__Myofascial_muscle_chains

MYOFASCIAL MUSCLE CHAINS PETER D.M. JONCKHEERE, Physical therapy, Principal Teacher Myofascial Therapy, Belgium. E-mail: [email protected]. JAN A.J. PATTYN, Physical therapy, Teacher MyofasciaI Therapy, Belgium. Objectives: To present a handy survey of the myofascial classification of the muscles according to their pain region in function of their focus and radiation. With this survey the myofascial muscle chains can be consulted instantly. Methods: In function of the myofascial pain regions, per muscle, painfocus and radiation pain have been visually presented on the computer, based upon data out of the international myofascial literature. Out of these findings, for each myofascial region, primary (muscles that give focal pain) and secondary (muscles that give radiation pain) myofascial muscle chains were determined and charted. Results: 1. Classification of the muscles divided into 61 pain regions according to focality and radiation. 2. Classification of the associated chains in dysfunction according to pain region. 3. Classification of the development of myofascial muscle chains departing from a well-defined muscle. 4. Classification of the myofascial muscle chains where a well-defined muscle occurs in the muscle chain of another muscle. Conclusions: The examiner or therapist can easily trace the myofascial dysfunctions with the help of a compact reference book (practical workbook). The progress of pain can be explained by the development of the myofascial - muscle chains and so there is a point of application to dissolve myofascial dysfunctions efficiently by means of these causal muscle chains. ISBN: 90-804265-1-2

FRONT 23 P. 89 Face - Upper Cheek & Jaw ......... ....... ... .......12 107 & . 13Face - Lower Cheek Jaw . . .. . . . . . . . . . . . . . . . . . . . . . Eye 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ear - TMJ . . ... . .. . . . . .. . . .15. . . . . . . . . . . . . . . . .... . . . .... . .. . . . ... . Teeth . . .... . . . . . . . ... 16. . . . . . . . . . . . . . ... ... ..... ....... ........... .. Throat . . . . . . .. . . ... . . .. . . .... ... 17. . . . . . . . . . . . . . . . . . . . . . . . .. . ... . .. . Head - Frontal . . . . 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Head - Temporal . . . . 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Head - Vertex . . . . . 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shoulder Anterior ..........................................40 Shoulder Lateral............................................46 . . 49Upperarm Anterior . . . . . . . . ..... . . . . . . . .. . . . . . . . . . ...... . . Upperarm Lateral ..........................................53 Elbow - Epicondylus Lateralis .......................54 Elbow - Epicondylus Medialis .......................56 Elbow - Antecubital .......................................58 Forearm - Volar .............................................59 . 61Forearm - Radial .. . ........ . . . . . . . . . . . . . . . . . . ... . ...... .. . Forearm - Ulnar . . . . . 62. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Hand - Wrist - Radial . . . . ..... ... . . . . . . . . . . . . . . ....... .. Hand - Volar side & Wrist .............................69 Hand - Wrist - Ulnar ......................................71 Fingers Volar . . . . ..... 75. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 76Chest - Front .. .. .. . . . . . . . . . .. . .. . . ... . .. .... . ... . .. . .. . .. . Chest Side . .. .. . .. .. ... ..... .. 78_ . .. .. ........... ....... .... . .. Abdomen .......................................................79 Groin .............................................................83 Hip - Anterior .................................................85 Thigh - Medial ...............................................89 Thigh - Anterior ...................................:.........90 Thigh - Lateral. ..............................................94 Knee - Anterior ..............................................97 Knee - Medial.. ... .. . . . . . ... .... .. ............... ..... ... ....99 Knee - Lateral .............................................100 Leg - Anterior (shank) .................................101 Leg - Lateral................................................104 Leg - Medial ................................................105 Ankle - Malleolus Externus .........................106 107Ankle - Malleolus Internus .. . ... . . . . . . . . . . . . . . . . . ... Foot - Dorsal ...............................................110

