Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

The new edition of Clinical Application of Neuromuscular Techniques are described within the context of normal anatomy and physiology Volume 1 - The Upper Body updates and expands on the theories, of the structures, as well as the common dysfunctions that may arise. validation and techniques for the manual treatment of chronic and Indications for treatments and guidance on making the appropriate acute neuromuscular pain and somatic dysfunction. Over 600 pages treatment choice are given for 'each muscle to be addressed, and of highly illustrated material from the two leaders in the field of particular attention is paid to the treatment of trigger points. Clinical manual therapy ensure the anatomy and techniques involved in the insights stem from many years of clinical and teaching experience of application of neuromuscular techniques are easier to follow than both authors. ever before. This new edition of Clinical Application of Neuromuscular Techniques New to this edition is a CD-ROM containing fully searchable and Volume 1 - The Upper Body continues to combine and integrate key referenced book text complete with the illustrations and bonus information from several sources. The result is a textbook which will illustrative material. do much to ensure the safe and effective application of soft tissue techniques and provide an invaluable source of reference to all students The content covers NMT (neuromuscular techniques), MET· (muscle and practitioners in the field of manual therapy. energy techniques). PR (positional release) and many other bodywork techniques for neuromusculoskeletal disorders. The text is arranged This updated volume is accompanied by Volume 2 - The Lower Body, by regions in a muscle-by-muscle approach with templated headings which addresses the problems of the lower body (lumbar spine, sacrum, making important information easy to locate. The theory and practice pelvis, hip, leg, and foot). Key Features About the Authors • Comprehensive 'one-stop' text on care of somatic pain and dysfunction Leon Chaitow NO DO is an internationally known and respected osteopathic • Foundations, theories, and current research perspectives as to causes of and naturopathic practitioner and teacher of soft tissue manipulation methods of treatment. He is author of over 60 books, including a series on Advanced Soft myofascial pain Tissue Manipulation (Muscle Energy Techniques, Positional Release Techniques, • All muscles covered from the perspective of assessment and treatment of Modern Neuromuscular Techniques) and also Palpation Skills; Cranial Manipulation: Theory and Practice; Fibromyalgio Syndrome: A Practitioner's myofascial pain Guide to Treatment, and many more. He is editor of the peer reviewed Journal of • Describes the normal anatomy and physiology as well as the common Bodywork and Movement Therapies, that offers a multidisciplinary perspective on physical methods of patient care. Leon Chaitow was for many years senior lecturer dysfunctions on the Therapeutic Bodywork degree courses which he helped to design at the • Provides indications for treatments and guidance on making the appropriate School of Integrated Health, University of Westminster London, where is he now an Honorary Fellow. He continues to teach and practice part-time in London, when treatment choice for each patient not in Corfu, Greece where he focuses on his writing. • Practical step-by-step technique descriptions for each treatment • Describes the different neuromuscular techniques (NMn in relation to the Judith Delany LMT has spent two decades developing neuromuscular joint anatomy involved therapy techniques and course curricula for manual practitioners as well • Includes muscle energy, myofascial release, and positional release techniques, as for massage schools and other educational venues. Her ongoing private trainings with the Tampa Bay Devil Rays athletic trainers (professional as well as NMT to offer a variety of treatment options baseball) as well as customized trainings for noteworthy US-based spas show • Includes location and treatment of trigger points incorporation of NMT into diverse settings. She has contributed a chapter • Covers manual and complementary techniques. to Modern �uromusular Techniques and co-authored a contribution to Principles and Practices of Manual Therapeutics. As an international instructor New to this edition of NMT American version, co-author of three NMT textbooks, and associate • Expanded text includes additions on the 'internal environment' (biochemistry), editor for Journal af Bodywark and Movement Therapies, her professional focus aims to advance education in all healthcare professions to include connective tissue, updated research, and many new illustrations myofascial therapies for acute and chronic pain syndromes. She resides in • Illustrations demonstrating the bony anatomy under the treating fingers St. Petersburg, Florida where she is the director of and primary curriculum developer for NMT Center. enhance aid to the reader in visualizing what is under palpation • Fully searchable text on CD-ROM • Additional, full-colour illustrations on CD-ROM • Evolve website with downloadable image collection for lecturers. Reader reviews from the first edition -As the massoge profession embraces the knowledge base that is the foundation for the work that we do, there is a need for texts and reference bootes that provide concrete, researched, and integrated information free from the influence of personal sty/e. This text has accomplished the task by expertly weaving the sciences with the skills, and blending methods for physiologic outcomes� Sandy Fritz BS NCTMB \"This book mosterfully integrates the biomechanical biopsychosocial and biomechanicol approoches of monogement of the soft tissue dysfunction: Craig Liebenson DC \"This book is destined to become a classic and a 'must have' in every seriaus manual therapist's library for years to come ... I, for one, will be recommending it to everyone I con becouse it is without a doubt the most well thought out ond well orgonized presentation of soft tissue manual therapy thot I have seen to date� Whitney W Lowe LMT ISBN 978-0-443-07448-6 CHURCHILL 9780443074486 LIVINGSTONE ELSEVIER www.elsevierhealth.com

Clinical Application of Neuromuscular .Techniques

For Elsevier: Senior Commissioning Editor: Sarena Wolfaard Associate Editor: Claire Wilson Project Manager: Gail Wright Designer: Eric Drewery Illustration Manager: Bruce Hogarth lIlustrators: Graeme Chambers, Peter Cox, Bruce Hogarth, Paul Richardson, Richard Tibbitts

Clinical Application of Neuromuscular Techniques Volume 1 - The Upper Body Second Edition leon Chaitow ND DO Consultant Naturopath and Osteopath. Honorary Fellow, University of Westminster, London, UK Judith Delany LMT Lecturer in Neuromuscular Therapy, Director of NMT Center, St Petersburg, Florida, USA Foreword by Diane lee BSR FCAMT CGIMS Director, Diane Lee Et Associates, Consultants in Physiotherapy, White Rock, BC, Canada CHURCHILL LIVINGSTONE ELSEVIER EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2008

CHURCHILL LIVINGSTONE ELSEVlER © Elsevier Limited 2000. All rights reserved. © Elsevier Ltd, 2008. All rights reserved. The right of Leon Chaitow and Judith DeLany to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. No part of this publication may be reproduced, stored in a retrievaL system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier's Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103- 2899, USA: phone: (+ 1) 215 239 3804; fax: (+ 1) 215 239 3805; or, e-mail: healthpennissions@elseviL>r.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com). by selecting 'Support and contact' and then 'Copyright and Permission'. First edition 2000 Second edition 2008 ISBN 978-0-443-07448-6 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is avaUabJe from the Library of Congress Notice Neither the Publisher nor the authors assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher your source for books, The journals and multimedia Publishers in the health sciences policy is to use www.elsevierhealth.com paper manufactured from sustainable forests Working together to grow libraries in developing countries I WW\"W.clscvicr.com I .... .r. w.booka.id.org I \\I.'W\\..,.sabre.org l:l.SI:-Vlt�R �'����'�I:��,I�J Printed in China

vii Contents List of boxes xv Major types of voluntary contraction 33 Foreword xvii Terminology 33 Preface to the Second Edition xix Muscle tone and contraction 33 Acknowledgments xxi Vulnerable areas 34 Muscle types 34 Connective tissue and the fascial system 1 Cooperative muscle activity 35 Muscle spasm, tension, atrophy 37 The fascial network 2 17 Fascia and proprioception 2 Contraction (tension with EMG elevation, Fascia: collagenous continuity 2 voluntary) 38 Further fascial considerations 2 Elasticity 3 Spasm (tension with EMG elevation, involuntary) 38 Plastic and elastic features 3 Connective tissue as a 'sponge' 6 Contracture [tension of muscles without Deformation characteristics 6 EMG elevation, involuntary) 38 Hypermobility and connective tissue 7 Trigger points, fascia and the nervous system 8 Increased stretch sensitivity 38 Viscoelastic influence 39 The importance of Langevin's research 9 Atrophy and chronic back pain 39 Summary of fascial and connective tissue function 13 What is weakness? 39 Fascial dysfunction 16 Trick patterns 39 Restoring gel to sol 17 Joint implications 40 A different model linking trauma and connective tissue When should pain and dysfunction be Therapeutic sequencing 1 9 left alone? 40 Beneficially overactive muscles 41 Somatization - mind and muscles 41 But how is one to know? 41 2 Muscles 23 Dynamic forces - the 'structural continuum' 23 3 Reporting stations and the brain 45 Signals 25 Essential information about muscles 25 Proprioception 45 Types of muscle 25 Fascia and proprioception 46 Energy production in normal tissues 27 Energy production in the deconditioned Reflex mechanisms 47 Local reflexes 50 individual 28 Central influences 50 Muscles and blood supply 28 Motor control and respiratory alkalosis 31 Neuromuscular dysfunction following injury 51 Mechanisms that alter proprioception 52 Two key definitions 32 An example of proprioceptive dysfunction 52 The Bohr effect 32 Core stability, transversus abdominis, the Rectus capitis posterior minor (RCPMin) research evidence 52 diaphragm and BP D 32 Summary 32 Neural influences 53 Effect of contradictory proprioceptive information 53 Neural overload, entrapment and crosstalk 57

viii CONTENTS Manipulating the reporting stations 58 Scapulohumeral rhythm test 91 Therapeutic rehabilitation using reflex systems 59 Neck flexion test 92 Conclusion 60 Push-up test 92 Breathing pattern assessments 92 4 Causes of m usculoskeletal d ysfunction 63 Seated assessment 92 Supine assessment 93 Adaptation - GAS and LAS 63 Sidelying assessment 93 Posture, respiratory function and the adaptation Prone assessment 93 Trigger point chains 94 phenomenon 64 An example of 'slow' adaptation 66 6 Trigger points 97 What of adaptation to trauma? 67 What of adaptation to habits of use? 67 Ischemia and muscle pain 101 Making sense of the picture 67 Ischemia and trigger point evolution 102 Example 68 Postural and emotional influences on Trigger point connection 102 musculoskeletal dysfunction 69 Microanalysis of trigger point tissues 103 PosturaI interpretations 69 Ischemia and fibromyalgia syndrome (FMS) 1 03 Contraction patterns 69 FMS and myofascial pain 105 Emotional contractions 69 Facilitation - segmental and local 105 'Middle fist' functions 70 Trigger points and organ dysfunction 106 'Upper fist' functions 70 How to recognize a facilitated spinal area 108 Behavior and personality issues 71 Local facilitation in muscles 1 08 Cautions and questions 72 Lowering the neural threshold 109 Postural imbalance and the diaphragm 73 Varying viewpoints on trigger points 109 Balance 74 Awad's analysis of trigger points 109 Respiratory influences 75 Nimmo's receptor-tonus techniques 109 Effects of respiratory alkalosis in a Improved oxygenation and reduced trigger deconditioned individual 75 point pain - an example 110 Respiratory entrainment and core stability issues 75 Pain-spasm-pain cycle 110 Summary of effects of hyperventilation 76 Fibrotic scar tissue hypothesis 110 Neural repercussions 77 Muscle spindle hypothesis 110 Tetany 77 Radiculopathic model for muscular pain 111 Biomechanical changes in response to upper Simons' current perspective: an integrated hypothesis 111 Central and attachment trigger points 112 chest breathing 77 Primary, key and satellite trigger points 112 Additional emotional factors and musculoskeletal Active and latent trigger points 113 Essential and spillover target zones 114 dysfunction 78 Trigger points and joint restriction 1 1 4 Selective motor unit involvement 78 Trigger points associated with shoulder restriction 114 Conclusion 79 Other trigger point sites 114 Testing and measuring trigger points 114 5 Patterns of dysfunction 81 Basic skill requirements 115 Needle electromyography 116 Upper crossed syndrome 82 Ultrasound 116 Lower crossed syndrome 82 Surface electromyography 116 Layer (stratification) syndrome 83 Algometer use for research and clinical training 117 Chain reaction leading to facial and jaw pain: Thermography and trigger points 117 Clinical features of myofascial trigger points 118 an example 84 Developing skills for TrP palpation 1 1 9 Patterns from habits of use 84 Which method i s more effective? 121 The big picture and the local event 85 Janda's 'primary and secondary' responses 85 7 The internal environment 125 Recognizing dysfunctional patterns 86 Local myofascial inflammatory influences 125 Excessive muscular tone 86 Pain progression 126 Simple functional tests for assessing excess Sensitization 126 Mechanisms of chronic pain 126 muscular tone 87 Functional screening sequence 88 Prone hip (leg) extension (PLE) test 89 Trunk flexion test 90 Hip abduction test 90

Contents ix Glutamate: a contrary view of the cause of Psychosocial factors in pain management: the tendon pain 127 cognitive dimension 170 Acute (lag) phase of the inflammatory response 128 Guidelines for pain management 171 Regeneration (repair) phase 128 Group pain management 171 Remodeling phase 128 The litigation factor 171 Difference between degenerative and Other barriers to progress in pain management 171 Stages of change in behavior modification 171 inflammatory processes 129 Antiinflammatory nutrients and herbs 129 Wellness education 172 What about antiinflammatory medication7 130 Goal setting and pacing 172 Controlled scarring - friction and prolotherapy 130 When inflammation becomes global 131 Low back pain rehabilitation 172 Hormonal influences 131 The biopsychosocial model of rehabilitation 172 Muscles, joints and pain 140 Concordance 173 Reflex effects of muscular pain 141 Patient advice and concordance (compliance) issues 173 Source of pain 142 Is it reflex or local? 142 9 Modern neuromuscular techniques 17 7 Radicular pain 142 Are the reflexes normal? What is the source of Neuromuscular therapy - American version 177 Biomechanical factors 178 the pain? 142 BiochemicaI factors 179 Differentiating between soft tissue and joint pain 143 Psychosocial factors 180 Neuropathic pain 143 Biomechanical, biochemical and psychosocial Neurotoxic elements and neuropathic pain 144 interaction 180 Effects of pH changes through breathing 149 NMT techniques contraindicated in initial Alkalosis and the Bohr effect 149 stages of acute injury 181 Deconditioning and unbalanced breathing 149 NMT for chronic pain 182 Caffeine in its various forms 150 Palpation and treatment 182 When should pain and dysfunction be left alone? 151 Treatment and assessment tools 189 Somatization 152 Pain rating tools 190 How is one to know? 152 Treatment tools 190 Pain management 154 Gunn's view 154 European (Lief's) neuromuscular technique (NMT) 191 Questions 154 NMT thumb technique 192 Pain control 154 Lief's NMT finger technique 193 Use of lubricant 194 8 Assessment, treatment and rehabilitation 161 Variations 194 Variable ischemic compression 194 Numerous influences 162 A framework for assessment 195 A biomechanical example 162 Some limited NMT research 196 'Looseness and tightness' as part of the Integrated neuromuscular inhibition technique 197 biomechanical model 163 10 Associated therapeutic modalities and techniques 205 Lewit (1996) and 'loose-tight' thinking 164 Soft tissue treatment and barriers 164 Hydrotherapy and cryotherapy 206 Pain and the tight-loose concept - and the How water works on the body 206 Warming compress 206 trigger point controversy 164 Alternate heat and cold: constitutional Three-dimensional patterns 165 hydrotherapy (home application) 208 Neutral bath 209 Methods for restoration of 'three-dimensionally Alternate bathing 209 patterned functional symmetry' 165 Alternating sitz baths 210 Ice pack 210 Neuromuscular management of soft tissue dysfunction 166 Manipulating tissues 166 Integrated neuromuscular inhibition technique (lNIT) 210 INIT method 1 210 Nutrition and pain: a biochemical perspective 167 INIT rationale 211 Nutritional treatment strategies 167 Ruddy's reciprocal antagonist facilitation (RRAF) 212 Specific nutrients and myofascial pain 167 Allergy and intolerance: additional biochemical Lymphatic drainage techniques 212 influences on pain 168 McKenzie Method® 213 What causes this increase in permeability? 169 Massage 215 Treatment for 'allergic myalgia' 169 Antiinflammatory nutritional (biochemical) strategies 169

x CONTENTS Petrissage 215 Landmarks 255 Kneading 215 Functional features of the cervical spine 255 Inhibition 215 Muscular and fascial features 256 Effleurage (stroking) 215 Neurological features 256 Vibration and friction 216 Circulatory features and thoracic outlet syndrome 256 Transverse friction 216 Cervical spinal dysfunction 259 Effects explained 216 Assessments 259 Mobilization and articulation 217 Assessment becomes treatment 266 Notes on sustained natural apophyseal Assessment and treatment of glides (SI'JAGs) 217 occipitoatlantal restriction (CO-C'I) 268 Muscle energy techniques (MET) and variations 218 Functional release of atlantooccipital joint 269 Translation assessment for cervical spine (C2-7) 269 l'Jeurological explanation for MET effects 218 Treatment choices 270 Use of breathing cooperation 218 Alternative positional release approach 271 Muscle energy technique variations 219 SCS cervical flexion restriction method 271 Myofascial release techniques (MFR) 221 SCS cervical extension restriction method 271 Exercise 1 Longitudinal paraspinal myofascial release 222 Stiles' (1984) general procedure using MET Exercise 2 Freeing subscapularis from serratus for cervical restriction 272 anterior fascia 223 Harakal's (1975) cooperative isometric Myofascial release of scar tissue 223 Neural mobilization of adverse mechanical or technique (MET) 272 neural tension 223 Cervical treatment: sequencing 273 Adverse mechanical tension (AMT) and pain sites Cervical planes and layers 274 are not necessarily the same 224 Posterior cervical region 275 Types of symptoms 224 NMT for upper trapezius in supine position 277 Neural tension testing 224 MET treatment of upper trapezius 278 Positional release techniques (PRT) 225 Positional release of upper trapezius 279 The proprioceptive hypothesis 225 Myofascial release of upper trapezius 280 The nociceptive hypothesis 226 Variation of myofascial release 280 Resolving restrictions using PRT 226 NMT: cervical lamina gliding techniques - supine 281 Circulatory hypothesis 227 Semispinalis capitis 282 Variations of PRT 227 Semispinalis cervicis 283 Rehabilitation 230 Splenii 283 Relaxation methods 231 NMT techniques for splenii tendons 284 Rhythmic (oscillatory, vibrational, harmonic) methods 231 Spinalis capitis and cervicis 285 What's happening? 231 NMT for spinalis muscles 286 Application exercise for the spine 232 Longissimus capitis 286 Trager® exercise 233 Longissimus cervicis 286 Spray and stretch for trigger point treatment 233 Iliocostalis cervicis 286 Additional stretching techniques 235 Multifidi 287 Facilitated stretching 235 Rotatores longus and brevis 287 Proprioceptive neuromuscular facilitation Interspinales 287 NMT for interspinales 289 (PNF) variations 235 Intertransversarii 289 Active isolated stretching (AIS) 236 Levator scapula 289 Yoga stretching (and static stretching) 236 NMT for levator scapula 290 Ballistic stretching 236 MET treatment of levator scapula 291 Using multiple therapies 236 Positional release of levator scapula 291 Suboccipital region 292 11 The cervical region 243 Rectus capitis posterior minor 294 Rectus capitis posterior major 295 The vertebral column: a structural wonder 244 Obliquus capitis superior 295 Cervical vertebral structure 246 Obliquus capitis inferior 295 The upper and lower cervical functional units 248 NMT for suboccipital group - supine 296 Platysma 298 Movements of the cervical spine 250 NMT for platysma 299 Upper cervical (occipitocervical) ligaments 251 General anterior neck muscle stretch utilizing MET 299 Lower cervical ligaments 253 Assessment of the cervical region 253

