Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

536 CLI N I CAL APPLICATI O N OF N EU RO M USCU LA R TEC H N I QU ES : THE U PPER BODY Liebenson C 2006 Rehabilitation o f the spine, 2nd edn. Lippincott Rubin B 1997 Rheuma tology. In: Ward R (ed) Foundations of osteo­ Williams and Wilkins, Ba l timore pathic medicine. Williams and Wilkins, Baltimore Lim V, AltelUnuller E 2001 Focal dystonia: current theories. Human Ruch D, Papadonikolakis A, Campolattaro R 2006 The posterolat­ Movement Science 20(6):875-9 1 4 eral plica: a cause of refractory lateral elbow pain. Journal of Shoulder and Elbow Surgery 15(3) :367-370 Liversedge L A 1960 Conditioning tedmiques i n the treatment of writer's cramp. Pergamon Press, Oxford Ruddy T J 1962 Osteopa thic rapid rhythmic resistive technic. Academy of Applied Osteopathy Yearbook, Colorado Springs, Lowe W 2006 Orthopedic assessment in massage therapy. Daviau­ pp 23-31 Scott, Sisters, OR Sadler T W 1995 Muscular system. Langman's medical embryology, Ltmdberg U, Kadefors R, Melin B et al 1994 Psychophysiologica l 7th edn. Williams and Wilkins, Baltimore, p 168 stress and EMG activity of the trapezius muscle. International Journa l o f Behavioral Medicine 1 (4) :354-370 Salmons S 1985 FlU1ctional adaptation of skeletal muscle. In: Evarts E V, Wise S P, Bousfield D (eds) The motor system in neurobiol­ Mai N, Marguardt C 1994 Treatment of writer's cramp. Europia, ogy. Elsevier Biomed ical Press, Amsterdam Paris Sanders R, Hammond S 2005 Subclavian vein obstruction without Maigne J 1991 Upper thoracic dorsal rami. Surgical and thrombosis. Journal of Vascular Surgery 41 (2) :285-290 Radiological Anatomy 13:109-112 Sanger T, Merzenich M 2000 Computational model of the role of Maitland G 1986 Vertebral manip ulation. Butterworths, London sensory disorganization in focal task-specific dystonia. Journal Marsden C D, Sheehy M P 1990 Writer 's cramp. Trends in of Neurophysiology 84(5):2458-2464 Neurosciences 13(4) : 1 48-153 Schafer R 1987 Clinical biomechanics. Williams and Wilkins, McAtee R, Charland J 1999 Faci litated stretching, 2nd edn. Human Baltimore Kinetics, Champaign, IL Simons D, Travell J, Simons L 1999 Myofascial pain and dysfunc­ McNab l, McCulloch J 1994 Neck ache and shoulder pain. Williams tion: the trigger point manual, vol 1: upper ha lf of body, 2nd edn. Williams and Wilkins, Bal timore and Wilkins, Baltimore McQuade K, Smi d t G 1998 Dynamic scapulohumeral rhythm: the Smith J, Padgett D, Kaufman K et al 2004 Rhomboid muscle electromyography activity d u ring 3 di fferent manual muscle effects of external resistance d uring elevation of the arm in the tests. Archives of Physical Medicine and Rehabilitation scap u la r plane. Journal of Orthopaedic a n d Sports Physical 85(6):987-992 Therapy 27(2) : 1 25-133 Spencer H 1916 Shoulder technique. Journal of the American MitcheU F, Moran P, Pruzzo N 1979 Evaluation of osteopathic Osteopathic Association 1 5:211 8-2220 muscle energy procedure. Privately published, Valley Park, MO Stedman's Electronic Medical Dictionary 2004 version 6.0. Mock L 1997 Myofascial release treatment of specific muscles. Lippincott Williams and Wilkins, Baltimore Bul letin of Myofascial Therapy 2(1) :5-23 Stiles E 1984 Manipulation - a tool for your practice. Patient Care Mulligan B 1992 Manual thera py. Plane View Services, Wellington, 1 8 : 699-704 New Zealand Stock S 1991 Workplace ergonomic factors and the development of Murase N, Kaji R, Shimazu H et al 2000 Abnormal premovement musculoskeletal disorders of the neck and upper limbs: a meta­ analysis. American Journal of Industrial Medicine 19(1 ):87-107 ga ting of soma tosensory input in writer's cramp. Brain 123(9) : 1 8 1 3-1829 Stuart P 1996 Pronator quadratus rev isited. Journal of Hand Myers T 2007 Treatment approaches for three shoulder ' tethers ' . Surgery [Br] 21 (6):71 4-722 Journal of Bodywork & Movement Therapies 1 1 ( 1 ) :3-8 National Cancer Institute 2006 Breast C ancer (PDQ®): Prevention. Sugamoto K, Harada T, Machida A et al 2002 Scapulohumeral Online. Available: http : / / www.cancer.gov/ cancertopics/pdq/ rhythm: relationship between motion velocity and rhythm . prevention /breast/ patient Clinical Orthopaedics and Related Research 401 :119-124 Netter F H 2006 Atlas of human anatomy, 4th edn. Saunders, Philadelphia Sunderland S 1 976 The nerve lesion in carpal tunnel syndrome. Nichols A 1996 Thoracic outlet syndrome in a thletes. Journal of the Journal of Neurology, Neurosurgery and Psychiatry 39:615-626 American Board of Family Practice 9(5):346-355 Noth J, Dietz V, Mauritz K 1980 Cyclist's palsy: neurological a n d Sweetland H 2006 Breast reconstruction. Women's Health Medidne EMG study in 4 cases with distal ulnar lesions. Journal of 3 ( 1 ) : 34-35 Neurologica l Sciences 47(1):111-116 O'Hara J, Stone J 1996 Ulnar nerve compression a t the elbow caused Taleisnik J 1988 Fractures of the carpal bones. In: G reen D P (ed) by a prominent medial head of the triceps and an anconeus Operative hand surgery 2. Churchill Livingstone, New York, epitrochlearis muscle. Journal of Hand Surgery [Br] 21(1):133-135 p 813 Ozel ius L, Hewett J W, Page C E et al 1997 The early onset of tor­ sion dystonia gene (DYTl) encodes an ATP-binding protein. Tinazzi M, Rosso T, Fiaschi A 2003 Role of the soma tosensory Nature Genetics 40:40-48 system in primary dystonia. Movement Disorders 18(6):605-622 Patriquin D 1992 Evolution of osteopa thic manipulative technique: the Spencer technique. Journal of the American Osteopathic Toro C, Deuschl G, Hallett M 2000 Movement-related electroen­ Association 92:1 134-1146 cephalographic desynchronization in patients with hand Petty N 2006 Neuromusculoskeletal examination and assessment. cramps: evidence for motor cortical involvement in focal dysto­ Churchill Livingstone, Edinburgh nia. Annals of Neurology 47(4):456-461 Platzer W 2004 Color atla s / text of h uman anatomy: vol 1, locomo­ tor system, 5th edn. Georg Thieme, Stuttgart Trastour C, Machiavelio J-c, Chapeliier C et al 2006 Le muscle Priori A, Pesenti A, Cappeliari A et a l 2001 Limb immobilization for sternal is : derriere quel sein se cache-t-i17 Sternalis muscle in the treatment of focal occupational dystonia. Neurology breast surgery [article in French] . Annales de Chirurgie 5 7 ( 3 ) : 405-409 131 (10):623-625 Rosenbaum F, Jankovic J 1988 Focal task-specific tremor and dysto­ nia : categorization of occupational movement disorders. Tubiana R 2003 Musician's focal dystonia. Hand Clinics Neurology 38:522-527 1 9(2) :303-308, vii Tucker A 1 994 Shoulder pain in a football player. Med icine and Science in Sports and Exercise 26(3):281-284 Upledger J, Vredevoogd J 1983 Craniosacral therapy. Eastland Press, Seattle Upton A, McComas A 1973 The double crush syndrome. Lancet 2:359

1 3 Shoulder, arm and hand 537 Utti R, Vingerhoets J, Tsui J 1995 Limb dystonia. Marcel Dekker, Warner J, McMahon 1995 The role of the long head of the biceps New York brachii in su perior stability of the glenohumeral joint. Journal of Bone and Joint Surgery 77(3):366-372 van Hilten B, van de Seek W-J, Hoff J et al 2000 intrathecal baclofen for the treatment of dystonia in patients with reflex Weiner W 2001 Can peripheral trauma induce dystonia? No' sympathetic dystrophy. New England Journal of Medicine Movement Disorders 16(1):13-22 343(9):625-630 Wilson F R, Wagner C, Homberg V 1993 Biomechanical abnormali­ Viikari-Juntura E, Silverstein B 1999 Role of physical load factors in ties in musicians with occupational cramp/ focal dystonia. carpal tunnel syndrome. Scand inavian Journal of Work, Journal o f Hand Therapy 6(4) :298-307 Environment and Health 25(3):163-185 Woodward T, Best T 2000 The painful shoulder: part I. C l inical eval­ Walther D 1988 Applied kinesiology. Systems DC, Pueblo, CO Ward R (ed) 1997 Foundations for osteopathic medicine. Williams uation. American Family Physician 61 (10) :3079-3088 Xerri C, Merzenich M, Jenkins W et al 1999 Representational plas­ and Wilkins, Balti more Warfel J 1985 The extremities, 5th edn. Lea and Febiger, ticity in cortical area 3b paraBeling tactual-motor skill acquisi­ tion in adult monkeys. Cerebral Cortex 9(3):264-276 Philadelphia

539 Chapter 14 The thorax CH APTER CONTENTS Specific 1 st rib palpation 554 Test and treatment for elevated and depressed ribs 554 Structure 540 Rib motion 554 Tests for rib motion restrictions 554 Structural features of the thoracic spine 540 Discussion 556 T horacic treatment techniques 557 Structural features of the ribs 541 Posterior superficial thoracic muscles 557 NMT: posterior thoracic gliding techniques 560 Structural features of the sternum 541 NMT for muscles of the thoracic lamina groove 562 Spinalis thoracis 563 Posterior thorax 541 Semispinalis thoracis 563 Multifidi 563 Identification of spinal levels 542 Rotatores longus and brevis 564 The sternosymphyseal syndrome 542 NMT for thoracic (and lumbar) lamina groove Spinal segments 543 . muscles 565 PR method for paraspinal musculature: Palpation method for upper thoracic segmental induration technique 566 facilitation 544 Muscles of respiration 567 Serratus posterior superior 567 How accurate are commonly used palpation methods? Serratus posterior inferior 568 Levatores costarum longus and brevis 568 544 Intercostals 570 NMT for intercostals 571 Red reflex assessment (reactive hyperemia) 545 Influences of abdominal muscles 571 NMT assessment 571 Biomechanics of rotation in the thoracic spine 546 PR of diaphragm 572 MET release for diaphragm 572 Coupling test 547 Interior thorax 572 Diaphragm 572 Observation of restriction patterns in thoracic spine NMT for diaphragm 573 Transversus thoracis 574 (C-curve observation test) 547 Thoracic mobilization with movement - SNAGs method 575 Breathing wave assessment 547 Breathing wave - evaluation of spinal motion during inhalation/exhalation 548 Passive motion testing for the thoracic spine 548 Flexion and extension assessment of T1-4 548 Flexion and extension assessment of T5-12 548 Sideflexion palpation of thoracic spine 549 Rotation palpation of thoracic spine 549 Prone segmental testing for rotation 550 Anterior thorax 550 Respiratory function assessment 550 Palpation for trigger point activity 554 Alternative categorization of muscles 554 Rib palpation 554

540 CLI N ICAL APPLICATI O N O F N EU R O M USCU LA R T EC H N IQU ES: T H E U PP E R B O DY The posterior aspect of the thorax is represented by a mobile and records that articular discs or little 'menisci' of syn­ func tional unit - the thoracic spinal column - through ovial tissue are found in these costal joints, as in almost all which the sympathetic nerve supply emerges. In addition, other synovial articulations of the spinal column. the thorax acts as a protective cage for the hear t and lungs, • Erwin et al (2000) have also reported the presence of large inside which respiratory function, with its powerful lym­ intraarticular inclusions or 'meniscoids' in the costover­ phatic and circula tory influences, occurs. Muscular attach­ tebral joint complexes. ments to the thorax that serve other areas are numerous and • The thoracic facet joints, which glide on each other and include muscles of the shoulder, neck and lower back. The restrict and largely determine the range of spinal move­ extrinsic thoracic musculature is responsible for positioning ment, have typical plane-type synovial features, includ­ the torso and, therefore, a lso the placement in space of the ing an articular capsule. shoulders, arms, neck and head. The intrinsic thoracic mus­ • Hruby et al (1997) describe a useful method for remem­ cles move the thoracic vertebrae or the rib cage (and possibly bering the s tructure and orientation of the facet joints: the entire upper body) and /or are associated with respiration. The superior facets of each thoracic vertebrae are slightly con­ The degree of movement in all directions (flexion, exten­ vex and face posteriorly (backward), somewhat superiorly sion, sideflexion and rotation) allowed by therelatively rigid (up), and laterally. Their angle of declination averages 60° struc ture of the thorax is less than that available in the cer­ relative to the transverse plane and 20° relative to the coronal vical or lumbar spines, being deliberately limited in order to plane. Remember the facet facing by the mnemonic, 'BUL' protect the vital organs housed within the thoracic cavity. (backward, upward, and lateral). This is in contrast to the cervical and lumbar regions where the superior facets face STRUCTURE backwards, upwards, and medially ('BUM'). Thus, the superior facets [of the entire spine] are BUM, BUL, BUM, ST R U CT U RA L F EAT U R E S O F TH E TH O RA C I C S PI N E from cervical, to thoracic, to lumbar. • In most individuals the thoracic spine has a kyphotic (for­ �f-- ward bending) profile that varies in degree from individual to individual. C2 • The thoracic spinous processes are especially prominent Figure 1 4.2 Facet angles. Orientation of zyga pophysea l joi n ts. and therefore easily palpated. Reprodu ced with permission of the Cha rtered Society of Physioth e ra py from Physiotherapy 1996; 81(12}:724-729. • The angles of orientation of the thoracic spinous processes are increasingly caudad, from Tl to T9, with a modification toward an almost horizontal orientation from TlO to Tl2. • The transverse processes from Tl to TlO carry costotrans­ verse join ts for articulation with the ribs. • Edmonston & Singer (1997) have reported that degenera­ tion and osteophyte forma tion can be seen in these joints by the third and fourth decades of life. • Grieve (1988) describes acute fixations of the rib joints which show all the characteristics of synovial joint locking, Demifacet for articulation Fig ure 1 4.1 Typical thoracic vertebra. with head of rib Reprod u ced with permission from Gray's Anatomy for Students (2005). --_.>-l _ Facet for articulation with tubercle of rib Superior view Demifacet for articutation with head of rib below Lateral view