BACK 23 P. 73 Ear - TMJ 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Head - Occipital 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Head - Vertex 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neck - Posterior 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Upper-Thoracic 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Mid-Thoracic 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Low-Thoracic 30. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Lumbar 3 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Sacral 34. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - SIJ 37. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back - Coccyx 39. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shoulder Posterior 43. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shoulder Lateral 46. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Upperarm Posterior 51. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Upperarm Lateral 53. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Elbow - Epicondylus Lateralis . . . . . . . . . . . . . . . . . . . . . . . 56Elbow - Epicondylus Medialis . . . . . . . . . . . . . . . . . . . . . . . Elbow - Olecranon 57. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forearm - Dorsal 60. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forearm - Radial 6 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forearm - Ulnar 6 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hand - Dorsal side & Wrist 63. . . . . . . . . . . . . . . . . . . . . . . . . . . Hand - Wrist - Radial 66. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hand - Wrist - Ulnar 71. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fingers Dorsal 73. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chest - Side 78. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Buttock 80. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hip - Lateral 87. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thigh - Medial 89. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thigh - Posterior 92. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thigh - Lateral 94. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Knee - Posterior 95. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Knee - Medial 99. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Knee - Lateral 100. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leg - Posterior (calf) 102. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leg - Lateral 104. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leg - Medial 105. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ankle - Malleolus Externus 106. . . . . . . . . . . . . . . . . . . . . . . . . Foot - Plantar 108. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Peter Jonckheere Jan Pattyn MYOFASCIAL MUSCLE CHAINS Trigger vzw

Title: \"Myofascial Muscle Chains\" Authors: Peter D.M. Jonckheere Jan A.J. Pattyn Cover: Ignace Pattyn Translation: Kathelijne Decloedt Copyright © 1998 Trigger vzw Weidestraat 234 8310 Brugge Belgium All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copywright owner. Printed in Belgium - All rights reserved. ISBN 90-804265-1-2 979287

MYOFASCIAL MUSCLE CHAINS

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Index Introduction 1 Chapter 1 : Practical Working Method 2 Procedure chapter 4 : muscle chains according to their pain region 2 Procedure chapter 5 : the muscle chains of each particular muscle 4 Chapter 2 : Definitions 7 Myofascial Muscle Chains 7 Trigger Point 8 Chapter 3 : Algometrics 9 Purpose 9 Myofascial Pain Index (MPI) 9 10 Myofascial Dysfunctions 10 Conclusions 11 Chapter 4 : Myofascial Chains in function of the 12 pain region 13 14 Face - Upper Cheek & Jaw 15 Face - Lower Cheek & Jaw 16 17 Eye 18 Ear - TMJ 19 21 Teeth 23 Throat 24 Head - Frontal 25 Head - Occipital 27 Head - Temporal 30 Head - Vertex 31 Neck - Posterior 34 Back - Upper-Thoracic 37 Back - Mid-Thoracic Back - Low-Thoracic Back - Lumbar Back - Sacral Back - SIJ

Back - Coccyx 39 Shoulder - Anterior 40 Shoulder - Posterior 43 46 Shoulder - Lateral 49 Upperarm - Anterior 51 Upperarm - Posterior 53 54 Upperarm - Lateral 56 Elbow - Epicondylus Lateralis 57 Elbow - Epicondylus Medialis 58 59 Elbow - Olecranon 60 Elbow - Antecubital 61 62 Forearm - Volar 63 Forearm - Dorsal 66 Forearm - Radial 69 71 Forearm - Ulnar 73 Hand Dorsal Side & Wrist 75 76 Hand - Wrist - Radial 78 Hand Volar Side & Wrist 79 80 Hand - Wrist - Ulnar 83 Fingers - Dorsal 85 Fingers - Volar 87 Chest - Front 89 Chest - Side 90 Abdomen 92 Buttock 94 Groin 95 Hip - Anterior 97 Hip - Lateral 99 Thigh - Medial 100 Thigh - Anterior 101 102 Thigh - Posterior 104 Thigh - Lateral 105 106 Knee - Posterior 107 Knee - Anterior 108 Knee - Medial 110 Knee - Lateral Leg - Anterior (shank) Leg - Posterior (calf) Leg - Lateral Leg - Medial Ankle - Malleolus Externus Ankle - Malleolus Internus Foot - Plantar Foot - Dorsal Chapter 5 : Myofascial Muscle Chains per muscle 11 2 Abductor Digiti Minimi (fingers) 113 Abductor Hallucis 114 Adductor Brevis 115 Adductor Hallucis 118