Contents xi Sternocleidomastoid 300 Muscles of mastication 358 NMT for SCM 301 Neck pain and TMD 359 Treatment of shortened SCM using MET 303 External palpation and treatment of Positional release of sternocleidomastoid 304 Suprahyoid muscles 304 craniomandibular muscles 365 Infrahyoid muscles 304 I'JMT for temporalis 366 Sternohyoid 305 NMT for masseter 367 Sternothyroid 306 Massage/myofascial stretch treatment of masseter 368 Thyrohyoid 306 Positional release for masseter 368 Omohyoid 306 NMT for lateral pterygoid 369 NMT for infrahyoid muscles 307 NMT for medial pterygoid 369 Soft tissue technique derived from Stylohyoid 369 External palpation and treatment of styloid and osteopathic methodology 308 Longus colli 308 mastoid processes 371 Longus capitis 309 Intraoral palpation and treatment of NMT for longus colli and capitis 311 MET stretch of longus capitis 31 2 craniomandibular muscles 372 Rectus capitis anterior 312 Intraoral NMT applications 372 Rectus capitis lateralis 313 Temporalis 372 NMT for rectus capitis lateralis 31 3 NMT for intraoral temporalis tendon 373 Scalenii 314 Masseter 373 NMT for scalenii 316 NMT for intraoral masseter 375 Treatment of short scalenii by MET 318 Lateral pterygoid 375 Positional release of scalenii 319 NMT for intraoral lateral pterygoid 378 Cervical lamina - prone 319 Medial pterygoid 379 NMT for posterior cervical lamina - prone position 320 NMT for intraoral medial pterygoid 380 NMT for posterior cranial attachments 320 Musculature of the soft palate 380 NMT for soft palate 382 12 The cranium 3 25 Muscles of the tongue 382 NMT for muscles of the tongue 383 Cranial structure 326 Suprahyoid muscles - the floor of the mouth 384 Occiput 328 NMT for intraoral floor of mouth 385 Sphenoid 332 Cranial treatment and the infant 387 Ethmoid 335 The craniocervical link 388 Vomer 336 Sleeping position and cranial deformity 389 Mandible 337 What other factors do medical authorities Frontal 340 Parietals 343 think cause serious cranial distortion in infants? 389 Temporals 344 What are the long-term effects of deformational Zygomae 347 Maxillae 349 plagiocephaly? 389 Palatines 350 Different cranial approaches 390 Ear disease and cranial care 390 NMT treatment techniques for the cranium 351 Summary 392 Muscles of expression 351 Mimetic muscles of the epicranium 352 13 Shoulder. arm and hand 3 99 Occipitofrontalis 352 Temporoparietalis and auricular muscles 352 Shoulder 401 NMT for epicranium 354 Structure 40 1 Positional release method for occipitofrontalis 355 Key joints affecting the shoulder 401 Mimetic muscles of the circumorbital and Pivotal soft tissue structures and the shoulder 404 palpebral region 355 Assessment 407 NMT for palpebral region 355 Repetitions are important 408 Mimetic muscles of the nasal region 356 Janda's perspective 41 0 NMT for nasal region 356 Observation 41 0 Mimetic muscles of the buccolabial region 356 Palpation of superficial soft tissues 41 1 NMT for buccolabial region 357 Range of motion of shoulder structures 41 1 Active and passive tests for shoulder girdle motion (standing or seated) 41 2 Strength tests for shoulder movements 41 3

xii CONTENTS NMT for anconeus 453 Teres minor 453 Muscular relationships 41 3 Assessment for teres minor weakness 453 Spinal and scapular effects of excessive tone 415 NMT for teres minor 454 Shoulder pain and associated structures 415 PRT for teres minor (most suitable for Therapeutic choices 416 Specific shoulder dysfunctions 417 acute problems) 455 Specific muscle evaluations 420 Teres major 456 Infraspinatus 420 NMT for teres major 457 Levator scapula 420 PRT for teres major (most suitable for Latissimus dorsi 420 Pectoralis major and minor 421 acute problems) 457 Supraspinatus 421 Latissimus dorsi 458 Subscapularis 421 Assessment for latissimus dorsi shortness/dysfunction 458 Upper trapezius 421 NMT for latissimus dorsi 459 Is the patient's pain a soft tissue or a joint problem? 422 MET treatment of latissimus dorsi 460 The Spencer sequence 422 PRT for latissimus dorsi (most suitable for Treatment 429 Trapezius 429 acute problems) 460 Assessment of upper trapezius for shortness 431 Subscapularis 460 NMT for upper trapezius 432 Assessment of subscapularis dysfunction/shortness 462 NMT for middle trapezius 433 Observation of subscapularis dysfunction/shortness 462 NMT for lower trapezius 433 Assessment of weakness in subscapularis 463 NMT for trapezius attachments 434 NMT for subscapularis 463 Lief's NMT for upper trapezius area 434 MET for subscapularis 463 MET treatment of upper trapezius 435 PRT for subscapularis (most suitable for Myofascial release of upper trapezius 435 Levator scapula 435 acute problems) 464 Assessment for shortness of levator scapula 436 Serratus anterior 464 NMT for levator scapula 436 Assessment for weakness of serratus anterior 465 MET treatment of levator scapula 438 NMT for serratus anterior 465 Rhomboid minor and major 438 Facilitation of tone in serratus anterior using Assessment for weakness of rhomboids 439 Assessment for shortness of rhomboids 439 pulsed MET 466 NMT for rhomboids 439 Pectoralis major 467 MET for rhomboids 440 Assessment for shortness in pectoralis major 470 Deltoid 441 Assessment for strength of pectoralis major 470 NMT for deltoid 443 NMT for pectoralis major 471 Supraspinatus 443 MET for pectoralis major 472 Assessment for supraspinatus dysfunction 446 Alternative MET for pectoralis major 473 Assessment for supraspinatus weakness 446 MFR for pectoralis major 474 NMT treatment of supraspinatus 446 Pectoralis minor 474 MET treatment of supraspinatus 446 NMT for pectoralis minor 476 MFR for supraspinatus 447 Direct (bilateral) myofascial stretch of shortened Infraspinatus 447 Assessment for infraspinatus shortness/dysfunction 447 pectoralis minor 477 Assessment for infraspinatus weakness 448 Subclavius 477 NMT for infraspinatus 448 MFR for subclavius 477 MET treatment of short infraspinatus Sternalis 479 Coracobrachialis 479 (and teres minor) 448 Assessment for strength of coracobrachialis 479 MFR treatment of short infraspinatus 449 NMT for coracobrachialis 481 PRT treatment of infraspinatus (most suitable for acute MFR for coracobrachialis 481 PRT for coracobrachialis 481 problems) 449 Biceps brachii 482 Triceps and anconeus 449 Assessment for strength of biceps brachii 483 Assessment for triceps weakness 452 Assessment for shortness and MET treatment of biceps NMT for triceps 452 MET treatment of triceps (to enhance shoulder flexion brachii 483 NMT for biceps brachii 483 with elbow flexed) 452 MET for painful biceps brachii tendon (long head) 484 PRT for biceps brachii 485 Elbow 485

Contents xiii Introduction to elbow treatment 485 Carpal tunnel syndrome 507 Structure and function 485 Phalanges' 508 Humeroulnar joint 486 Carpometacarpal ligaments (2nd, 3rd, 4th, 5th) 509 Humeroradial joint 486 Metacarpophalangeal ligaments 510 Radioulnar joint 486 Range of motion 510 Assessment of bony alignment of the epicondyles 486 Thumb 511 The ligaments of the elbow 486 Thumb ligaments 511 Assessment for ligamentous stability 487 Range of motion at the joints of the thumb 511 Evaluation 487 Testing thumb movement 511 Biceps reflex 487 Dysfunction and evaluation 511 Brachioradialis reflex 487 Preparing for treatment 511 Triceps reflex 488 Terminology 512 Ranges of motion of the elbow 488 Neural entrapment 513 Range of motion and strength tests 488 Distant influences 513 Elbow stress tests 488 Anterior forearm treatment 513 Strains or sprains 489 Palmaris longus 513 Indications for treatment (dysfunctions/syndromes) 489 Flexor carpi radialis 515 Median nerve entrapment 489 Flexor carpi ulnaris 515 Carpal tunnel syndrome 489 Flexor digitorum superficialis 515 Ulnar nerve entrapment 489 Flexor digitorum profundus 51 6 Radial nerve entrapment 492 Flexor pollicis longus 516 Tenosynovitis (,tennis elbow' and/or 'golfer's elbow') 492 NMT for anterior forearm 518 Assessments for tenosynovitis and epicondylitis 492 Assessment and MET treatment of shortness in the Elbow surgery and manual techniques 492 Treatment 493 forearm flexors 519 Brachialis 493 MET for shortness in extensors of the wrist and hand 521 NMT for brachialis 493 PRT for wrist dysfunction (including carpal tunnel Triceps and anconeus 493 NMT for triceps (alternative supine position) 494 syndrome) 521 NMT for anconeus 494 MFR for areas of fibrosis or hypertonicity 521 Brachioradialis 494 Posterior forearm treatment 522 Assessment for strength of brachioradialis 494 Superficial layer 522 NMT for brachioradialis 495 Extensor carpi radialis longus 523 MFR for brachioradialis 495 Extensor carpi radialis brevis 523 Supinator 495 Extensor carpi ulnaris 524 Assessment for strength of supinator 496 Extensor digitorum 524 NMT for supinator 496 Extensor digiti minimi 525 MET for supinator shortness 496 NMT for superficial posterior forearm 525 MFR for supinator 496 Deep layer 527 Pronator teres 496 Abductor pollicis longus 527 Assessment for strength of pronator teres 497 Extensor pollicis brevis 528 NMT for pronator teres 497 Extensor pollicis longus 528 MFR for pronator teres 498 Extensor indicis 528 PRT for pronator teres 498 NMT for deep posterior forearm 528 Pronator quadratus 498 Intrinsic hand muscle treatment 529 NMT for pronator quadratus 498 Thenar muscles and adductor pollicis 530 Forearm, wrist and hand 498 Hypothenar eminence 532 Forearm 499 Metacarpal muscles 532 Wrist and hand 499 NMT for palmar and dorsal hand 533 Capsule and ligaments of the wrist 501 Ligaments of the hand 502 14 The thorax 539 Key (osteopathic) principles for care of elbow, Structure 540 540 forearm and wrist dysfunction 503 Structural features of the thoracic spine Active and passive tests for wrist motion 503 Structural features of the ribs 541 Reflex and strength tests 506 Structural features of the sternum 541 Ganglion 506 Posterior thorax 541 Identification of spinal levels 542

xiv CONTENTS The sternosymphyseal syndrome 542 Thoracic treatment techniques 557 Spinal segments 543 Posterior superficial thoracic muscles 557 Palpation method for upper thoracic NMT: posterior thoracic gliding techniques 560 NMT for muscles of the thoracic lamina groove 562 segmental facilitation 544 Spinalis thoracis 563 How accurate are commonly used palpation Semispinalis thoracis 563 Multifidi 563 methods? 544 Rotatores longus and brevis 564 Red reflex assessment (reactive hyperemia) 545 NMT for thoracic (and lumbar) lamina Biomechanics of rotation in the thoracic spine 546 groove muscles 565 Coupling test 547 PR method for paraspinal musculature: Observation of restriction patterns in thoracic spine induration technique 566 Muscles of respiration 567 (C-curve observation test) 547 Serratus posterior superior 567 Breathing wave assessment 547 Serratus posterior inferior 568 Breathing wave - evaluation of spinal motion Levatores costarum longus and brevis 568 Intercostals 570 during inhalation/exhalation 548 NMT for intercostals 571 Passive motion testing for the thoracic spine 548 Influences of abdominal muscles 571 Flexion and extension assessment of Tl-4 548 NMT assessment 571 Flexion and extension assessment of T5-12 548 PR of diaphragm 572 Sideflexion palpation of thoracic spine 549 MET release for diaphragm 572 Rotation palpation of thoracic spine 549 Interior thorax 572 Prone segmental testing for rotation 550 Diaphragm 572 Anterior thorax 550 NMT for diaphragm 573 Respiratory function assessment 550 Transversus thoracis 574 Palpation for trigger point activity 554 Thoracic mobilization with movement - SNAGs Alternative categorization of muscles 554 method 575 Rib palpation 554 Specific 1st rib palpation 554 Index 579 Test and treatment for elevated and depressed ribs 554 Rib motion 554 Tests for rib motion restrictions 554 Discussion 556

xv List of boxes 1.1 Definitions 1 7.3 Leptin and other chemical influences in 1.2 Biomechanical terms relating to fascia 3 1.3 Biomechanical laws 2 systemic inflammation 134 1.4 Connective tissue 4 7.4 Key concepts in the relation between adipose 1.5 Myers' fascial trains 11 1.6 Tensegrity 14 tissue and inflammation 140 1.7 Postural (fascial) patterns 18 7.5 Mercury - is there a 'safe' level? 145 7.6 Umami 1 47 2.1 Muscle contractile mechanics and the 7.7 Health influences of tea, coffee, and other beverages 1 50 sliding filament theory 26 7.8 Placebo power 153 2.2 The lymphatic system 29 8.1 Tight-loose palpation exercise 164 2.3 Alternative categorization of muscles 36 2.4 Muscle strength testing 39 9.1 The roots of modern neuromuscular techniques 178 2.5 Two-joint muscle testing 39 9.2 Semantic confusion 178 9.3 Summary of rehabilitation sequencing 182 3.1 Neurotrophic influences 47 9.4 Effects of applied compression 183 3.2 Reporting stations 51 9.5 Two important rules of hydrotherapy 185 3.3 Co-contraction and strain 54 9.6 The general principles of hot and cold applications 185 3.4 Biochemistry, the mind and 9.7 Compression definitions 187 9.8 Summary of American NMT assessment protocols 189 neurosomatic disorders 55 9.9 Positional release techniques (PRT) 198 3.5 Centralization mechanisms including 9.10 Muscle energy techniques 199 9.11 Notes on synkinesis 201 wind-up and long-term potentiation [LTP] 58 9.12 Ruddy's pulsed muscle energy technique 201 4.1 Partial pressure symbols 76 1 0.1 Acupuncture and trigger points 207 4.2 Hyperventilation in context 76 10.2 A summary of soft tissue approaches to FMS and CFS 211 5.1 Hooke's law 85 11.1 Water imbibition by the nucleus 247 5.2 Trigger point chains 94 11.2 Important questions to ask 254 11.3 How acute is a problem? 254 6.1 Historical research into chronic referred 11.4 Posttrauma fibromyalgia 256 muscle pain 98 11.5 Tests for circulatory dysfunction 257 11.6 Tests for cervical spinal dysfunction 257 6.2 Fibromyalgia and myofascial pain 105 11.7 Whiplash 261 6.3 Trigger point activating factors 113 11.8 Lief's NMT for upper trapezius area 278 6.4 Active and latent features 114 11.9 Summary of American NMT assessment protocols 281 6.5 Trigger point incidence and location 11 6 11.10 Spinal mobilization using mobilization 6.6 Trigger point and referred inhibition 117 6.7 Trigger point perpetuating factors 119 with movement (MWM) 288 6.8 What are taut bands? 1 1 9 11 .11 Cranial base release 296 6.9 Clinical symptoms 120 11.1 2 Lief's NMT for the suboccipital region 297 6.10 Lymphatic dysfunction and trigger point activity 120 11.1 3 PRT (strain-counterstrain) for any painful areas 7.1 The endocrine system 132 located in the posterior cervical musculature 298 7.2 Underactive thyroid 133

xvi LIST OF BOXES 13.8 Acromioclavicular and sternoclavicular MET approaches 426 11.14 Balancing of the head on the cervical column 302 11.15 Sidelying position repose 316 13.9 Spencer's assessment sequence including MET and PRT treatment 427 12.1 Cranial terminology and associated motion patterns based on traditional osteopathic methodology 326 13.10 MFR 466 13.11 Shoulder and arm pain due to neural impingement 475 12.2 The meaning of 'release' 327 13.12 Modified PNF spiral stretch techniques 478 12.3 Cranial bone groupings 328 13.13 Sternalis and chest pain 479 12.4 Temporomandibular joint structure, function and 1 3.1 4 Definition of enthesitis 492 13.15 Focal hand dystonia (FHd) - 'repetitive strain injury' 503 dysfunction 359 13.16 Nerve entrapment possibilities 507 12.5 Temporal arteritis 366 13.17 Mulligan's mobilization techniques 520 1 2.6 Notes on the ear 370 13.18 Arthritis 529 12.7 How do we maintain equilibrium? 370 12.8 Muscles producing movements of mandible 371 14.1 Identification of spinal level from spinous process 546 12.9 Latex allergy alert 371 14.2 Liefs NMT of the upper thoracic area 549 12.10 Tinnitus: the TMD and trigger point connection 374 14.3 Respiratory muscles 550 12.11 Deglutition 386 14.4 Respiratory mechanics 551 12.12 Muscles of the eye 392 14.5 Some effects of hyperventilation 553 14.6 Upper ribs and shoulder pain 556 13.1 Ligaments of the shoulder girdle 405 14.7 Pressure bars 566 13.2 Caution: Scope of practice 409 14.8 Liefs NMT of the intercostal muscles 569 13.3 Reflex tests (always compare both sides) 411 14.9 McConnell and the diaphragm 572 13.4 What is normal range of arms? 411 13.5 Neutralizers 413 1 3.6 Spencer's assessment sequence 423 13.7 Clavicular assessment 425

