent relaxation phase she increases rotation, straight leg raising and adduction. This procedure is repeated two or three times. Self-treatment For self-treatment, the patient stands with feet apart: the foot to be treated is rotated inward with its outer edge propped against a table leg, for exam- ple. To take up the slack the patient moves a step 276
Therapeutic techniques Chapter 6 (see Figure 6.130B). He then presses his foot (iso- metrically) against the table leg and holds this for 5–10 seconds. While he relaxes, knee flexion and foot rotation increase. This procedure is repeated two or three times. This technique is awkward, which explains why mobilization of the fibula is generally used in practice. Foot and toe extensors Increased tension (TrPs) of the extensor muscles on the ventral aspect of the lower leg manifests itself primarily as fatigue pain. For treatment, the patient is seated. The practitioner sits next to him and places the lower leg to be treated across her thigh. With one hand she fixes his lower leg, and places her other hand dorsally over his forefoot and toes, simultaneously performing plantar flex- ion of the toes and foot to take up the slack (see Figure 6.131A). She then tells the patient to resist for 5–10 seconds before instructing him to let go until the slack is taken up again. This procedure is repeated two or three times. For RI the patient offers resistance against rhyth- mic repetitive extension of the flexed toes. Self-treatment Figure 6.131 • PIR of the foot and toe extensors: (A) examination and treatment; (B) self-treatment. For self-treatment, the patient is seated and uses his opposite hand to flex his toes and forefoot Self-treatment (see Figure 6.131B). The subsequent details are as described for the procedure performed by the prac- Gravity-induced PIR is used for self-treatment. The titioner. patient stands in front of a table, supporting him- self against it on his hands. He steps forward with Painful Achilles tendon the foot being treated and flexes his leading leg at the knee until the slack is taken up at the talocru- Pain at the Achilles tendon and at its attachment to ral joint (see Figure 6.132B). The patient resists the calcaneus is caused by TrPs with increased ten- with his foot in the direction of plantar flexion sion in the soleus muscle. For treatment, the patient for 20 seconds, after which he relaxes for a fur- lies prone with the knee on the lesioned side flexed. ther 20 seconds in dorsiflexion. This procedure is With one hand the practitioner takes hold of the repeated three times. patient’s foot and brings it into dorsiflexion and, depending on whether the tendon is tender on Painful calcaneal spur the medial or lateral side, either into pronation or supination to take up the slack on the painful side A painful calcaneal spur is caused by increased ten- (see Figure 6.132A). She then tells the patient to sion (TrPs) in the deep short toe flexors, which have resist using counterpressure of minimum force for their points of attachment there. For treatment, about 10 seconds. During the subsequent relaxation the patient is prone and flexes the knee of the leg phase, the patient is instructed to actively enhance to be treated. The practitioner places one hand dorsiflexion (= RI). This procedure is repeated with the goal of increasing dorsiflexion. 277
Manipulative Therapy Figure 6.132 • PIR of the soleus for a tender Achilles tendon: (A) examination and treatment; (B) self-treatment. round the patient’s heel and with her other hand Figure 6.133 • (A) Examination and treatment of increased takes hold of the patient’s forefoot; she next brings tension in the plantar aponeurosis for a tender calcaneal the forefoot and toes into dorsiflexion relative to spur. (B) PIR with accentuation of the plantar arch during the heel to take up the slack (see Figure 6.133A). isometric contraction. (C) Flattening of the arch during The patient is then told to flex his toes and fore- relaxation. foot relative to his heel, making his foot ‘hollow’; the practitioner offers light resistance to this flex- ion movement. As far as possible, all plantar flexion 278
Therapeutic techniques Chapter 6 must be avoided. During the ensuing relaxation also has a part to play here, enabling muscle tone to phase there is an increase in the dorsiflexion of the become balanced on both sides of the body. toes and forefoot relative to the heel. This proce- dure is repeated three times. 6.7.1 Muscles of the trunk RI takes the form of dorsiflexion of the toes, The deep flexors of the neck against which the practitioner offers rhythmic repetitive resistance. These muscles belong to the deep stabilization sys- tem and are therefore extremely important. Head In chronic cases, there may be an indication for anteflexion against resistance can be practiced very needling the TrP on the sole of the foot. simply: the patient is seated at a table, with elbows on the table and chin cupped in both hands. She Self-treatment now pushes against the resistance of her hands. The exercise is effective but not specific for the deep Gravity-induced PIR is used for self-treatment. neck flexors. The patient is standing or seated with his feet on the floor. During the isometric phase he accen- The following exercise is more specific and tuates the arch of the foot by drawing his toes in highly effective. The seated patient bends backward and he holds this position for 20 seconds (see Fig- over the low back of a chair and in that position ure 6.133B). He then relaxes again for 20 seconds makes a nodding movement by drawing her chin (see Figure 6.133C) and this procedure is repeated down to her neck (see Figure 6.134). The exercise three times. is repeated daily. Backward bending serves primarily to inhibit the sternocleidomastoid. The exercise can In view of recent experience with the stabiliza- also be performed supine with the head retroflexed tion system of the feet, it seems both simpler and over the end of the treatment table; however, this more effective to train automatic toe flexion by for- modified version is very strenuous. ward inclination during standing (see Section 6.8.8 and Figure 6.157). Using a pressure sensor