Adductor Longus 119 Adductor Magnus 122 124 Adductor Pollicis 125 Anconeus 126 128 Biceps Brachii 130 Biceps Femoris 132 134 Brachialis 135 Brachioradialis 137 140 Coccygeus 141 Coracobrachialis 143 146 Deltoideus 147 Digastricus 149 Extensor Carpi Radialis Brevis 151 Extensor Carpi Radialis Longus 152 Extensor Carpi Ulnaris 154 Extensor Digitorum (middle finger) 155 Extensor Digitorum (ring finger) 157 Extensor Digitorum Brevis 158 Extensor Digitorum Longus 160 Extensor Hallucis Brevis 161 Extensor Hallucis Longus 162 Extensor Indicis 164 Flexor carpi Radialis 165 Flexor Carpi Ulnaris 166 Flexor Digitorum Brevis 167 Flexor Digitorum Longus 168 Flexor Digitorum Superficialis & Profundus 170 Flexor Hallucis Brevis 172 Flexor Hallucis Longus 175 Flexor Pollicis Longus 178 Gastrocnemius 179 Gluteus Maximus 181 Gluteus Medius 183 Gluteus Minimus 185 188 Gracilis 190 Iliocostalis Lumborum 191 194 Iliocostalis Thoracis 195 Iliopsoas 196 199 Infraspinatus 201 Interosseus Dorsalis 1 & 2 (fingers) 202 204 Interosseus Dorsalis 1 (toes) 205 Latissimus Dorsi 206 Levator Ani 207 208 Levator Scapulae Longissimus Thoracis Masseter Multifidus (neck) Multifidus (back) Obliquus Externus Abdominis Obturatorius Internus Occipitofrontalis Opponens Pollicis Orbicularis Oculi

Palmaris Longus 209 Pectineus 210 212 Pectoralis Major 215 Pectoralis Minor 217 Peroneus Brevis 218 Peroneus Longus 220 Peroneus Tertius 221 223 Piriformis 224 Plantaris 225 Popliteus 226 Pronator Teres 227 Pterygoideus Lateralis 228 Pterygoideus Medialis 231 Quadratus Lumborum 232 Quadratus Plantae 234 Quadriceps Femoris Rectus Femoris 235 Quadriceps Femoris Vastus Intermedius 237 Quadriceps Femoris Vastus Lateralis 240 Quadriceps Femoris Vastus Medialis 242 Rectus Abdominus 243 Rhomboideus Major 244 Rhomboideus Minor 246 Sartorius 249 Scalenus 251 Semimembranosus 252 Semispinalis Capitis 253 Semispinalis Cervicis 255 Semitendinosus 256 Serratus Anterior 257 Serratus Posterior Inferior 258 Serratus Posterior Superior 260 261 Soleus 263 Splenius Capitis 264 Splenius Cervicis 267 268 Sternalis 270 Sternocleidomastoideus 272 275 Suboccipitale . 277 Subscapularis 278 280 Supinator 282 Supraspinatus 283 284 Temporalis 287 Tensor Fasciae Latae Teres Major Teres Minor Tibialis Anterior Tibialis Posterior Trapezius Triceps Brachii