1 4 The thorax 541 • As with most synovial joints, small intraarticular synovial • Ribs 11 and 12 do not articulate with the sternum (,float­ folds (IASFs), also known as meniscoids, may be located ing ribs'), whereas all other ribs do so, in various within the thoracic zygapophyseal (facet) joints (Singer ways, either by means of their own cartilaginous et aI1990) . synovial joints (i.e. ribs 1-7 are 'true ribs') or by means of a merged cartilaginous structure (ribs 8-1 0, which • Grieve (1988) comments that the facet joints of the thoracic are 'false ribs'). spine contain meniscoid structures like those found in the cervical spine. • The head of each rib articulates with its thoracic vertebra at the costovertebral joint. • Bogduk & Engel (1984) cite European literature that describes fibrous annular menisci as being well devel­ • Ribs 2-9 also articulate with the vertebrae above and oped in the thoracic spine. below by means of a demifacet. • In the thoracic zygapophyseal jOints, the IASFs originate • Ribs 1, 11 and 12 articulate with their own vertebrae by medially from the ligamentum flavum, or laterally from means of a unifacet. the fibrous joint capsule, and extend towards the medial joint cavity. These structures may act as passive space • Typical ribs (3-9) comprise a head, neck, tubercle, angles fillers during axial rotation (Bogduk & Engel 1984, Singer and shafts and connect directly, or via cartilaginous struc­ et aI1990). tures, to the sternum • Additionally, there are larger fibroadipose synovial folds • A typical ribs and their key features include: that project between the articular surfaces (Singer et a l 1. rib 1 which is broad, short and flat, the most curved . 1990). The subclavian artery and cervical plexus are anatom­ ically vulnerable to compression if the 1st rib becomes • Bogduk & Engel (1984) also describe these structures compromised in relation to the anterior and/or mid­ in the lumbar zygapophyseal joints. They have been dle scalenes, or the clavicle implicated by Bogduk & Jull (1984) in their meniscus 2. rib 2 carries a tubercle that attaches to the proximal extrapment theory of acute locked lumbar spine. Since portion of serratus anterior these structures also exist in the thoracic spine it is possi­ 3. ribs 11 and 12 are atypical due to their failure to ble that meniscus extrapment may also occur in the articulate anteriorly with the sternum or costal thoracic spine. cartilages. • The disc structure of the thoracic spine is similar to that STR U CT U R A L F E ATU R E S O F TH E ST E R N U M of the cervical and lumbar spine. The notable difference is the relative broadness of the posterior longitudinal lig­ There are three key subdivisions of the sternum. ament, which, together with the restricted range of motion potential of the region, makes herniation of thoracic discs 1. The manubrium (or head), which articulates with the clav­ an infrequent occurrence. icles at the sternoclavicular joints. The superior surface of the manubrium (jugular notch) lies directly anterior to the • Only a small proportion of all disc disease occurs in the 2nd thoracic vertebra. The manubrium is joined to the thoracic spine, generally estima ted at about 1-2%, mainly body of the sternum by means of a fibrocartilaginous sym­ in the fourth decade. Onset is usually insidious, with physis, the sternal angle (angle of Louis) which lies directly trauma being a causative factor in a minority. Many will anterior to the 4th thoracic vertebra. often report a long history of months or years of symp­ toms (Arce & Dohrmann 1985). 2. The body of the sternum provides the attachment sites for the ribs, with the 2nd rib attaching at the sternal • Grieve (1988) mentions that the etiology of the thoracic angle. This makes the angle an important landmark when disc lesion is primarily degenerative, and affects, in par­ counting ribs. ticular, the lower thoracic spine. 3. The xiphoid process is the 'tail' of the sternum, joining i t • Edmonston & Singer (1997) comment that disc space nar­ at the xiphisternal symphysis (which fuses i n most peo­ rowing at multiple levels is a common finding from the ple during the fifth decade of life) - usually anterior to third decade of life, and is associated with d isc degenera­ the 9th thoracic vertebra. tion, decreased d isc height and osteophyte formation, particularly in the mid-thoracic segments. PO STERIOR THORAX • Degenerative changes due to osteoporosis and aging, as The thorax can be described both structurally and function­ well as trauma, are relatively common in this region. ally in order to make sense of i ts numerous complex fea­ tures. It can be thought of in terms of a thoracic spinal STR U CTU RAL F EATU R E S O F TH E RIB S column as well as a thoracic cage. Each approach will have features and functions that are considered both separately • The ribs are composed o f a segment o f bone and a costal and together. cartilage. • The costal cartilages a ttach to the costochondral joint of most ribs (see variations below), depressions in the bony segment of the ribs.

542 C LI N I CAL A P P L I CATI O N O F N E U R O M USCULAR TECH NIQU ES: T H E U PP E R B O DY In regional terms, the thoracic spine is usually divided degrees of addi tional coupled extension also occur in the into (White & Panjabi 1978): lower thoracics during rotation (Grice 1980). 1. upper - Tl-4 where, at each segment, approximately 4° of I D E N T I FICAT I O N O F S P I N A L LEVE LS flexion and extension, 1 0° of rotation and no more than 1 0° of lateral flexion is possible Hruby et al (1997) state: 2. middle - T5-8 where, at each segment, approximately 6° A useful way of identifying the thoracic vertebrae involves of flexion and extension, 6° of rotation and 10-12° of lat­ the 'rule of threes'. This 'rule' is a generalization that is only eral flexion is possible approximate, but positions the palpatingfingers in the esti­ mated positions for location of individual thoracic vertebrae. 3. lower - T9-12 where, at each segment, approximately 12° of flexion and extension, 3° of rotation and 12-13° of lat­ • Spinous processes of Tl-3 project directly posteriorly so eral flexion is possible. that the tip of each spinous process is in the same plane as the transverse process of the same vertebra. A degree of disagreement, with resulting confusion, exists in regard to the total range of motion of the thoracic spine, pos­ • The spinous processes of T4-6 project caudally so that the sibly due to age variables, as well as the influence of coupled tip of each spinous process is in a plane that is approxi­ or combined motions, as reported by Grice (1980), below. mately halfway between the transverse processes of its own vertebra and those of the vertebra immediately below. For example, the ranges, reported by Liebenson (1996), immediately below, vary somewhat from those listed by • The spinous processes of T7-9 project more acutely cau­ Troke et al (1998), also below. dally so that the tip of each spinous process is in the same plane as the transverse processes of the vertebra immedi­ Liebenson (1996) suggests the following ranges: ately below. 1. The total range of thoracic flexion and extension com­ • T10 spinous process is similar to T7-9 (same plane as the bined (between Tl and Tl2) is approximately 60°. transverse processes of the vertebra immediately below). 2. The total range of thoracic rotation is approximately 40°. • Tl1 spinous process is similar to T4-6 (in a plane that is This, of course, is the limit ascribed to the thoracic spine approximately halfway between the transverse processes alone, not taking account of the rotational component of of its own vertebra and those of the vertebra immediately the lumbar spine on which it rests, which allows an addi­ below) . tional 50° and therefore a total of approximately 90° of trunk rotation. • Tl2 spinous process i s similar to Tl-3 (in the same plane as the transverse process of the same vertebra) . 3. Total range of lateral flexion of the thoracic spine is approximately 50° This knowledge is particularly useful when using positional release methods, such as the induration technique (see p. 000), Troke et al (1998) have established their reported ranges of in which vertebrae are treated individually, using the spinous motion of the thoracic spine using a reliable and valid process as a point of contact. If the induration technique were instrument, the modified CA6000 Spine Motion Analyzer.! being used in treatment of associated rib attachment dysfunc­ In a study, 11 asymptomatic subjects, aged between 18 and tion, contact on the appropriate vertebrae would be clinically 37, were assessed . Results showed, with a high degree of important. reliability, that: The sympathetic supply to the organs is as follows. 1. the mean flexion range of the thoracic spine is 70° 2. lateral flexion 75° • Tl-4: head and neck 3. axial rotation 64°. • Tl-6: heart, lungs • T5-9: stomach, liver, gallbladder, duodenum, pancreas, Troke et al note that ranges would be expected to decline with age. spleen • TlO-11 : rest of small intestines, kidney, ureters, gonads Coupling and right colon In addition to the individual degrees of flexion and exten­ • Tl2-L2: pelvic organs, left colon sion listed above, several degrees of additional coupled flexion occur in the upper thoracics when rotation is intro­ TH E STE R N O SY M PHYS EAL SY N D RO M E duced . This represents a functional advantage created by the linking of combined vertebral movement potentials The sternosymphyseal syndrome (SSS) was described by during rotation (known as 'coupling') . In this way a few Lewit (1999) and Brugger (2000). In the SSS the pelvis is tilted posteriorly and the lumbar lordosis is reduced or reversed 1 Orthopedic Systems Inc., Union City, CA, and Troke/University so that the sternum and symphysis pubis become closer to of Brighton, UK. each other. Individuals display a thoracolumbar kyphosis, rounded shoulders and forward head carriage. The posture

1 4 The thorax 543 � Lacrimal gland GY-........... Eye C1 - Gray rami Parotid gland communicantes Submandibular gland Sublingual gland •.... ............1.......... Larynx Trachea •.... ................. Bronchi Lungs .... .... Heart T1 Innervalion to arrector Stomach pili muscles, vascular smooth musde, and :........ ,..... . sweal glands of skin Gray ramus communicans Kidneys While ramus communicans Intestines L1 -- Descending colon Sigmoid cclon Rectum S1 -- � Preganglionic fibres Urinary bladder Prostate ..................... Poslganglionic fibres Inferior _ _...J hypogaslfic External genitalia plexus Figure 1 4.3 Visceral pathology can refer pain to associated somatic tissues, as illustrated here rega rd ing hea rt pa i n referra ls i nvolving Tl-4. Drawn after Netter (2006). suggests someone far older than the chronological age of the abdominal excursion is altered by the proximity of the the individual . anterior ribs and pubis. With SSS the gluteus maximi tend to be deconditioned SPI NAL SEGMENTS and weak because of limited hip extension. The hamstrings commonly tighten due to the modified gait, while the abdom­ The process of facilitation, described in Chapter 6, results in inal muscles are inclined to be deconditioned and weak. The spinal segments - and their paraspinal musculature - becom­ thoracolumbar spine becomes excessively stiff due to spinal ing dysfunctional in response to nociceptive bombardment osseous-viscoelastic resistance . As a result, respiration will from the organs they supply when the organs become be compromised due to reduced diaphragmatic activity, as

544 CLI N ICAL A P PLICAT I O N O F N E U RO M USCULA R TECH N I QUES: THE U PPER B O DY diseased or distressed (BeaI 1985). Clinically the practitioner • It is suggested that such palpation be performed on peo­ may consider that a paraspinal region involves a facilitation ple with and without known cardiovascular dysfunction, process when the soft tissues fail to respond to normal treat­ in order to develop a degree of discrimination between ment procedures. In such circumstances consideration of normal and abnormal tissue states of this sort. visceral involvement is warranted and organ pathologies may need to be ruled out. • It is also suggested that the 'red reflex' assessment method (discussed below) be performed to evaluate its ability Segmental facilitation example to identify areas of reflexively active tissue (possibly facilitated). Myron Beal DO, Professor in the Department of Family Medicine at Michigan State University, College of HOW ACCU RATE A R E CO M M O N LY U S E D Osteopathic Medicine, conducted a study in which over 1 00 PAL PATI O N M ETH O D S? patients with diagnosed cardiovascular disease were exam­ ined for patterns of spinal segment involvement (BeaI 1983). Three types of palpation of the thoracic spine, commonly used by therapists and practitioners, were evaluated for Around 90% had 'segmental dysfunction in two or more accuracy (Christensen et al 2002): adjacent vertebrae from T1 to T5, on the left side'. More than half also had left-side C2 dysfunction. Beal reports that the 1. motion palpation with patient prone, evaluating joint play estimation of the intensity of the spinal dysfunction corre­ 2. motion palpation with patient seated for end-play restric­ lated strongly with the degree of pathology noted (ranging from myocardial infarction, ischemic heart disease and tion, for example involving lateral flexion or rotation hypertensive cardiovascular disease to coronary artery dis­ 3. paraspinal palpation for tenderness (or altered tissue ease). He further reports that the greatest intensity of the cardiac reflex occurred at T2 and T3 on the left. The texture texture). of the soft tissues, as described by Beal, is of interest: 'Skin and temperature changes were not apparent as consistent It was found that, in regard to the motion palpation assess­ strong findings compared with the hypertonic state of the ments, 'an experienced observer can achieve acceptably low deep musculature.' hour-to-hour and day-to-day variability after a training ses­ sion as long as exact anatomic localization is less important The major palpatory finding for muscle was of hyper­ than the presence or absence of a positive finding in the tho­ tonicity of the superficial and deep paraspinal muscles with racic spine'. fibrotic thickening. Tenderness was usually this was not specifically assessed in this study. Superficial Brismee et al (2006) examined the reliability of a passive hypertonicity lessened when the patient was supine, mak­ physiological intervertebral motion (PPIM) test of a mid­ ing assessment of deeper tissue states easier in that position. thoracic spinal segment. They were able to demonstrate that PPIM testing demonstrated a fair to substantial degree of interrater reliability (see Figs 14.1 and 14.4). PA LPATI O N M ETH O D F O R U P P E R TH O RA C I C Fig ure 14.4 Springing assessment for tissue resistance associated S E G M E NTAL FAC I LITATI O N with segmental facilitation. • With the patient supine, the thoracic spine is examined by the practitioner (who is seated or standing at the head of the table) by sliding the fingers of both hands (one on each side of the spine) under the upper thoracic trans­ verse processes. • An anterior compressive force is applied with the fingers (Fig. 14.4) to assess the status of the superficial and deep paraspinal tissues and the response of the transverse process to the 'springing'. • This compression is performed, one segment at a time, progressively down the spine, until control becomes dif­ ficult or tissues inaccessible. • A positive test (indicating probable facilitation of the seg­ ments being tested) would involve a 'wooden', non-elastic response to the springing effort produced by the fingers, involving two or more segments. • It is also possible to perform the test with the patient seated or sidelying, though neither is as accurate as the supine position.

14 The thorax 545 Overall the evidence suggests that manual assessment regard to diagnosing spinal tenderness in the thoracic can be as accurate as mechanized measuring methods, if the spine'. practitioner is welJ trained. When the accuracy of the paraspinal tenderness palpation was assessed, the findings An Australian study (Fryer et a12004) found that the nature were that 'after some training, it is possible to obtain an of abnormal paraspinal tissue texture located by palpation acceptably low intra- and interobserver variability with was not readily identifiable, although palpation for tender­ ness can commonly reliably locate dysfunction. The researchers note that although li ttle direct evidence exis ts of the nature of clinically detected paraspinal tissue texture change, the concept of reactive muscle contraction appears plausi­ ble (Solomonow et al 1998). In other words, when palpating paraspinal musculature, tenderness can quite accurately be identified, and while this is associated with a different 'feel' of the tissues, exactly what that difference is cannot be accu­ rately iden tified with any certainty. As with so much in manual therapy assessment, these studies suggest that it is wise to be cautious, and to attempt to correlate one set of findings with others before deciding on a therapeutic plan. Figure 14.5 G raphic representation of the position of the t h u m b of R E D R EFLEX ASSESSM ENT (REACTIVE the practitioner blocki ng the rotation of the spinous process of T7 HY P E R E M IA) and fee l i n g the seg mental motion of rotation of T6 spinous process on T7 with the tip of the thumb. Reproduced with perm ission from Late in the 19th century Carl McConnell DO ( 1962) stated: Brismee et al (2006). I begin at thefirst thoracic [vertebral and examine the spinal column down to the sacrum by placing my middle fingers over [each side of] the spinous processes and standing directly back of the patient draw theflat surfaces of these two fingers over the spinous processes from the upper thoracic to the B Figure 14.6 Thoracic PPIM testing proce d u re. A: Passive extension of the thoracic spine into T6-7 spinal seg ment. B: Sidebending toward the practitioner into T6-7 spinal seg ment. C: Rotating opposite to the side of sidebe n d i n g until the practitioner detects with the thumb the beg i n n i n g of seg mental rotation in the T7 spinous process and eva l u a tes seg mental rotation of T6 vertebra on T7. The sa me proced u re can be repeated with the practitioner rema i n i n g on the same side of the patient and perform i n g s i m i l a r extension and rotation motions, but sidebending the patient i n a d i rection ipsilateral to the side of rotation. Reproduced with perm ission from Brismee et a l (2006).