inserted under the neck in the supine position, Jull (2000) discovered that 6.7 Training weak muscles patients following cervical spine injury are unable (facilitation) to exert pressure on the sensor with their neck In general, true paresis is absent in our patients; Figure 6.134 • Training the deep neck flexors by nodding their muscle weakness is instead the result of inhi- the head forward at the craniocervical junction with the bition and neglect or disuse. Our task is therefore thoracic spine in retroflexion; the diagram illustrates the to teach the patient how to use these neglected sequence of movements into maximal dropping of the chin muscles correctly again. This goal can be achieved (‘nodding’) and then back to the starting position. using a variety of facilitation methods, which will be described below. The common feature shared by all these methods is that the patient must become aware of the inhibited muscles. This means that for a certain period the patient must learn consciously to control these muscles until correct function becomes automatic again. Facilitation implies creating ideal conditions for the weakened muscles. In this setting, posture has an especially important role to play. A bent posture intensifies the activity of the phylogenetically older, predominantly tonic muscles, whereas an upright posture with the extremities in slight abduction and external rotation facilitates the phylogeneti- cally younger, phasic muscles with their tendency to become weak and inhibited. Exteroceptive stim- ulation in the form of specific judicious stroking 279
Manipulative Therapy Figure 6.136 • Training the lower part of the trapezius. Figure 6.135 • Training the deep neck flexors: the patient hands are on the crown of her head, and her elbows exerts pressure with his fingers against the cervical spine are flexed and resting loosely on the treatment as it exerts counterpressure against his fingers; at the same table roughly level with her ears (see Figure 6.136). time he palpates his sternocleidomastoid. Throughout the exercise her elbows should not be pressed down on to the padded surface. In this without sternocleidomastoid contraction. This fact position the medial border of the shoulder blade is exploited when exercising the deep neck flexors. diverges from the spinal column in a caudal direc- tion. The patient is then told to draw her shoulder The patient is supine (or standing against a wall) blade in a caudal direction, thus bringing the medial and places two fingers laterally under his cervi- border of the shoulder blade parallel with the spi- cal spine, while with his other hand he palpates nal column. The shoulder blades must not be drawn the sternocleidomastoid on the opposite side (see together in this process. To begin with, it is recom- Figure 6.135). He then presses his fingers on his mended that the practitioner touches the patient cervical spine and exerts counterpressure with his to indicate which muscle she should contract. It spine, but only for as long as the sternocleidomas- can often be helpful if the patient herself uses the toid does not contract. He then learns to increase thumb of her opposite hand to monitor the con- the pressure against his own fingers using the deep traction of the lower part of the trapezius. neck flexors in such a way that the sternocleido- mastoid does not contract. Once the patient has mastered this exercise in the facilitation position, she should learn to per- The lower part of the trapezius form it in the prone position, with her arms by her sides in internal rotation. Immediately she man- This muscle has a key role in the fixation of the ages to contract the lower part of the trapezius, shoulder blade. The following exercise should be the upper part will relax owing to reflex inhibition. carried out to facilitate contraction: the patient sits Once the patient has mastered the contraction of on her heels and bends her upper body and head the lower part of the trapezius in the prone posi- forward to rest her forehead on the padded surface tion, she will also be able to do it upright, whether of the treatment table in front of her. As she does seated or standing. She can always use the thumb this she may lift her buttocks off her heels. Her of her opposite hand to monitor the contraction of this muscle. This exercise plays a crucial role in good fixation of the shoulder blade. Serratus anterior This muscle, which also fixes the shoulder blade from below and is connected to the oblique abdom- inal muscles, can be tested and exercised using the 280
Therapeutic techniques Chapter 6 following method. The patient is on all fours with Figure 6.138 • Patient on all fours with a book on her head held horizontally. Her weight is mainly on her occiput, to train the serratus anterior and the lower part of hands, which are in internal rotation so that the the trapezius. fingers are pointing toward each other (see Figure 6.137A). She then performs a press-up so that her has a book resting on her occiput. It, too, trains the center of gravity is shifted forward and her elbows correct fixation of the shoulder girdle by contrac- are pointing outward as she exhales. Her forehead is tion of the serratus anterior muscles and the lower now pointing at the floor (see Figure 6.137B). Dur- part of the trapezius (see Figure 6.138). In this ing this movement the contraction of her abdominal instance it is important that the patient supports ‘muscle corset’ should fix her trunk. Her shoulder herself radially on her thenar eminences. At the blades are kept maximally apart, and the muscles same time there should be coordinated contraction between them must show only eccentric contrac- of the flexors and extensors of the cervical spine. tion. One very important aspect is the contraction The upper part of the trapezius remains relaxed and of the upper quadrants of the abdominal muscles the abdominal muscles are contracted. The back because only then will the patient’s back remain as and neck should be as straight as a board. straight as a board. In lordosis the serratus anterior is unable to fix the shoulder blade and a winged scapula is seen (see Figure 6.137C). A comparable effect