Foreword For the therapist who has to deal with a pain problem of the locomotor system there is an enormous amount of information available. Along with the \"classical\" orthopaedic approach, the manual, osteopathic or chiropractical vision, the electro­ magnetical therapies a.o. acupuncture etc., the Myofascial approach gains more and more importance. For a great number of therapists, Myofascial Therapy is the ideal completion of their other techniques. This new book: \"Myofascial Muscle Chains\" is to be situated within the Myofascial Therapy. With impatience we have been looking forward to this book. It really fills up a gap in which the myofascial pain therapist will find practical information which cannot be found anywhere at the moment. How did this book come into existence? Why throw a book about Muscle Chains and more specifically Myofascial Muscle Chains on the market? The deeper roots of \"Myofascial Muscle Chains\" can naturally be found in the splendid basic work written by Travell and Simons: Myofascial Pain and Dysfunction: The Trigger Point Manual I and II. In this systematic work, Travell and Simons make mention of the fact that each particular muscle has associated muscles. When active trigger points are found in one particular muscle, Travell discovered on a clinical basis that there are permanent connections between this muscle and other muscles. In practice this means that, when dealing with a pain problem, one muscle is found to be prominent, the associated muscles have to be checked and treated as well. Peter Jonckheere is the principal teacher of the highly qualified course of \"Myofascial Therapy\" at the Jing Ming School in Flanders, Belgium. On the basis of his clinical practice and his intrrest in computer programs he went in search of systems among these associated muscles and created the concept \"Myofascial Muscle Chains\" in the early 90ties. With the help of his own ingeniously built-up schedule of muscles and the year-long clinical testing and debating with his students, this basic concept was gradually turned into what is lying now in front of you: a very handy workbook about clinically relevant links between muscles and their pain patterns. The manual is divided into 2 chapters: In the first chapter the therapist can start from the PAIN REGION. For this region all prominent muscles are presented into a schedule, together with their associative chains. (The definitions of these chains can be found in an introductory chapter). In this way the therapist immediately knows which main muscles he is dealing with.

In the second chapter the therapist can start from a MUSCLE. Which chains start from this muscle and which chains this muscle forms a part of? In that way surprising links between muscles of the same region occur. Links can also be made with more distant muscles. This knowledge can help the treatment spectacularly. The neurological segment per muscle is also mentioned: in that way the link between the relevant muscle chains and potenially primary dysfunctions in the vertebral column can be put more easily. Both authors are teachers at the Jing Ming School for \"Myofascial Therapy\" in Belgium. Peter Jonckheere works as a physiotherapist in Bruges, is a pioneer of the Myofascial Therapy in Flanders, Belgium. He started the above training from scratch and is author of some basic works on MT.: 'Spieren en Dysfuncties, Trigger Punten, Basisprincipes van de Myofasciale Therapie', Publ. SATAS and 'Pijn, u kunt er iets aan doen', Publ. SATAS. Peter is vice-president of the Myofascial Therapists' Association and editor of \"Trigger Nieuws\", the three-monthly magazine about MT. Jan Pattyn works as a physiotherapist in Torhout, attended the training as a student of Peter's and some years ago he was qualified as a fellow-teacher. His enthusiasm and dynamism formed the start of their co-operation which resulted in the publishing of this manual in less than 1 year. As president of 'Trigger\", ex-student and fellow teacher of the training and dedicated user and defender of the MT., I am convinced this manual is indispensable in the library of every pain therapist. Moreover, it deserves a place, within reach, to be consulted easily, between two palpations or function tests, which, sadly enough, can not be said of a lot of manuals. Kris Demanet, M.D. Sports Medicine Private Practice Torhout, Belgium.

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Introduction Objectives To present a handy survey of the myofascial classification of the muscles according to their pain region in function of their focus and radiation. With this survey the myofascial muscle chains can be consulted instantly. Methods In function of the myofascial pain regions, per muscle, painfocus and radiation pain have been visually presented on the computer, based upon data out of the international myofascial literature. Out of these findings, for each myofascial region, primary (muscles that give focal pain) and secondary (muscles that give radiation pain) myofascial muscle chains were determined and charted. Results 1. Classification of the muscles divided into 61 pain regions according to focality and radiation. 2. Classification of the associated chains in dysfunction according to pain region. 3. Classification of the development of myofascial muscle chains departing from a well-defined muscle. 4. Classification of the myofascial muscle chains where a well-defined muscle occurs in the muscle chain of another muscle. Conclusions The examiner or therapist can easily trace the myofascial dysfunctions with the help of a compact reference book (practical workbook). The progress of pain can be explained by the development of the myofascial muscle chains and so there is a point of application to dissolve myofascial dysfunctions efficiently by means of these causal muscle chains.