xvii Foreword Headache, TMJ, neck/shoulder pain and tennis elbow are evidence-based and I think it is worthwhile defining exactly all common complai nts of patients seeking help from vari­ what evidence-based practice is. According to Sackett et al ous hea lth practitioners. The source of the impairment (2000), and/or the pain is often found in the neuromyofascial sys­ tem. As a novice, a cli nician will approach the problem Evidence-based practice is the integration of best research based on the paradigm taught in their formal training such as physiotherapy, osteopathy, massage therapy, Rolfing, evidence, clinical expertise and patient values. External acupuncture or chiropractic. Thus we see the advocacy of many different traditional treatments for myofascial pain clinical evidence can inform, but can never replace individ­ such as: ual clinical expertise, and it is this expertise that decides • Physiotherapy - thermal agents followed by stretching exercises whether the external evidence applies to the patient at all, • Osteopathy - strain/counterstrain, positional release, and ifso, how it should be integrated into a clinical decision. functional and muscle energy techniques W hat is expertise? Expertise has been defined as the abil- • Massage therapy - deep pressure on tender points, ity to do the right thing at the right time (Ericsson & Smith stroking, lymphatic massage techniques 1991). Indeed, I believe that this monumental text is evi­ dence-based since it includes the best a vailable research evi­ • Rolfi ng - deep fascial release/stretching tec hniques dence and integrates it with the multi-disciplinary clinical • Acupunc ture - dry needling of 'An Shi' pOints expertise that has accumulated over the last 100 years. • Chiropractic - manipulation (high velocity, low amphtude As mentioned earlier, this text is a bout more than neuro­ thrust techni ques) of the spinal segment which correlates muscular techniques. It begins with an o verview of the to the segmental nerve supply of the affected muscle. anatomy and function of connective tissue, fascia, muscles and the nervous systems (peripheral and central). The At this point, you may be thinking 'Wait a mi nute! I do anatomical illustrations are clear, weU-labeled and perti­ more than tha t (or all of that, or some of tha t) for my nent. Many of the current hypotheses regarding the ca uses patients with myofascial pain'. This is true enough, since of musculoskeletal dysfunction and the various patterns of over time most clinicians gain expertise and are exposed to presentation are outlined . There is an extensive discussion the paradigms of other disciplines and thus their 'tool box' on the current theories and evidence pertaining to the grows. l1s1i book is a wonderful representation of all the cause, effect and cli nical presentation of myofascial trigger paradigms of the many discipl ines that ha ve ever consid­ points. While ultima tely the text turns to the detailed trea t­ ered how to rela x/release a muscle or a trigger point in a ment of every possible muscle you could think of i n the muscle. Yet, this book is way more than this and even more upper half of the body, prior to this the a uthors discuss than the title Clinical Application ofNeuromuscular Techniques where, when and how the neuromuscular techniques fit alludes to. into the entire treatment protocol. This ensures tha t the reader is not left with the impression that neuromuscular While this text relies heavily on the clinical expertise of release is all that is needed for treating a patient. Once into both the authors and the historical leaders in both their pro­ trea tment, consideration is given to the role of non-manual fessions and others, it also refers and draws on the current therapies such as thermal modalities, spray and stretch and scientific evidence where it is available. Some may say that exercise, and then the use of the manual techni ques is the techniques and suggested protocols in this text are not explained in great detail. Following this, the upper half of the body is divided and each section begins with a review of

xviii FOREWORD the regional anatomy and biomechanics and a Hsting of the Neuromuscular Techniques, a text which is applicable to the muscles in which trigger p oints are commonly found. Each manual tecl mique is illustrated and described in explicit novice and the expert of any discipline that deals with detail. This is easy for the novice to follow and often con­ patients p resenting with i mp airments of the neuromyofas­ tains 'pearls of clinical wisdom' for the expert clinician. ciaI system. Leon C haitow and Judith DeLany are to be congratu­ White Rock, Be C anada 2007 Diane Lee lated for the second editi on of Clinical Application of References Sackett DL, Strauss SE, Richardson WS, et al 2000 How to practice & teach evidence-based medicine. Elsevier Science, New York Ericsson KA, Smith J 1991 Towards a general theory of expertise: prospects and limits. Cambridge University Press, New York

xix Preface to the Second Ed ition The clinical utilization of soft tissue manipulation has logically the main focus for the p atient. However, we believe increased dramatically in recent years in all areas of manual it is vital that loc al problems should be commonly seen by health-care provision. A text that integrates the safe and the p ractitioner to form p art of a larger picture of compensa­ proficient application of some of the most effective soft tis­ tion, adaptation and/or decompensation and that the back­ sue tedmiques is both timely and necessary. The decision to ground causes (of local myofascial pain, for example) be write this book was therefore based on a growing aware­ sought and, where possible, removed or at least m odified. ness of the need for a text that describes, in some detail, the clinical applications of neuromuscular techniques in p artic­ We also take the position t hat it is the p ractitioner's role ular, and soft tissue manipulation in general, on each and to take account of biochemical (nutriti onal and hormonal every area of the musculoskeletal system. influences, allergy, etc.), biomec hanical (posture, b reathing p atterns, habits of use, etc.) and/or psychosocial (anxiety, There are n umerous texts c ommunicating the features of depression, stress factors, etc.) influences that might be different manual therapy systems (osteopathy, chiropractic, involved, as far as this is p ossible. If appropriate, suitable physical therapy, manual medicine, massage the rapy, etc.) advice or treatment c an then be offe red. However, if the and of modalities employed withi. n these health-care deliv­ p ractitioner is not trained and licensed to do so, profes­ ery systems (high-velocity thrust techniques, muscle energy sional referral becomes the obvious choice. In this way, the tedmiques, myofascial release and many, many more). focus of health care goes beyond treatment of local condi­ There are also excellent texts that describe regional p rob­ tions and moves toward holism, to the benefit of the patient. lems (say of the pelvic region, temporomandibular j oint or the spine) with protocols for assessment and treatment, In this volume, the person applying the techniques i s often presented from a p articular perspective. Increasingly, referred t o as the 'practitioner' so as to include all the ra­ edited texts incorporate a variety of perspectives when pists, physicians, nurses or others who apply manual tech­ focusing on particular regions, offering the reader a broad niques. To ease confusion, the practitioner is depicted as view as well as detailed informati on on the topic. And t hen male and t he recipient of the treatment modalities (the there are wonderfully crafted volumes, such as those p ro­ patient) is depicted as female so that gender references (he, duced by Travell and Simons, covering the spectrum of his, she, hers) used within the text are n ot ambiguous. In 'myofascial pain and dysfu nction' and incorporating a Volume 2, the roles are reversed with the female p racti­ deeply researched and evolving model of care. tioner treating the male p atient. We adopted Travell andSimons' view of the human b ody, The protocols described in this text fall largely within the which offers a valuable regional approach model on which biomechanical arena, with the main emphasis being the first to base our own perspectives. To this practical and intellec­ comprehensive, detailed description of the clinical applica­ tually satisfying model, we have added detailed anatomical and physiological descripti ons, coupled with clinically prac­ tion of NMT (neuromuscular therapy in the USA, neuro­ tical 'bodywork' solutions to t he problems located in each muscular technique in Europe). The descriptions of NMT are region. In this first vol ume of the text, the upper b ody is cov­ ered; in Volume 2, the region from the waist down is sur­ mainly of the modern American version, as described by veyed in the same way. As authors, we have attempted to Judith DeLany, whose many years of involvement with place in context the relative importance and significance of NMT, both clinically and academically, make her a leading local conditions, pain and/or dysfu nction, which are quite authority on the subject. Additional therapeutic choices, including nutri tional and hydrotherapeutic, as well as complementary bodywork methods, such as muscle energy, positional release and

xx PREFACE TO THE SECOND EDITION variations of myofascial release teclmiques, and the especially if they have had previous training in soft tissue European version of NMT, are largely the contribution of palpation and treatment. The text of this book is therefore Leon Chaitow, as are, to a large extent, the opening chapters intended as a framework for the clinical application of NMT regarding the physiology of pain and dysfunction. for those already quali fied (and, where appropriate, licensed to practice), as well as being a learning tool for In addition to the practical application sections of the those in training. It is definitely not meant to be a substitute book, a nwnber of chapters offer a wide-ranging overview for hands-on training with skilled in structors. of current thinking and research into the background of the dysfunctional sta tes for which solutions a nd suggestions To this volume is married the companion text for the are provided in later chapters. The overview, 'big picture' lower body, the layout and style of which is very similar. Its chapters cover the latest research findings a nd information foundational chapters cover posture, gait, balance, influ­ relevant to understanding fascia, muscles, neurological fac­ ences of the close environment surrounding the body, adap­ tors, pa tterns of dysflmction, pain and inflammation , tations from sport and other repetitious use, and other myofascial trigger points, emotional and nutritional influ­ contextual material that influences clinical thinking. ences a nd much more. It is our assertion tha t the combina­ Additionally, Clinical Application of Neuromuscular tion of the 'big picture', together with the detailed NMT Techniques - Practical Case Study Exercises is now available to protocols, offers a foundation on which to build the excep­ support the practitioner in developing a model by which to tional palpation and treatment skills necessary for finding apply the protocols to clinical cases. The use of the study effective, practical solutions to chronic pain conditions. guide cases is enhanced with the addition of key words printed in red that may be found in the indices of the larger Some chapters, such as Chapters 6 and 7, have evolved texts. We trust that these tools, together with practitioner's substantially since the first edition, based on integration of skills and training, will assure that NMT remains a power­ our diverse viewpoints, with the occasional result being ful tool in the manual therapy fields. paradigm shifts that altered therapeutic platforms. We believe that this integration of new i rtforma tion and London 2007 LC research, in ta ndem with our combined clinical experience, Florida 2007 JD offers an expanded perspective. Readers can use these con­ cepts to assist in safe application of the methods described,

xxi Acknowl ed g m ents In the first edition of this text and its companion volume for support is threaded through these pages in remarkable yet the lower body, a substantial number of people dedica ted indiscernible ways. many hours of time to assure clarity and accuracy of the final text. Their contribution was not lost in the second edi­ ACK N OWLEDGEM ENTS FROM THE tion. Instead, it served as a solid foundation to be built upon FI RST E D ITIO N with the contributions of revised and added material. Books are wri tten by the efforts of numerous people, The authors once again express sincere gratitude to the a l though most of the support team is invisible to the reader. original team who help formulate this project many years We humbly express our appreciation to our friends and col­ ago and to the various authors and illustrators whose work leagues who assisted in this project and who enrich our was cited, quoted and borrowed. Addi tionally, contribu­ lives simply by being themselves. tions, support and inspiration for this revised edition were given by William Ellio tt, Donald Kelley, Ken Crenshaw, Ron From the long list of staff members and practitioners who Porterfield, Nathan Shaw, Mary-Beth Wagner, Andrew and dedicated time and effort to read and comment on this text, Kaila DeLany, and Adam Cunliffe. we are especially grateful to Jamie Alagna, Paula Bergs, Bruno Chikly, Renee Evers, Jose Fernandez, Gretchen Fiery, In the second edition of this book, a new team of talented Barbara Ingram-Rice, Donald Kelley, Leslie Lynch, Aaron staff members at Elsevier offered insightful ideas, patient Mattes, Chama Rosenholtz, Cindy Scifres, Alex Spassoff, support to achieve deadlines, and a variety of professional Bonnie Thompson and Paul Witt for reviewing pages of services in order for the work to evolve. Among those who material, often at a moment's notice. And to those whose made this second edition possible, the a uthors especially work has inspired segments of this text, such as John acknowledge and appreciate the efforts of Claire Wilson, Hannon, Tom Myers, David Simons, Janet Travell and Gail Wright, Claire Bonnett and the illustration team who others, we offer our heartfelt appreciation for their many gave visual life to the pages of text. contributions to myofascial therapies. To Sarena Wolfaard , we express deep apprecia tion for her John and Lois Ermatinger spent many hours as models for steady nature and for her ability to juggle the assorted the photographs in the book, some of which eventually deadlines and the many phases of the project so as to keep became line art, while Mary Beth Wagner dedicated her time it close to its production schedule. She has proven herself as coordinating each photo session. The enthusiastic attitudes capable of filling the extraordinary shoes of Mary Law, who and tremendous pa tience shown by each of them turned served as the editorial director of the first edition. As to what could have been tedious tasks into pleasant events. Mary, her contributions will last forever and her presence is continually missed. Many people offered personal support so tha t quality time to write was available, including Lois Allison, Jan And, most endearingly, we offer our deepest gratitude to Carter, Linda Condon, Andrew DeLany, Valerie Fox, our families for their pa tience, support, and inspiration, all Patricia Guillote, Alissa Miller, and Trish Solito. Special of which fills an ever-present and deep well from which we appreciation is given to Mary Beth Wagner and Andrea can draw to sustain and nurture ourselves. Their loving

xxii ACKNOWLED G M ENTS Conley for juggling many, many ongoing tasks which serve worldwide. Mary's ability to foster organization amidst to enhance and fortify this work. chaos, to find solutions to enormous challenges and to sim­ ply provide a listening ear when one is needed has Jane Shanks, Katrina Mather, and Valerie Dearing each put endeared her to our hearts. forth exceptional dedication to find clarity, organization and balance within this text, which was exceeded only by their And finally, to each of our families, we offer our deepest patience. The illustration team as well as the many authors, gratitude for their inspiration, patience, and ever present artists and publishers who l oaned artwork from other books understanding. Thei r supporting l ove made this project have added visual impact to help the material come alive. possible. To Mary Law, we express our deepest app reciation for her vision and commitment to complementary medicine

Chapter 1 Connective tissue and the fascial system CHAPTER CONTENTS Connective tissue forms the single largest tissue component of the body. The material we know as fascia is one of the The fascial network 2 13 many forms of connective tissue. Fascia and proprioception 2 Fascia: collagenous continuity 2 In this chapter we will examine some of the key features Further fascial considerations 2 and functions of fascia in particular, and connective tissue Elasticity 3 in general, with specific focus on the ways in which: Plastic and elastic features 3 • these tissues influence myofascial pain and dysfunction Connective tissue as a 'sponge' 6 • their unique characteristics determine how they respond Deformation characteristics 6 Hypermobility and connective tissue 7 to therapeutic interventions, as well as to adaptive stresses Trigger points, fascia and the nervous system 8 imposed on them. The importance of Langevin's research 9 In order to understand myofascial dysfunction, it is impor­ Summary of fascial and connective tissue function tant to have a clear picture of this single network that Fascial dysfunction 1 6 enfolds and embraces all other soft tissues and organs of the Restoring gel to sol 17 body, the fascial web. In the treatment focus in subsequent A different model linking trauma and chapters, a great deal of reductionist thinking will be called for as we identify focal points of dysfunction, local trigger connective tissue 17 points, individual muscular stresses and attachment prob­ Therapeutic sequencing 19 lems, with appropriate local and general treatment descrip­ tions flowing from these identified areas and structures. Box 1.1 Definitions Stedman's Medical Dictionary (2004) says fascia is: A sheet of fibrous tissue that envelops the body beneath the skin; it also encloses muscles and groups ofmuscles, and separates their several layers or groups and that connective tissue is: The supporting or framework tissue of the . . . body. formed of fibraus and graund substance with more or less numerous cells of various kinds; it is derived fram the mesenchyme, and this in turn from the mesoderm; the varieties of connective tissue are: areolar or loose; adipose; dense, regular or irregular, white fibrous; elastic; mucous; and lymphoid tissue; cartilage; and bone; the blood and lymph may be regarded as connective tissues, the ground sub­ stance of which is a liquid. Fascia, therefore, is one form of con nective tissue.

2 CLI N I CA L A P P L I CATIO N OF N E U R O M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY The truth, of course, is that no tissue exists in isolation but • fascia moves in response to complex muscular activities acts - is bound to and is interwoven - with other structures, to acting on bone, joints, ligaments, tendons and fascia the extent that a fallen arch can directly be shown to influence TMJ dysfunction (Janda 1986). In contrast, loss of occlusal • fascia, according to Bonica (1990), is critically involved in supporting zone can change weight distribution on the feet proprioception, which is, of course, essential for postural and alter overall body posture (Yoshino et aI 2003a,b). When integrity (see Chapter 3) we work on a local area, we need to keep a constant aware­ ness of the fact that we are influencing the whole body. • research by Staubesand (using electron microscope stud­ ies) shows that 'numerous myelinated sensory neural Remarkable research (see Box 1.5 in particular) is adding structures exist in fascia, relating to both proprioception to our understanding of just how important connective tis­ and pain reception' (Staubesand 1996) sues are in relation to musculoskeletal function, and to pain management (Chen & Ingber 1999, Langevin et al 2001, • after joint and muscle spindle input is taken into account, 2004, 2005, Schleip et al 2004). As a foundation of under­ the majority of remaining proprioception occurs in fas­ standing of connective tissue is built within this chapter, cial sheaths (Earl 1965, Wilson 1966) this and other research evidence is presented that alters pre­ vious concepts of this extraordinary matrix. • new research by Langevin et al (2001, 2004, 2005), described later in this chapter, suggests that a great deal of commu­ nication occurs by means of fascial cellular structures (integrins). THE FASCIAL NETWORK FASCIA: COLLAGENOUS CONTINUITY Fascia comprises one integrated and totally connected net­ Fascia is one form of connective tissue, formed from colla­ work, from the attachments on the inner aspects of the skull gen, which is ubiquitous. The human framework depends to the fascia in the soles of the feet. If any part of this net­ upon fascia to provide form, cohesion, separation and sup­ work becomes deformed or distorted, there will be com­ port and to allow movement between neighboring structures pensating adaptive stresses imposed on other parts of the without irritation. Since fascia comprises a single structure, connective tissue web, as well as on the structures that it from the soles of the feet (plantar fascia) to the inside of the divides, envelopes, enmeshes, supports and with which it cranium (dura and meninges), the implications for body­ connects. There is ample evidence that Wolff's law (Wolff wide repercussions of distortions in that structure are clear. 1870) applies, in that fascia accommodates to chronic stress An example is found in the fascial divisions within the cra­ patterns and deforms itself (Cailliet 1996), something which nium, the tentorium cerebelli and falx cerebri, which are often precedes deformity of osseous and cartilaginous struc­ commonly warped during birthing difficulties (too long or tures in chronic diseases (see Box 1.3). As fascia, ligaments too short a time in the birth canal, forceps delivery, etc.). and tendons deform when accommodating to chronic stress They are noted in craniosacral therapy to affect total body (Dorman 1997, Lederman 1997), this might disrupt the home­ mechanics via their influence on fascia (and therefore the ostasis of the body (Keeffe 1999, Kochno 2001) and certainly musculature) throughout the body (Brookes 1984, Carreiro interferes with normal function. 2003, Von Piekartz & Bryden 2001). Visualize a complex, interrelated, symbiotically function­ Dr Leon Page (1952) discusses the cranial continuity of ing assortment of tissues comprising skin, muscles, ligaments, fascia: tendons and bones, as well as the neural structures, blood and lymph channels and vessels which bisect and invest The cervical fascia extends from the base of the skull to the these tissues - all given shape, cohesion and functional abil­ mediastinum and forms compartments enclosing the esoph­ ity by the fascia. Now imagine removing from this all that is agus, trachea and carotid vessels and provides support for not connective tissue. What remains would still demon­ the pharynx, larynx and thyroid gland. There is direct con­ strate the total form of the body, from the shape of the eye­ tinuity of fasciafrom the apex of the diaphragm to the base ball to the hollow voids for organ placement. of the skull. Extending through the fibrous pericardium upward through the deep cervical fascia the continuity FASCIA AND PROPRIOCEPTION extends not only to the outer surface of the sphenoid, occip­ ital and temporal bones but proceeds further through the Research has shown that: foramina in the base of the skull around the vessels and nerves to join the dura. • muscle and fascia are anatomically inseparable • fascia and other connective tissues form a mechanical con­ FURTHER FASCIAL CONSIDERATIONS tinuum that extends throughout the body that includes Fascia is colloidal, as is most of the soft tissue of the body (a even the innermost parts of each cell - the cytoskeleton colloid is defined as comprising particles of solid material (Chen & Ingber 1999, Oschman 2000)