is achieved with the follow- ing exercise in which the patient, again on all fours, Figure 6.137 • Training the serratus anterior: (A) starting Rectus abdominis position; (B) press-up with arms flexed, correct position; (C) faulty position with lordosis. The simplest test for this muscle is for the patient to sit up from the supine position and to lie back down again. In this process her legs remain bent at the hips and knees and her feet should not lift up from the mat. In order to practice coordination even more precisely, the patient may actively con- tract her knee flexors to press with her heels against an object solidly placed behnd her heels (see Figure 6.139A). It would be a major error to fix her feet from above (see Figure 6.139B). If the patient is unable to sit up in this way, and provided that her lumbar erector spinae is not too short, then she may train her abdominal muscles as follows: the patient is seated with legs flexed at the hips and knees, and then lies back slowly with her spine in kypho- sis so that her lowest lumbar vertebrae touch the table first, followed in sequence by her other verte- brae up as far as the shoulders (eccentric contrac- tion). The exercise must be stopped the moment the patient’s feet are lifted from the table or if lumbar kyphosis cannot be maintained. Only once the patient has learnt to lie down in this way from 281
Manipulative Therapy Figure 6.140 • Drawing in the navel. Figure 6.139 • Strengthening the rectus abdominis by lying this system is of major importance and even today down from a sitting position and sitting up from a recumbent it represents uncharted territory. position: (A) correct and (B) faulty. The simplest way to start is for the patient the sitting position should she attempt to sit up to draw in his navel (see Figure 6.140). Here it is from the supine position by the same method in important for the abdominal wall laterally at the reverse. waist and for the lower abdomen to contract simul- taneously (or autonomously). This primarily involves Nowadays it is more common practice to exer- the transversus abdominis, but also the obliquus cise the deep stabilizers rather than the rectus internus abdominis. There is a special reason for this abdominis. contraction at the waist: it involves eccentric con- traction of the abdominal wall coupled with concen- The deep stabilizers of the lumbar tric contraction of the diaphragm, unless the two are spine and pelvic floor being exercised separately (see Figure 6.141). Koláˇr ’s tests, as outlined in Section 4.20.5, can also be used for the purposes of exercise: by rais- ing his head and chest in the prone and/or supine position the patient learns to contract not only his abdominal or back muscles, but also the lateral part In principle this group comprises the muscles of Figure 6.141 • Testing for and stimulation of isolated the pelvic floor, deep abdominal region, diaphragm, contraction of the lateral abdominal wall. and the multifidus muscles. It is very important to note that the individual muscles form a chain so that the others also react when one is successfully facilitated. For practice, this is of major significance because not all these muscles are equally accessible to therapy; thus Hides (2004) principally advo- cates exercising the multifidus muscles, with visual feedback provided by ultrasound imaging. While we endeavor to use methods that are more acces- sible in a clinical setting, we share the view of that Australian physiotherapy team that the function of 282
Therapeutic techniques Chapter 6 of the abdominal wall. The same applies for flexion floor, particularly the coccygeus muscle. For this of the bent legs against resistance, whether supine it is necessary to distinguish the TrP and its sig- or sitting upright against gravity. If the patient is nificance here from the TrP in the levator ani that performing the exercise alone, it is always possible causes attachment point pain at the coccyx. Palpa- for him to use his own hands to check what is hap- tion of the TrP in the coccygeus has been described pening at the waist. in Section 4.5.8 (see Figure 4.12). Transversus abdominis The exercise begins with the side-lying patient drawing in his navel (the principle is illustrated in Once the patient has mastered the previous exercises Figure 6.140). Once he is able to do this, he places he can perform the following exercise himself, as the fingers of one hand flat over his anal region developed by Wohlfahrt et al (1993). Lying supine, and attempts in a similar manner to draw this in he raises and flexes his legs as if cycling and in so (see Figure 6.143). The practitioner may ask the doing exerts pressure on a sensor placed beneath his patient whether he can feel this happening. The lumbar spine. Then, instead of the pressure sensor, problem is that there is no direct means of con the patient inserts both hands (palms facing down firming contraction of the pelvic floor. The patient against the padded table surface) and, by flexing his is therefore instructed to pinch his nose with his fingers, exerts pressure against his lumbar spine while other hand and to breathe in against resistance simultaneously applying counterpressure against the with his mouth closed. The resultant suction will backs of his hands (see Figure 6.142). To prevent any enable the patient to be considerably more aware discomfort, the patient may cover the backs of his (perhaps for the very first time) of pelvic floor con- hands with a soft material. traction. In both scenarios it is possible to tell that the patient is actually contracting his pelvic floor. This exercise can only be performed correctly if the patient has learnt to contract the lateral part of his abdominal wall and his lower abdomen; other- wise, in this exercise that is targeted specifically at the transversus abdominis, he will make his abdo- men protrude. Coccygeus The following exercise is designed to help the patient learn both to contract and relax his pelvic Figure 6.142 • Training the transversus abdominis. Figure 6.143 • Training the pelvic floor, especially the coccygeus. 283