Chapter 1 Practical working-method Myofascial therapy treats, by means of trigger points, pains that are caused by the malfunctioning of muscles. The purpose of this work is to present a handy survey of the myofascial classification of the muscles according to their pain region, in function of focus and radiation. This survey enables the user to consult the myofascial muscle chains instantly. Procedure chapter 4 muscle chains according to their pain region PURPOSE: searching the main muscles starting from the pain region indicated by the patient. We argue horizontally. How do we determine which muscles are responsable for pain in a certain region? We start from a specific pain region, indicated by the patient Per pain region you get a survey of the primary and secondary muscle chains • primary m uscle chain = minimum 3 muscles that cause focal pain. • secondary m uscle chain = minimum 3 that cause referred pain. e.g. patient complains of pain in the neck. pain focus referred pain Splenius Cervicis (UTP) Infraspinatus (Upper 2TPs) Levator Scapulae Sternocleidomastoideus (sternal) Multifidus (neck) Suboccipital Trapezius (TP1 ,2,3) Out of this schedule we immediately read there are 4 muscles that cause focal pain in the neck. By means of algometries (see chapter 2) we can determine which of these muscles contain an active trigger point. active TP = TP that provokes the recognizable pain when palpated. 2

An association muscle chain can start from each muscle with an active TP out of the primary muscle chain. • association m uscle chain = a muscle chain that only consists of muscles that from their muscle in dysfunction develop TPs in associated muscles. Example 1 : our patient with pain in the neck shows an active TP in the M. Multifidus Multifidus Levator Scapulae Semispinalis Capitis Semispinalis Cervicis Sternocleidomastoideus Splenius Cervicis This schedule shows that the M.Multifidus has 5 associative muscles. Which of these 5 associative muscles also cause focal or referred pain? Multifidus(neck) In our example the 2 above-mentioned muscles are the only ones that cause focal pain in the neck. We speak of a primary association chain. We neglect the M.Sternocieidomastoideus because this muscle only causes radiation pain for the neck and therefore cannot be fitted into the primary association chain. In this book we only sum up the sheer primary and secondary association chains in function of each pain region. Example 2 : our patient with pain in the neck shows an active TP in the M. Splenius Cervicus. Splenius Cervicis Sternocleidomastoideus Trapezius Splenius Capitis Suboccipital This schedule shows the M. Splenius Cervicus contains 4 associative muscles. Which of these 4 associative muscles also cause focal or radiation pain? Splenius Cervicis Suboccipital Sternocleidomastoideus (Sternal) 3

In our example only the 2 above-mentioned muscles. Since both cause merely radiation pain, we can speak of a secondary association chain. For the same reason the M. Trapezius does not belong here. In this chapter we have determined which muscles are myofascially involved in a certain pain region . When we want to go further into this matter, we consult chapter 5 : the muscle chains of each particular muscle. In that way we can put the links to other pain regions. procedure Chapter 5 the muscle chains of each particular muscle PURPOSE: Finding the links (possibly to other pain regions) starting from the muscle that is already defined. The working-method is vertical. We start from a muscle in dysfunction , as defined in chapter 3. e.g. a dysfunction of the M. Trapezius. Chains starting from the Trapezius We give a catalogue of the muscles associated with the M. Trapezius. associated muscles Levator Scapulae (according to Travell & Trapezius (contralateral) Simons) Supraspinatus Rhomboideus Major Rhomboideus Minor Pectoralis Major Scalenus Temporalis Occipitofrontalis We now give a catalogue of the primary and secondary asociative chains starting from the M. Trapezius in function of the different pain regions. Primary associated chains Temporalis head - lateral Trapezius (contralateral, TP1 ) neck - posterior Occipitofrontalis etc. Levator Scapulae Trapezius (contralateral, TP 1 ,2,3) 4