546 C L I N I CA L A PP L I CAT I O N O F N E U R O M US C U LA R TECH N I QU E S : T H E U P P E R B O DY sacrum in such a manner that the spines of the vertebrae pass Hruby et al (1997) describe the thinking regarding this tightly between the two fingers; thus leaving a red streak phenomenon: where the cutaneous vessels press upon the spines of the ver­ tebrae. In this manner slight deviations of the vertebrae lat­ Perform the red reflex test byfirmly, but with light pressure, erally can be told with the greatest accuracy by observing stroking two fingers on the skin over the paraspinal tissues the red line. When a vertebra or section of vertebrae are too in a cephalad to a caudad direction. The stroked areas briefly posterior a heavy red streak is noticed and when a vertebra become erythematous and almost immediately return to their or section of vertebrae are too anterior the streak is not so usual color. Ifthe skin remains enjthematous longerthan a feu) noticeable. seconds, it may indicate an acute somatic dysfunction in the area. As the dysfunction acquires chronic tissue changes, In the 1 960s Hoag (1 969) wrote: the tissues blanch rapidly after stroking and are dnj and cool to palpation. Withfirm but moderate pressure the pads of the fingers are repeatedly rubbed over the surface of the skin, preferably with The reader is reminded that Hilton's law (see p. 3) confirms extensive longitudinal strokes along the paraspinal area. The simultaneous innervation to the skin covering the articular appearance of less intense and rapidly fading color in certain insertion of the muscles, not necessarily the entire muscle. areas, as compared with the general reaction, is ascribed to increased vasoconstriction in that area, indicating a distur­ B I O M E CHA N I CS O F R OTATI O N I N TH E bance in autonomic reflex activity. Others give significance TH O RA C I C S PI N E to an increased degree of erythema or a prolonged lingering of the red line response. • In the cervical spine between C3 and C7 a coupling occurs, in which sidebending and rotation take place toward the Upledger & Vredevoogd (1983) suggest: same side (type 2). Skin texture changes produced by a facilitated segment are • There is a great deal of disagreement among experts as to palpable as you lightly drag your fingers over the nearby what is 'normal coupling behavior ' in the thoracic spine. paravertebral area of the back. I [Upledger] usually do skin drag evaluation movingfrom the top of the neck to the sacral • The upper four thoracic segments are said by some (Grice area in one motion. Where your fingertips drag on the skin 1 980) to behave in the same manner as the cervical spine you will probably find a facilitated segment. After several (type 2) when the spine is in neutral (not flexed or repetitions, with increased force, the affected area will appear extended), i.e. rotation and sidebending take place toward redder than nearby areas. This is the 'red reflex'. Muscles the same sides. and connective tissues at this level will: • This is contradicted by Grieve (1981) who says that 1. have a 'shotty' feel (like buckshot under the skin) between T3 and no, 'in neutral and extension, sidebend­ 2. be more tender to palpation ing and rotation occur to opposite sides (type 1). In flex­ 3. be tight, and tend to restrict vertebral motion, and ion, they occur to the same side (type 2)'. 4. exhibit tenderness of the spinous processes when tapped • The mid-thoracic segments also represent a confusing byfingers or a rubber hammer. mixture of types in their coupling behavior, so that dur­ ing sidebending, rotation may occur to either the concave Korr (1970) described how this red reflex phenomenon cor­ (type 2) or the convex side (type 1), depending on whether responded well with areas of lowered electrical resistance, the spine is in flexion, extension or neutral. which themselves correspond accurately to regions of low­ ered pain threshold and areas of cutaneous and deep ten­ • The lower thoracic coupling pattern is generally agreed to derness (termed 'segmentally related sympa theticotonia'). be similar to the lumbar spine (type 1 ) in which sidebend­ Korr was able to detect areas of intense vasoconstriction ing and rota tion coupling are toward opposite sides (e.g. that corresponded well with dysfunction elicited by manual sidebend right, rotation of vertebral body left). clinical examination. • The spinous processes of Tl, T2, T3 are on the same plane as You must not look for perfect correspondence between the skin the transverse process of the sa me vertebra resistance (or the red reflex) and the distribution of deeper pathologic disturbance, because an area of skin that is seg­ • The spinous processes of T4, T5, T6 are in a plane approxi­ mentally related to a particular muscle does not necessarily mately halfway between the transverse processes of their own overlie that muscle. With the latissimus dorsi, for example, vertebra and those of the vertebra i mmediately below the myofascial disturbance might be over the hip but the reflex manifestations would be in much higher dermatomes • The spinous processes of T?, T8, T9 are in the same plane as because this muscle has its innervation from the cervical the transverse processes of the vertebra immediately below part of the cord. • T l O spinous process is si milar to T7 to T9 • T 1 1 spinous process is similar to T4 to T6 • Tl2 spinous process is similar to Tl to T3

14 The thorax 547 • Grieve (1981) comes to the rescue of the (by now) confused • Confirmation of findings in this test is available by obser­ practitioner, by saying that it is wise 'to allow the joints of vation - see stages 9 and 1 0 of the C-curve observation individual pa tterns to speak for themselves, in the prime test, below. matter of the na ture and direction of the most effective therapeutic movement'. He suggests that, 'individual O BS E RVAT I O N O F R E STR I CTI O N PATT E R N S I N responses and clinical assessment should take precedence TH O RA C I C S PI N E ( C- C U RVE O BS E RVAT I O N TE ST) over \"theories of biomechanics'''. • The patient is seated on the table with the legs fully C O UP L I N G TEST extended, pelvis vertical, and bends into fu l lest flexion possible. In order to establish the specific coupling pattern in an indi­ vidual segment, the following simple sidebending and rota­ • A sequential (C-shaped) curve should be observed when tion palpa tion procedure is used. the profile of the spine is viewed from the side with the patient in full flexion. • The patient is seated or standing with arms folded on chest, hands on opposite shoulders. • No knee flexion should take place and all movement should be spinal . • The practitioner stands behind and to the side of the patient and passes an arm across the chest to cup the • Any areas of 'fla tness' should be noted as these represent patient's hand that is resting on the opposite shoulder. regions where normal flexion of one segment on the other is absent or reduced. • The practitioner 's other hand is placed so that the index and middle fingers lie on one side and the ring and small • The pa tient then sits with knees flexed, thus relaxing fingers on the other side, wi th the fingertips pointing hamstrings, and again bends into fullest flexion possible cephalad para llel with the thoracic spinal segment under with hands resting on the crest of the pelvis. review. • Observation from the side should indicate which seg­ • A horizontal line drawn through the fingertips would ments remain unable to move fully into flexion. place them on a line dissecting the one collectively repre­ sented by the spinous processes, although not necessar­ • If there is a greater degree of flexion possible in this posi­ ily the spinous process of the one tha t is being assessed tion (knees flexed) as compared to that noted with knees due to the inclination of the thoracic spinous processes. straight, then hamstring restriction is a factor. These fingers monitor the rotational pattern followed by the segment when i t is sidebent. • All flat a reas should be charted. • The practitioner should at this time view the spine from • The practitioner introduces slight sideflexion precisely at the segment, by means of contact on the patient's shoul­ the perspective gained by looking at it along its length, der, and repeats this in both directions as the rotational from the head or from the lower lumbar area, while the response, which has to accompany sideflexion, is patient is flexed. palpated. • Segments that are in a rotated state will be easily identi­ fied and the direction of their rotation observed by • If 'fullness' (,backwards pressure') is noted on the side means of the rotational deviation caused by their trans­ toward which sideflexion is taking place, this represents a verse processes. The transverse processes and ribs will type 2 response. If sideflexion is toward the right and the produce a 'mounding' or fullness on the side toward fingers on the right register greater pressure or 'fullness' which the vertebra has rotated. Any such findings can be during this movement, this indicates that the body of compared with those of the palpation evaluation (cou­ that vertebra has rotated toward the right (the concavity) pling test described above), which palpates for fullness so that the right side of the transverse process is produc­ during sideflexion. ing the fullness, pressure, on the palpating fingers. B R EATH I N G WAVE ASS E SS M E NT • Alternatively if, on right sideflexion, fullness is noted on the left, this indicates that rotation of the vertebral body • The patient should now be placed lying prone, ideally is toward the left side (the convexity) and the palpated with the face in a cradle or padded hole, for comfort and response therefore represents a type 1 coupling. to avoid cervical rotation (Fig. 14.7). • This same assessment can be carried out at each segment • The operator squats at the side and observes the 'spinal and with the spine in relative neutral, as well as flexion breathing wave' as deep breathing is performed (see and extension, to experience the variations in the biome­ below). Areas of restriction, lack of movement or where chanica I coupling responses that occur. motion is not in sequence should be noted and com­ pared with fi ndings from the observation of the C-curve • This knowledge is of clinical value when attempting to ( a b o ve ) . increase range of motion in restricted segments, as will become clear when specific MET protocols are suggested • Commonly, areas of the spine that appea r to move as a toward this objective later in this chapter. block during this evaluation are areas where there is lim­ ited flexion potential, as observed during the C-curve assessment.

548 CLI N I CAL APPLICATI O N OF N E U RO M USCULAR TECH N I QU ES: T H E U P P E R B O DY PASSIVE M OTI O N TESTI N G F O R TH E TH O RACIC S P I N E Segmental palpation is used to iden tify specific (ra ther than general) areas of restriction. The areas of the spine observed in the C-curve which remain 'flat' on flexion are almost cer­ tain to palpate as restricted. Such restrictions might be the result of joint dysfunction or of muscular and /or ligamen­ tous restrictions. The nature of the end-feel noted during any spinal palpation exercise (below) offers some guidance as to whether a problem is osseous (hard end-feel) or mus­ cular / ligamentous (softer end-feel). Figure 14.7 Fu nctional (top) a n d dysfu nctional breathing wave FLEXION AN D EXTENSION ASSESSMENT movement patterns. O F T1 -4 B R EATH I N G WAVE - EVA L U AT I O N O F S PI N A L • The patient is seated and the practitioner is standing to M OT I O N D U R I N G I NHALAT I O N/ EXHALAT I O N the side with one hand on top of the patient's head. • The patient is placed prone and the 'breathing wave' • The practitioner's other hand is placed, palmar surface observed. on the patient's posterior upper thoracic region, so that the ring and middle fingers can be placed between the • When the spine is fully flexible this wave-like motion spinous processes of three vertebrae (between T1 and T2 commences in the lower lumbar region, near the sacrum, and between T2 and T3, for example). and spreads as a wave up to the base of the neck. • The hand on the head guides the neck into unforced flex­ • If there is restriction in any of the spinal segments or if ion and extension until the palpating fingers note motion. associated muscles of the region are short and tight, the pattern will vary. • A normal response in both flexion and extension would be for the most cephalad segment to move before the • Movement may start somewhere else (the patterns more caudad one. It is worth recalling that the entire observed will differ as widely as the patterns of restric­ range of flexion /extension in these vertebrae is less tion in individual spines) so that areas which are lacking than 5°. in flexibility may be seen to move as a block, rather than as a wave. • The practitioner evaluates whether there is an appropri­ ate degree of separation of the spinous processes on flex­ The observing practitioner should question: ion and of closure on extension and also takes note of the quality of end-feel in these movements. • Does movement start at the sacrum? • Does it start elsewhere? F L E X I O N AN D EXTE N S I O N A S S E S S M E NT O F • Does it move caudad, cephalad or in both directions? TS-12 • Where does the wave cease - in the mid-thoracic area or • Once the upper four segments (including movement as it should, at the base of neck? between T4 and T5) have been evaluated for flexion and • How does this relate to the observations already made extension, the palpating fingers are placed between T5 and T6. and the patient's symptoms? • The practitioner passes the other arm across the patient's As spinal, rib or muscular restrictions are removed or upper chest to cup the opposite shoulder, enabling flexion improved - by treatment or exercise - the breathing wave and extension to be controlled via this contact (control should be seen to gradually benefit, with the wave com­ is further enhanced if the practitioner's axilla can con­ mencing closer to the sacrum and finishing closer to the tact the superior aspect of the patient's ipsilateral neck. The breathing wave observation test can therefore be shoulder). used as a means of monitoring progress; it is not in itself diagnostic. • It is worth recalling that the entire range of flexion/ extension in the lower eight segments ranges from approx­ imately 6° (at T5) to 12° (at T12). • The spine is sequentially flexed and extended as the practitioner evaluates whether there is an appropriate degree of separation of the spinous processes on flexion and closure on extension and also takes note of the qual­ ity of end-feel in these movements.

1 4 The thorax 549 S I D E F LEXI O N PA LPAT I O N O F TH O RA C I C S PI N E • As sidefle;xion is induced to the level being assessed, the practitioner notes whether the transverse processes sepa­ • The assessment method outlined earlier in this section, in rate and approximate appropriately during the different which coupling motions were assessed in relation to phases of sideflexion. sideflexion and rotation, forms a basis for similar assess­ ment of rotation and /or sideflexion individually. • Both the range (10-12° is normal) and quality (end-feel) of the movement are noted and a judgment is reached as • The patient is sea ted or standing with arms folded across to the relative symmetry and normality of the segment in the chest and the hands resting on the opposite shoulders. its sideflexion potential. • For the upper three or four thoracic segments the practi­ ROTAT I O N PA LPATI O N O F TH O RA C I C S PI N E tioner uses a light contact on the patient's head to intro­ duce sideflexion. For the lower segments the practitioner • The assessment method outlined above for sideflexion stands behind and to the side of the patient and passes an forms the basis for this assessment of rotation. arm across the chest to cup the patient's hand, which rests on the opposite shoulder, and uses this contact to • The patient is seated or standing with arms folded on the introduce sideflexion in either direction. chest, hands on opposite shoulders, as above. • The practitioner's other hand is placed with the fingers • For the upper three or four thoracic segments the practi­ pointing cephalad, so that the index and middle finger tioner uses a light contact on the patient's head to introduce pads lie on one side of the spinous process and the ring rotation down to the level being palpated. For the lower and small fingers on the other side, with the fingers segments, the practitioner stands behind and to the side pointing cephalad. of the patient and passes an arm across the chest to cup • The practitioner stands on the prone patient's left side at the . .,. ':j level of the patient's waist, facing diagona l ly toward the head of the patient. position) in rhomboids major and mi nor, infraspinatus, and a number of sma l l er lamina muscles (Melzack 1 977). • With the right hand resting at the level of the lower thoracic • A series of tsubo, or a cupressure points, l i e symmetrica l ly on spine where its function is to distract tissue, the left thumb com­ either side of the spine and a long the m id-line and are said to mences a series of strokes cephalad from the mid-thoracic area, have great reflex i mporta nce (Serizawe 1 980). immediately to the left of the spinous processes. • TheBladder meridian points lie in two lines running para llel with the spine, one level with the medial border of the scapula and the • Each stroke covers two or three spinal segments and runs in a other mid-way between it and the lateral border of the spinous cephalad direction, immediately lateral to the spinous process, so processes (Ma n n 1 971 ). that the angle ofpressure imparted, via the medial tip of the • Goodhea rt's work suggests that rhomboid weakness indicates l iver thumb, is rou gh ly toward the contra latera l n ipple. Note: While problems and that pressure on C7 spinous process and a point on this series of strokes is cephalad, the pressure exerted by the the right of the interspace between the 5th and 6th dorsal spinous thumb tip is not toward the floor, rather it angles toward the processes assists its normalization. Latissi mus dorsi wea kness contralateral side. apparently indicates pancreatic dysfunction. Lateral to the 7th and 8th dorsal interspace is the posterior pressure reflex to normal ize • A series of light assessment and deep therapeutic strokes are this (Wa lther 1 988). These and other reflexes wou ld appear to employed and a degree of overlap is suggested with successive derive from Chapma n's reflex theories (Mannino 1 979, Owens strokes (see Fig. 1 4.24). 1 980). Caso (2004) has reported on the usefu l ness of these reflex points in assessment of a congen ita l intestinal abnormal ity. I n • In this way the first two strokes might run from T8 to T5 followed addition, research relating to Chapman reflex points has demon­ by two strokes (one light, one deeper) from T6 to T3 and fin a l ly strated a statistical ly significant relationship between the pres­ two strokes from T4 to Tl . ence of Chapman reflex points and pneumonia in hospitalized patients (Washington et al 2003). However, the findings of this • Deeper and more sustained pressure is exerted upon discovering research have been questioned (Testa 2006), rendering certainty as marked contraction or resistance to the gl iding, probing thumb. to the value of Chapman's reflexes inconclusive at this time. • Viscerosomatic infl uences that produce dysfunction of the erector • In the thoracic area a second line of upward strokes is employed spinae g roup of m uscles between the 6th and 1 2th thoracics to include the spinal border of the scapula, as well as one or two ind icate liver involvement B( eal 1 985). searching, latera l ly directed, probing strokes along the inferior • Sim i larly 4th, 5th and 6th thoracic area congestion or sensitivity spine of the scapula and across the muscu lature inferior to and may involve stomach reflexes and gastric disturbance, whereas inserting into the scapula. facilitation at the levels of Tl 2 a nd/or L2 indicates possible kid­ ney dysfu nction. • Treatment of the right side may be carried out without necessar­ • The connective tissue zones affecting the arm, stomach, heart, ily changing position, other than to lean across the patient, as l iver and gallbladder are noted in this region (Ebner 1 962) and long as this causes no d istress to the practitioner's back. Chapman's neurolymphatic reflexes relating to the arm, thyroid, lungs, throat and heart are located in the upper thoracic spine, • A shorter practitioner shou ld change sides so that, standing ha lf­ including the scapular area (DiGiova nna 1 99 1 ) . facing the head of the patient, the right thumb can perform the strokes outlined above. What may be found? • Apart from trigger points in the lower trapezius fibers, other trig­ ger points may be sought (while in this assessment/treatment