Manipulative Therapy This exercise is repeated two or three times. The practitioner then checks whether palpation of the pelvic floor is still painful and to what extent the usually numerous additional TrPs and restrictions linked with the pelvic floor are still present. If the outcome is satisfactory, the patient can perform the exercise several times daily in the seated posi- tion, simultaneously drawing his navel in. He can also do this while at work without anyone noticing. The patient should be instructed always to perform the exercise slowly, otherwise relaxation will fail to materialize. The exercise also shows that relaxation of the coccygeus takes place in an entirely different manner from relaxation of the levator ani. In the exercise to educate the levator ani and gluteus max- imus, the patient clenches his buttocks together and also contracts his sphincter. In the present case, however, the buttocks are relaxed and the patient does the exercise while imagining that he is sucking something in. All this illustrates the two very differ- ent functions of the pelvic floor: first, as a compo- nent of the deep stabilization system, and second, in connection with sphincteric function. The ‘cradle’ Figure 6.144 • The ‘cradle’: (A) knees drawn up to the thorax the chest; (B) hip extension against resistance at The patient lies supine, drawing her knees up to the knee. her chest and holding them there with her arms clasped. She then lifts her pelvis and brings her contracting her erector spinae (see Figure 6.145A), lumbar spine into kyphosis by contracting her glu- and then relaxes the erector spinae while contracting teal muscles (hip extension), causing her arms her abdominal and gluteal muscles, thus flattening around her knees to come under tension. At the her lumbar spine against the treatment table. same time she lifts her head and chest and breathes out, thus producing maximal contraction of her Once the patient has mastered this phase, abdominal muscles. By rhythmic pressure of her another element is added to the exercise. As before, knees against her clasped arms, she rocks herself up she presses her entire lumbar spine flat against the into a sitting position, before rolling on her lumbar treatment table without her calm breathing becom- kyphosis back to her starting position (see Figure ing irregular in any way. She then presses her knees 6.144A and B). At a later stage she may perform together and, in a caudal-to-cranial sequence, raises this exercise without the help of her arms, which first her pelvis, then her (kyphosed) lumbar spine, she holds out in front of her. and finally her thoracic spine away from the treat- ment table while ensuring that her lumbar spine The purpose of this exercise is to strengthen and kyphosis is not reduced. Her knees remain pressed improve coordination between the abdominal and together and finally she clenches her buttocks to gluteal muscles and to relax the erector spinae. straighten her pelvis slightly more dorsally. Then in reverse sequence (thoracic spine, lumbar spine, pel- The ‘pelvic see-saw’ vis) she lowers her back down on to the treatment table (see Figure 6.145B). The patient is supine with knees bent and feet placed flat on the treatment table. Breathing calmly and The purposes of this exercise are to control pel- regularly, she brings her lumbar spine into lordosis by vic movement, to coordinate the abdominal and buttock muscles, and to strengthen the gluteals in particular. 284
Therapeutic techniques Chapter 6 tilt – probably their most important postural func- tion. For this, there is an especially effective exer- cise that is also used for self-mobilization of the lower lumbar spine (see Figure 6.70). In the routine activities of daily living the gluteus maximus contracts primarily when a person rises vertically from a squatting or sitting position, that is the individual must not bend forward in the proc- ess. This can be practiced if the patient rises verti- cally from a chair and palpates her gluteus maximus on the side of the weakened buttock muscle. Gluteus medius Figure 6.145 • The ‘pelvic see-saw’: (A) bringing the The following method has proved most effective for lumbar spine into lordosis; (B) raising the pelvis and lying facilitating the gluteus medius: the patient is side- back on the padded surface of the treatment table, with the lying and, because the gluteus medius is weak, she lumbar spine in kyphosis. performs ‘false abduction’ chiefly using the tensor fasciae latae and the hip flexors (see Figure 4.48). As a minor modification, and from the same The practitioner then passively performs maxi- starting position, the patient can press her lumbar mum abduction correctly, and from that position spine flat against the treatment table while simulta- suddenly and unexpectedly lets go of the patient’s neously stretching one leg (resting on its heel), but leg. This will cause her gluteus medius to contract only so far that her lumbar spine does not diminish automatically. This maneuver is repeated, with the its pressure against the treatment table. The extent practitioner palpating first how the gluteus medius of this stretch will increase with practice. contracts (and later encouraging the patient to pal- pate this for herself). This will make the patient 6.7.2 Muscles of the hip aware of her own gluteus medius. Once she has learnt to identify gluteus medius contraction, she Gluteus maximus can check this with her fingers. Within the space of a few exercises she will learn how to abduct her leg If this muscle is found to be weak, that is if it correctly – in the frontal plane – using the simulta- is flaccid or displays only minimal activity dur- neous and coordinated contraction of both the ten- ing hyperextension of the hip (see Figure 4.47), sor fasciae latae and the gluteus medius. the most effective and simplest facilitation tech- nique is for the patient to lie prone and perform 6.8 Re-training to correct hyperextension with her leg in external rotation. faulty movement patterns However, if this is insufficient, the patient can consciously contract her buttocks and hold this 6.8.1 Standing on both feet contraction during hyperextension of the hip in the prone position. An important criterion for standing posture is that it should be stable. Furthermore, the muscle activity In patients with hyperactive erector spinae and required to maintain balance should be as minimal hyperlordosis, lordosis can be reduced by placing as possible. However, there is always some activity a cushion under the patient’s abdomen. She then at the level of the feet, and this fact is consistent again consciously contracts her buttock muscles with the decisive role of the feet in this context. and raises her extended leg very slightly so as not This is no mere coincidence: the major role played to lordose her lumbar spine or contract her erector by the feet, together with the hands and mouth, is spinae. Once she has mastered this she can learn to reflected in their extensive representation in the use both gluteus maximus muscles to reduce pelvic 285