Secundary associated chains Trapezius (contralateral) head - occipital Temporalis Occipitofrontalis shoulder - posterior Levator Scapulae Scalenus Chains in which Trapezius is involved Dealing with a chronological complaint in which different pain regions are involved, you don't always find the solution to the problem, because already several muscle chains have developed and succeeded one another. To go back to the initial muscle chain we have to proceed in a reversed order . We can do this by looking in which chain of another muscle the Trapezius occurs. The scheme below shows the muscle of which the Trapezius is an associative muscle. associated muscles Supraspinatus (according to Travell & Rhomboideus Major Simons) Rhomboideus Minor Pectoralis Major Scalenus Temporalis Suboccipital Sternocleidomastoideus Splenius Cervicis Splenius Capitis Biceps Brachii We schedule all the different associative chains which the M. Trapezius occurs in.We make three columns. Firstly, the muscle out of which the associative chain starts. In the second column, the likely involved pain region and in the third column the actual associative chain which the M. Trapezius occurs in. Primary associated chains ... neck - Levator Scapulae Trapezius posterior Trapezius Suboccipital head-lateral (contralateral, .. . TP1,2,3) Semispinalis Capitis Sternocleidomastoi- deus (Sternal) Trapezius (TP1) 5

Secundary associated chains ... back - Trapezius mid - thoracic Rhomboideus Levator Scapulae Minor Splenius Cervicis Sternocleidom head - Temporalis astoideus occipital Trapezius ... (TP 1 ,2,3) 6

Chapter 2 Definitions Myofascia/ Muscle Chains Conditions: • the presence of at least 3 muscles • the presence of at least 1 TP per muscle involved • the presence of at least 1 active TP in the chain Kinds: Direct myofasciaJ muscle chain Collection of muscles that, in dysfunction,can cause pain, for a well-defined region. Primary direct myofascia/ muscle chain Collection only of muscles that , in dysfunction, for a well-defined region, can cause FOCAL PAIN. Secondary direct myofascia/ muscle chain Collection of muscles that, in dysfunction, can cause not merely focal but referred pain as well. MyofasciaJ Associative muscle chain Collection of muscles that starting from their muscle in dysfunction develop associative TPs in other muscles. Primary myofascia/ associative muscle chain Collection of muscles that, starting from their muscle in dysfunction, develop associative TPs that cause FOCAL pain for a well-defined region. Secondary myofascia/ associative muscle chain Collection of muscles that, starting from their muscle in dysfunction, develop associative TPs that not necessarily cause merely focal pain for a well-defined region. 7

Trigreg Point A self-maintaining hyper-irritable spot in a skeleton muscle or its associated fascia. Active Trigger Point A very sensitive spot that , when palpated, causes an identifiable pain that totally or partly agrees with the pain track of the muscle in dysfunction. Latent Trigger Point A spot that causes local pain only when palpated. False Positive Trigger Point A spot that causes referred pain: or: - not in accordance with the identifiable pain or: - in accordance with the specific track for this trigger point but with an algometric score higher than the MPI 8

Chapter 3 Algometries Purpose The purpose of algometrics is to define whether a TP is active, latent, falsely positive or absent.This knowledge is based on the most recent data from the American study: \"PressureThreshold for referred pain by compression on the trigger point and adjacent area.\" (Chang-Zern Hong, Yuh-Ning Chen, Debra, Twehous, Dennis H. Hong. Journal of Musculoskeletal Pain.) Myofascial Pain Index (MPI) Pain is subjective. To get an idea by means of algometrics of the pain the patient experiences , we must be able to make an objective evaluation. By means of the calculation of a myofascial pain index we can estimate objectively the value of the pain the patient can bear. The MPI is calculated by measurements on the 18 Tender Points with the Algoprobe® . The Algoprobe® is an electric algometer by means of which the MPI is automatically calculated . , The trigger point research is linked to the MPI and evaluated in that way in function of the individual pain threshold of each patient. These are the locations of the Tender Points we have to measure : 1. occiput : at the insertions of the Suboccipital muscles. 2. lower cervical: at the anterolateral aspect of C5-C6 3. edge of trapezius: in the middle of the shoulder 4. supraspinatus: the fossa supraspinatus at the medium edge of the scapula 5. second rib: up lateral at the sterno-costal junction 6. lateral epicondyl: 2 cm distal of the epicondyl 7. knee: at the medium fleshy thickness proximal of the jOint 8. major trochanter: posterior of the prominentia trochanterica 9. gluteal: in the upper lateral quadrant anterior The MPI is the average pressure that is measured at these 18 Tender point locations (9 right - 9 left) => 18 values have to be registered by pressure with the probe => The MPI is simply the average value measured at the Tender Points. Here comes an example how the MPI is calculated. 9