550 CLIN ICAL APPLICATIO N OF N EU RO M U SCULAR TECH N I Q U ES : THE UPPER BODY the pa tient's hand resting on the opposite shoulder and Muscles of inhalation uses this contact to introduce rota tion in either direction. • The prac titioner 's other hand is placed so that the index Primary and middle fingers lie on one side and the ring and small fingers on the other side, with the tips pointing cephalad, Diaphragm (70-80%) on the transverse processes of the thoracic spinal seg­ Parasternal (intercartilaginous) internal intercostals ment under review. Upper and more latera l external intercostals • As rota tion is ind uced to the level being assessed the Levator costae practitioner notes the range (100 in the upper, reducing to Scalenii 3° in the lower segments) and quality of movement (end­ feel) of the transverse process on the side toward which Accessory rotation is taking place. • Judgment is reached as to the relative symmetry and nor­ Ster n o c l e i d o m a s t o i d mality of the segment in its rota tional potential. Upper trapezius Serratus a n terior (arms elevated) P RO N E S E G M E NTAL T E ST I N G F O R ROTAT I O N Latissimus dorsi (arms elevated) Serratus posterior superior • The pa tient is prone. Iliocostalis thoracis • The practitioner places the thumbs onto the transverse Subclavius Omohyoid processes of the segment under assessment. • An anterior pressure is applied with each thumb alter­ Muscles of exha lation nately, taking out the slack and sensing the range of rota­ Primary tion as well as the quality of the end-feel of the movement on each side. Elastic recoil of lungs, pleura and costal cartilages • If a transverse process feels less free in its ability to move anteriorly, the vertebra is rotated in that direction (i.e. if A ccess o r y the right transverse process is less yielding in its anterior movement than the left transverse process, this indicates I nterosseous internal intercostals a vertebra that is inappropriately rotated to the right and Abdominal m uscles that cannot easily rotate left). Transversus thoracis Subcostales Comment I liocostalis lumborum Quadratus lumboru m Many spinal restrictions a re 'held' by soft tissue restrictions Serratus posterior inferior and can be normalized by release of the soft tissue compo­ Latissimus dorsi nent. Almost all the positions of assessment described above can immediately become the commencement positions for Chila (1997) suggests the following in order to evaluate the application of muscle energy techniques, via the introduc­ respiration function. tion of isometric contractions, either toward or away from the restriction barrier, or by means of Ruddy's pulsed MET • Category: Does breathing involve the diaph.ragm, the procedures. See MET notes on pp. 199-200, which explain lower rib cage or both? these concepts. • Locus of abdominal motion: Does it move as far as the A NT ER IOR THORAX umbilicus or as far as the pubic bone? In earlier chapters emphasis has been given to the profound • Rate: Rapid, slow? The rate should be recorded before negative influence on emotions, structure and function when and after trea tment. breathing function is disturbed (Chapter 2). In purely struc­ tural terms, Lewit (1999) states: 'The most important distur­ • Duration of cycle: Are inhala tion and exhalation phases bance of breathing is overstrain of the upper auxiliary equal or is one longer than the other? muscles by l ifting of the thorax during quiet respira tion l R ESP I RATO RY F U N CT I O N A S S E SS M E NT In order to normalize brea thing function, a focus is required which evaluates structural and functional elements Assessment of breathing function should begin by means and which offers appropriate therapeutic and rehabilita tion of palpa tion and observation with the patient both seated approaches to wha t is revealed. and supine and should be accompanied by a general evalu­ ation of overall posture and especially head, shoulder and torso positioning. Treatment of associated myofascial tissues will be enhanced by the addition of b reathing awareness exercises tha t will, in part, reduce stressful loading of tissues tha t are assisting in dysfunctional brea thing patterns. Seated • The patient places one hand on the upper abdomen and the other on the upper chest (Fig. 14. 10). The hands are

1 4 The thorax 551 Respiratory function is extremely complex and no attem pt will be EXP. INSP. made in this text to fu l ly elaborate on this complexity, other than to highlig ht those aspects wh ich impact on somatic dysfunction and/or t• wh ich ca n be helpfu lly modified by means of NMT and its associated modalities. v Breathing depends on four areas of infl uence: t 1 . efficient ventilation o 2. gas exchange 3. gas transportation to and from the tissues of the body {7 4. breathing regulation. Figure 1 4.8 A working model w i t h si m i lariti es to thoracic air The status of the muscles and joints of the thorax and the way the m ove m e n t is demonstrated by Ka pa ndji ( 1 974). individual breathes can influence all of these, to some extent. moves anteriorly and superiorly. Thus, by the action of the Ventilation itself is dependent o n : diaphragm a lone, the vertical, transverse and a n teroposterior diameters of the thoracic cavity a re increased. If a g reater volu m e of 1 . the muscles o f respiration and their attach ments breath is n eeded, other m uscles may be recruited. 2 . the mechan ica l characteristics of the ai rways • Abdominal m uscle tone provides correct positioning of the 3. the health and efficiency of the l u ngs' parenchymal u n its. abdominal viscera so that appropriate central tendon resistance Inha lation and exha lation involve expansion and contraction of the can occur. If the viscera a re d isplaced or abdominal tone is weak lu ngs themselves and this occurs by means of: and resistance is reduced, lower rib elevation will not occur and volume of air intake will be reduced. 1 . movement of the diaphragm, which lengthens and shortens the • The posterior rib a rticulations a l low rotation during breathing, vertical diameter of the thoracic cavity. This is the normal means while the anterior carti lagi nous elements store the torsional of breathing at rest. This diameter can be further increased when energy produced by this rotation. The ribs behave l i ke tension the upper ribs are raised during forced respiration where the nor­ rods and elastica l ly recoil to their previous position when the mal elastic recoil of the respiratory system is insufficient to meet muscles relax. These elastic elements reduce with age and may demands. This bri ngs into play the accessory breathing m uscles, also be lessened by intercostal muscu lar tension (see tests for rib incl uding sternocleidomastoid, the sca lenes and the external restrictions, p. 41 2). i n tercosta l s • Rib articulations, thoracic vertebral positions and myofascial ele­ ments must all be fu nctional for normal breathing to occur. 2 . move ment of the ribs into elevation and depression w h ich a l ters Dysfu nctional elements may reduce the range of mobility and the diameters of the thoracic cavity. therefore l u ng capacity. • Whereas inhalation requires m uscular effort, exhalation is prima­ The main purpose of respiration is to assist in providing gas ri ly a passive, elastic recoil m echanism provided by the tensional exchange between inha led air and the blood. Additional ly, the elements of the ribs (see above), the elastic recoil of the l u ng tis­ actions of the d iaphragm enhance lymphatic fl uid movement by sues and pleura and abdominal pressure created directly by the means of a l ternating intrathoracic pressure. Th is produces a suction viscera and the m uscles of the abdomen. on the thoracic duct and cisterna chyli and thereby increases lymph movement in the duct and presses it toward the venous arch (Kurz 1 986, 1 987). Venous circu lation is likewise assisted by this alternating pressure between the thoracic and abdom inal cavity, suggesting that respi ratory dysfunction ('shal low breathing') may negatively impact on venous return from the lower extremities, contributing to cond itions such as varicose veins. Kapandji ( 1 974), in his discussion of respiration, has described a respiratory model.By replacing the bottom of a flask with a membrane (representing the diaphragm), providing a stopper with a tube set into it (to represent the trachea) and a bal loon within the flask at the end of the tube (representing the lungs within the rib cage), a crude respiratory model is created.By pulling down on the membra ne (the d iaphragm on inhalation), the internal pressure of the flask (thoracic cavity) falls below that of the atmosphere and a volume of air of equal amount to that being d isplaced by the membrane rushes into the balloon, inflating it. The ba lloon relaxes when the lower membrane is released, elastically recoiling to its previous position, as the air escapes through the tube. The human respi ratory system works in a sim ilar, yet much more complex and highly coordinated manner.During inhalation, the diaphragm displaces caudal ly, pulling its central tendon down, thus increasing vertical space within the thorax. As the diaphragm descends, it is resisted by the abdominal viscera. At this point, the central tendon becomes fixed against the pressure of the abdominal cavity, while the other end of the diaphragm's fibers pulls the lower ribs cephalad, so d isplacing them latera l ly (Fig. 1 4.9). As the lower ribs are elevated and simulta neously moved latera l ly, the sternu m box continues

552 CLIN ICAL APPLICATIO N OF N EU RO M USCULAR TECH N IQUES: T H E U PPER BODY Figure 1 4.9 Latera l excu rsion of ribs due to e levation by • Quadratus l u m borum acts to fix the 1 2th rib, so offering a firm d i a phra gm . attachment for the diaphragm. If QL is weak, as it may be in cer­ tain individuals, this stability is lost (Norris 1 999). • Being a fl uid-fi l l ed conta iner, t h e abdominal cavity i s incompress­ ible as long as the abdominal m uscles and the perineum a re con­ • Bronchial obstruction, pleura l inflam mation, l iver or intestinal tracted (Lewit 1 999). encroachment and ensuing pressure against the diaphragm, as well as phrenic nerve para lysis, are some of the pathologies • The alternating positive and negative pressures of the thoracic which will interfere with diaphrag matic and respiratory and abdominal cavities participate in the processes of inhalation efficiency. and exha lation, as well as in fluid mechan ics, assisting in venous return and lymphatic flow. Si nce the volume of the lungs is determ ined by the vertical, transverse a nd anteroposterior diameters of the thoracic cavity, the • Gravity directly influences d iaphrag matic, a nd therefore respira­ ability to produce movements which increase a ny of these three tory, function. When the individual is upright, diaphragmatic diameters (without reducing the others) should increase respiratory excursion has to overcome gravitational forces. When lying down, capacity under normal circumstances (i ntact pleura, etc.). While respiratory function is easier as this demand is reduced or a bsent. simple steps, such as improving upright posture, may influence The excursion of the dia ph ra g m is l i m ited during sitti ng, espe­ volume, treatment of the associated musculature, coupled with cially if slumped, because of relaxation of the a bdominal m uscles. breathing exercises, may substa ntially enhance breathing function. • When the integrity of the pleural cavity is lost, whether by punc­ • Vertical dimension is increased by the actions of diaphragm and ture of its elastic m em bra ne or damage to its hard casing (broken scalenes. ribs), inflating vol ume of the l u ng(s) will decrease, resu lting in respiratory distress. • Transverse dimension (bucket handle action) is increased with the elevation and rotation of the lower ribs - d iaphragm, external • The i ntercostal m uscles, while participating in inhalation (exter­ intercostals, levatores costarum. nal intercostals) and exha lation (i nternal intercostals), a re a lso responsible for enhancing the stability of the chest wa ll, so pre­ • Elevation of the sternu m (pu m p handle action) is provided by venting its i n wa rd movement d u ring inspiration. upward pressure due to spreading of the ribs and the action of SCM and sca lenes. The muscles associated with respiration function can be grouped as either inspiratory or expiratory a nd a re either primary in that capacity or provide accessory support. It should be kept in mind that the role which these muscles might play in i n h ibiting respiratory function (due to trigger points, ischemia, etc.) has not yet been clearly established and that their overload, due to dysfunctional breathing patterns, is l i kely to im pact on cervical, shoulder, lower back and other body regions. • The primary inspirational m uscles are the diaphragm, the more latera l external intercostals, parasternal internal intercosta ls, sca­ lene group and the levator costa rum, with the diaphragm provid­ ing 70-80% of the inhalation force (Si mons et al 1 999). • These m uscles a re supported by the accessory m uscles during increased demand (or dysfu nctional breathing patterns) : SCM, u pper trapezius, pectora lis major and minor, serratus a nterior, latissi mus dorsi, serratus posterior superior, il iocosta lis thoracis, subclavius and omohyoid (Kapandji 1974, Simons et aI 1 999). Si nce expiration is primarily an elastic response of the lungs, pleura and 'torsion rod' elements of the ribs, all m uscles of expiration could be considered to be accessory m uscles as they are recruited only during increased demand. They include internal intercosta ls, abdom inal m uscles, transverse thoracis and su bcostales. With increased demand, il iocostalis lumborum, q uadratus lumborum, serratus posterior inferior and latissimus dorsi may su pport expiration, including during the high demands of speech, coughing, sneezing, singing and other special functions associated with the breath. observed as the person inhales and exhales several times. (midway between base of neck and tip of shoulder). The If the upper hand (chest) moves superiorly rather than patient is asked to inhale and the practitioner notes anteriorly and moves significantly more than the hand whether the hands move toward the ceiling significantly. on the abdomen, this is noted as indicating a dysfunc­ If so, scalenes are exceSSively active and since these tional pa ttern of upper chest brea thing. are (or may have become - see p. 314) type I postural • The practitioner stands behind the seated patient and muscles, the indication is that shortening will have places both hands gently over the upper trapezius area occurre d .