Manipulative Therapy motor region of the cerebral cortex and in the fact walking entails alternate standing on one leg (see that they have the highest density of sensory Figure 4.77). However, a certain degree of asym- receptors. This is commensurate with the impor- metry is normal, and this is why we distinguish the tance of the feet as stabilizers of upright posture. supporting leg from the free leg. The supporting However, this function is constantly compromised leg is the one a person puts more weight on when by wearing shoes, which causes a certain degree of standing at ease. The asymmetry should not be sensory deprivation. too marked, however. In both standing and walk- ing, it is essential to pay attention to the activity of First and foremost, therefore, it is necessary to the feet, and of the toes in particular. In standing, activate the feet. In the ‘Chinese stance’ the patient the knee should be bent very slightly and the toes stands with her legs slightly apart, her feet parallel should be pressing against the floor. In walking, the to each other and knees slightly bent. This position heel strikes the ground first, then the foot rolls on greatly facilitates the activity of the foot flexors, to its lateral edge and its arch should not sink down enabling the patient to ‘grip’ the surface on which medially. Pronation does not occur until toe-off; she is standing. Obviously, this is easier to do with- that is toe-off is achieved by the metacarpal bone out shoes. of the hallux and flexion of all toes. The stability of this type of standing can be tested Understanding and correcting very simply by giving a gentle unexpected push to pelvic obliquity the patient’s trunk from in front or behind. If she is standing in the conventional way with her feet in The supine patient is instructed to push one leg and external rotation, she is likely to lose her balance. Her the corresponding side of her pelvis away from her stability is greatly enhanced if she stands with legs in the direction of its long axis (see Figure 6.146). slightly apart, feet parallel in slight internal rotation At the same time she is told to make the opposite and knees bent. This, however, is not the only effect: movement with her other leg, thus producing pelvic the pelvis will automatically be in a neutral position, obliquity due to contraction of her non-tense quad- thus greatly improving body statics and posture. ratus lumborum. While this is happening, her lum- bar spine is firmly fixed against the treatment table 6.8.2 Standing on one leg by contraction of the abdominal musculature. Her and walking other muscles are relaxed. Because these are asymmetric functions, asym- The purpose of this exercise is to help the metric exercises are used to bring about correc- patient understand how pelvic obliquity occurs and tion. The ability to stand correctly on one leg is also how she can correct this. a prerequisite for a normal gait pattern because Figure 6.146 • Alternate pushing away and drawing back of the legs, patient supine. 286
Therapeutic techniques Chapter 6 Figure 6.147 • (A) External rotation and (B) internal rotation of the hip, patient side-lying with uppermost leg abducted. Rotation of the hip offers light resistance at the knee against flexion and at the heel against extension. The side-lying patient abducts (raises) her extended uppermost leg and (as in the preceding exercise) The purpose of this exercise is to re-educate the pushes it away from her. She then performs exter- hip stabilizers and abdominal muscles, and to re- nal and internal rotation of her foot (see Figure learn the coordinated movement pattern as in walk- 6.147). In the process the position of her pelvis is ing where movement is controlled not by the hip fixed by her abdominal and buttock muscles. but by the lumbar spine. It has proved effective to have the exercise performed side-lying, that is in an The purpose of this exercise is to re-educate the exercise position that is ‘unusual’ for the patient. hip muscles while the pelvis and lumbar spine are fixed in position. 6.8.3 Sitting Flexion and extension of the leg See also Section 4.15.1. As for the preceding exercise the patient is side- Sitting erect with trunk rotation lying with her uppermost leg slightly raised (abducted) and flexed at the knee. This leg is then The patient is seated on the floor, resting back flexed at the hip (see Figure 6.148A) and extended on her ischial tuberosities. Her knees are parallel (see Figure 6.148B). and slightly flexed, and her hands are clasped over her occiput (see Figure 6.149A). The coordinated Her pelvis and lumbar spine are fixed in position. contraction of her abdominal muscles holds her Flexion of all leg joints is accompanied by moder- spinal column erect in a neutral position. In the ate kyphosis of the lumbar spine via the pelvis. The second phase of the exercise, the patient rotates abdominal muscles and hip flexors are involved in her trunk from her hips up to and including her this movement. In the second phase of the exercise, head (see Figure 6.149B). The movement must be as the leg is extended, all the extensor muscles of performed smoothly from bottom to top and back the leg contract, and the lumbar spine participates again. The patient’s spinal column must be kept in this movement only by going into moderate lor- vertical, avoiding all anteflexion, retroflexion, and dosis. Correct contraction of the abdominal mus- side-bending. cles should prevent hyperlordosis during extension. The exercise can be made easier if the practitioner 287