1 Connective tissue a n d the fascial system J Creep Continued deformation (i ncreasing strai n) of a viscoelastic stick or spoon. A slowly moving stick or spoon will travel material with time under constant load (traction, compression, smoothly thlough the paste, whereas any attempt to move twist) it rapidly will be met with a semirigid resistance (known as 'drag'). This makes a gentle touch a fundamental require­ Hysteresis Process of energy loss due to friction when tissues are ment if viscous drag and resistance are to be avoided when loaded and unloaded attempting to produce a change in, or release of, restricted fascial structures, which are all colloidal in their behavior. Load The degree of force (stress) applied to an area or an organism as a whole ELASTICITY Strain Change in shape as a result of stress (external force) Soft tissues, and other biological structures, have an inan te, variable degree of elasticity, springiness, resilience or 'give', Stress Force (load) normalized over the area on which it acts which allows them to withstand deformation when force (all tissues exhibit stress-strain responses) or pressure is applied. This provides the potential for sub­ sequent recovery of tissue to which force has been applied, so Thixotropy A qua lity of colloids in wh ich the more rapidly force that it returns to its starting shape and size. This quality of is applied ( load), the more rig id the tissue response and to elasticity derives from these tissues' (soft or osseous) ability become less viscous when shaken or subjected to shearing forces to store some of the mechanical energy applied to them and and to return to the original viscosity upon standing. to utilize this in their movement back to their original sta­ tus. This is a process known as hysteresiS (see below). Viscoelastic The potential to deform elastica lly when load is applied and to return to the original non-deformed state when The stability and movement characteristics of each body load is removed part - whether this involves organs, vessels, nerves, mus­ cles or bones - is defined by a fibrin matrix combined with Viscoplastic A perma nent deformation resulting from the elastic other elements. For example, bone incorporates calcium potential having been exceeded or pressure forces susta i ned for phosphate to lend rigidity, while muscle contains neurore­ too great a period of time sponsive proteins that enable changes in shape. Each ele­ ment in connective tissue contributes to its strength, resilience Mecha nical princi ples i nfluencing the body neurologica l ly and and compliance, with elastin allowing controlled, reversible anatom ica l ly are governed by basic laws. deformation under strain, and fibrin, laid out along the lines of the local axis of motion, serving as a check on the extent • Wolffs law states that biological systems (including soft and of this deformation. hard tissues) deform in relation to the l ines of force imposed on them. Although a certain amount of deformation is physiologi­ cally necessary, trauma may cause deformation beyond the • Hooke's law states that deformation (resulting from strain) elastic limit of the tissues, thereby causing permanent dam­ imposed on an elastic body is in proportion to the stress age or possibly resulting in a semipermanent distortion of (force/load) placed on it. the connective tissue matrix if the damage is not too severe. Return to normal is then sometimes possible, but only with • Newton's third law states that when two bodies interact, the the reintroduction of sufficient energy to allow a reversal of force exerted by the first on the second is equa l in magnitude the deformation process - for example, by means of manual and opposite in di rection to the force exerted by the second therapy ('soft tissue manipulation'). Appropriately applied on the first. 'force' (i.e. slowly) can assist in resolving the deformation results of strain. In such processes energy is both absorbed • Ardnt-Schultz's law states that weak stimuli excite and released. This energy transfer feature, known as hystere­ physiological activity, moderately strong ones favor it, strong sis, is described further below (Becker 1997, Comeaux 2002). ones retard it and very strong ones a rrest it. • H i l ton's l aw states that the nerve su pplying a joint a lso supplies the muscles that move the joint and the skin covering the a rticular insertion of those muscles. • Head's law states that when a painful stimulus is applied to a body part of low sensitivity (such as a n organ) that is in close central connection (the same segmenta l supply) with an area of higher sensitivity (such as a part of the soma), pain will be felt at the point of higher sensitivity rather than where the stimulus was applied. suspended in fluid - for example, wallpaper paste or, PLASTIC AND ELASTIC FEATURES indeed, much of the human body). Scariati (1991) points out that colloids are not rigid - they conform to the shape of Greenman (1989) describes how fascia responds to loads and their container and respond to pressure even though they stresses in both a plastic and an elastic manner, its response are not compressible. The amount of resistance colloids offer depending, among other factors, upon the type, duration increases proportionally to the velocity of force applied to and amount of the load. When stressful forces (undesirable them. A simple example that gives a sense of colloidal behav­ or therapeutic) are gradually applied to fascia (or other bio­ ior is available when flour and water are stirred together logical material), there is at first an elastic reaction in which with the resulting colloid being mixed into a paste, using a the degree of slack is reduced. If the force persists, this is

4 C L I N I CAL APP LICAT I O N O F N E U R O M USCU LAR TECH N I QU ES: T H E UPPER B O DY Box 1.4 Connective tissue abnorma l crossbridges which prevent normal movement. Fol lowing tissue i nju ry, it is important that activity be introduced as soon as Connective tissue is composed of cells (including fibroblasts and the healing process will allow in order to prevent maturation of the chond rocytes) and an extrace l l ular matrix of collagen and elastic sca r tissue and development of adhesive crossl inks (Lederman 1 997). fibers surrounded by a g round substance made primarily of acid glycosam inoglycans (AGAGs) and water (Gray's Anatomy 2005, Lederman (1 997) tells us: Lederman 1997). Its patterns of deposition change from location to location, depending upon its role and the stresses applied to it. The pattern of collagen deposition varies in different types of The collagen component is com posed of three polypeptide cha ins connective tissue. It is an adaptive process related to the direction wound around each other to form triple hel ixes. These microfi la ments are arranged in parallel manner and bound together by crossl inking of forces imposed on the tissue. In tendon, collagen fibers ore hydrogen bonds, which 'glue' the elements together to provide strength and stabil ity when mecha nical stress is applied. Movement organized in parallel orrangement; th is gives the tendon stiffness and encourages the collagen fibers to align themselves along the lines of structural stress as well as improving the ba lance of strength under unidirectional loads. In ligaments, the organization of glycosami noglycans and water, therefore lubricating and hydrating the connective tissue (Lederman 1997). the fibers is looser. groups of fibers lying in different directions. This While these bonding crossbridges do provide structu ra l support, reflects the multidirectional forces that ligaments are subjected to, injury, chronic stress and immobility cause excessive bonding, leading to the formation of scars and adhesions wh ich limit the for example during complex movements of ajoint such as flexion movement of these u sually resil ient tissues (Juhan 1 998). The loss of tissue lengthening potential would then not be due to the volume of combined with rotation ond shearing . . . Elostin has an arrongement collagen but to the random pattern in which it is laid down and the similar to that of collagen in the extracellular matrix, and its Procollagen Fibroblast deposition is also dependent on the mechanical stresses imposed on --�- --- the tissue. \\ \\� /O-TropOCOllagen Elastin provides an elastic-l ike quality that allows the connective tissue to stretch to the limit of the collagen fiber's length, while '--Collagen microfibril absorbing tensile force. If this elastic quality is stretched over time, it may lose its abil ity to recoil (as seen in the stretch marks of L preg nancy). When stress is applied, the tissue can be stretched to the limit of the collagen fiber length with flexibility being Fibroblasts dependent upon elastic quality (and quantity) as well as the extent of crossbridging that has occurred between the col lagen Fascicle fibers. Additional ly, if heavy pressure is suddenly appl ied, the connective tissue may respond as brittle and may tea r more easily Tendon (Ku rz 1 986). Figure 1.1 Col lagen is p rod uced locally for repa i r of d a maged Surrounding the col lagen and elastic fibers is a viscous, gel-l ike connective tissue. After Lederman 1997. g round substance, composed of proteoglycans and hyaluronan (formerly called hyaluronic acid), which l ubricates these fibers and allows them to sl ide over one another (Barnes 1 990, Ca illiet 1 996, Gray'sAnatomy 2005, Jackson et al 2001 ). • Ground substance provides the immediate environment for every cell in the body. • The protein component is hydrophilic (draws water into the tis­ sue), producing a cushion effect as well as maintaining space between the collagen fibers (Jackson et al 200 1 ). • Ground substance provides the med ium through which other ele­ ments are exchanged, such as gases, nutrients, hormones, cel l ular waste, antibodies and white blood cells (Juhan 1998). • The condition of the g round substance ca n then affect the rate of diffusion and therefore the health of the cel l s it su rrounds. The consistency of the connective tissue varies from tissue to tissue. Where fewer fibers and more liquid is found, an ideal environment for metabolic activities abounds. With less fluid and more fibers, a soft, flexible lattice is achieved that can hold skin cel ls, nerve cells or organ tissue in place. With little fluid and many fibers, a tough, stringy material forms for use in muscle sacs, tendons and ligaments. When chondroblasts (ca rtilage-producing cel ls) and their hya l ine secretions are added, a more solid substance occurs, a nd when mineral salts are added to achieve a rock-like hardness, bones a re formed (Juhan 1998). Unless irreversible fibrotic changes have occurred or other pathologies exist, connective tissue's state ca n be changed from a gelatinous-like substance to a more solute (watery) state by the i ntroduction of energy through muscu lar activity (active or passive movement provided by activity or stretching), soft tissue manipulation (as provided by massage) or heat (as in hydrotherapies). Th is characteristic, cal led thixotropy, is a 'property of certain gels of becoming less viscous when shaken or subjected to shea ring forces box continues

1 Connective tissue and the fascial system 5 Box 1 .4 (continued) Toe Elongation region Elastic region Pre-elastic Elastic rangel Initially, molecular range physiological displacement Slack range range leading to microtears and complete Intramolecular rupture crosslinks Loss of mechanical properties Figure 1.2 Collagen's triple helices are bound together by inter­ and intramolecular crosslinking bonds. After Lederman ( 1997). and returning to the original viscosity upon standing' (Stedman's Figure 1 . 3 Schematic represen tation of the stress-strain cu rve. Medical Dictionary 2004). Without thixotropic properties, movement After Lederman (1 997). would eventually cease due to solid ification of synovium and connective tissue. con ten t and in its ability to conduct energy and movement. The ground substance becomes more porous, a better medium for the Oschman states (1997): diffusion of nutrien ts, oxygen, waste products of metabolism and the enzymes and building blocks involved in the 'metabolic regenera tion ' If stress, disuse and lack of movement cause the gel to deh ydrate, process .. contract and harden (an idea that is supported both by scientific evidence and by the experiences of many somato therapists) the application of pressure seems to bring about a rapidsolation and rehydration. Removal of the pressure allows the system to rapidly re-gel, but in the pracess the tissue is transformed, both in its water followed by what is colloquially referred to as creep - a vari­ fracture when rapid force meets the resistance of bone. If able degree of resistance (depending upon the state of the tis­ force is applied gradually, 'energy' is absorbed by and stored sues). This gradual change in shape is due to the viscoelastic in the tissues. The usefulness of this in tendon function is property of corulective tissue. obvious and its implications in therapeutic terms profound (Binkley 1989). Creep, then, is a term that accurately describes the slow, delayed, yet continuous deformation that occurs in Hysteresis is the term used to describe the process of energy response to a sustained, slowly applied load, as long as this loss due to friction and to minute structural damage that is gentle enough not to provoke the resistance of colloidal occurs when tissues are loaded and unloaded. Heat will be 'drag'. During creep, tissues lengthen or distort ('deflect') produced during such a sequence, which can be illustrated until a point of balance is achieved. An example often used by the way intervertebral discs absorb force transmitted of creep is that which occurs in intervertebral discs as they through them as a person jumps up and down. During gradually compress during periods of upright stance. treatment (tensing and relaxing of tissues, for example, or on-and-off pressure application), hysteresis induction reduces Stiffness of any tissue relates to its viscoelastic properties stiffness and improves the way the tissue responds to sub­ and, therefore, to the thixotropic colloidal nature of colla­ sequent demands. The properties of hysteresis and creep gen/fascia. Thixotropy reIates to the quality of colloids in provide much of the rationale for myofascial release tech­ which the more rapidly force is applied (load), the more niques, as well as aspects of neuromuscular therapy, and rigid the tissue response will be - hence the likelihood of

6 CLINICAL A PPLICATION OF NEUROMUSCULAR TECHN IQUES: THE U P PER BODY L need to be taken into account during technigue applica­ tions. Especially important are the facts that: • rapidly applied force to collagen structures leads to defen­ Figure 1 .4 Electron photomicroscopy of a typical smooth muscle sive tightening cell within the fascia cruris. Above it is the terminal portion of a • slowly applied load is accepted by collagen structures and allows for lengthening or distortion processes to type IV (unmyelated) sensory neuron. ( Photo reproduced with the commence. kind permission of Springer Verlag, first published in Staubesand When tissues (cartilage, for example) that are behaving vis­ coelastically are loaded for any length of time, they first 1 996.) Reproduced with permission from Journal of Bodywork and deform elastically. Subseguently, there is an actual volume Movement Therapies 2003; 7(2) :104-11 6. change, as water is forced from the tissue as they become less sol-like and more gel-like. Ultimately, when the applied force ceases, there should be a return to the original non­ deformed state. However, if the elastic potential has been exceeded, or pressure forces are sustained, a viscoplastic response develops and deformation can become perma­ nent. When the applied force ceases, the time taken for tis­ sues to return to normal, via elastic recoil, depends upon the uptake of water by the tissues. This relates directly to osmotic pressure, and to whether the viscoelastic potential of the tis­ sues has been exceeded, which can result in a viscoplastic (permanent deformation) response. CONNECTIVE TISSUE AS A 'SPONGE' Schleip et al (2004) have shown that when an isometric con­ to sponge-like squeezing and refilling effects in the semi-liquid traction takes place - as in sustained effort, or therapeuti­ ground substance, with its intricate scrub-like arrangement cally with methods such as muscle energy technigue (MET), of water binding glycosaminoglycans and proteoglycans. proprioceptive neuromuscular facilitation (PNF) or other similar techin gues Schleip et al (2004) have presented evidence that derives from simultaneously loses some of its stability, making it easier to the same German research, showing that the thoracolumbar stretch. fascia has the ability to contract, suggesting that the 'fascia may play an active role in joint dynamics and regulation'. It behaves like a sponge, and if the contraction is long Schleip et al also suggest that this research 'offers new insights and strong enough, and if no movement occurs after the into understanding low back instability, compartment syn­ contraction, the fascia reabsorbs water, becoming stiffer as it drome, and my ofascial release therapies'. does so. Research into this phenomenon is in its early stages but at this time the researchers (Schleip et a12004) have been DE FORMATION CHARACTERISTICS able to report: Cantu & Grodin (1992) describe what they see as the 'unigue' By carefully measuring the wet weight of our fascial strips, feature of connective tissue as its 'deformation characteris­ at different experimental stages, plus the final dry weight tics'. This refers to the combined viscous (permanent, plastic) (after later drying the strips in an oven), we found the fol­ deformation characteristic, as well as an elastic (temporary ) lowing pattern: During the isometric stretch period, water deformation status discussed above. The fact that cOIUlective is extruded, which is then refilled in the following rest period. tissues respond to applied mechanical force by first chang­ Interestingly if the stretch is strong enough, and the following ing in length, followed by some of the change being lost rest period long enough, more water soaks into the ground while some remains, has implications in the application of substance than before. The water content then increases to a stretching technigues to such tissues. It also helps us to higher level than before the stretch. Fascia seems to adapt in understand how and why soft tissues respond as they do to very complex and dynamic ways to mechanical stimuli, to postural and other repetitive insults that exert load on them, the degree that the matrix reacts in smooth-muscle-like con­ often over long periods of time. traction and relaxation responses of the whole tissue. It seems likely that much of what we do with our hands in Structural It is worth emphasizing that although viscoplastic changes Integration and the tissue response we experience, may not are described as 'permanent', this is a relative term. Such be related to cellular or collagen arrangement changes, but

changes are not necessarily absolutely permanent since col­ 1 Connective tissue a nd the fascial system 7 lagen (the raw material of fascia/connective tissue) has a limited (300-500 day) half-life and, just as bone adapts to B stresses imposed upon it, so will fascia. If negative stresses (e.g. poor posture, use, etc.) are mod­ ified for the better and/or positive (therapeutic) 'stresses' are imposed by means of appropriate manipulation and/or exercise, apparently 'permanent' changes can modify for the better. Dysfunctional connective tissue changes can usually be improved, if not quickly then certainly over time (Brown 2000, Carter & Soper 2000, Neuberger 1 953). However, some connective tissue changes are more permanent. Schleip et al (2004) have observed many examples of tis­ sue contractions caused by connective tissue cells called myofibroblasts (see Box 1 .5): This happens naturally in wound healing, but also in sev­ eral chronic fascial contractures. In the hand, it presents as palmar fibromatosis, also known as Dupuytren's contrac­ ture, or as a pad-like thickening of the knuckles. In the foot the same process is called plantarfibromatosis, while in club foot contraction of the myofibroblasts is focused on the medial side. In frozen shoulder, the contraction occurs in the shoulder capsule . . . considering the existence of pathologi­ cal faSCial contractures, it seems likely that there may be lesser degrees offascial contractions, which may influence biomechanical behavior. Important features of the response of tissue to load include: • the degree of the load • the amount of surface area to which force is applied • the rate, uniformity and speed at which it is applied • how long load is maintained • the configuration of the collagen fibers (i.e. are they par­ allel to or differently oriented from the direction of force, offering greater or lesser degrees of resistance?) • the permeability of the tissues (to water) • the relative degree of hydration or dehydration of the indi­ vidual and of the tissues involved • the status and age of the individual, since elastic and plastic qualities diminish with age • another factor (apart from the nature of the stress load) that inl1uences the way fascia responds to application of a stress load, and what the individual feels regarding the process, relates to the number of collagen and elastic fibers contained in any given region. HYPERMOBILITY AND CONNECTIVE TISSUE • Ligamentous laxity and general increased mobility of the C connective tissues creates a background of instability. Fig u re 1.5 A-C: Examples of hypermobility. Reproduced with • Hypermobility is usually genetically acquired. Kerr & permission from Kerr Et Grahame (2003). Grahame (2003) describe the sequence that leads to this as follows: 'Genetic aberrations affecting fibrous proteins give rise to biochemical variations, then in turn to