• Reduction in pC02 (tension of carbon dioxide) causes respira­ 14 The thorax 553 tory alkalosis via reduction in arterial carbonic acid, which leads to abnormally decreased a rterial carbon d ioxide tension • The practitioner squats behind the patient and places (hypocapnia) and major systemic repercussions. both hands onto the lateral aspect of the lower ribs and notes whether there is lateral excursion on inhalation (are • The first and most d irect response to hyperventilation is cere­ the hands pushed apart?) and, if lateral excursion does bral vascular constriction, red ucing oxygen availability by occur, is it bilateral and/ or symmetrical? a bout 50%. Supine • Of a l l body tissues, the cerebral cortex is the most vul nerable to hypoxia, which depresses cortical activity and causes dizzi­ • The breathing pattern is observed. ness, vasomotor i nstability, blurred consciousness ('foggy brain') and blurred vision. 1. Does the abdomen move anteriorly on inhalation? 2. How much of the abdomen is involved? • Loss of cortical i n hibition results in emotional labil ity. 3. Does the upper chest move anteriorly or cranially on Neural repercussions of hyperventi lation inhalation while the abdomen retracts? • Loss of CO2 ions from neurons d uring moderate hyperventila­ 4. Is there an observable lateral excursion of the lower tion stimulates neuronal activity, while producing m uscular tension and spasm, speeding spinal reflexes as well as ribs? producing heightened perception (pa i n, photophobia, • Shortness in pectoralis major and latissimus dorsi is hyperacusis), all of which are of major importance in chronic pain conditions. assessed (arms extended above head; see p. 421 . • When hypocapnia is more severe or prolonged, it depresses • Chin protrusion ('poking') is observed a s the patient neural activity until the nerve cel l becomes inert. moves the neck/head into flexion, trying to place the chin on the chest. If this movement is not possible with­ • What seems to occur in advanced or extreme hyperventilation out 'chin poking' or the position cannot be maintained is a change in neuronal metabolism : anaerobic g lycolysis without protrusion of the chin, sternomastoid is short produces lactic acid in nerve cel ls, while lowering pH. Neuronal activity is then diminished so that in extreme (see Janda's functional tests, pp. 88-92) . hypoca rbia, neurons become inert. Thus, in the extremes of this c l i nical condition, i n itial hyperactivity gives way to • With folded arms on the chest (or extended in 'sleep­ exhaustion, stupor and coma. walking' position), knees flexed and feet flat on the table, the patient is asked to raise the head, neck and shoulders Figure 1 4. 1 0 Hand positions for brea thing fu nction assessment. from the surface without allowing the feet to leave the surface or the back to arch (see Fig. 5.6). If this is not pos­ sible then psoas is considered short (and rectus abdo­ minis weak). Since psoas merges with the diaphragm it should receive attention in any program of breathing rehabilitation. Sid elying Quadratus lumborum is assessed by palpation and obser­ vation (leg abduction, look or palpate for 'hip hike') (see Janda's functional assessment, p. 90) . P rone • The practitioner observes the breathing wave - the movement of the spine from the sacrum to the base of the neck on deep inhalation, as described on p. 548. • Scapula stability is observed as the patient lowers the torso from a push-up position. A normal functional eval­ uation reveals the scapulae stable and moving medially toward the spine. If, however, winging occurs or if either or both scapulae move significantly cephalad then the rhomboids and serratus anterior are weak and inhibited, which could impact on respiratory function. A further implication of weakness in these lower scapula fixators is that the upper fixators (levator and upper trapezius in particular) will usually be overactive and short.

554 CLI N I CAL A PP L I CATI O N O F N E U R O M U SC U LAR TECH N I Q U E S : TH E U P PER B O DY PA LPATI O N F O R T R I G G E R PO I NT ACT I V I TY S PE C I F I C 1 ST R I B PALPATI O N All muscles that are shown to be dysfunctional in the above • The patient is seated. The practitioner stands behind with assessments (whether shortened or lengthened) should be fingers covering the upper trapezius close to the base of evaluated for trigger point activity using NMT and / or the neck. other palpation methods. • Trapezius is drawn posteriorly by the practitioner 's fin­ ALTE RNATIVE CAT E G O RIZAT I O N O F M USCLES gers to allow access for the fingertips to move caudally to make contact with the superior surface of the posterolat­ Information was presented i n Chapter 2 (Box 2.3) relating to eral portion of the first rib. alternative ways of conceiving the muscular imbalances commonly listed as postural and phasic. According to Norris' • The rib on one side may be noted to be more cephalad research (1995a--e, 1998), inhibited/weak muscles often actu­ ('higher ') than the other side. The higher side will also ally lengthen, ad ding to the instability of the region in which usually be reported as being more sensitive to the palpa­ they operate. Muscles that fall into this category are more tion contact. deeply situated, are slow twitch and have a tendency to weaken and lengthen if deconditioned. These include trans­ • Scalene assessment may also indicate greater shortening versus abdominis, multifidus, internal obliques, medial fibers on the same side. of external oblique, gluteus maxirnus and medius, quadratus lumborum, deep neck flexors and, of interest in the region TEST A N D T R EATM E N T F O R E L EVAT E D A N D under review, serratus anterior and lower trapezius. These DEPRESSED RIBS muscles can be correlated, to a large extent (apart from quadratus lumborum), with muscles designated by Janda It is important that the functional freedom of ribs be (1983) and Lewit (1999) as 'phasic'. assessed in any overall evaluation of thoracic structure and function. One of the commonest dysfunctional states The more superficial, fast-twi tch muscles, which have a involving the ribs is for one or more ribs to be restricted in tendency to shortening, include the suboccipital group, their normal range of motion (this more commonly occurs sternocleidomastoid, upper trapezius, levator scapula, in groups rather than single ribs) . iliopsoas and hamstrings. These fall into the category of 'postura l' muscles as described by Lewit, Janda and 1 . If ribs do not rise fully on inhalation they are said to be Liebenson. Norris calls these mobilizers because they cross 'depressed', locked in relative exhalation. more than one joint. 2. If ribs do not fall fully on exhalation they are said to be Examples of pa tterns of imbalance emerge in the thoracic 'elevated', locked in rela tive inhalation. region, as some muscles weaken and lengthen while their synergists become overworked and their antagonists R I B M OTION shorten. • Pump handle motion: On inhalation, the anterior aspect of R I B PA LPATI O N the upper ribs (in particular) moves cephalad, causing an increase in the anteroposterior d iameter of the thorax. • With the patient seated, the practitioner, standing This action is less apparent in the lower ribs. behind, palpates the angles of the ribs for symmetry/ asymmetry. • Bucket handle motion: On inhalation, the lateral aspect of the lower ribs (in particular) moves cephalad, causing an • If any rib angles appear more prominent than others or increase in the transverse diameter of the thorax. This if any individual rib contours seem asymmetrical, these action is less apparent in the upper ribs. should receive more detailed attention in subsequent tests for elevation or depression (see below) . • Ribs 11 and 12 do not exhibit either pump or bucket han­ dle motion because they lack a cartilaginous attachment • Finger pad tracing o f the intercostal spaces can reveal to the sternum. These 'floating' ribs move posteriorly and areas in which the width of the interspace is red uced. la terally on inhalation and anteriorly and medially on Ideally, the width should be symmetrical along i ts entire exhalation. Assessment of these ribs' respiratory response length, from the sternum to the vertebral ends and sym­ is best performed with the patient prone with hands in metrical with the contralateral side. contact with the rib shafts. On inhalation, a posterior motion should be noted and on exhalation an anterior • As this palpation proceeds, any tissue changes or sensi­ motion. tivity should be noted. The description of Lief's NMT (see Box 14.8, p. 569) includes indications as to what might TESTS FOR R I B M OT I O N R ESTRI CTI O N S be palpa ted for in the intercostal spaces. Based on clinical [FIG. 1 4. 1 2) experience the lower aspect of the rib shaft is more easily palpa ted than the superior border. Palpation and evaluation are performed from the side of the table that brings the dominant eye over the centerline. Examination is performed using full inhalation and

1 4 The thorax 555 ! Figure 1 4. 1 2 Test for rib dysfunction. B • The patient inhales and exhales fully as the practitioner observes movement of the fingers overlying the upper ribs during pump handle motion. • Is movement symmetrical and equal as the inhalation ends and as the exhalation ends? • Each rib from 1 to 6 is assessed individually in this manner. • The fingers are then placed on the mid-axillary lines and bucket handle motion is observed in the same manner, looking for asymmetry at the end of the inhalation and exhalation phases. • Each of the lower ribs, down to the 10th, is assessed indi­ vidually in this manner. • Ribs 11 and 12 are assessed with the pa tient prone, as described above. Figure 1 4. 1 1 Movement of thoracic wa l l during breathing. A : Pu m p Dysfunctional patterns handle movement o f ribs and sternum. B : Bucket h a n d l e movement of ri bs. Reproduced with permission from Gray's Anatomy for • If the ribs (fingers) rise symmetrically on inhalation, com­ Studen ts (2005). pleting the excursion at the same time, but on exhalation one seems to continue falling toward its exhalation posi­ exhalation to assess the comparative rise and fall of the ribs tion after the other has ceased, then the one that ceased on either side (pump handle movement, mainly in the five moving earlier is regarded as an elevated rib, restricted in or six upper ribs) as well as lateral excursion (bucket handle its ability to exhale and 'locked' in the inhalation phase. movement mainly in the lower six or seven ribs). • Conversely, should the ribs commence inhalation together • The patient is supine and the practitioner stands at waist with one ceasing to rise while the other continues, then level and places the middle or index fingers on the infe­ the one that has ceased to rise is regarded as a depressed rior borders of the clavicle, 1 inch (2.5 em) or so lateral to rib, restricted in its ability to inhale and 'locked' in the the sternum. exhalation phase. Treatment hints • Most rib restrictions are found in groups of two or more, suggesting that they are in this state as a result of an adaptive compensation process (see Chap ter 5 for discus­ sion of adaptation patterns).

556 CLIN ICAL APPLICATIO N OF N EU RO M USCU LAR TECH N I QUES: T H E UPPER BODY • When a single rib is found to be dysfunctional i t almost • This 'key rib' concept has a long tradition in osteopathic always can be shown to have resulted from direct trauma medicine. rather than a compensation process. DISCUSSION • In a group of depressed ribs, there is usually no need to All the rib restrictions described are usually capable o f being release any rib other than the most superior (cephalad) of successfully treated by either positional release or muscle energy approaches. NMT (as described for intercostal the group. treatment) may also be beneficial. This suggests that the • In a group of elevated ribs the most inferior (caudad) is usu­ ally the key rib requiring treatment. If this is successfully achieved, the others in the group will release automatically. An association has frequently been shown between thoracic outlet • The possibility of a 2nd rib involvement should not disgu ise the syndrome and 1 st rib restriction (Nichols 1 996, Tucker 1 994). possibility that this coexists with a true impingement lesion. However, a connection between 2 n d rib restriction and shoulder pain has not been recorded i n the literature until recently. Pa l pation Boyle (1 999) reports on two case h istories in which symptoms • With the patient prone and the scapula protracted to expose the were present which resembled, in a l l respects (diagnostic criteria, angle of the rib, practitioner standing at the head of the table, etc.), shoulder i m pingement syndrome or rotator cuff partial tea r, direct thumb pressure (both thumbs) a pplied at the angle of the which responded rapidly to mobil ization of the 2nd rib. The patients rib in an a nterocaudal direction will demonstrate relative rigid ity, both had positive tests for shoulder impingement, implicating compared with normal rib motion. This palpation will probably supraspinatus and/or bicipital tendon dysfunction (see I mpingement produce pain if the rib is dysfu nctional. test description below). • The test for assessment of depressed rib function is described on Boyle (1 999) describes evidence to support the way(s) in which pp. 554-555. 2nd rib restrictions (in particular) might produce fa lse-positive test results and give rise to shoulder symptoms. Treatment possi bil ities and choices • The dorsal ra mus of the 2nd thoracic nerve contin ues laterally to • If the posterior aspect of the 2nd rib is 'subluxated' superiorly, the acromion, providing a cutaneous distribution in the region because of a combination of excessive activity and subsequent of the posterolateral shoulder (Maigne 1 99 1 ). hypertonicity and shortness of the rhomboids and/or the poste­ rior scalene muscles, NMT attention to these should assist in res­ • Rotational restrictions i nvolving the cervicothoracic region have olution of the problem. been shown to produce a variety of neck and shoulder symptoms. Since the 2nd rib a rticu lates with the tra nsverse process ofT1 • If the posterior aspect is 'subluxated superiorly', this will automat­ (costotransverse joint) and the superior border ofT2 (costoverte­ ically produce a 'depressed' rib appearance anteriorly, i.e. the rib bral joi nt), rotational restrictions of these vertebrae could pro­ will be relatively locked in its exhalation phase. Positional release duce rib dysfu nction (Jirout 1 969). and MET methods exist to assist in releasing such restrictions. • Habitual overactivity involving scalenus posterior can produce • Boyle describes a treatment method (successfu l in both the cases 'chronic subluxation of the 2nd rib at its vertebral articulation' reported) based on Maitla nd's ( 1 986) oscillatory mobilization (Boyle 1 999). This could result in a superior glide of the tubercle te c h n i q u e. of the 2nd rib at the costotransverse ju nction. 1 . The patient lies prone, with the scapula on the side to be treated passively protracted. • Boyle reports that 'true' i mpingement syndrome is often related 2. Thumb pressure (both thumbs adjacent to each other), suffi­ to overactivity of the rhomboids which would 'downwardly rotate cient to take out all slack, is applied to the angle of the rib in the scapula', impeding elevation of the h umerus at the g leno­ an anterocaudal d i rection. humeral joint. 3. Depending on the degree of acuteness, oscillatory movements are applied using a small or a large amplitude. A series of • He suggests that rhomboid overactivity m ight a lso impact on ra pid, rhythmic osci l lations is executed for 30-60 seconds, the upper thoracic region as a whole (Tl -4), locking these repeated three or more times, until retesting indicates seg ments into an extension posture. If this situation were improved mobility. accompanied by overactivity of the posterior scalene, the 2nd rib 4. Attention to the m usculature, particularly the posterior sca­ might 'subluxate superiorly on the fixed thoracic segment', lead­ lene and possibly serratus anterior muscles, is indicated. ing to pa in and dysfu nction m imicking shou lder impingement syndrome. I m p ingement syndrome test • Boyle hypothesizes that mechanical interference might occur • The patient is supine with the arms at the sides with the elbow involving 'the dorsal cutaneous branch of the 2nd thoracic nerve on the side to be tested flexed to 90' and internally rotated so ... in its passage through the tunnel adjacent to the costotrans­ that the forearm rests on the patient's abdomen. verse joint'. This nerve might be 'drawn taut, due to the superior anterior subluxation of the 2nd rib', leading to pain and associ­ • The practitioner places one hand to cup the shoulder in order to ated restricted movement symptoms. stabil ize it, while the other hand cups the flexed elbow. • The reason for a fa lse-positive impingement test, Boyle suggests, • A com pressive force is applied through the long axis of the relates to the i nternal rotation component, which adds to h u merus, forcing the humerus against the inferior aspect of the the mechanical stress of the dysfu nctional rib area. This cou ld acromion process and glenohu meral fossa. a lso, through pain in hibition, result i n rotator cuff m uscles test­ ing as weak, suggesting incorrectly that a partial tea r had • If symptoms are reproduced or if pain is noted, supraspinatus occurred. and/or bicipital tendon dysfunction is indicated.