e.g. left right TeP 1 3,70 4,30 at the insertions Suboccipital muscles TeP2 3,30 3,30 anterolateral aspect C5-C7 TeP3 4,80 5,30 middle point of the shoulder TeP4 4,00 3,60 TePS 3,90 3,50 fossa supraspinatus, medium edge scapula TeP6 3,60 4,30 upper lateral at costochondral junction rib 2 TeP7 6,10 7,40 TeP8 8,90 7,20 2 cm distal of the epicondylus lateralis TeP9 6,20 4,50 at the medium side of the knee posterior of prominentia trochanterica in upper exterior quadrant 44,50 43,40 0,12 4,94 4,82 MPI 4,88 The calculation of an individual MPI is essential for the following reasons: I. pain is subjective and has to be assessed objectively and individually. 2. when, as in the example above, a palpation pressure of 2 kg is used, a lot of muscle indications will be missed, as for this person too little pressure is given. When, on the other hand, a palpation pressure of 6 kg is used, this is too high for this person and a lot of false positive results will be registered. 3. when diagnosing myofascial dysfunctions, this MPI is determining whether we are dealing with active TPs, latent TPs or with False positive TPs. This information is essential as to stipulate the way of treatment. Myofascial dysfunctions In function of the pain region (dr. Chapter 4) and the already determined MPI we measure the Trigger Points that are considered. In function of the individual pain index we can automatically read whether a Trigger Point is active, latent or falsely positive. A TP is active when it has a lower score than the MPI and is attended with the typical referred pain . A TP is latent with a lower score than the MPI but without radiation. A TP is falsely positive when it has referred pain with a score higher than the MPI or when the patient experiences a non-recognizable referred pain with a score lower than the MPI. Conclusions. It is useless to apply algometrics without determining a Myofascial Pain Index. The interpretation of the measurements can only be objectified in function of the patient himself. 10

Chapter 4 Myofascial Chains in function of the pain region 11

Face - Upper Cheek & Jaw pain focus referred pai n Masseter Tempora lis (3 anterior TPs) Pterygoideus Lateralis Sternocleidomastoideus (sternal) Zygomaticus Major Masseter Sternocleidomastoideus (sternal) Orbicularis Oculi Soleus (Iat UTP) Platysma Pterygoideus Medialis Masseter T e m p o ra l i s Pterygoideus Lateralis Pterygoideus Medialis Zygomaticus Major Sternocleidomastoideus Sternocleidomastoideus (sternal) Digastricus Pterygoideus Lateralis Soleus Sca l e n u s Trapezius Levator Scapulae Splenius Cervicis Pectoralis Major Masseter Temporalis Orbicularis Oculi Occipitofro n ta l i s Gastrocnemius Tibialis Posterior Haliucis Longus Flexor Digitorum Longus Gluteus Minimus Tibialis Anterior Extensor Digitorum Longus Extensor Haliucis Longus Peroneus Tertius Secundary associated chains Masseter Pterygoideus Lateralis S t e r n o c l e i d o m a s to i d e u s Pterygoideus Medialis Temporalis S t e r n o c l e i d o m a s to i d e u s Masseter Tempo ra l i s 12

Face - Lower Cheek & jaw pain focus referred pain Masseter Sternocleidomastoideus (sternal) Trapezius (TP1) Digastricus Platysma Masseter Pterygoideus Medialis Trapezius (TP 1 ) T e m p o ra l i s Pterygoideus Med ialis Sternocleidomastoideus (sternal) Digastricus Pterygoideus Lateralis (inferior) Levator Scapulae Trapezius (contralateral) Supraspinatus Rhomboideus Major Rhomboideus Minor Pectoralis Major S ca l e n u s Temporalis Occipitofro n ta l i s Masseter Secundary associated chains Digastricus Sternocleidomastoideus 13