8 CLI N I CAL APPLICATI O N OF N E U R O M USCULAR TECH N I QUES: TH E UPPER BODY Mechanical failure at the cost of stability (Simons 2002, Thompson 2001). Simons (2002) concurs: Figure 1 .6 Pathophysiology of heritable connective tissue disorders. Reproduced with permission from Kerr Et Grahame (2003). In this case it is wise to correct the u nderlying cause of ins tability before releasing the MTrP tension. Infact, cor­ impairments of tensile strength, resulting in enhanced recting the underlying instability often results in sponta­ mobility but at a cost of increased fragility, ultimately risk­ neous resolution of the M TrP. It is important to identify ing mechanical tissue failure.' and remove or modify as many etiological and perpetuat­ • A number of disorders derive from connective tissue ing influences as can befound, however, without creating pathophysiology, including Marfan syndrome, Ehlers­ further distress or a requirementfor excessive adaptation. Danlos syndrome, osteogenesis imperfecta and joint It is also important to consider that, at times, apparent hypermobility syndrome. symptoms may represent a desirable physiological • The commonality of these different syndromes, all result­ response (Thompson 2001). ing from variations of connective tissue laxity, is a ten­ dency toward hypermobility, arthralgia, tendency to • A safer alternative is to encourage fitness training, dislocation (and possible fracture), osteoporosis, thin along with the self-use of ice, hydrotherapy and gentle skin (and stretch marks), varicose veins, prolapse (rectal, stretching and toning exercises (Goldman 1991). It might uterine, mitral valve), hernia and diverticulae. also be helpful to selectively deactivate the most painful • Hypermobility has been shown to be a major risk factor MTrPs before movement therapies can begin; active in the evolution of back pain (Muller et aI2003). movement and, therefore, toning can then be part of the • Hypermobile individuals often present with chronic pain immediate therapy session when the MTrPs are suffi­ syndromes and an increased tendency to anxiety and ciently reduced. panic attacks (Bulbena et al 1 993, Martin-Santos et al 1998). TRIGGER POINTS. FASCIA AND THE NERVOUS • Hypermobility is more common in people of African, Asian and Arab origin where rates can exceed 30% (as SYSTEM compared with Caucasians ±6%), as well as being more frequently identified in the young compared with the Changes that occur in connective tissue, and which result in elderly, and in females compared with males (Hakim & alterations such as thickening, shortening, calcification and Grahame 2003). erosion, may be a painful result of sudden or sustained ten­ • When joints are vulnerable because of hypermobility, pas­ sion or traction. Cathie (1 974) points out that many trigger sive stretches and end-range positions seem to be able to points (he calls them trigger 'spots') correspond to points trigger musculoskeletal symptoms (Russek 2000). where nerves pierce fascial investments. Hence, sustained • Patient care requires that patients modify their ergonom­ tension or traction on the fascia may lead to varying degrees ics and body mechanics (avoiding overuse and extreme of fascial entrapment of neural structures and consequently positions) to avoid stretching their joints past end-range a wide range of symptoms and dysfunctions. Neural recep­ during activities of daily living (Russek 2000). tors within the fascia report to the central nervous system as • Trigger point evolution in associated muscles is a com­ part of any adaptation process, with the pacinian corpuscles mon result of the relative laxity of joints (Kerr & Grahame being particularly important (these inform the CNS about 2003). The authors of this text hypothesize that these energy the rate of acceleration of movement taking place in the efficient (if painful) entities may offer an efficient means area) in terms of their involvement in reflex responses. of achieving short-term stability in unstable areas (Chaitow Other neural input into the pool of activity and responses to 2000, Chaitow & DeLany 2002, DeLany 2000). biomechanical stress involve fascial structures, such as ten­ • The implications of this possibility are clear. If myofascial dons and ligaments which contain highly specialized and trigger points (MTrPs) are serving functional roles, such sensitive mechanoreceptors, and proprioceptive reporting as in stabilization of hypermobile joints, deactivation of stations (see reporting stations, Chapter 3). potentially stabilizing trigger points may ease pain but Additionally: • German research has shown that fascia is 'regularly' pen­ etrated (via 'perforations') by a triad of venous, arterial and neural structures (Heine 1995, Staubesand 1996) • these seem to correspond with fascial perforations previ­ ously identified by Heine, which have been correlated (82% correlation) with known acupuncture points (Heine 1 995). Further, Bauer & Heine (1998) showed that the triad of pedorating neurovascular structures was regu­ larly 'strangulated' by an excessive amount of collagen

SJ1 1 Connective tissue and the fascial system 9 P2 Figure 1 .7 Location of acupuncture points and meridians in serial gross anatomical sections through a human arm. Reproduced from Langevin H M , Yandow J A Relationship of acupuncture points and meridians to connective tissue planes. Anatomical Record 269(6):257-265, 2002. Copyright 2002, Wiley-Liss, Inc. Reprinted with permission of Wiley-Liss, Inc., a subsidiary of John Wiley Et Sons, Inc. Meridians @ acupunclure Yin Yang pOint H= heart SJ triple heat\"r SI= small intestine meridian p= pencarolum • intersection L= lung fibers around these openings in most of the acupoints of THE IMPORTANCE OF LANGEVIN'S RESEARCH the painful region. When those strangulated areas were surgically opened a little, most of the patients experi­ Ongoing research at the University of Vermont has pro­ enced significant improvements (i.e. less pain) duced remarkable new information regarding the function • many of these fascial neural structures are sensory and of fascial connective tissue (Langevin et al 2001, 2004, 2005). capable of being involved in pain syndromes. In evaluating the importance of the research information (below) it is important to recall that approximately 80% of Staubesand states: common trigger point sites have been claimed to lie pre­ cisely where traditional acupuncture points are situated on The receptors we found in the lower leg fascia in humans meridian maps (Wall & Melzack 1 990). Indeed, many could be responsible for several types of myofascial pain experts believe that trigger points and acupuncture points sensations . . . Another and more specific aspect is the inner­ are the same phenomenon (Kawakita et al 2002, Melzack vation and direct connection offascia with the autonomic et al 1 977, Plummer 1 980). nervous system. It now appears that thefascial tonus might be influenced and regulated by the state of the autonomic Others, however, take a different view. For example, nervous system . . . intervention in the fascial system might Birch (2003) and Hong (2000) have revisited the original have an effect on the autonomic nervous system, in general, work of Wall & Melzack (1 990) and have both found this and upon the organs which are directly effected from it. to be flawed, particularly when the acupuncture points (Schleip 1998) referred to as correlating with trigger points are seen to be 'fixed' anatomically, as on myofascial meridian maps. Both

1 0 CLINICAL APPLICATION O F NEUROMUSCULAR TECHNIQUES: THE UPPER BODY Birch and Hong agree, however, that so-called 'Ah shi' tissue matrix (e.g. fibroblasts, sensory afferents, immune acupW1cture points may well represent the same phenome­ and vascular cells)'. non as trigger points. Ah shi points do not appear on the classical acupW1cture meridian maps, but refer to 'sponta­ The key elements of Langevin's research can best be sum­ neously tender ' points which, when pressed, create a marized as follows: response in the patient of, 'Oh yes' ('Ah shi'). In Chinese medicine Ah shi points are treated as 'honorary acupuncture • Acupuncture points, and many of the effects of acupW1c­ points' and are needled or receive acupressure in the same ture, seem to relate to the fact that most of these localized way as regular acupW1cture points, if/when they are ten­ 'points' lie directly over areas where there is fascial cleav­ der/painful. This would seem to make them, in all but in age; where sheets of fascia diverge to separate, surround name, identical to trigger points. and support different muscle blmdles (Langevin et al 200 1 ) . It is clearly important therefore, in attempting to under­ stand trigger points more fully, to pay attention to current • COlU1ective tissue is a commW1ication system of as yet research into acupuncture points and cOlU1ective tissue in unknown potential. The tiny projections emerging from general, as noted in the following research. each cell are called 'integrins'. Ingber demonstrated (Ingber 1993b, Ingber & Folkman 1 989; see Box 1.6) inte­ Langevin & Yandow (2002) have presented evidence that grins to be a cellular signaling system that modify their links the network of acupW1cture points and meridians to a fW1ction depending on the relative normality of the shape network formed by interstitial cOlU1ective tissue. Using a of cells. The structural integrity (shape) of cells depends unique dissection and charting method for location of on the overall state of normality (deformed, stretched, etc.) cOlU1ective tissue (fascial) planes, acupW1cture points and of the fascia as a whole. As Langevin et al (2004) report: acupuncture meridians of the arm, they note that: 'Overall, more than 80% of acupuncture points and 50% of meridian 'Loose' connective tissue forms a network extending intersections of the arm appeared to coincide with inter­ throughout the body inc/uding subcutaneous and intersti­ muscular or intramuscular cOlU1ective tissue planes.' tial connective tissues. The existence of a cellular network of fibroblasts within loose connective tissue may have Langevin & Yandow's research further shows microscopic considerable significance as it may support yet unknown evidence that when an acupuncture needle is inserted and body-wide cellular signaling systems . . . Our findings rotated (as is classically performed in acupW1cture treatment), indicate that soft tissue fibroblasts form an extensively a 'whorl' of cOlU1ective tissue forms around the needle, interconnected cellular network, suggesting they may thereby creating a tight mechanical coupling between the have important, and so far unsuspected integrative func­ tissue and the needle. The tension placed on the cOlU1ective tions at the level of the whole body. tissue as a result of further movements of the needle delivers a mechanical stimulus at the cellular level. They note that • Perhaps the most fascinating research in this remarkable changes in the extracellular matrix '. . . may, in turn, influ­ series of discoveries is that cells change their shape and ence the various cell populations sharing this connective behavior following stretching (and crowding/deforma­ tion) . The observation of these researchers is that: 'The Figure 1 .8 Formation of a connective tissue 'whorl' when an acupuncture needle was inserted through the tissue and progressively rotated. Reproduced from Langevin H M, Yandow J A Relationship of acupuncture points and meridians to connective tissue planes. Anatomical Record 269(6): 257-265, 2002. Copyright 2002, Wiley-Liss, Inc. Reprinted with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.

1 Connective tissue and the fascial system 1 1 dynamic, cytoskeleton-dependent responses of fibrob­ when gravity is removed or reduced. The behavior of cells lasts to changes in tissue length demonstrated in this changes to the extent that, irrespective of how good the study have important implications for our understand­ overall nutritional state is, or how much exercise (static ing of normal movement and posture, as well as thera­ cycling in space) is taking place, individual cells cannot pies using mechanical stimulation of connective tissue, process nutrients normally, and problems such as decalcifi­ including physical therapy, massage and acupuncture' cation emerge. (Langevin et aI2005). The importance we give to this information should be As will become clear, changes in the shape of cells also alter tied to the awareness that, as we age, adaptive forces cause their ability to function normally, even in regard to how changes in the structures of the body, with the occurrence of they handle nutrients. Ingber conducted research (Ingber shortening, crowding and distortion. With this, we are see­ 1993a,b, 2003, Ingber & Folkman 1989), much of it for ing in real terms, in our own bodies and those of our NASA, into the reasons that astronauts lose bone density patients, the environment in which cells change shape. As after a few months in space. He showed that cells deform they do so they change their potential for normal genetic Box 1 .5 Myers' fascial tra i n s (Myers 1 99 7 . 2001 ) • subcutaneous ligament, l i n king the ischial tuberosities to sacrum • l u mbosacra l fascia, erector spinae and nuchal ligament, linking Tom Myers, a distinguished teacher of structural i ntegration, has described a number of clinically useful sets of myofascial chai ns. The the sacrum to the occiput connections between different structures ('long functional • sca lp fascia, linking the occiput to the brow ridge. continuities') that these insights a l low will be drawn on and referred to when treatment protocols are discussed in this text. They a re of The superficial front line (Fig. 1 .1 0) i nvolves a chain that starts particu lar importance in helping draw attention to (for example) with: dysfu nctional patterns in the lower limb which impact d i rectly (via these chains) on structures in the upper body. • the anterior compartment and the periostium of the tibia, linking the dorsal surface of the toes to the tibial tuberosity The five major fascial ch a i ns • rectus femoris, linking the tibial tuberosity to the anterior i nferior The superficial back line (Fig. 1 .9) involves a chain that starts with: iliac spine and pubic tubercle • the plantar fascia, linking the plantar su rface of the toes to the • rectus abdominis as well as pectora lis and sternalis fascia, linking calcaneus the pubic tubercle and the anterior i nferior iliac spine with the manubrium • gastrocnem ius, linking calcaneus to the femoral condyles • hamstrings, l inking the femoral condyles to the ischial • sternocleidomastoid, linking the manubrium with the mastoid process of the temporal bone. tuberosities Figure 1 .9 Myers' superficial fascial back l i n e. Reproduced with permission from t h e Journal o fBodywork and Movement Therapies 1 99 7 ; 1 (2):95. The superficial back line (SBl) box con tinues

1 2 CLI N I CAL APPLICATION OF N E U R O M USCU LAR TECH N I QUES: THE UPPER BODY c:: • the sacrotuberous ligament li nks the ischial tuberosity to the sacrum • the sacral fascia and the erector spinae link the sacrum to the occipital ridge. The deep front line describes several a lternative chains i nvolving the structures anterior to the spine (internally, for example) : • the anterior longitud inal l iga ment. diaph rag m, pericardium, mediastinum, parietal pleura, fascia prevertebralis and the scalene fascia, which connect the lumbar spine (bodies and transverse processes) to the cervical tra nsverse processes and via longus ca pitis to the basilar portion of the occiput • other links in this chain might involve a connection between the posterior manubrium and the hyoid bone via the subhyoid muscles and • the fascia pretrachealis between the hyoid and the cranium/mandible, involving suprahyoid muscles • the muscles of the jaw li nking the mandible to the face and c ra n i u m . Myers includes in his cha in description structures of the lower limbs that connect the tarsum of the foot to the lower l u mbar spine, making the li nkage complete. Additional smaller chains involving the a rms are described as follows. The superficial front line (SFL) Back of the a rm l i nes Fig u re 1 . 1 0 Myers' su perficial fascial front l i ne. Reproduced with • The broad sweep of trapezius links the occipital ridge and the perm ission from the Journal of Bodywork and Movement cervical spinous processes to the spine of the scapula and the Therapies 1 997 ; 1 (2) :97. clavicle. The lateral line involves a chain that starts with: • The deltoid, together with the latera l intermuscu lar septum, connects the scapula and clavicle with the lateral epicondyle. • peroneal muscles, l i n king the 1 st and 5th metatarsal bases with the fibular head • The latera l epicondyle is joined to the hand and fi ngers by the com mon extensor tendon. • ilioti bial tract, tensor fascia latae and g luteus maximus, linking the fibu lar head with the iliac crest • Another track on the back of the arm can arise from the rhomboids, which link the thoracic transverse processes to the • external obliques, internal obliques and (deeper) quadratus lum­ medial border of the sca pula. borum, linking the iliac crest with the lower ribs • The sca pula in turn is linked to the olecranon of the u l na by • externa l i ntercostals and internal intercostals, l i n king the lower infraspinatus and the triceps. ribs with the remaining ribs • The olecranon of the ulna connects to the sma l l fi nger via the • splenius cervicis, iliocostalis cervicis, sternocleidomastoid and periostium of the u l na. (deeper) sca lenes, linking the ribs with the mastoid process of the temporal bone. • A 'stabil ization' feature in the back of the arm i nvolves latissimus dorsi and the thoracolumbar fascia, which connects The spiral line involves a chain that starts with: the arm with the spinous processes, the contralateral sacral fascia and gluteus maximus, which in turn attaches to the shaft • splenius capitis, which wraps across from one side to the other, of the femur. linking the occipital ridge (say, on the rig ht) with the spinous processes of the lower cervical and u pper thoracic spine on the left • Vastus latera lis connects the femur shaft to the tibial tuberosity and (via this) to the periostium of the tibia. • continuing in this direction, the rhomboids (on the l eft) l i n k via the medial border of the scapula with serratus anterior and the Front of the arm l i nes ribs (still on the left), wrapping around the trunk via the external obliques and the abdom inal a poneurosis on the left, to connect • Latissimus dorsi, teres major and pectoralis major attach to the with the internal obliques on the right and then to a strong humerus close to the medial i ntram uscular septum, connecting it anchor point on the anterior superior iliac spine (ASIS) (right side) to the back of the trunk. • from the ASIS, the tensor fascia latae and the il iotibial tract link • The medial i ntramuscu lar septum connects the humerus to the to the lateral tibial condyle medial epicondyle which con nects with the palmar hand and fi ngers by means of the common flexor tendon. • tibialis anterior links the lateral tibial condyle with the 1 st metatarsal and cuneiform • An additional line on the front of the arm involves pectoralis mi nor, the costocoracoid ligament, the brachial neurovascular • from this a pparent endpoint of the chain ( 1 st metatarsal and bundle and the fascia clavipectoral is, which attach to the cuneiform), peroneus longus rises to link with the fibular head coracoid process. • biceps femoris connects the fibular head to the ischial tuberosity • The coracoid process also provides the attachment for biceps brachii (and coracobrachialis), linking this to the radius and the thumb via the flexor compartment of the forearm. • A 'stabil ization' line on the front of the arm involves pectora lis major attaching to the ribs, as do the external obliques, which box continues

1 Con nective tissue a n d the fascial system 1 3 then run to the pubic tubercle, where a con nection is made to AB the contralateral adductor longus, graci lis, pes anserinus and the tibial periostium. Fig u re 1 . 1 1 AEtB: The cont i n u ity of vertical a n d spira l myofascia l l i n es i m plies a mechanical con nection from head to toe. In the following chapters' discussions of local dysfu nctional patterns R eproduced with permission from Myers (2001 ). involving the cervical, thoracic, shoulder and arm regions, it will be useful to hold in mind the direct muscular and fascia l connections that Myers highlig hts, so that the possibil ity of d istant infl uences is never forgotten. Dissection confirmation of fascia l contin u ity (Fig. 1 . 1 1 ) Barker Et Briggs ( 1 999) have shown the lu mbodorsal fascia to extend from the pelvis to the cervical area and base of the cranium, in a n unbroken sweep: 'Both superficial a n d deep laminae o f the posterior layer are more extensive superiorly than previously thought: There is fibrous continuity throughout the lumbar, thoracic and cervical spine and with the tendons of the splenius muscles superiorly. There is a lso growing i nterest in the possible effects that contractile smooth muscle cells (SMC) may have in the many fascial/connective tissue sites in which their presence has now been identified, including cartilage, ligamen ts, spinal discs and the lu mbodorsal fascia (Ah luwalia et a l 2001 , Hastreiter et a l 200 1 , Meiss 1 993, Murray Et Spector 1 999). For example, Yahia et a l (1 993) have observed that: 'H istologic studies indicate that the posterior layer of the (Iumbodorsal) fascia is able to contract as if it were infiltrated with muscular tissue: Schleip and colleagues (2006) report that: 'Morphological considerations, as well as histological observations in our laboratory, suggest that the perimysium is characterized by a high density of myofibroblasts, a class of fibroblasts with smooth muscle-like contractile kinetics: Analysis of 39 tissue samples from the thoracolumbar fascia of 1 1 human donors (aged 1 9-76 years) by Schleip e t al (2004) demonstrated the widespread presence of myofibroblasts in all samples, with an average density of 79 cells/mm2 i n the longitudi na l sections. Schleip et al (2006) suggest that: 'These fi ndings confirm that fascial tissues can actively contract, and that their contractility appears to be driven by myofibroblasts. The q uestion as to whether or not these active fascial contractions could be strong enough to exert any sig nifican t impact on musculoskeletal dynamics has previously been addressed in this journal (Schleip et al 2005) the fol lowing way: taking the g reatest measu red force of in vitro fascial contractions and extra polating that to an average size of the superficial layer of the thoracolumbar fascia in humans the resulting contraction force can amount to 38N, which may be a force strong enough to infl uence biomechanical behaviour, such as in a contribution to paraspinal compartment syndrome or in the prevention of spinal segmental instability: expression, as well as their abilities to communicate and to changes that follow the application of manual techniques handle nutrients efficiently. that offer pain relief and improve function is sorely needed. Reversing or slowing these undesirable processes is SUMMARY OF FASCIAL AND CONNECTIVE the potential of appropriate bodywork and movement TISSUE FUNCTION approaches. It is yet to be precisely established to what degree cellular function can be modified by soft tissue tech­ Fascia is involved in numerous complex biochemical niques, such as those used in neuromuscular therapy. activities. However, the normalizing of structural and functional fea­ • Connective tissue contains a subtle, bodywide signaling tures of connective tissue by means of addressing myofas­ cial trigger points, chronic muscle shortening and fibrosis, system with as yet unknown potentials. as well as perpetuating factors such as habits of use, has clear implications. Well-designed research to assess cellular