Manipulative Therapy Figure 6.148 • (A) Flexion and (B) extension of the slightly abducted uppermost leg, patient side-lying. Figure 6.149 • (A) Sitting erect on the floor. (B) Trunk This exercise is demanding because the patient’s rotation. pelvis is not fixed. Therefore it should be practiced initially with the patient sitting astride a chair or 288 treatment table, thus fixing the pelvis. Good facili- tation can be obtained if the patient looks toward the side of rotation and up a little, breathing in dur- ing rotation to the side and breathing out as she returns to a neutral position. All this holds true for trunk rotation while standing with legs apart. Lateral movement of the thorax The patient is seated on a chair with her feet sup- ported on the floor, and preferably in front of a mirror so that she can correct her position. Her arms are held in abduction at 90°. She then moves her thorax to one side, as if someone were pulling her arm horizontally. If the patient contracts her abdominal wall correctly, her thoracic spine will move sideways without itself curving laterally (see Figure 6.150A and B). During this sideways move- ment the patient’s body weight will shift on to one buttock and the leg on the same side. The exercise can be facilitated if the practitioner effects light
Therapeutic techniques Chapter 6 Figure 6.150 • Laterolateral horizontal movement of the thorax with the patient seated: (A) correct and (B) faulty. resistance against the patient’s ribs, first from one The purpose of this exercise is for the patient side and then from the other. to achieve ‘dynamic sitting’, something that can be practiced particularly well on an exercise ball. The purpose of this exercise is for the patient to become aware of how to compensate for scoliotic 6.8.4 Anteflexion posture and how to control the oblique and deep abdominal muscles that are so important in this It is well-known that a stooped or forward-bent context. posture can be indicative of underlying pathology. However, anteflexion is an entirely normal function Correction of pelvic tilt while seated of the locomotor system that should not be avoided but carried out correctly. The patient sits on a stool or on her heels facing a mirror. She first intentionally relaxes her abdomi- Straightening up from anteflexion nal muscles, bringing her lumbar spine into lordosis. She then slowly contracts her abdominal and glu- The patient is seated on her heels, resting her hands teal muscles to cause lumbar kyphosis. Her shoul- on the floor in front of her knees. As she breathes ders should move as little as possible during this exercise. 289
Manipulative Therapy Figure 6.151 • Uncurling from anteflexion with patient sitting on heels: (A) with hands on the floor; (B) straightening up. calmly, her lumbar spine is in kyphosis (see Fig- Lifting an object ure 6.151A). On coordinated contraction of her abdominal and back muscles and with her pelvis In a standing position, the patient places one foot fixed by her gluteals, the patient lifts her hands forward, simultaneously bending her trunk and from the floor and her lumbar spine and thoracic the knee of her forward leg to pick up the object spine straighten up (see Figure 6.151B). (see Figure 4.72). In this way the load is evenly distributed between leg, pelvis, and trunk. She The purpose of this exercise is to prepare the then straightens her trunk, simultaneously extend- patient for subsequent exercises. ing her forward leg and righting her pelvis using her gluteal and ischiocrural muscles, while her Anteflexion and retroflexion of the abdominal and back muscles control the (succes- trunk with pelvis upright sive) uncurling of her spinal column. Facilitation of the abdominal muscles can be enhanced by the Standing erect, the patient contracts her abdominal patient either breathing out against resistance or and gluteal muscles, and begins anteflexion of the pressing her outstretched fingers toward the floor. head and neck followed by her thoracic and lum- Contraction of the abdominal muscles should be bar spine. Her pelvis should remain upright, which maintained as the patient straightens up and sub- means that anteflexion is never extremely pro- sequently also during forward-bending, and she nounced. The patient never touches the floor with can check this using her fingers. She should also her hands, and usually cannot reach further than keep her trunk as close as possible to her thighs, her knees. From this position she straightens up which in turn prevents leverage. Her body’s center in reverse sequence (lumbar spine, thoracic spine, of gravity is over the advanced knee and is sup- head) and continues seamlessly into retroflexion, ported to some extent. contracting her gluteal muscles and pushing her pelvis forward. She then straightens up again to her 6.8.5 Lifting the arms starting position. The critical constants here are correct fixation of The purpose of this exercise is for the patient to the shoulder girdle and hence relaxation of the cer- learn how to control the position of her pelvis and vical spine. to master the smooth straightening of her thoracic and lumbar spine. 290