1 4 The thorax 557 muscular ('soft tissue') component of these restrictions is a aponeurosis, iliocostalis lumborum and iliocostalis tho­ major influence on their continued existence. racis (among others). 2. Gluteus maximusforce is transmitted superiorly via the Puckree et al (2002) examined nine healthy subjects as to lumbodorsalfascia and latissimus dorsi. changes in tidal volume, breathing frequency and inspira­ Gracovetsky (1997) continues: tory / expiratory durations when stretch was applied to selective intercostal muscles. As a consequence, firing hip extensors extends and raises the trunk in the sagittal plane. The chemical energy liber­ Inspiratory Ie stretch of either the third or eighth Ie space ated within the muscles is now converted, by the rising resulted in a slower, deeper breathing pattern and phase­ trunk, into potential energy stored in the gravitationalfield. dependent increases in diaphragm and parasternal Ie activ­ When a person is running, so much energy needs to be ity. . . . The enhancement of inspiratory muscle activity In) Ie stored that the necessary rise in the center ofgravity forces stretch is most likely due to stimulation ofIe muscle spindles. the runner to become airborne. They suggest stretch applied to in tercostal muscles of some A more detailed review of these and other gait-related influ­ patients with pulmonary disorder may al ter breathing suf­ ficiently to improve gas exchange. The authors of this text ences is to be found in Volume 2 of this text. suggest that this may be enhanced even further if combined The intrinsic thoracic muscles are largely responsible for with NMT, MET, PR and other techniques described in this movement of the thoracic spinal column or cage, as well as respiratory function. Though many of these muscles have book, and those of postural corrections as described in very short fibers and therefore may appear relatively unim­ portant, they are strategically placed to provide, or initiate, Volume 2. precisely directed movement of the thoracic vertebrae and / or ribs. They therefore demand due attention in the develop­ THORAC IC TREAT ME NT TECH N I QUE S ment of treatment plans. Positioning and movements of the thorax and upper body PO STERIOR S U PER FICIAL T HORACIC M U S C LES are strongly influenced by muscles that attach to the lower back and pelvis. These extrinsic muscles of the thorax move When viewing the posterior thorax, the trapezius is imme­ it as a unit and offer it many options when postural com­ diately obvious as it lies superficially and ex tensively covers pensa tions are necessary. While many osseous elements of the upper back, shoulder and neck. In addition to trapezius, the lower body influence upper body posture, such as leg the la tissimus dorsi - which superficiaUy covers the lower length differential or anterior pelvic tilt, the muscles which back, as well as the rhomboids, serratus anterior and pec­ most readily adjust the position of the torso for these and toralis major and minor - should be assessed and treated other compensations include erector spinae, quadratus lum­ prior to the development of a thoracic protocol since they borum, obliques, psoas and rectus abdominis, all of which overlie the deeper tissues to be examined and may also be are discussed in detail in Volume 2 of this text. involved. They are all discussed in Chapter 13, which dea ls Interesting new research shows tha t many of the m uscles with the upper ex tremity. supporting and moving the thorax and / or the spinal seg­ A complex array of short and long extensors and rotators ments (including erector spinae) prepare to accommodate for subsequent movement as soon as arm or shoulder activ­ lies deep to the more superficial trapezius, latissimus dorsi ity is initiated, with deep stabilizing activity from transver­ and the rhomboids. sus abdominis, for example, occurring miniseconds before • Those muscles that support and laterally flex the spinal unilateral rapid arm activity (Hodges & Richardson 1997). column (including erector spinae group) a re oriented for the most part vertically. Stabilization of the lumbar spine and thorax has been shown to depend, to a large extent, on abdominal muscle • Those muscles that rotate the column (such as multifidi) are oriented more diagonally. activity (Hodges 1999). These concepts are explored in more detail in Volume 2 of this text. Platzer (2004) further breaks these two groups into lateral Gait significantly involves the spine in general and the (superficial) and medial (deep) tracts, each having a vertical (intertransverse) and a diagonal (transversospinal) compo­ thoracic spinal muscles in particular. Gracovetsky (1997) nent. It is useful to envisage this subdivision, especially when assessing rotational dysfunctions, as the superficial reports: rotators are synergistic with the contrala teral deep rotators. In walking, the hip extensors fire as the toe pushes the • The la teral (superficial) tract consists of the iliocostalis ground. The muscle power is directly transmitted to the spine and longissimus groups and the (cervical) splenii mus­ and trunk via two distinct but complementary pathways. cles, with the vertical components bilaterally ex tending 1. Biceps femoris has its gait action extended by the sacro­ tuberous ligament, which crosses the posterior superior iliac spine and continues upwards as the erector spinae

558 CLI N ICAL A P P L I CATI O N OF N E U RO M U S C U LAR TECH N I Q U E S : T H E U P PER B O DY the spine and unilaterally sidebending it and the diago­ ... • nal splenii rotating the spine ipsilaterally. • The medial (deep) tract includes the spinalis group, the interspinalis (cervical and lumbar) and intertransversarii as the vertical components and the semispinalis group, rotatores and multifidus comprising the deep diagonal group that rotate the spine contralaterally. Respi ratory synkinesis Figure 1 4. 1 3 During flexion-extension, each lumbar vertebra exhibits an a rculate motion in relation to the vertebra below. The Numerous combinations of adaptation are possible in the center of the arc l ies below the moving vertebra a n d is known as the thoracic spine, partly as a result of the compound influences i nsta nta neous axis of rotation (IAR). Reproduced with permission and potentials of the muscles attaching to each segment, as from Bogduk (2005). well as the 'interdependent combination of asymmetrical vertebral and upper rib shapes and attachments, and their downwards, type 2 (also known as 'non-neutral') is the interaction w ith cervical muscle extensors and sidebenders norm, i.e. sidebending and rotation are to the same side. that attach as low as T5 and T6' (Hruby et aI 1997). (These concepts are discussed further in Chapter 11, which covers the cervical spine.) Compensatory patterning seems to be available, and sup­ portable, at any thoracic spinal level. For example, Lewit Hruby et al (1997) state: (1999) has discussed the work of Gaymans (1980) who demonstrated a surprising phenomenon, which he called Upper thoracic coupling is typically [non-}neutral/type 2 'respiratory synkinesis'. This refers, in part, to the alternating [i.e. sidebending and rotation to the same side} and generally inhibitory and mobilizing effects on spinal segments that occurs as low as T4 . . . [whereas} . . . middle thoracic coupling inhalation and exhalation produce. These follow a predictable is commonly a mix ofneutral/type 1 and non-neutral/type 2 pattern in the cervical and thoracic spine during sideflex­ movements, that may rotate to either the formed convexity ion, as follows. [type I} or concavity [type 2]. Lower thoracic coupling is more apt to accompany lumbar neutral/type 1 mechanics. • On inhalation, resistance increases to sideflexion in the even segments (occiput-atlas, C2, etc., T2, T4, etc.) while An assessment exercise is described on p. 547 to enable the in the odd segments there is a mobilizing effect (i.e. they practitioner to identify the coupled behavior of specific seg­ are more free) . ments. • On exhalation, resistance increases to sideflexion in the odd Vertical components that lie lateral to the spine include the segments (C1, C3, etc., T3, T5, etc.) while in the even seg­ following (Fig. 14.14). ments there is a mobilizing effect (i.e. they are more free). • Iliocostalis lumborum extends from the iliac crest, • The area involving C7 and T1 seems 'neutral' and unin­ sacrum, thoracolumbar fascia and the spinous processes volved in this phenomenon. of T11-L5 to attach to the inferior borders of the angles of the lower 6-9 ribs. • The restrictive and mobilizing effects at the cervicocranial j unction, to inhalation and exhalation respectively, seem to • Iliocostalis thoracis fibers run from the superior borders involve not just sidebending but all directions of motion. of the lower six ribs to the upper six ribs and the trans­ verse process of C7. • The 'mobilizing influences' of inhalation, as described above, diminish in the lower thoracic region. • Longissimus thoracis shares a broad thick tendon with iliocostalis lumborum and fiber attachments to the trans­ The clinical value of this information becomes obvious, for verse and accessory processes of the lumbar vertebrae example, during mobilization of any of these segments in and thoracolumbar fascia, which then attaches to the tips which sideflexion is a component. In the thoracic region in of the transverse processes and between the tubercles particular, the value of encouraging the appropriate phase and angles of the lower 9-10 ribs. of respiration during application of the induration tech­ nique (see p. 566) is easily testable by the practitioner. Segmental coupling A more obvious form of adaptation involves the biome­ chanicaI coupling of segments during compound move­ ments of the spine. This is based on the fact that during sideflexion an automatic rotation occurs (due ·to the planes of the facets). In the thoracic spine this coupling process is less predictable than in the cervical region where, from C3

1 4 The thorax 559 Figure 1 4. 1 4 The vertical col u m ns of m uscles on the posterior thorax serve to powerfu l ly erect a nd latera lly flex the u pper body. Dysfu nctional ly, they prod uce excessive curvature (lordosis a nd scol iosis) of the spinal column. Reproduced with perm ission from Gray's Anatomy for Students (2005). Splenius capitis ---H� +H-fH'+I-�9' Ligamentum nuchae .1------- Longissimus capitis Spinous process of C7 --I-+f'\"r . /1\\-\\ lIiocostalis cervicis /-1'-1 10\\.- =._. _---- Longissimus cervicis Spinalis ---l17\"d'6tTr4 ---- Spinalis t horacis Longissimus ---\":�\\I1 Longissimus t horacis Iliocostalis thoracis I liocostalis --.7-\",H�' ...fL.P .-!\"r'I__-- lIiocostalis lumborum I liac crest ---.,_ The trigger points for these vertical muscular columns refer treatment is indicated. Later in the protocol, when the inter­ caudally and cranially across the thorax and lumbar costal muscles are examined, the practitioner may encounter regions, into the gluteal region and anteriorly into the chest tender attachment sites that appear to lie in the erectors. Marking each tender spot with a skin-marking pencil may and abdomen (Fig. 14.16). reveal vertical or horizontal patterns of tenderness. Clinical The erector spinae system is discussed more fully in the experience suggests that horizontal patterns often represent intercostal involvement, as they are segmentally innervated, second volume of this text due to its substantial role in whereas vertically oriented patterns of tenderness usually postural positioning and its extensive attachment to, and relate to the erector spinae muscles. influence on, the lumbar and sacral regions. Its thoracic components warrant its mention here and its numerous Vertical lines of tension imposed by the erector system attachments onto the ribs require that it be released before can dysfunctionally distort the torso and contribute signifi­ the deeper tissues are examined. While a more extensive cantly to scoliotic patterns, especially when unilaterally treatment of erector spinae may be necessary, the practi­ tioner can apply NMT strokes (described below) in order to hypertonic. Leg length differential, whether functional assess tenderness in the muscles and to note if a lengthier or structural, may need attention in order to sustain any

560 C LI N I CA L APPLICATI O N OF N EU R O M USCULAR TECH N I Q U E S : T H E U P PER B O DY Figure 1 4. 1 5 Deep group of back muscles - transversospinalis and seg mental muscles. Reproduced with perm ission from Gray's Anatomy far Students (2005). Rectus capitis posterior minor Semispinalis capitis --------.... IW-- Obliquus capilis superior {l-- Rectus capitis posterior major '-- Obliquus capitis inferior Spinous process of C7 -------,I't '4T4fT1.:;.; .�. ���r-.Semispinalis thoracis --.r='�-H,M: Rotatores thoracis (short, long) E�����I- Levatores costarum (short, long) Multifidus --Alf-H' \\-I<'\\--t' t ntertransversarius --'-..'. f--- Erector spinae long-term improvement in the myofascial tissue brought positions of balance and the body's cen ter of gravity is about by treatment or exercise. altered. The patient's home-care use of stretching, applied to the neck, shoulder girdle, lower back and pelvis, coupled The posterior fascial lines (of potential tension) which with postural exercises, should be designed to normalize run from above the brow to the soles of the feet (see fascial the induced adaptational changes. chains, p. 11) are a critical line of reference to altered biome­ chanics of the spine and thorax. There may be widespread ,� N MT : POST E R I O R TH O RAC I C G LI D I N G effects on postural adaptation mechanisms following any \" TECH N I Q U E S ( F I G . 1 4. 1 7) substantial release, for example, of the middle portion (erec­ tor group) of that posterior line. If the lamina myofascial tis­ Long, gliding strokes may be applied to the posterior thorax sues are also released, the tensegrity tower (the spine) could w ith the patient prone and with the practi tioner posi tioned then more effectively adapt and rebalance. However, the at the head end of the table (facing caudally) or near the practitioner should note that following such a series of waist or lower ribs (facing cranially). By posi tioning at the releases, a requirement for structural adaptations will be head, the practitioner 's own body weight can be centered imposed on the body as a whole, as the arms move to new

1 4 The thorax 56 1 Figure 1 4. 1 6 Superficial paraspi n a l muscles col lectively known as erector spi nae have combined target zones which refer across most of the posterior surface of the body as well as a nteriorly. D rawn after Simons et a l (1999). '1iIrH--1 Iliocostalis thoracis --t-_+-(J.I T1 1 �/ Longissimus thoracis Y --++-�AT10, 11 (or near centered) over the tissues in order to avoid back (e.g. in reducing anterior pelvic positioning) when glides strain during application of the techniques. The glides may be are applied toward the pelvis over lines of normal myofas­ reapplied in two or three shorter vertical segments, one after cial tension, such as those provided by the erector group. the other. Clinically there appear to be postural benefits Lengthening these lines, between the upper thorax and

562 CLI N I CAL A P P L I CATI O N OF N EU RO M U SCU LA R TEC H N I Q U E S : TH E U P P E R B O DY A spinous processes. Progressive applications usually encounter less tenderness and a general relaxation of the myofascial B tissues, especially if heat is applied to the tissues while the contralateral side is being treated. Unless contraindicated Figu re 1 4. 1 7 A : Gliding strokes applied w ith the blade of the (e.g. by recent injury, inflammation or excessive tenderness) proximal forearm. B: Avoid ol ecra non con tact with spinous a hot pack may be moved back and forth from one side to processes. the other between the gliding strokes in order to 'flush' the tissues. sacroiliac areas, may result in reductions of anterior pelvic tilt, excessive lumbar lordosis and forward head posture. The connective tissues may become more supple or the myofascial tensional lines (induced by trigger points, Each gliding stroke is applied several times while pro­ ischemia, connective tissue adaptations) may be released gressively increasing the pressure (if appropriate) before and softened by the gliding strokes, as described above. moving the thumbs (palms) laterally, to glide on the next Trigger points may become more easily palpable as exces­ segment of the back, from the first rib through the sacrum, sive ischemia is reduced or completely released by these or to the pelvic crest. A flat, palm stroke or one performed gliding strokes. Palpation of the deeper tissues is usually by the proximal portion of the forearm (Fig. 14.17A) (not the more defined and tissue response to applied pressure is point of the elbow as it causes too much discomfort when usually enhanced by this sequence of strokes. much pressure is applied) may also be used. While release of tension might appear to always be desir­ These strokes are applied alternately to each side, until able, it is important to consider the demands for compensa­ each has been treated 4-5 times, while avoiding excessive tion imposed by induced releases. Local tissues, and the pressure on the bony protuberances of the pelvis and the individual as a whole, will be obliged to adapt biomechani­ cally, neurologically, proprioceptively and emotionally. Inducing any substantial release of postural muscles before other areas of the body (and the body as a whole) are pre­ pared may overload compensatory adaptation potentials, possibly creating other areas of pain, structural distress or myofascial dysfunction ('The part you treated is better, but now I hurt here and here'). Other osseous and myofascial elements may already be adapting to preexisting stresses and may become dysfunctional under such an increased load . However, if treatment has been carefully planned and executed, the process of adaptation to a new situation, fol­ lowing local soft tissue treatment, while almost inevitably producing symptoms of stiffness and discomfort, should be recognized as a probable indication of desirable change and not necessarily 'bad'. The patient should therefore be fore­ warned to anticipate such symptoms for a day or two fol­ lowing NMT or other appropriate soft tissue manipulation. It should also be suggested to the patient that if conditions, such as a substantial headache, burning pain, numbness or other serious symptoms, emerge, contact with the practi­ tioner should be made at once since these might indicate vascular or neurological situations that need immediate attention. I,. N MT F O R M U SC L E S O F TH E TH O RACIC , LA M I NA G R OOVE Numerous muscles attach into the thoracic lamina and layer upon each other in a \\�ariety of fiber directions. The power­ ful influence of effleurage strokes, when applied repeatedly to the thoracic and lumbar lamina groove, should not be underestimated. Clinical experience strongly suggests that the application of this form of repetitive NMT effleurage has the ability to significantly influence layer upon layer of fibers attaching into the lamina. Such strokes are among the