1 4 CLI N I CA L A PPLICATI O N O F N EU R O M USCU LAR TECH N I Q U E S : T H E U P P E R B O DY L • The fascial cleavage planes appear to be sites of unique • Many of the neural structures in fascia are sensory in sensit ivity and of great importance in manual (and nature. acupuncture) therapeutic focus. • Fascia supplies restraining mechanisms by the differenti­ • Connective tissue provides a supporting matrix for more ation of retention bands, fibrous pulley s and check liga­ highly organized s tructures and attaches extensively to ments as well as assist ing in the harmonious production and invests into muscles. and control of movement. • Individual muscle fibers are enveloped by endomysium, • Where connective tissue is loose in texture it allows move­ which is connec ted to the stronger perimy sium that sur­ ment between adjacent structures and, by the formation of rounds the fasciculi. bursal sacs, i t reduces the effects of pressure and friction . • The perimysium's fibers attach to the even stronger • Deep fascia ensheaths and preserves the characteristic epimy sium that surrounds the muscle as a whole and contours of the limbs and promotes the circulation in the attaches to fascial tissues nearby. veins and lymphatic vessels. • Because it contains mesenchymal cells of an embry onic • The superficial fascia, which forms the panniculus adipo­ type, connective tissue provides a generalized tissue sis, allows for the storage of fat and also provides a sur­ capable of giving rise, under certain circumstances, to face covering that aids in the conservation of body heat. more specialized elements. • By virtue of its fibroblastic activity, connective tissue aids • It provides (by its fascial planes) pathway s for nerves, in the repair of injuries by the deposition of collagenous blood and lymphatic vessels and structures. fibers (scar tissue). Box 1 .6 Tensegrity A Tensegrity, a term coined by architect/eng ineer Buckmi nster Fuller, Figure 1 . 1 2 ARB: Tenseg rity-based structures. Reproduced w ith represents a system characterized by a discontinuous set of perm ission from the Jaurnal ofBodywork and Movement compressional elements (struts) which are held together, u prighted Therapies 1 99 7 ; 1 (5) :300-302. and/or moved by a continuous tensional network (Myers 1 999, 2001 , the point of impact and to be absorbed throughout the structure. Oschman 1 997, 2000). Fu l ler, one of the most original thinkers of the 'The more flexible and balanced the network (the better the 20th centu ry, developed a system of geometry based on tetrahedral tensiona l integ rity), the more readily it absorbs shocks and converts (four-sided) shapes found i n nature which maximize strength while them to information rather than damage: occupying minima l space (maxi mum stabil ity with a minimum of materials) (Juhan 1 998). From these concepts he designed the box con tinues geodesic dome, including the US Pavilion at Expo '67 in Montreal. Tensegrity structures actually become stronger when they are stressed as the load a ppl ied is distributed not only to the area being directly loaded but a lso throughout the structure (Barnes 1 990). They employ both compressional and tensional elements. When applying the principles of tensegrity to the human body, one ca n readily see the bones and i ntervertebral discs as the disconti nuous compressional u n its and the myofascial tissues (muscles, tendons, l igament, fascia and to some degree the discs) as the tensiona l elements. When load is applied (as in lifting) both the osseous and myofascial tissues distribute the stress incu rred. Ingber ( 1 999) concurs with this concept and then adds to it: I n reality. our bodies are composed of206 compression-resistant bones that are pulled up against the force ofgravity and stabilized through interconnection with a continuous series of tensile muscles, tendons, and ligaments . . . cells may sense mechanical stresses, includ­ ing those due to gravity. through changes in the balance of forces that are tronsmitted across transmembrane adhesion receptors that link the cytoskeleton to the extracellular matrix ond to the other cells (e.g. in tegrins, cadherins, selectins). The mechanism by which these mechanical signals are transduced and converted into a biochemical response appears to be based, in part, on the finding that living cells use a tension-dependent form ofarchitecture, known as tensegrity. to organize and stabilize their cytoske/etons. Oschman (2000) suggests that bones fit in both the strut and tensile categories, argu ing that: 'Bones contai n both compressive and tensile fibres, and are therefore tensegrity systems unto themselves: Tensegrity a l lows mecha nica l energy to be transmitted away from

1 Connective tissue a n d the fascial system 1 5 Regarding Ingber's work, Oschman (2000) points out that the Osch man ( 1 997) concurs, adding another element: living tensegrity network is not only a mechanical system, but a lso a vibratory continuum. When a part of a tensegrity structure is Robbie (1977) reaches the remarkable conclusion that the soft tissues plucked, the vibration produced travels throughout the entire structure: araund the spine, when under apprapriate tension, can actually lift Restrictions in one part have both structural and energetic each vertebra off the one below it. He views the spine as a tensegrity consequences for the en tire organism. Structural integrity, vibratory integrity, and energetic or information integrity go hand in hand. mast. The various ligaments form 'slings ' that are capable of support­ One cannot influence the structural system without influencing the energetic/informational system, and vice versa. Ingber's work ing the weight of the body without applying compressive forces to the shows how these systems also interdigitate with biochemical poth ways. vertebrae and intervertebral discs. In other words, the vertebral col­ Of tensegrity, Juhan (1 998) tells us: umn is not, as it is usually portrayed, a simple stack of blocks, each Besides this hydrostatic pressure (which is exerted by every fascial cushioned b y an intervertebral disc. compartment, notjust the outer wrapping), the connective tissue framework - in conjunction with active muscles - provides another These views are also suggested by Myers (200 1 ) in his enlightening kind of tensional force that is crucial to the upright structure of the book, Anatomy Trains: Myofascial Meridians for Manual and skeleton. We are not made up ofstacks of building blocks resting Movemen t Therapists (see a lso Box 1 .4). securely upon one another, but rather ofpoles and guy-wires, whose stability relies not upon flat stacked surfaces, but upon praper angles Later Oschman continues: of the poles and balanced tensions on the wires. . . . There is not a single horizontal surface anywhere in the skeleton that pravides a Cells and nuclei are tensegrity systems (Coffey 1 985, Ingber Et stable base for anything to be stacked upon it. Our design was not Folkman 1989, Ingber Et Jamieson 1985). Elegant research has docu­ conceived by a stone-mason. Weight applied to any bone would cause it to slide right offitsjoints if it were not for the tensional mented how the gravity system connects, via a family of molecules balances that hold it in place and contral its pivoting. Like the beams in a simple tensegritystructure, our bones act more known as in tegrins, to the cytoskeletons of cells throughout the body. as spacers than as compressional members; more weigh t is actually borne by the connective system of cables than by the bony Integrins 'glue' every cell in the body to neighbouring cells and to the beams. surrounding connective tissue matrix. An important study by Wang et al (1 993) documents that integrin molecules carry tension from the extracellular ma trix, across the cell surface, to the cytoskeleton, which behaves as a tensegrity matrix. Ingber (1 993a,b) has shown how cell shape and function are regulated by an interacting tension and compression system within the cytoskeleton. Levin (1 997) informs us that once spherica l shapes involving tensegrity structures occur (as in the cells of the body), a many-sided framework evolves which has 20 triangular faces. This is the hierarchica lly constructed tensegrity icosahedron (icosa is 20 in Greek) which a re stacked together to form an infinite n u mber of tissues. Levin ( 1 997) further explains a rchitectural aspects of tensegrity as it relates to the human body. He discusses the work of Wh ite Et Panjabi ( 1 978) who have shown that any part of the body wh ich is free to move in any direction has 1 2 degrees of freedom: the abil ity to rotate around three axes, in each direction (six degrees of freedom) as well as the ability to translate on three planes in either direction (a further six degrees of freedom). He then asks, how is this stabil ized? To fix in space a body thot has 12 degrees of freedom it seems logical that there need to be 12 restraints. Fuller (1975) proves this ... This Fig u re 1 . 1 3 Tensegrity-based structures. Fig u re 1 . 1 4 Cycle wheel structure a l l ows com pressive load to be distributed to rim t h rough tension network. box con tinues

1 6 CLI N ICAL APPLICATIO N O F N EU RO M USCU LAR TECH N IQUES: THE UPPER BODY L Box 1 .6 (tottt{ntled) Fig u re 1 . 1 5 A : Dehydration of g round su bstance may ca use kinking of collagen AB fibers. B: Sustained pressure may result principle is demonstrated in a wire-spoked bicycle wheel. A minimum i n tempora ry solation of g round of 12 tension spokes rigidly fixes the hub in space (anything more substance, allowing kinked collagen than 12 is a fail safe mechanism). fibers to lengthen, thereby redu cing m uscular stra i n. Reproduced with Levin points out that the tension-loaded spokes transmit permission from the Journal of Bodywork compressive loads from the fra me to the ground while the hub and Movemen t Therapies 1 99 7 ; 1 (5) :309. remains suspended in its tensegrity network of spokes: 'the load distributes evenly around the rim and the bicycle frame and its load hangs from the hubs l i ke a ham mock between trees'. Other examples of tensegrity in common use include a tent and a crane. In the body this architectural principle is seen in many tissues, most specifically in the way the sacrum is suspended between the ilia. • The ensheathing lay er of deep fascia, as well as inter­ ubiquitous, tenacious, living tissue that is deeply muscular septa and interosseous membranes, provides involved in almost all of the fundamental processes of vast surface areas used for muscular attachment. the body 's structure, function and metabolism. • In therapeutic terms, there can be little logic in try ing to • The meshes of loose connective tissue contain the 'tissue consider muscle as a separate structure from fascia since fluid' and provide an essential medium through which they are so intimately related. the cellular elements of other tissues are brought into • Remove connective tissue from the scene and any muscle functional relation with blood and ly mph. left would be a jelly -like structure without form or func­ tional ability. • This occurs partly by diffusion and partly by means of hy drokinetic transportation encouraged by alterations in FASCIAL DYS FUNCTION pressure gradients - for example, between the thorax and the abdominal cavity during inhalation and exhalation. Mark Barnes (1997) states: • Connective tissue has a nutritive function and houses Fascial restrictions can create abnormal strain patterns that nearly a quarter of all body fluids. can crowd, or pull the osseous structures out of proper • Fascia is a major arena of inflammatory processes (Cathie alignment, resulting in compression of joints, producing 1 974) (see Chapter 7). pain and/or dysfunction. Neural and vascular structures • Fluids and infectious processes often travel along fascial can also become entrapped in these restrictions, causing planes (Cathie 1 974). neurological or ischemic conditions. Shortening of the myofascialfascicle can limit itsfunctional length - reducing • Chemical (nutritional) factors influence fascial behavior its strength, contractile potential and deceleration capacity. directly. Pauling (1976) showed that 'Many of the results Facilitating positive change in this system [by therapeutic of deprivation of ascorbic acid [vitamin C] involve a defi­ intervention] would be a clinically relevant event. ciency in connective tissue which is largely responsible for the strength of bones, teeth, and skin of the body and Cantu & Grodin (1992) have stated that 'The response of which consists of the fibrous protein collagen'. normal connective tissue [fascia] to immobilization pro­ vides a basis for understanding traumatized conditions'. • The histiocytes of connective tissue comprise part of an important defense mechanism against bacterial invasion A sequence of dy sfunction has been demonstrated as by their phagocytic activity. follows (Akeson & Amiel 1977, Amiel & Akeson 1983, Evans 1960). • They also play a part as scavengers in removing cell debris and foreign material. • The longer the immobilization, the greater the amount of infiltrate there will be. • Connective tissue represents an important 'neutralizer' or detoxicator to both endogenous toxins (those produced under phy siological conditions) and exogenous toxins. • The mechanical barrier presented by fascia has important defensive functions in cases of infection and toxemia. • Fascia, then, is not just a background structure with little function apart from its obvious supporting role, but is an

1 Connective tissue and the fascial system 1 7 • If immobilization continues beyond about 12 weeks, colla­ To achieve this, he says: gen loss is noted; however, in the early days of any restric­ tion, a significant degree of grolU1d substance loss occurs, Most important is the change in the ground substancefrom particularly glycosarninoglycans and water. Loss of (47% a gel to a sol. T his occurs with a state phase realignment of of) muscle strength due to immobilization has been shown crystals exposed to electromagneticfields. This may occur as to occur in as little as 3 weeks (Hortobagyi et al 2000). a piezoelectric event (changing a mechanical force to electric energy) which changes the electrical charge of collagen and • Since one of the primary purposes of ground substance is proteoglycans within the extracellular matrix. the lubrication of the tissues it separates (collagen fibers), its loss leads inevitably to the distance between these In offering this opinion Barnes is basing his comments on fibers being reduced. the research evidence relating to connective tissue behavior which takes the properties of fascia into an area of study • Loss of interfiber distance impedes the ability of collagen involving liquid crystal and piezoelectric events to glide smoothly, encouraging adhesion development. (Athenstaedt 1 974, Pischinger 199 1). Appropriately applied manual therapy can, Barnes suggests, often achieve such • This allows crosslinkage between collagen fibers and changes, whether this involves stretching, direct pressure, newly formed connective tissue, which reduces the myofascial release or other approaches. As noted earlier, degree of fascial extensibility as adjacent fibers become much that changes can be seen to possibly involve the more and more closely bound. 'sponge-like' behavior of connective tissues as they extrude and absorb water. All these elements form part of neuro­ • Because of immobility, these new fiber connections will muscular therapy interventions. not have a stress load to guide them into a directional for­ mat and they will be laid down randomly. A DIFFERENT MODEL LINKING TRAUMA AND • Similar responses are observed in ligamentous as well as CONNECTIVE TISSUE periarticular connective tissues. Discussion of trauma and connective tissue has focused • Mobilization of the restricted tissues can reverse the thus far on the physical changes that evolve, and the adap­ effects of immobilization as long as this has not been for tations and compensations that are often amenable to soft an excessive period. tissue therapeutic interventions. • If, due to injury, inflammatory processes occur as well as Oschman (2006) offers a different perspective, which immobilization, a more serious evolution occurs, as may be seen to build on the observations above on the work inflammatory exudate triggers the process of contrac­ of Langevin, since both conceive connective tissue as ture, resulting in shortening of connective tissue. (amongst other things) a communication network. Oschman summarizes this hypothesis as follows: • This means that, following injury, two separate processes may be occurring simultaneously: there may be a process The hypothesis is that the connective tissue matrix and its of scar tissue development in the traumatized tissues and extensions reaching into every cell and nucleus in the body also fibrosis in the surrolU1ding tissues (as a result of the is a whole-person physical system that senses and a bsorbs presence of inflammatory exudate). the physical and emotional impact in any traumatic experi­ ence. T he matrix is also the physical material that is influ­ • Cantu & Grodin ( 1992) give an example: 'A shoulder may enced by virtually all hands-on, energetic and movement be frozen due to macroscopic scar adhesion in the folds therapies. It is suggested that the living [connective tissue] of the inferior capsule . . . a frozen shoulder may also be matrix is the physical substrate where traumatic memories caused by capsulitis, where the entire capsule shrinks.' are stored and resolved. • Capsulitis could therefore be the result of fibrosis involv­ Oschman continues: ing the entire fabric of the capsule, rather than a localized scar formation at the site of injury. The living matrix is a pervasive system, consisting of both the nerves and the connective tissues and cytoskeletons of Noted author Rene Cailliet (2004) points out that the vis­ every neural and non-neural cell in the body. On the basis of coelastic properties of collagen are influence by tempera­ the known biophysical properties of this system, we can ture, 'which, when added to the equation of force and speed visualize this as a high-speed solid-state information proces­ of stress, may cause irrecoverable damage'. Prolonged immo­ sor with capabilities that far exceed the brightest minds and bilization results in a number of alterations in tissue, includ­ fastest computers. Intuition can therefore be described as an ing failure of collagen fibers to physiologically elongate and emergent property of a very sophisticated semiconducting loss of collagen strength in as little as 4 weeks. liquid crystalline molecular matrix that is capable of stor­ ing, processing and communicating a vast amount of sub­ RESTORING GEL TO SOL liminal information that never reaches the nervous system Mark Barnes ( 1997) insists that therapeutic methods that try to deal with this sort of fascial, connective tissue change (summarized above in relation to trauma or immobilization) would be to 'elongate and soften the connective tissue, cre­ ating permanent three-dimensional depth and width'.