Therapeutic techniques Chapter 6 Lifting the sideways-extended arms (see Figure 6.152B and C). In this process the lower fixators of her shoulder girdle remain con- The patient is prone, with arms relaxed and tracted, while the upper fixators are relaxed. This extended sideways and her forehead resting on the exercise can be performed on one side initially, and exercise mat. Her arms are in internal rotation with later on both sides. palms facing upward (see Figure 6.152A). Her pel- vis is fixed by the abdominal and gluteal muscula- The purposes of this exercise are to enhance ture. The practitioner brings the patient’s shoulder coordinated rotation at the shoulder while the blade passively into the correct starting position upper shoulder blade fixators are relaxed, to by raising her shoulders and moving her shoulder achieve coordinated fixation of the trunk, to stretch blades caudally. In this process the patient’s arms the pectoralis, and to strengthen the lower shoulder go into external rotation and her palms are now blade fixators. flat on the floor. In this position the patient now actively fixes her shoulders. She then raises her Raising and lowering the forehead slightly and moves her outstretched arms shoulders up toward the level of her head, rotating them fur- ther externally and lifting them only so far that The patient is seated erect on a chair, preferably her forearms are still touching the exercise surface in front of a mirror, with arms hanging down. while her shoulders remain higher than her hands As forcefully as she can, she fixes her shoulder Figure 6.152 • Lifting the sideways-extended arms, patient prone: (A) first phase; (B) second phase; (C) third phase; (D) faulty. 291
Manipulative Therapy Figure 6.154 • Lifting the arms above the head: (A) correct and (B) faulty. Figure 6.153 • Raising and lowering the shoulders: cervical and upper thoracic spine, and the shoulder (A) relaxed starting position; (B) faulty. blades should remain fixed from below, with the upper shoulder blade fixators relaxed (see Section blades using the lower shoulder blade fixators (see 4.15.1, Figure 4.75). There should be no side-bend- Figure 6.153A). Now chiefly using the levator ing and the rotational movement should be around scapulae, she lifts her shoulders, leaving the upper the vertical axis of the body. part of the trapezius as relaxed as possible while activating the lower part (see Figure 6.153B). If The purpose of this exercise is to train properly only one side is being exercised, the patient can coordinated head rotation with the upper shoulder check the lower part of the trapezius with her blade fixators relaxed. other hand. 6.8.6 Carrying loads correctly The purpose of this exercise is for the patient to learn to feel the relaxation of the upper fixators For correct load-carrying, the proper fixation of of the shoulder while consciously contracting the the shoulder blades is just as essential as during lower fixators. lifting of the arms. Here, however, special atten- tion must be paid to relaxing the subclavicular part Lifting the arms above head height of the pectoralis major so as to avoid drawing the shoulders forward. The coordinated contraction of The patient is seated erect on a chair and performs the interscapular muscles is also important. Once a routine movement, bringing one hand up to her the patient succeeds in holding her shoulders back head (e.g. as when combing her hair). It is impor- behind the body’s gravity line, the upper fixators tant that the shoulder blades are fixed properly, of the shoulder girdle remain relaxed and the load the neck muscles are relaxed, and head posture being carried is not transmitted to the cervical is correct. The levator scapulae and upper part of spine (see Figure 4.76). It is no less important to the trapezius should also remain relaxed (see Fig- keep the head back, otherwise the shoulders are ure 6.154A). The exercise can be performed on one again drawn forward. It is also necessary to relax side only, and if done on both sides, the two hands the hands when carrying something and not to do not need to be lifted equally high. actively flex the fingers, instead holding a handle by the terminal phalanges, whenever possible. Head rotation In fact, the terminal phalanges flex automati- cally thanks to the same mechanism that enables The patient, who is seated on a chair, is instructed rock-climbers to hold on to the rock face without to rotate her head. There should be rotation of the actively flexing their fingers. This also helps to pre- vent epicondylopathy. 292
Therapeutic techniques Chapter 6 6.8.7 Breathing The most serious fault here is clavicular breathing Figure 6.155 • Activation of thoracic fixation during in which the thorax is lifted during inhalation (see inhalation using co-contraction of the diaphragm and the Figure 4.78). When this occurs, the tensed sca- transversus abdominis. lenes take over the activity of the diaphragm, which means that the deep stabilizers are no longer able preventing his navel from moving cranially and his to function as they should. In this faulty breathing abdomen from protruding. pattern, not only is the cervical spine constantly overloaded, but the thorax also moves away from Once the patient is breathing properly in the the pelvis with every breath taken, causing the dia- supine position, he is invited to sit on a chair. He phragm to tilt and abolishing any fixation of the should be erect and not leaning back, stabilizing thorax from below by the abdominal wall. The first himself with both legs in slight abduction and feet step is to restore coordinated activity between the rotated externally; he can check his position in diaphragm and the deep abdominal muscles. As the mirror. In this position the practitioner starts preparation for this it is also helpful to relax the by placing his hands on the patient’s waist while scalenes (see Figure 6.94). simultaneously checking the lower abdomen with his fingers. As soon as he notices that the patient During normal breathing there is eccentric con- is contracting his lateral abdominal wall and lower traction of the transversus abdominis as a result of abdomen, and that his thorax is widening instead of the concentric contraction of the diaphragm during lifting as he breathes in, then the practitioner places inhalation, which can be easily palpated at the waist the patient’s hands on his waist so that he can feel and lateral abdominal wall. To teach this to the with the radial edge of his forefingers for him- patient, the practitioner places his hands with the self the contraction of the lateral abdominal wall radial edge of his forefingers at the waist and tells and palpate with his other fingers his lower abdo- the patient to apply pressure against the fingers at men. He can also watch his clavicles in the mirror the waist. After a little stimulation with the hands, to check that these are not lifting during inhalation this will be learned in most cases. However, if this (see Figure 6.156). After a few repeats, the