1 4 The thorax 563 most important tools in neuromuscular therapy. Treatment Function: Acting unila terally, it rotates the spine contralat­ of this sort can beneficially influence segmental spinal erally; bila terally, it extends the spine mobility, postural integrity and the potential for tensegrity processes to function more effectively in dealing with the Synergists: For rotation : multifidi, rota tores, ipSila teral stresses and strains to which the body is exposed . external obliques and external intercostals and contralat­ eral internal obliques and internal intercostals A repeat of these gliding strokes at the end of the session For extension: posterior spinal muscles (precise muscles will allow a comparative assessment, which often demon­ depending upon what level is being extended) strates the changes in the tissues (and discomfort levels) to the practitioner as well as the patient. Antagonists: To rotation: matching contrala teral fibers of semispinalis as well as contralateral multifidi, rotatores, Many muscular attachments will be assessed with the external obliques and external intercostals and the ipsi­ use of a small pressure bar, or finger friction, applied to the lateral internal obliques and internal intercostals lamina groove, as described below. These attachments may For extension: spinal flexors (precise muscles depending include trapezius, rhomboids, latissimus, splenii, spinalis, upon what level is being extended) semispinalis, multifidus, rotatores and serratus posterior superior and inferior, depending upon which spinal level is Indications for treatment of spinalis and being examined . Determining exactly which fibers are semispina l i s involved is sometimes a difficult task and success is based strongly on the practitioner 's skill level and knowledge of • Reduced flexion of spine anatomy, including the order of the multiple layers overly­ • Restricted rotation (sometimes painfully) ing each other and their fiber directions. Fortunately, the tis­ • Pain along spine sue response is not always based on the practitioner's • Tenderness in lamina groove ability to decipher these fiber arrangements (especially in the lamina) and the tender or referring myofascia may M U LTI FIDI ( F I G S 1 4. 1 8 , 1 4. 1 9) prove to be responsive, even when tissue identification is unclear. Attachments: From the posterior surface or the sacrum, iliac crest and the transverse processes of all lumbar and Not every muscle attaching to the lamina is discussed thoracic vertebrae and articular processes of cervicals below, as some have been detailed together with the 4-7; these muscles traverse 2-4 vertebrae and attach descriptions of the upper extremity and / or the cervical superiorly to the spinous processes of all vertebrae apart region. Because of an overlap in their actions and influ­ from the atlas ences, additional coverage of many of these muscles is found in volume 2 of this text, which deals with the lower Innervation: Dorsal rami of spinal nerves body. Most of the remaining deeper muscles of the thorax Muscle type: Postural (type I), shortens when stressed are either discussed here or together with the muscles of Function: When these contract unilaterally they produce respiration. ipsilateral flexion and contralateral rotation; bilaterally, S PI N A LIS T H O RACIS they extend the spine Synergists: For rotation : multifidi, semispinalis, ipsilateral Attachments: Spinous process of T11-L2 to the spinous external obliques and external intercostals and contralat­ process of T4-8 (variable) eral internal obliques and internal intercostals For extension : posterior spinal m uscles (precise muscles I nnervation: Dorsal rami of spinal nerves depending upon what level is being extended) Muscle type: Not established Antagonists: To rotation: matching contralateral fibers Function: Acting unilaterally, flexes the spine laterally; of rotatores as well as contralatera l multifidi, semi­ spinalis, external obliques and external intercostals bilaterally, extends the spine and the ipsilateral internal obliques and internal intercostals Synergists: For lateral flexion: ipsilateral semispinalis, For extension: spinal flexors (precise muscles depending upon what level is being extended) longissimus and iliocostalis thoracis, iliocostalis lumbo­ rum, quadratus lumborum, obliques and psoas Indications for treatment Antagonists: To lateral flexion: contralateral semispinalis, • Chronic instability of associated vertebral segments • Reduced flexion of spine longissimus and iliocostalis thoracis, iliocostalis lumbo­ • Restricted rotation (sometimes painfully) rum, quadratus lumborum, obliques and psoas • Pain along spine • Vertebral scapular border pain (referral zone) S E M I S PI N A L I S T H O RACIS Attachments: Transverse process of T6-1 0 to the spinous processes of C6-T4 Innervation: Dorsal rami of thoracic nerves Muscle type: Not established

564 CLI N I CA L A PP L I CATI O N O F N E U R O M U SCU LA R TECH N I Q U E S : T H E U P P E R B O DY Fig u re 14. 1 8 Composite ---.;\\, T4-5 trigger point referral patterns of m u l tifi d i and rotatores. Drawn after Simons et a l (1 999). y Serratus posterior Antagonists: To rotation: matching contralateral fibers of rotatores as well as contralateral multifidi, semispinalis, superior ---;�:l external obliques and external intercostals and the ipsi­ lateral internal obliques and internal intercostals For extension: spinal flexors (precise muscles depending upon what level is being extended) Levator Ind ications for treatment costae brevis --hb\"-\"c;r'£f7 • Pain and tenderness of associated vertebral segments • Tenderness to pressure or tapping applied to the spinous Levator processes of associated vertebrae costae longus -+�='r-+ Special notes Multifidi --_-'1/\"+ Multifidi and rota tores muscles comprise the deepest layer Figure 1 4.1 9 Levatores costae elevate and 'spin' ribs during of the laminae and are responsible for fine control of the inhalation. rotation of vertebrae. They exist through the entire length of the spinal column. In addition, the multifidi also broadly R OTATO R E S LO N G U S A N D B R EVI S attach to the sacrum, after becoming appreciably thicker in (see FIG. 1 4. 1 9) the lumbar region. Attachments: From the transverse processes of each verte­ These muscles are often associated with vertebral seg­ bra to the spinous processes of the second (longus) and ments that are difficult to stabilize and should be addressed first (brevis) vertebrae above (ending at C2) throughout the spine when scoliosis is present, along with Innervation: Dorsal rami of spinal nerves the associated intercostal muscles and pelvic positioning. Muscle type: Postural (type I), shortens when stressed Function: When these contract unilaterally they produce Note: Balance mechanisms seem to strongly influence the contralateral rotation; bilaterally, they extend the spine evolution of scoliosis. Unilateral labyrinthine stimulation Synergists: For rotation: multifidi, semispinalis, ipsila teral (or removal) results in scoliosis, pointing to the relationship external obliques and external intercostals and contralat­ between the righting reflexes and spinal balance (Michelson eral internal obliques and internal intercostals 1 965, Ponsetti 1 972). In one study, the majority of 1 00 scoli­ For extension: posterior spinal muscles (precise muscles otic patients were shown to have associated equilibrium depending upon what level is being extended) defects, with a direct correlation between the severity of the spinal distortion and the degree of proprioceptive and optic dysfunction (Yamada 1971). Discomfort or pain provoked by pressure or tapping, applied on the spinous processes of associated vertebrae, a test used to identify dysfunctional spinal articulations, also often indicates multifidi and rotatores involvement. Trigger

1 4 The thorax 565 points in rotatores (see Fig. 14. 18) tend to produce rather patients, when compared with healthy volunteers localized referrals whereas the multifidi trigger points refer (Parkkola 1993). locally and also to the suboccipital region, medial scapular • Hides et al (1994) showed that there was unilateral, seg­ border and top of shoulder. These local (for both) and dis­ mental wasting of multifidus in acute low back patients. tant (for multifidi) patterns of referral continue to be These changes occurred rapidly and were not consistent expressed through the length of the spinal column. In fact, with 'disuse atrophy' . the lower spinal levels of multifidi may even refer to the anterior thorax or abdomen. • Other researchers have shown type 1 fiber hypertrophy on the symptomatic side and type 2 atrophy bilaterally in Local tissue changes in these important muscles (multi­ multifidus, in chronic low back pain patients (Fitzmaurice fidi and rotatores), including chronic hypertonus and 1992). ischemia that are precursors to the evolution of trigger points, may result from segmental facilitation (see p. 544). \",� NIVI T F O R T H O RA C I C (A N D L U M BAR) LAMINA G ROOVE M USCLES When segmental facilitation occurs, as a result of either organ disease (i.e. involving viscerosomatic reflexes) or To prepare the superficial posterior thorax for treatment of spinal overuse factors, the local musculature becomes hyper­ the tissues that lie deep to them, lubricated gliding strokes tonic. Denslow (1944) first described this phenomenon, as may be applied repeatedly with one or both thumbs in follows: 'Motor neuron pools in spinal cord segments related the lamina groove and then alongside the lamina from Tl to to areas of somatic dysfunction were maintained in a state of the sacrum or iliac crest. The thumbnail is not involved in the facilitation.' He later concluded (Denslow et al 1947): stroke nor allowed to encounter the skin, as the thumb pads 'Muscles innervated from these segments are kept in a state are used as the treatment tool (see p. 184 for hand positioning of hypertonus much of the day with inevitable impediment and cautions in gliding). Each gliding stroke is applied sev­ to spinal motion.' These concepts were confirmed by eral times from Tl through the sacrum while progressively research in later years, especially by Korr (1976). increasing the pressure (if appropriate) with each new stroke. Elkiss & Rentz (1997) summarize: The lubricated glides are applied alternately to each side until each has been treated 4-5 times with several repeti­ In the early stages [offacilitation} a continued barrage (noci­ tions each time. Excessive pressure on the bony protuber­ ceptive, proprioceptive, autonomic) and a widening zone of ances of the pelvis and the spinous processes throughout involvement maintain the state of chronicfacilitation. With the spinal column should be avoided. Progressive applica­ chronic lesions a more lasting mechanism must be at work. tions usually encounter less tenderness and a general soft­ Sustained patterns ofexcitability and synaptic transmission ening of the myofascial tissues, especially if moist heat is become learned behavior in the spinal cord and brain . . . [and applied to the tissues while the contralateral side is being there will be} increased signs ofsomatic dysfunction. treated. Unless contraindicated, a hot pack may be placed alternately on each side while the other side is being treated In practice this means that tense, ta ut paraspinal tissues that so as to 'flush' the tissues between applications of strokes. are unresponsive to normal treatment procedures should always be considered to possibly involve facilitation and to The fingertip (with the nail well trimmed) may be used to require further investigation as to underlying causes. friction or assess individual areas of isolated tenderness and to probe for ta ut bands that house trigger points. Trigger Multifidus should co-contract with transversus abdo­ points lying close to the lamina of the spinal column often minis to assist in low back stabilization (Richardson & Jull refer pain across the back, w rapping around the rib cage, 1995), which suggests that any chronic weakness (or atro­ anteriorly into the chest or abdomen and frequently refer phy) is likely to impact strongly on spinal stability. While 'itching' patterns. The trigger points may be treated w ith shortness and tightness are obvious indicators of dysfunc­ static pressure or may respond to rapidly alternating appli­ tion, it is therefore important, when considering muscular cations of contrasting hot and cold (repeated 8-10 times for imbalances, to also evaluate for weakness. Actual atrophy 10-15 seconds each), always concluding with cold (see of the multifidi has been reported in a variety of low back hydrotherapy notes in Chapter 10). pain settings (see below). Liebenson (1996) observes: The beveled pressure bar (as described in Box 14.7) may The initial muscular reaction to pain and injury has tradi­ also be used to assess the fibers attaching in the lamina (Fig. tionally been assumed to be an increased tension and stiff­ 14.20). The tip of the bar is placed parallel to the midline ness. Data . . . indicates inhibition is at least as significant. and at a 45° angle to the lateral aspect of the spinous process Tissue immobilization occurs secondarily, which leads to of Tl. In this way it is 'wedged' into the lamina groove where joint stiffness and disuse muscle atrophy. cranial to caudal to cranial friction is applied at tip-width intervals. The assessment begins at T1 and the process con­ • Atrophy and fibrosis of multifidus are associated with tinues to (but not onto) the coccyx. Each time the pressure disc herniation in the lumbar spine (Lehto et aI 1989). bar is moved, it is lifted and placed at the next point, which is a tip width further d own the column. The beveled tip is • Increased fatty deposits in multifidus ('fatty metaplasia') was a common finding in a population of low back pain

566 CLI N I CAL APPLICATION OF NEUROM USCULAR TEC H N I QUES: THE U PPER BODY Box 1 4. 7 Press u re bars - - c - - Pressure bars (see p. 1 91 ) are popular tools for NMT treatment c:><. .\" ' made of a (light wood) 1 \" dowel horizontal crossbar and a 1 /4\" vertical shaft and have either a 1 /2\" flat (smooth) rubber tip or a / \" --' 1 /4\" beveled rubber tip at the end of the vertical shaft. The large flat tip is used to press into large muscle bellies (such as the / gluteals) or to glide on flat bellies (such as the anterior tibialis) so as to avoid excessive pressure on thumb joints. The small beveled /, / tip is used in the lamina groove, under the spine of the scapula, between the ribs and to friction certain tendons which are / difficult to reach with the thumb (Delany 2003). Figu re 1 4.21 Hand positions for induration technique. Reprod uced • Contracted tissues, fibrosis and bony surfaces may be 'felt' with permission from Chaitow (2002), through the bars. • The pressure bars are NEVER used on extremely tender tissues, at vulnerable nerve areas (such as the clavicular area) or to 'dig' into tissues. • The tips of the tools should be cleaned in a manner similar to the hands after each use. • The beveled end of a flat typewriter eraser (protected by plas­ tic wrap) may be substituted. ( PR M ET H O D F O R PA RASPI N A L M U S C U LATU R E : I N D U RAT I O N TE C H N I Q U E Figure 1 4.20 A beveled rubber tip pressure bar can be used in the (Chaitow 2002, Morrison 1 969) lamina groove to assess the many layers of tissues that attach there. • The practitioner stands on the side of the prone patient not used as a gliding tool, although it is sometimes used to opposite the side in which pain has been discovered in 'scrape' tissue, such as the palmar fascia. The short frictional paraspinal tissues. stroke may also be applied unidirectionally (in either direc­ tion), which sometimes more clearly defines the fiber direc­ • Tender or painful points (lying no more lateral than the tion of the involved tissue. The location of each involved tip of the transverse process) are palpated for the level of segment may be marked with a skin-marking pencil so that their sensitivity to pressure. it may be retreated several times during the session_ The 'collection' of skin markings may provide clues as to pat­ • Once confirmed as painful, the point is held by firm terns of involved tissues. thumb pressure and the patient is told that the pain being felt represents a score of '10'. Friction may also be applied between spinous processes (pressure bar or fingertip) in order to treat the supraspinous • With the soft thenar eminence of the other hand, the tip ligament ( throughout the spine) and the interspinalis mus­ of the spinous process most adj acen t to the painful point cles (lumbar region only). Although the interspinales mus­ is very gently eased toward the pain (ounces of pressure cles are also present in the cervical region, the pressure bar only), crowding and slackening the tissues in which the is not used there as fingers provide a sufficient and more tender point is being palpated until pain reduces by at precise treatment as well as protective of these more mobile least 75%. vertebrae (see cervical region, pp. 243 and 321). • Pressure on the spinous process, extremely lightly directed toward the painful point, should lessen the degree of tis­ sue tension and the sensitivity. • If it does not do so, then the angle of 'push' on the spinous process toward the painful spot should be varied slightly, so that, somewhere within an arc embracing a half circle, an angle of push toward the pain will be found to abolish the pain totally and will lessen the objective palpated sense of tension. • This position of ease is held for not less than 20 seconds after which the next point in the paraspinal musculature is treated. • If possible, Caymans' (1980) principles relating to alter­ nate segmental response to inhalation and exhalation, as outlined on p. 558, should be incorporated into the pro­ cedure. However, if holding of the breath (in or out) causes the patient any distress, this aspect of the proce­ dure should be ignored_