1 8 C L I N I CA L A P P LI CAT I O N O F N EU R O M U S C U LA R TECH N I Q U E S : T H E U PPER B ODY link Et Lawson have described patterns of postural patterning • link Et Lawson observed that the 20% of people whose compen­ determ ined by fascial compensation and decompensation. satory pattern did not alternate had poor health histories. • Fascial compensation is seen as a usefu l, beneficia l and, above all, • Treatment of either CCP or uncompensated fascial patterns has functional adaptation (i.e. no obvious symptoms) on the part of the objective of trying, as far as is possible, to create a sym metri­ the musculoskeleta l system, for exa mple, in response to anom­ cal degree of rotatory motion at the key crossover sites. alies such as a short leg, or to overuse. • The treatment methods used to ach ieve this ra nge from direct • Decompensation describes the same phenomenon but only in muscle energy approaches to indirect positional release techniques. relation to a situation in which adaptive changes are seen to be dysfunctional, to produce symptoms, evidencing a failure of Assessment of tissue preference homeostatic adaptation. Occipitoatl antal area (Fig. 1 . 1 6) By testing the tissue 'preferences' in different areas it is possible to • Patient is supine. classify patterns i n clin ically useful ways: • Practitioner sits at head, and cradles upper cervical region. • The neck is fu l ly flexed. • ideal (minimal ada ptive load transferred to other regions) • The occiput is rotated on the atlas to eva luate tissue preference • compensated patterns which alternate in direction from area to as the head is slowly rotated left and then right. area (e.g. atla ntoocci pital, cervicothoracic, thoracolumbar, lum­ Cervi cothoracic area (Fig. 1 . 1 7) bosacral) and which a re commonly adaptive in nature • Patient is seated in relaxed posture with practitioner behind, with • uncompensated patterns which do not a lternate and which are commonly the result of trauma. hands placed to cover medial aspects of upper trapezius so that fingers rest over the clavicles. Functi o n a l eva l u ation of fasci a l postural patterns A link Et Lawson ( 1 979) have described methods for testing tissue preference. • There a re fou r crossover sites where fascial tensions can be noted : occipitoatiantal (OA), cervicothoracic (CT), thoracolu mbar (TL) and lumbosacral (LS). • These sites a re tested for their rotation and side-bending preferences. • link Et Lawson's research showed that most people display alter­ nating patterns of rotatory preference with about 800/0 of people showing a common pattern of left-right-Ieft-right (termed the common compensatory pattern or CCP) 'reading' from the occipi­ toatlantal region downwards. B Fig u re 1 . 1 6 Alternative hand positions for assessment of u pper F i gu re 1 . 1 7 AEtB: Hand positions for assessment of u pper cervical region tissue d i rection prefe rence. cervicothoracic reg ion tissue di rection preference. box continues

1 Connective tissue and the fascial system 1 9 Box 1 . 7 (con�in ued) . '.' • The hands assess the area being palpated for its 'tightness/loose­ ness' preferences as a slight degree of rotation left and then right NOTE: By holding tissues in their 'loose' or ease positions, by holding is introduced at the level of the cervicothoracic junction. tissues in their 'tight' or bind positions and introducing an isometric contraction or just by holding tissues at their barrier, waiting Thoraco l u m b a r area for a release, changes ca n be encouraged. The latter a pproach would be i nducing the myofascial release in response to lig ht, sustained • Patient is supine, practitioner stands at waist level facing cepha­ load. lad and places hands over lower thoracic structures, fingers along lower rib shafts lateral ly. Questions following assessment exercise: • Treating the structure being pal pated as a cyl inder, the hands test 1 . Was there an 'a lternating' pattern to the tissue preferences? the preference the lower thorax has to rotate a round its central 2. Or was there a tendency for the tissue preference to be the same axis, one way and then the other. i n all or most of the four a reas assessed? Lumbosacral a rea 3. If the latter was the case, was this in an individual whose health • Patient is supine, practitioner stands below waist level facing is more compromised than average - in line with Zink & Lawson's cephalad and places hands on anterior pelvic structures, using the suggestion? contact as a 'steering wheel' to evaluate tissue preference as the 4. By means of any of the methods suggested in the 'Note' above, pelvis is rotated around its central axis while seeking information are you able to produce a more balanced degree of tissue as to its 'tightness/looseness' preferences. preference? and consciousness directly. A computer, with its software superficial tissues (involving autonomic responses) as well as programs and memory and information storage capacities deeper tissues (influencing the mechanical components of pales to insignificance in comparison with the evolutionar­ the musculoskeletal system) and that also address the factor ily ancient solid-state system that is expressed within every of mobility (movement) meet with the requirements of the cell and sinew of the body. body when dysfunctional problems are being treated. NMT, Since the primary channels of this informational system are the acupuncture meridians, it is not surprising that as presented in this text, adopts this comprehensive approach there are energy psychology methods that involve tapping and achieves at least some of its beneficial effects because of on key paints on the meridian system. Such tapping will its influence on fascia. introduce electrical fields into the meridian system because of the piezoelectric or pressure-electricity effect (e.g. In the upcoming chapters we will see how influences Lapinski 1977, MacGinitie 1995). Such currents, then, will from the nervous system, inflarrunatory processes and pat­ be transduced into signals that will be propagated through terns of use affect (and are affected by) the fascial network. the meridian/living matrix system for a certain distance, since the meridians are low resistance pathways to theflow In the second volume of this text, the principles of tenseg­ of electricity (e.g. Reichmanis et aI 1975). rity, thixotropy and postural balance will be seen to form an THERAPEUTIC SEQUENCING intricate part of the foundations of whole-body structural integri ty. As will become clear in the next chapter, Ingber Cantu & Grodin (1992) conclude that therapeutic approaches (2003) now tends to use the term 'structural continuum' as which sequence their treahuent protocols to involve the an advance on the tensegrity model, wherein the entire body and all its myriad structures are seen to be interde­ pendently enmeshed. The authors of this text believe that an understanding of these different ways of appreciating the structures of the body is a foundation for the use of ther­ apeutic bodywork methods. Refe r e n ces Barker p, Briggs C 1999 Attachments of the posterior layer of lum­ bar fascia. Spine 24(17):1757-1764 Ahluwalia S, Fehm M, Murray MM, Martin SD, Spector M 2001 Distribution of smooth muscle actin-containing cells in Barnes J F 1990 Myofascial release: the search for excellence. the human meniscus. Journal of Orthopaedic Research 19(4) :659-664 Myofascial Release Seminars, Paoli. PA Barnes M 1997 The basic science of myofascial release. Journal of Akeson W, Amiel D 1977 Collagen cross linking alterations in joint contractures. Connective Tissue Research 5: 15-19 Bodywork and Movement Therapies 1 (4):231-238 Bauer J, Heine H 1998 Akupunkturpunkte und Fibromyalgie ­ Amiel D. Akeson W 1983 Stress deprivation effect on metabolic turnover of medial collateral ligament collagen. Clinical Mbglichkeiten chirurgischer Intervention. Biologische Medizin Orthopedics 172:265-270 6 ( 1 2) : 257-261 Becker R 1997 Life in motion. Rudra Press, Portland A thenstaedt H 1974 Pyroelectric and piezoelectric properties of Binkley J 1989 Overview of ligaments and tendon structure and vertebrates. Annals of New York Academy of Sciences mechanics. Physiotherapy Canada 41(1):24-30 238 :68-110

20 CLIN ICAL APPLICATI ON O F N EU R O M USCULAR TECH N IQUES: TH E U PPER BODY Birch S 2003 Trigger pOint-acupuncture point correlations revisited. Ingber 0 E 1993a Cellular tensegrity: defining new rules of biologi­ Journal of Alternative and Complementary Medicine 9(1):91-103 cal design that govern the cytoskeleton. Journal of Cell Science 104:613-627 Bonica J 1990 The management of pain, 2nd edn. Lea and Febiger, Philadelphia Ingber 0 E 1993b The riddle of morphogenesis: a question of solution chemistry or molecular cell engineering. Cell Brookes 0 1984 Cranial osteopathy. Thorsons, London 75 : 1 249-1252 Brown J S 2000 Faulty posture and chronic pelvic pain. In: Howard Ingber 0 E 1999 How cells (might) sense microgravity. Workshop F M, Perry C P, Carter J E et al (eds) Pelvic pain d iagnosis and on cell and molecular biology research in space, Leuven, management. Lippincott Williams and Wilkins, Philadelphia, Belgium, June 1998. 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Churchill Livingston, Station Hill Press, Barrytown, NY Edinburgh, p 27 Kawakita K, Itoh K, Okada K 2002 The polymodal receptor hypoth­ Chen C, Ingber 0 1999 Tensegrity and mechanoregulation: from skeleton to cytoskeleton. Osteoarthritis and Cartilage esis of acupuncture and moxibustion, and its rational explana­ 7 ( 1 ) : 8 1 -94 tion of acupuncture points. International Congress Series: Coffey 0 1985 See Levine J The man who says YES. Johns Hopkins Acupuncture - is there a physiological basis? 1238:63-68 Magazine February /April:34-44 Keeffe E B 1999 Know your body. Times Edition, Ulysses Press, Comeaux Z 2002 Robert Fulford and the philosopher physician. Berkeley, CA Eastland Press, Seattle Kerr R, Grahame R 2003 Hypermobility syndrome. Butterworth­ DeLany J 2000 Multidisciplinary approaches to myofascial pain. Heinemann, Edinburgh, p 15-32 JBMT European Conference lecture, Dublin, Ireland Kochno T V 2001 Connective tissue perspective. Part 2: Active iso­ Dorman T 1997 Pelvic mechanics and prolotherapy. In: Vleeming A, lated stretching (the Mattes method). Journal of Bodywork and Mooney V, Dorman T et al (eds) Movement, stability and low Movement Therapies 6(4):226-227 back pain. Churchill Livingstone, Edinburgh Kurz I 1986 Textbook of Dr Vodder's manual lymph d rainage, vol 2: Earl E 1965 The dual sensory role of the muscle spindles. Physical Therapy, 2nd edn. Karl F Haug, Heidelberg Therapy Journal 45:4 Langevin H M, Yandow J A 2002 Relationship of acupuncture Evans E 1960 Experimental immobilization and mobilization. points and meridians to connective tissue planes. Anatomical Journal of Bone and Joint Surgery 42A:737-758 Record 269(6):257-265 Fuller B 1975 Synergetics. Macmillan, New York Langevin H, Churchill 0, Cipolla M 2001 Mechanical signaling Goldman J 1991 Hypermobility and deconditioning. Southern through connective tissue: a mechanism for the therapeutic Medical Journal 84:1192-1196 effect of acupuncture. FASEB Journal 15:2275-2280 Gray's anatomy 2005 (39th edn) Churchill Livingstone, Edinburgh LangeVin H, Cornbrooks C, Taa�es 0 et al 2004 Fibroblasts form a Greenman P 1989 Principles of manual medicine. Williams and body-wide cellular network. Histochemistry and Cell Biology Wilkins, Philadelphia 1 22 ( 1 ) : 7-15 Hakim A, Grahame R 2003 Joint hypermobility. Best Practice &. Langevin H, Bouffard N, Badger G et al 2005 Dynamic fibroblast Research CLinical Rheumatology 17:989-1004 cytoskeletal response to subcutaneous tissue stretch ex vivo and Hastreiter 0, Ozuna R M, Spector M 2001 Regional variations in in vivo. American Journal of Physiology - Cell Phys. iology cellular characteristics in human l u mbar intervertebral discs, 288:C747-756 including the presence of alpha-smooth m uscle actin. 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1 Connective tissue and the fascial system 2 1 Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro J C Schleip R 2003 Fascial plasticity - a new neurobiological 1998 Association between jOlnt hypermobility synd rome explanatiori, Part 2. Journal of Bodywork and Movement and panic disorders. American Journal of Psychiatry Therapies 7(2):104-116 155 : 1 578-1583 Schleip R, Klingler W, Lehmann-Horn F 2004 Active contraction of Meiss R A 1993 Persistent mechanical effects of decreasing length the thoracolumbar fascia. In: Vleeming A, Mooney V, Hodges P during isometric contraction of ova rian ligament smooth et al (eds) Proceedings of the 5th InterdiSciplinary World muscle. Journal of Muscle Research and Cell Motility Congress on Low Back and Pelvic Pain, Melbourne 14(2) :205-218 Schleip R, Klingler W, Lehmann-Horn F 2005 Active fascial contrac­ Melzack R, Stillwell 0 M, Fox E J 1977 Trigger points and tility: fascia may be able to contract in a smooth muscle-l ike acupuncture points for pain: correlations and implications. manner and thereby influence musculoskeletal dynamics. Pain 3:3-23 Medical Hypotheses 65(2):273-277 Muller K, Kreutzfeld t A, Schwesig R et a l 2003 Hypermobility and Schleip R, Naylor 1, Ursu 0 et a l 2006 Passive muscle stiffness may chronic back pain. Manuelle Medizin 4 1 (2):105-109 be influenced by active contractility of intramuscular connective tissue. Medical Hypothesis 66(1):66-71 Murray M, Spector M 1999 Fibroblast distribution in the anterome­ dial bundle of the human anterior cruciate ligament: the pres­ Simons 0 G 2002 Understanding effective treatments of myofascial ence of a lpha-smooth muscle actin-positive cel ls. Journal of trigger points. Journal of Bodywork and Movement Therapies Orthopaedic Research 17(1):18-27 6(2):81-88 Myers T 1997 Anatomy trains. Journal of Bodywork and Movement Staubesand J 1996 Zum Feinbau der fascia cruris mit Therapies 1 (2):91-101 and 1 (3):134-145 BerucksichtigLmg epi- und intrafaszialar Nerven. Manuelle Medizin 34: 196-200 Myers T 1999 Kinesthetic dystonia parts 1 and 2. Journal of Bodywork and Movement Therapies 3(1):36-43 and Stedman's Electronic Medical Dictionary 2004 version 6.0. 3(2):107-117 Lippincott Williams and Wilkins, Baltimore Myers T 2001 Anatomy trains: myofascial meridians for manual Thompson B 2001 Sacroiliac joint dysfunction: neuromuscular and movement therapists. Churchill Livingstone, Ed inburgh massage therapy perspective. Journal of Bodywork and Movement Therapies 5(4):229-234 Neuberger A 1953 Metabolism of collagen. Journal of Biochemistry 53:47-52 Von Piekartz H, Bryden L (eds) 2001 Craniofacial dysfunction and pain. Butterworth-Heinemann, Oxford Oschman J L 1997 What is healing energy? Part 5: Gravity, struc­ ture, and emotions. Journal of Bodywork and Movement Wal l P, Melzack R 1990 Textbook of pain, 2nd edn. Churchill Therapies 1(5):307-308 Livingstone Edinburgh Oschman J L 2000 Energy medicine: the scientific basis. Churchill Wang J Y, Butler J P, Ingber 0 E 1993 Mechanotransd uction across Livingstone, Edinburgh the cell surface and th.rough the cytoskeleton. Science 260:1124-1127 Oschman J L 2006 Trauma energetics. Journal of Bodywork and Movement Therapies 10(1):21-34 White A, Panjabi M 1978 Clinical biomechanics of the spine. J B Lippincott, Philadelphia Page L 1952 Academy of Applied Osteopathy Yearbook Pauling L 1976 The common cold and flu. W H Freeman, New York Wilson V 1966 Inhibition in the CNS. Scientific American Pischinger A 1991 Matrix and matrix regulation. Haug 5:102-106 international, Brussels Wolff J 1870 Die i.n.nere Architektur der Knochen. Arch Anat Plummer J 1980 Anatomical findings at acupuncture loci. American Phys 50 Journal of Chinese Medicine 8:170-180 Yahia L, Pigeon P, DesRosiers E 1993 Viscoelastic properties of the Reichmanis M, Marino A A, Becker R 0 1975 Electrical correlates of human lumbodorsal fascia. Journal of Biomedical Engineering 15(5):425-429 acupuncture points. IEEE Transactions on Biomedical Engineering 22(Nov):533-535 Yoshino G, Higashi K, Nakamura T 2003a Changes in head pOSition Robbie 0 L 1977 Tensional forces in the human body. OrthopaediC d ue to occlusal supporting zone loss during clenching. Journal Review 6:45-48 of Craruomandibular Practice 21(2):89-98 Russek L N 2000 Examination and treatment of a patient with hypermobility syndrome. Physical Therapy 80:386-398 Yoshino G, Higashi K, Nakamura T 2003b Changes in weight Scariati P 1991 Myofascial release concepts. In: DiGiovanna E (ed) distribution at the feet due to occlusal supporting zone loss An osteopathic approach to d iagnosis and treabnent. Lippincott, during clenching. Journal of Craniomandibular Practice 21 (4):271-278 London Schleip R 1998 Interview with Prof. Dr. med. J Staubesand in Rolf Zink G, Lawson W 1979 An osteopathic structural examination and functional interpretation of the soma. Osteopathic Annals Lines. Rolf Institute, Boulder, CO 12(7):433-440

Chapter 2 I Muscles 23 I I CHAPTER CONTENTS In this chapter our focus of a ttention is placed on the prime movers and stabilizers of the body, the muscles. It is neces­ Dynamic forces - the 'structural continuum' 23 sary to understand those aspects of muscle structure, func­ Signals 25 tion and dysfunction that can help to make selection and Essential information about muscles 25 application of therapeutic interventions as suitable and Types of muscle 25 effective as possible. Unless otherwise noted, the general Energy production in normal tissues 27 muscle discussions in this chapter refer to skeletal muscles. Energy production in the deconditioned individual 28 Muscles and blood supply 28 The skeleton provides the body with an appropria tely Motor control and respiratory alkalosis 31 semlflgld framework that has facility for movement a t its Two key definitions 32 junctions a�d joints. However, it is the muscular system, The Bohr effect 32 Core stability, transversus abdominis, the given coheslOn by the fascia (see Chapter 1), that both sup­ ports and propels this framework, providing us with the diaphragm and BPD 32 Summary 32 mrafaabCnoiIl.ugaitlinynetgaxtom.pferrsexosptmsorl.eOgcsnl�svotomoputpgrhsienealgbvmeewasatsoitnshoagrdgooeutf.ogtAhhbelmmrhaooienvsaetrstme,uviersegnrdety,erytiphn,einanclcdgitm,eivnfbrittioinoemngs Major types of voluntary contraction 33 Terminology 33 muscular function. Muscle tone and contraction 33 Synchronized and coordinated movement depends on Vulnerable areas 34 Muscle types 34 structural integration, in which the form of the body parts, Cooperative muscle activity 35 and how they interrelate spatially, from the smallest to the Muscle spasm, tension, atrophy 37 largest, determines the efficiency of function. It is in this Contraction (tension with EMG elevation, complex setting that muscle function (and dysfunction) should be seen. voluntary) 38 Spasm (tension with EMG elevation, involuntary) 38 DYNAMIC FORCES - THE 'STRUCTURAL Contracture (tension of muscles without EMG elevation' CONTINUUM' involuntary) 38 It may be useful to qualify the description above, in which a Increased stretch sensitivity 38 division is suggested between the semirigid skeleton and Viscoelastic influence 39 the attaching elastic soft tissues that propel and move it. In Atrophy and chronic back pain 39 fact, the integrated systems of the body are better described What is weakness? 39 as representing a series of interrelated tensegrity structures. Trick patterns 39 Joint implications 40 It �as Fuller (1975) who used the term tensegrity to When should pain and dysfunction be left alone? 40 desc�lbe structures whose stability, or tensionaL integrity, Beneficially overactive muscles 41 Somatization - mind and muscles 41 reqUired a dynamic balance betvveen discontinuous com­ But how is one to know? 41 pression elements (such as bones) connected (and moved) by continuous tension cables (such as the soft tissues of the body, e.g. ligaments, tendons, muscle and fascia). There