patient fails to work, the patient should exercise using one will be able to perform the exercise at home in of the tests described in Figures 6.140 to 6.143, front of the mirror several times a day. After 10–14 which are designed to contract this muscle group. days he should attend a follow-up appointment where the main focus will be to establish whether Once the patient is able to contract the lateral and how he has practiced and what still needs to abdominal wall, he is asked to lie supine. The prac- be corrected. It should also be clarified whether the titioner stands at the head of the treatment table exercise has helped the patient. Mastery of correct and places both hands over the patient’s lower tho- breathing technique is usually associated with res- rax. As the thorax is usually fixed in an inspiratory toration of deep stabilizer function. position, the practitioner first mobilizes the thorax in a caudal direction during exhalation and then Actively exercising the deep stabilizers and their stimulates the lateral abdominal wall with his fore- function during breathing has the following astound- fingers (see Figure 6.155). The patient is instructed ing effect: TrPs and movement restrictions, including to breathe out. As he then breathes in, the prac- titioner uses his hands to prevent the patient’s thorax from moving cranially and simultaneously stimulates the lateral abdominal wall so that the patient feels how to fix his thorax himself using his own muscles. This process helps to coordinate the concentric contraction of the diaphragm and the eccentric contraction of the transversus abdominis in particular. After taking a few breaths, the patient will learn to fix his thorax himself using his abdomi- nal muscles. The practitioner next insists that the patient also contracts his lower abdomen, thus 293
Manipulative Therapy Figure 6.156 • Training correct breathing in front of a was clearly stated earlier (see Section 4.20) that mirror: the patient uses his hands to check contraction of the deep stabilizers are the source of the common- the lateral abdominal wall and lower abdomen. est chain reaction patterns, and the same claim can be made emphatically for the feet. chain reaction patterns, are routinely resolved in the same way as after PIR, RI, and manipulation (mobi- The latest research findings indicate that the feet lization). It is impossible to overestimate the impor- form a functional unit with the deep stabilizers, as tance of the activity and cooperation of the patient illustrated by the following: the feet play a promi- here. nent role in maintaining balance, especially in the sagittal plane. As is well known, when we stand ‘at 6.8.8 The feet ease’ our muscles are constantly having to compen- sate for the oscillations of our body in all directions In our earlier discussion of the key regions in the in order for us to keep our balance. If the feet are locomotor system, we already emphasized the functioning well, then the greatest muscle activity absolutely crucial role played by the feet. This is occurs in the muscles of the lower legs and feet. reflected in the simple fact that the feet have the It has also been emphasized that one of the char- highest density of sensory receptors, and is also acteristics of the deep stabilizers (e.g. the transver- commensurate with their very significant level of sus abdominis or the muscles of the pelvic floor) is representation in the sensorimotor part of the cere that we do not generally move them consciously; bral cortex. Clinically, this is manifested among therefore we have to learn how to control them other things in the unusually frequent chain reac- deliberately. A similar situation occurs with the tion patterns that have their origin in the feet. It autochthonous muscles of the foot; it is difficult consciously to accentuate the arch of the foot using the deep plantar flexors or to abduct the hallux. However, one special characteristic of the feet – something that is not as evident anywhere else in the locomotor system – is their tactile sensitivity and, in this connection, it is possible to use affer- ent impulses to achieve clinical effects. Although it is repeatedly stressed that the nervous system is an information-processing organ, our knowl- edge is insufficient to achieve rehabilitation. How- ever, amazing successes in this respect have been recorded with the feet. And here, too, it can be seen especially clearly how sensitivity is linked with changes in muscle tonus (see Section 6.3). This sensitivity of the soles of the feet to exteroceptive stimuli may also be linked to the fact that the feet are shielded by footwear from a host of physiologi- cal stimuli and are suffering from constant sensory deprivation. The following treatment option may therefore be inferred: if we notice during stroking (light scratch- ing) that the patient’s reaction is not symmetrical on both sides and/or the patient informs us that stroking is sensed differently on both soles (and neurological disease has been excluded), we can be satisfied that tonus differences are present in the soles of the feet. If this is the case, then the most effective therapy for TrPs and movement restric- tions in the feet and for chain reaction patterns emanating from the feet (most typically on leaning forward) is exteroceptive stimulation of the sole 294
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
- 308
- 309
- 310
- 311
- 312
- 313
- 314
- 315
- 316
- 317
- 318
- 319
- 320
- 321
- 322
- 323
- 324
- 325
- 326
- 327
- 328
- 329
- 330
- 331
- 332
- 333
- 334
- 335
- 336
- 337
- 338
- 339
- 340
- 341
- 342
- 343
- 344
- 345
- 346
- 347
- 348
- 349
- 350
- 351
- 352
- 353
- 354
- 355
- 356
- 357
- 358
- 359
- 360
- 361
- 362
- 363
- 364
- 365
- 366
- 367
- 368
- 369
- 370
- 371
- 372
- 373
- 374
- 375
- 376
- 377
- 378
- 379
- 380
- 381
- 382
- 383
- 384
- 385
- 386
- 387
- 388
- 389
- 390
- 391
- 392
- 393
- 394
- 395
- 396
- 397
- 398
- 399
- 400
- 401
- 402
- 403
- 404
- 405
- 406
- 407
- 408
- 409
- 410
- 411
- 412
- 413
- 414
- 415
- 416
- 417
- 418
- 419
- 420
- 421
- 422
- 423
- 424
- 425
- 426
- 427
- 428
- 429
- 430
- 431
- 432
- 433
- 434
- 435
- 436
- 437
- 438
- 439