24 C L I N ICAL A P P LICAT I O N OF N E U RO M U SCULAR T E C H N I QU E S : TH E U P P E R B O DY �-- Upper trapezius �--Spine of scapula Site of vertebral �--Infraspinatus malrotation--�-L '-- Teres minor --- Thoracolumbar junction �-- Piriformis Iliopsoas---t' TFUITB---1 t-- Biceps femoris Gastrocnemius and soleus---t Figure 2.2 Typical sites of increased muscle/tendon tension and tenderness resulting from malalignment. The drawing also indicates the typical lateralization; if the structure is involved bilaterally, the one indicated here is usually affected more severely. TFL/ITB, tensor fascia lata/iliotibial band. Redrawn with permission from Schamberger (2002). Figure 2.1 The miraculous possibilities of human balance. misuse (poor posture, for example) leads to structural mod­ ifications, and that once such structural rearrangements Reproduced with permission from Gray's Anatomy (1 995). have occurred, normal (or at least optimal) function may become impossible. was, in this construct, the implied balance created between tension and compression, involving all tissues, from an intra­ The interlocking elements of structure, function and dys­ and extracellular level, to the gross skeletal and muscular function are the territory of the manual therapist, as we structures of the physical body (Ingber 1993, 2003). evaluate in our patients these processes of 'coordinated structural rearrangement' that are capable of affecting all Ingber (2003) has, in fact, moved beyond the tensegrity tissues, including neural, fascial and muscular. The end model in his descriptions, having more recently discussed results of such 'rearrangement' will be noted when a muscle what he terms a 'structural continuum', in which every­ is found to be shortened, fibrotic or to contain trigger points. thing from the macro (skeleton, muscles, organs, etc.) to the These symptom-producing changes (reduced range of micro (intra- and extracellular structures) are interdepend­ motion, tense, tight and /or indurated muscles that may ently enmeshed. Ingber summarizes this when he states: be housing trigger points) are the manifestation of rearrange­ 'Mechanical deformation of whole tissues [the outcome of ment of the structural continuum. An example of a the interaction between tensional, shear and compression 'rearranged' structure is given by Schamberger (2002) who forces] results in coordinated structural re-arrangements on describes an example of what he terms a 'malalignment many different size scales.' syndrome' (Fig. 2.2). In this example rotational and other malalignments are seen to cause increased muscular ten­ He uses the word mechanotransduction to summarize the sions and corresponding adaptations. effects of shear and other forces on cells, which change their shape and function, including gene expression. These Fortunately, 'coordinated structural rearrangement' in a processes occur in tissues that have been, or are being, positive direction is also possible, when appropriate thera­ over- or underused, or abused. This implies that functional peutic measures are initiated to help restore the 'structural continuum', offering the chance for function to improve, or

2 Muscles 25 it will be possible to commence explora tion of the many dysfunctiomll patterns that can interfere with the quality of life and create painful leading to degenerative changes. Because the anatomy and physiology of muscles are ade­ quately covered elsewhere, the information in this chapter will be presented largely in summary form. Some specific topics (muscle type, for example) receive a fuller discussion due to the significance they have in regard to neuromuscu­ lar therapy. Triad --HI- ESSENTIAL IN FORMATION ABOUT MUSCLES Z disc --\"'I- (Fritz 1998, Jacob a Falls 1997, Lederman 1997, Liebenson 1996, Macintosh et al 2006, Schafer 1987) Figure 2.3 Details of the intricate organization of skeletal muscle. • Skeletal muscles are derived embryologically from mes­ Reproduced with permission from Gray's Anatomy (2005). enchyme and possess a particular ability to contract when neurologically stimulated. normalize. It is within this context that you should consider our survey of fascia (Chapter 1) and muscles (this chapter) • Skeletal muscle fibers comprise a single cell with hun­ and the dysfunctions that are described and the treatments dreds of nuclei. proposed throughout the book. • The fibers are arranged into bundles (fasciculi) contain­ SIGNALS ing approxima tely 100 fibers, with connective tissue fill­ ing the spaces between the fibers (the endomysium) as Healthy, well-coordinated muscles receive and respond to a well as surrounding the fasciculi (the perimysium). multitude of signals from the nervous system, providing the opportunity for coherent movement. When, through • Entire muscles are surrounded by denser connective tis­ overuse, misuse, abuse, disuse, disease or trauma, the sue (fascia, see Chapter 1 ) where it is known as the smooth interaction between the nervous, circulatory and epimysium. the musculoskeletal systems is disturbed, movement becomes difficult, restricted, commonly painful and, some­ • The epimysium is continuous with the connective tissue times, impossible. Dysfunctional patterns affecting the of surrounding structures. musculoskeletal system (see Chapter 5) which emerge from such a background lead to compensatory adaptations and a • Individual muscle fibers, which are bundles of 1000-2000 need for therapeutic, rehabilitation and / or educational myofibrils, can vary in length from a few millimeters to interven tions. This chapter will highlight some of the about 12 cm. When a muscle appears to be longer than unique qualities of the muscular system. On this founda tion this, it has fibers a rranged in series, separated into com­ partments by inscriptions. The sartorius, for instance, has three such inscriptions (four compartments), with each compartment having its own nerve supply (Macintosh et aI2006). • IndividuC{1 muscle fibers can vary in diameter from 10 to 60�m, with most adult fibers being a round 50�m. • Individual myofibrils are composed of a series of sarcom­ eres, the basic contractile units of a skeletal muscle, con­ nected end to end. Actin and myosin filaments overlap within the sarcomere and slide in rela tion to one another to produce shortening of the muscle (see Box 2.1). TYPES OF MUSCLE Muscle fibers can be broadly grouped into those that are: • longitudinal (or strap or parallel or fusiform), which have lengthy fascicles, largely oriented with the longitudinal axis of the body or its parts. These fascicles favor speedy action and are usually involved in range of movement (sartorius, for example, or biceps brachii)

26 CL I N I CAL A P P L I CAT I O N OF N E U R O M U SC ULAR TECH N I Q U E S : T H E U P P E R B O DY Striated (skeletal) muscles are com posed of fasciculi, the nu mber of filaments). it partially hydrolyzes them to produce an energized (pre­ which is dependent upon the size of the muscle. Each fascicle is made up of bundles of (approximately) 1 00 fibers with each fiber containing cocked) myosin head. This preloaded thick filament has a high up to around 2000 myofibrils (Macintosh et al 2006, Simons et a l 1 999). Each myofibri l is composed of a series of sarcomeres laid end to affinity for the thinner actin component. When a muscle is at rest, end; these conta in two primary types of protein filament, actin a nd binding of the two filaments m ust be blocked or else continual myosin, as well as a stabi lizing filament (titin) a nd other proteins, such contraction will resu lt, such as seen in rigor mortis. The tropomyosin as troponin, tropomyosin and nebulin. In most a natomy books the filament overlies the myosin binding sites on the actin molecule, reader can easily find illustrations and d iscussions regarding the thereby preventing coupling of the two fi la ments. distinct bands and shadings, such as the Z-line, H-zone and M-region, As an action potential spreads across the muscle fiber, signaling which are created by the myofibri l components. The sliding fi lament theory, first proposed by biophysicist Jea n contraction, it travels down the transverse tubu les, which lie close to the term inal cisternae (lateral sacs), the storage site for Ca2+. As the Hanson and physiologist H ugh Esmor H uxley in 1 954, offers a n action potential progresses, it causes a depolarization of the explanation of how m uscles shorten during contraction. Although membrane, an opening of the calcium cha n nels and the release of scientists have fa iled to fu l ly explain the biomechanics of movement, Ca2+ from the sarcoplasmic reticu lum. the sl iding fila ment theory remains today as the foundational platform. The fol lowing i l l u strates the basis of this theory. The release of Ca2+ cata lyzes tropon in to cha nge its sha pe, thereby moving tropomyosin aside. This process exposes the binding Figure 2.4 i l l u strates the relationsh ip of acti n, myosin and other sites on the actin molecule and allows myosin to attach itself to the components of the m u scle cell during contraction. As ATP binds to actin fi la ments. This occurs to many filaments sim u l taneously, not the myosin heads (which form the crossbridges between the two just the one described here. The myosin heads (and possibly shafts) flex, causing nu merous myosin and actin fi la ments to slide past each other, resulting in muscle contraction. Tropinin Actin Tropomyosin Z band At rest, ATP binds to myosin head --i;1l�sJ8jMI,SPe-Thin filament I groups and is partially hydrolyzed to I I produce a high-affinity binding site II for actin on the myosin head group. -r=�I!�=�=I\" i;!��iThick(myosin)filament However, the head group cannot I bind because of the blocking of the actin binding sites by tropomyosin. , Note: Reactions shown occurring in only one crossbridge, but same A new molecule of ATP binds to process takes place at all or most the myosin head, causing it to I crossbridges. release from the actin molecule. Partial hydrolysis of this ATP (ATP- Pi) will 'recock' the a8������;i;l������������ga�t� r Ca2+released from sarcoplasmic , reticulum in response to action myosin head and produce a I potential binds to troponin, causing tropomyosin to move and expose high-affinity binding site for actin. I� �the myosin binding site on the actin molecule, The crossbridge is If Ca2+levels are still elevated, ormed. , ,: the crossbridge will quickly I, reform, causing further sliding of I the actin and myosin filaments past each other. If Ca2+ is no I longer elevated, the muscle relaxes. ATP f I ,-Pi are released, the myosin I ADP and ADP-Pi head nexes, and the myosin and I actin filaments slide past each other. I I_ I __ Figure 2.4 The contraction of the myofilaments resu lts from the interaction of actin and myosin. Redrawn after Hansen Et Koeppen (2002). box continues

2 M uscles 27 Box 2.1 (continued) Once this occurs, the myosin loses its energy a nd remains bonded to the actin until it is re-energized with AlP. In other words, the AlP unlocks the myosin head and preloads it for the next cycle. However, the absence of adequate AlP and the presence of Ca2+ ca n cause the fi laments to remain in a shortened position for a n indefinite period of time. After the contraction is completed, if adequate AlP is avai lable, the myosin can be detached, the Ca2+ can be actively transported back into the terminal cisternae of the sarcoplasmic reticulum, thereby allowing the tropomyosin to slide back into place and cover the actin-reactive sites. Muscle fiber relaxation occurs. For best results (maximal force output and fu nctional shorten i ng) the fi la ments should beg in at normal resting length, neither overapproximated nor overstretched. This will a l low the maximal number of myosin heads to be used. Adequate AlP is needed for myosin energy and Ca2+ must be avai lable as a catalyst to tropon in. A functional calcium pump will a llow for removal of the molecule. AlP is also needed for this step since the calcium requires active transportation, which requires energy. When ischemia reduces the availability of elements used by the local mitochondria to produce AlP, a local energy crisis develops. When this is taken into account with the above description, one can readily understand how persistent muscle fiber shortening (contractu res) might form. Due to the unavai labil ity of AlP to d rive the ca lcium pump, the conti nual presence of Ca2+ in the immed iate vicinity of the filaments wou ld add to the conti nuity of muscle shortening. It is also easily apparent that these would be chemically induced by local factors rather than neurona lly d riven. In Chapter 6 we will explore what occurs when some of these steps are altered from their n ormal process (by trauma, overuse, strain, etc.) and how these filaments produce some of the most vicious, un relenting, pain-producing elements - myofascial trigger points. Thin filaments Figure 2.5 From whole muscle to t h e sarcomere's actin and myosin elements. Reproduced with pe rm ission from Gray's Anatomy (2005). • pennate, which have fascicles running at an angle to the energy from chemically bound energy (in the form of muscle's central tendon (its longitudinal axis). These fasci­ adenosine triphosphate - ATP). cles favor strong movement and are divided into unipennate • This process of energy production depends on an ade­ (flexor pollicis longus), bipennate, which has a feather-like quate supply of oxygen, something that will be normal in appearance (rectus femoris, peroneus longus) and multi­ aerobically fit tissues, but not in the tissues of the decon­ pennate (deltoid) forms, depending on the configuration of ditioned individual (see below). their fibers in relation to their tendinous attadunents • Some of the energy so produced is stored in contractile tissues for subsequent use when activity occurs. The force • circular, as in the sphincters that skeletal muscles generate is used to produce or pre­ • triangular or convergent, where a broad origin ends with a vent movement, to induce motion or to ensure stability. • Muscular contractions can be described in rela tion to narrow attachment, as in pectoralis major what has been termed a strength continuum, varying from • spiral or twisted, as in latissimus dorsi or levator scapulae. a small degree of force, capable of lengthy maintenance, to a full-strength contraction, which can be sustained for ENERGY PRO DUCTION IN NORMAL TISSUES very short periods. • When a contraction involves more than 70% of available • Muscles are the body's force generators. In order to strength, blood flow is reduced and oxygen availability achieve this function, they require a source of power, diminishes. which they derive from their ability to produce mechanical

28 CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY Strap Strap with tendinous Tricipital Triangular intersections Quadrilateral Bipennate Radial Multipennate Figure 2.6 Types of muscle fiber arrangement. Reproduced with permission from Gray's Anatomy (2005). ENERGY PRO DUCTION IN THE MUSCLES AND BLOOD SUPPLY DECONDITIONE D INDIVI DUAL Gray's Anatomy (2005, p. 118) explains the intricacy of blood • When anaerobic energy (ATP) pathways are activated in supply to skeletal muscle as follows: the tissues of deconditioned individuals, the result is accumulation of incompletely oxidized metabolic prod­ In most muscles the major source artery enters on the deep ucts, such as lactic acid and pyruvic acid (Fried 1987, surface, frequently in close association with the principal Nixon & Andrews 1996). vein and nerve, which together form a neurovascular hilum. The vessels course and branch within the connective tissue • The effects of this are described by Nixon & Andrews framework of the muscle. The smaller arteries and arterioles (1996) as leading to: 'Muscular aching at low levels of ramify in the perimysial septa and give offcapillaries which effort; restlessness and heightened sympathetic activity; run in the endomysium. Although the smaller vessels lie increased neuronal sensitivity; constriction of smooth­ mainly parallel to the muscle fibres, the1j also branch and muscle tubes [e.g. vascular, respiratory and gastrointesti­ anastomose around the fibres, forming an elongated mesh. nal], accompanying the basic symptom of inability to make and sustain normal levels of effort.' Gray's also tells us that the capillary bed of predominantly red muscle (type I postural, see below) is far denser than • Aerobic activity, if at all possible, is the solution to such that of white (type II phasic) muscle. problems. Research has shown tha t there are two distinct circula­ • As outlined later in this chapter, another feature that can tions in skeletal muscle (Grant & Payling Wright 1968). result in anaerobic glycolysis is a disturbed breathing pattern, where excessive levels of CO2 are exhaled (as in Nutritive circulation derives from arteriolar branches of hyperventilahon). arteries entering by way of the neurovascular hilus. These

2 M uscles 29 penetrate to the endomysium where all the blood passes site) will diffuse elsewhere until pressure is released, at through to the capillary bed before collection into venules which time a· 'flushing' of the previously ischemic tissues and veins to leave again through the hilus. Alternatively, will occur. A blanching/ flushing combination repeated sev­ some of the blood passes into the arterioles of the epi- and eral times can act as a local 'irrigation pump' to significantly perimysium in whichfew capillaries are present. Arteriove­ increase blood flow to localized ischemia. nous anastomosis [a coupling of blood vessels] are abundant here, and most of the blood returns to the veins without As explained below, when a situation of increased alka­ passing through the capillaries; this circuit therefore consti­ linity (respiratory a lkalosis) leads to the smooth muscles tutes a non-nutritive [collateral} pathway through which around blood vessels constricting, blood supply w ill be blood may pass when the flow in the endomysiaI capillary diminished. In addition, oxygen release to the tissues will bed is impeded, e.g. during contraction. also be reduced in such a setting due to the Bohr effect (Pryor & Prasad 2002). In this way blood would keep moving but would not be nourishing the tissues it was destined for, if access to the Some a reas of the body have relatively inefficient anasto­ capillary bed was blocked for any reason. This includes moses and are termed hypovascular. These are particularly when ischemia is present in the tissues due to overuse, pro­ prone to injury and dysfunction. Examples include the longed shortening due to postural positioning, and tight supraspinatus tendon, which corresponds with 'the most clothing, such as an elastic waistband in pants applying common site of rotator cuff tendinitis, calcification and pressure to the lower back tissues. spontaneous rupture' (Cailliet 1991, Tulos & Bennett 1984). Other hypovascular sites include the insertion of the infra­ This is also particularly relevant to deep pressure tech­ spinatus tendon and the intrascapular aspect of the biceps niques, designed to create 'ischemic compression' - for tendon (Brewer 1979). example, when treating myofascial trigger points. When ischemic compression is applied, the blood destined for the The lymphatic drainage of muscles occurs via lymphatic tissues being obstructed by this pressure ( the trigger point capillaries that lie in the epi- and perimysial sheaths. They converge into larger lymphatic vessels that travel close to the veins as they leave the muscle. Box 2.2 The lymphatic system 1813-1878) in which the cells are immersed, receive their nutritive Coming in contact with lymph is to connect with the liquid substances and reject damaging by-products. Lymph is a fluid which dimension of the organ ism. (Ch ikly 1 996) originates in the connective tissue spaces of the body. Once it has The lymphatic system serves as a collecting and filtering system for the body's interstitial fluids, while removing the body's cellular entered the first lymph capillaries ... this fluid is called lymph. debris. It is able to process the waste materials from cel l u lar metabolism and provide a strong line of defense agai nst foreign Col lection beg ins in the interstitial spaces as a portion of the invaders while reca pturing the protein elements and water content circu lating blood is picked up by the lymphatic system. This fl uid is for recycling by the body. Through 'immunolog ica l memory', comprised primarily of large waste particles, debris and other material lymphocyte cells, which reside in the lymph and blood a n d are part from which protein might need to be recovered or that may need to of the general immune system , recognize invaders (antigens) a nd be disposed. Foreign particulate matter and pathogenic bacteria are rapidly act to neutra l ize these. This system of defending during screened out by the lymph nodes, which a re interposed a long the invasion and then clea ning up the battleground makes the lymphatic course of the vessels. Nodes a lso produce lymphocytes, which makes system essential to the health of the organism. their location at various points a long the transportation pathway convenient should infectious material be encountered. Organization of the lymph system The lymphatic system comprises an extensive network of lymphatic Lym ph nodes (Chikly 200 1 ): capilla ries, a series of collecting vessels and lymph nodes. It is associated with the lymphoid system (lymph nodes, spleen, thymus, • filter and purify tonsi ls, appendix, mucosal-associated lym phoid tissue such as • capture and destroy toxins Peyer's patches and bone ma rrow), which is pri marily responsible for • reabsorb a bout 400/0 of the lymphatic liq uids, so concentrating the immune response (Braem 1 994, Chikly 1 996, 2001 ). The lym phatic system is: the lymph while recycling the removed water • produce mature lymphocytes - white blood cells that destroy • an essential defensive component of the immune system • a carrier of (especially heavy and large) debris on behalf of the bacteria, virus-infected cel ls, foreign matter and waste materia ls. circulatory system • a transporter of fat-soluble nutrients (and fat itself) from the Production of lymphocytes increases (in nodes) when lym phatic flow is increased (e.g. with lymphatic d ra i nage techniques). digestive tract to the bloodstream . A lymphatic ca pillary network made of vessels slightly larger than Chikly (2001) notes: blood ca pil laries d rains tissue fl uid from nearly a l l tissues and organs that have a blood vascularization. The blood circu latory system is a The lymphatic system is therefore a second pathway back to the closed system, whereas the lymphatic system is an open-end system, beginning blind in the interstitial spaces. The moment the fluid heart, parollel to the blood system. The interstitial fluid is a very enters a lymph capillary, a fla p valve prevents it from returning into the interstitia l spaces. The fluids, now cal led 'lymph', continue important fluid. It is the real 'interior milieu' (Claude Bernard, box continues