1 4 The thorax 567 • If the segment being treated is an odd one (i.e. T3,5,7,9,11), respiratory muscle mechanics, leading to diaphragmatic the sidebend, which is being initiated by light pressure weakness. She points out that: on the spinous process toward the painful point, should involve the patient inhaling and holding thatfor as long as All myopathies involving the thoracoabdominal and respi­ is comfortable, during the 20 seconds or so of applied gen­ ratory accessory muscles will impair breathing during sleep tle pressure. and cause breathing pattern changes including hypoventila­ tion, obstruction, and central apnea. - Indeed, trigger points, • If the segment being treated is an even one (i.e. T2,4,6,8, hypertonicity, myofascial restrictions, and resulting weakness 10,12), the sidebend, which is being initiated by light pres­ could be considered myopathies; abnormal conditions or dis­ sure on the spinous process toward the painful point, ease ofskeletal muscle. Exactly howfaulty breathing mechan­ should involve the patient exhaling and holding that for ics, along with hypocapnia and pH alterations, affect as long as is comfortable, d uring the 20 seconds or so of ventilation during nocturnal sleep in humans has yet to be applied gentle pressure. determined. • For Tl the phase of breathing is irrelevant and the patient S E R RATU S P O S T E RI O R S U P E RI O R should breathe normally during the procedure. Attachments: Spinous processes o f C7-T3 t o attach t o the • A full spinal treatment is possible using this extremely upper borders and external surfaces of ribs 2-5, lateral to gentle approach which incorporates the same principles their angles as strain/ counterstrain (SCS) and functional technique, with the achievement of ease and pain reduction as the Innervation : Intercostal nerves (T2-5) treatment focus (see Chapter 10 for details of the princi­ Muscle type: Phasic (type II), weakens when stressed ples involved). Function: Uncertain role but most likely elevate the ribs • There are no contraindications to this method, which (Gray's Anatomy 2005) and perhaps function primarily in was designed specifically for the fragile and sensitive proprioception (Vilensky et al 2001) individual. Synergists: Diaphragm, levatores costarum brevis, scalenus posterior M US C L E S OF R E S PI RATI O N Antagonists: Internal intercostals The deeper elements of the thoracic musculature represent Indications for treatment a remarkable system by means of which respiration occurs. Some of these muscles also provide rotational components • Pain that seems to be deep to the scapula which carry similar, spiraling lines of oblique tension from • Pain may radiate over the posterior deltoid, down the the pelvis (external and internal obliques) through the entire torso (external and internal intercostals), almost as if the back of the arm, ulnar portion of the hand and to the ribs were 'slipped into' this supportive web of continuous smallest finger muscular tubes. Rolfer Tom Myers (1997), in his brilliant • Numbness into the ulnar portion of the hand 'anatomy trains' concept (p. 11), describes the continuity which occurs between these muscles (obliques and inter­ Special notes costaIs) as part of his 'lateral line'. Above the pelvic crest this myofascial network creates a series of crossover (X-shaped) Trigger points for serratus posterior superior lie hidden patterns. under the vertebral border of the scapula. When the scapula is in the resting position, the trigger point is unavailable and The obliques tuck into the lower edges of the basket of ribs. may be missed during examination. Pressure of the scapula Between each of the ribs are the internal and external inter­ imposed against the trigger point by the patient's sleeping costals, which taken all togetherform a continuation of the position may irritate and activate the trigger point. Displace­ same 'X',formed by the obliques. These muscles, commonly ment of the scapula to reach the trigger point is imperative taken to be accessory muscles of breathing, are seen in this and can be accomplished in a seated position (Simons et al context to be perhaps more involved in locomotion [and sta­ 1 999) or the sidelying position offered here. bility], helping to guide and check the torque, swinging through the rib cage during walking and running. The patient is supported in a sidelying position (see p. 316) with the affected arm uppermost. The arm is draped See Chapter 1 for more of Myers' ideas. across the patient's chest and the hand allowed to hang Obstructive pulmonary diseases, neuromuscular diseases, toward the floor so that the scapula translates laterally as far as possible. Having the patient curl the torso into flexion poliomyelitis, obesity, heart failure and craniofacial anomalies may also assist in exposing more tissue. are all risks for disordered breathing during sleep. Coffee (2006a,b) proposes that chronic hyperventilation syndrome If the scapula can be sufficiently protracted (best achieved (HVS) and other upper chest breathing pattern disorders with the patient in sidelying posture), serratus posterior (BPD) are also risk factors for sleep apnea-hypopnea superior's rib a ttachments may be palpated j ust lateral to because of persistent hypocapnia (in chronic HVS) and poor

568 CLI N I CAL APPLICATION OF N EUROM USCULAR TECH N IQUES: THE U PPER BODY the angles of the ribs and medial to the vertebral border of S E R RATU S P O S T E RI O R I N F E RI O R the scapula. However, this m uscle is often relatively thin and its fiber direction is similar to overlying tissues. The Attachments: Spinous processes o f Tll-L3 and the tho­ practitioner is more likely to locate the exquisite tenderness racolumbar fascia to the inferior borders of the lower of any trigger points that may be present, and reproduce four ribs their referral patterns, than to locate the associated taut bands, although sometimes these may be felt (Fig. 14.22). Innervation: Intercostal nerves (T9-12) Muscle type: Phasic (type II), weakens when stressed Serratus posterior Function: Depresses lower four ribs and pulls them posteri- superior orly, not necessarily in respiration (Gray's Anatomy 2005) Synergists: Internal intercostals Antagonists: Diaphragm Indications for treatment • Leg length differential • Rib dysfunction in lower four ribs • Lower back ache in area of the muscle • Scoliosis Figure 1 4.22 The target zone for serra tus posterior superior is Special notes sign ifica nt w h i l e its h i dden trigger point often remains anonymous. Drawn after Simons et al (1 999). Trigger points in this muscle may produce lower back ache similar to that of renal disease. While its trigger points and attachments should be treated, kidney disease should also be ruled out as the source of viscerosomatic referral, espe­ cially when the myofascial pain keeps returning after treat­ ment. The quadratus lumborum muscle, located nearby, should also be examined. This is discussed in more detail in Volume 2 of this text and is also considered on p. 93. CAUTION: As detailed earlier in this chapter, the lower two ribs are 'floating ribs', varying in length, and are not attached anteriorly by costal cartilage. The distal ends of the ribs may be sharp, requiring that palpation be carried out carefully. Add itionally, excessive pressure is avoided, especially in patients w i th known or suspected osteo­ porosis due to possible fragility of the bones. The practitioner's thumb can be used to glide laterally along the inferior aspect of each of the lower four ribs (through the latissimus dorsi fibers). The patient will often report tender­ ness and a 'burning' discomfort as the thumb slides laterally. Repetitions of the stroke usually rapidly reduce the discom­ fort. Spot tenderness associated with a central trigger point may be found but taut fibers are difficult to feel through the overlying muscles (Simons et aI 1999). Figure 1 4.23 Trigger point referral pattern for serratus posterior LEVATO R ES COSTA R U M LO N G U S A N D B R EVIS i nferior. Drawn after Simons et al ( 1 999). Attachments: Longus: tips of transverse processes of T7-10 to the upper edge and external surface of the tubercle and angle of the 2nd rib below Brevis : tips of transverse processes of C7-TIl to the upper edge and external surface of the tubercle and angle of the next rib below Innervation: Dorsal rami of thoracic spinal nerves Muscle type: Not established Function: Elevate the ribs, although their role in respiration is unclear (Gray's Anatomy 2005); contralateral spinal

1 4 The thorax 569 rotation, ipsilateral flexion and bilaterally extend the Indications for treatment col umn Synergists: For rib elevation: serratus posterior superior, • Rib dysfunction external intercostals, diaphragm, scalenes • Breathing dysfunctions, especially ribs locked in elevation Antagonists: Internal intercostals, serratus posterior infe­ • Vertebral segmental facilitation • Scoliosis rior, elastic elements of thorax Box 1 4.8 Uefs NMT of the intercostal nt useleS (Cha itow 2003) Fig u re 1 4.24 Map of suggested NMT stroke patterns for eval uation of lower t horacic a rea and intercostal spaces. Reproduced with permission from Chaitow (2003). The intercostal spaces should be assessed for dysfunction. Figure 1 4.25 Finger strokes as employed in NMT assessment and treatment. • The (well-trimmed) thumb tip or a finger tip should be run along both surfaces of the rib margin, as well as in the intercostal • When an area of contraction is noted, firm pressure toward the space itself. center of the body is applied to elicit a response from the patient ('Does it hurt? Does it radiate or refer? If so, where to7'). • In this way the fibers of the internal and external intercostal muscles will receive adequate assessment contacts. • Trigger points noted during the assessment may be treated using standard NMT protocols or INIT combination procedures • If there is overapproximation of the ribs, then a simple stroke (see p. 1 97). along the intercostal space may be all that is possible until a degree of rib and thoracic normalization has taken place, allow­ ing greater access. • The intercostal areas are commonly extremely sensitive and care must be taken not to distress the patient by using inappropriate pressure. Sometimes a 'tickling' element may be eliminated by gently increasing the pressure of the stroke (if appropriate), which will often reveal underlying tenderness in the same tissues. • At times it is useful to take the patient's hand, have her extend a finger and start the process of stroking through a n intercostal space, using her own hand contact, until she desensitizes suffi­ ciently to allow the practitioner's hand to replace her own. • In most instances the intercostal spaces on the contralateral side will be treated using the finger stroke, as illustrated (Fig. 1 4.25). • The tip of a finger (supported by a neighboring digit) is placed in the intercostal space, close to the mid-axillary line, and gently but firmly brought around the curve of the trunk toward the spine. • The probing digit feels for contracted or congested tissues in which trigger points might be located.

570 CLI N I CA L APPLICAT I O N OF N EU R O M U SC U LAR T EC H N I Q U E S : T H E U PPER BODY Special notes Synergists: For respiration: external: muscles of inhala tion; internal and innermost: muscles of exhalation The leva tores costarum appears innocuous in its small, For rotation: external: ipSilateral multifidi and rotatores, short passage from the transverse process to the exterior contralateral internal obliques; internal: contralateral exter­ aspect of the ribs. However, this advantageous placement, nal obliques, multifidi and rotatores directly over the costovertebral joint, puts it in a powerful position to rotate the ribs during inhalation. Simons et al Antagonists: For respiration: external: muscles of exhalation; (1999) state: 'They elevate the rib cage with effective lever­ internal and innermost: muscles of inhalation age. A small upward movement of the ribs so close to the For rotation: external: contralateral multifidi and rotatores, vertebral column is greatly magnified at the sternum .' ipsilateral internal obliques; internal: ipsilateral external obliques, multifidi and rotatores These muscles can be difficult to locate precisely and are addressed with the intercostals, if the overlying tissues are Indications for treatment not too thick. Additionally, the gliding stroke, described previously for the lamina groove, may also be applied over • Respiratory dysfunctions, including dysfunctional breath- the costovertebral joints and j ust lateral to them, in order to ing patterns and asthma assess for tender levatores costarum. • Scoliosis I NT E R CO STALS (FI G . 1 4. 2 6) • Rib dysfunctions and intercostal pain • Cardiac arrhythmia (see pectoralis major, p. 467) Attachments: External, internal and innermost lie in three layers, with the innermost outermost, and attach the infe­ Special notes rior border of one rib to the superior border of the rib below it. See notes below for direction of fibers Whereas the internal intercostal muscles attach to the ribs and fully to the costal cartilages, the external intercostals attach Innervation: Corresponding intercostal nerves only to the ribs, ending at the lateral edge of the costal carti­ Muscle type: Not established lages with the external intercostal membrane expanding the Function : For respiration: external: eleva tes ribs; internal: remaining few inches to the sternum. The external and inter­ nal intercostal fibers lie in opposite directions to each other depresses the ribs; innermost: unclear function but most with the external fibers angling inferomedially and the likely acts with internal fibers (Gray's Anatomy 2005) internal fibers coursing inferolaterally when viewed from For rotation: external: rotates torso contralaterally; inter­ the front. The reverse is true when viewed from the back. nal: rotates torso ipsilaterally These fiber directions coincide with the direction of Innermost Internal External external and internal obliques and provide rota torial move­ intercostal intercostal intercostal ment of the torso and postural influences in addition to res­ piratory responsibilities (Simons et aI 1 999). Fig u re 14.26 I n tercostal m uscles provide rota tion ohhe thorax as well as assisting in breathing. Reproduced with permission from Controversy exists as to the role these muscles play in Gray's Anatomy (2005). quiet breathing, with some texts suggesting involvement only d uring forced respiration (Platzer 2004). Simons et al ( 1999) discuss progressive recruitment depending upon degree of forced respiration. lntercostals may also provide rigidity to the thoracic cage to prevent inward pull of the ribs during inspiration. The s ubcostales muscles (when present) are usually only well developed in the lower internal thoracic region. Their fiber direction is the same as that of internal and innermost intercostals and they span across the internal surface of one or two ribs rather than j ust the intercostal space. They most likely have the same function as the deeper intercostal mus­ cles (Gray's Anatomy 2005, Platzer 2004, Simons et aI 1999). Since these muscles are segmentally innervated, neuro­ pathies (such as shingles) will be noted to run a course lat­ erally around the torso and may affect one (or more) intercostal spaces along their full length. When shingles (herpes zoster) is present or has been noted in the last 6-8 months, applications of NMT are contraindicated. When this segmental pattern of tenderness is noted and the condi­ tion of shingles has not been diagnosed, caution should be

14 The thorax 571 exercised due to the fact that the tenderness may be the first of the neurovascular supply to the upper ex tremity and the sign of an oncoming eruption. Though the condition is self­ pectoralis minor. Lief's NMT incorporates assessment and limiting, inappropriate treatment of the tissues may irritate treatment of the lower intercostal spaces with the patient the condition. supine, as part (usually the commencement) of an abdomi­ nal NMT sequence. This is outlined fully in Volume 2 of A skin-marking pen may be used to record tender tissues this text. found during the palpa tion exercise below. Marking each tender spot may reveal vertical or horizontal patterns of In the la teral thorax, the region high in the axilla is avoided tenderness. Horizontal patterns often represent intercostal due to lymph nodes. In the posterior thorax, caution is exer­ involvement whereas vertically oriented patterns of tender­ cised regarding the floating ribs (noted with serratus poste­ ness are usually indicative of erector spinae muscle rior inferior). Additionally, in the upper posterior thorax, dysfunction. palpa tion of the intercostal space is obscured by overlying tissue, and location of the intercostals may be unclear. It N M T F O R I NTE RCOSTALS I N F LU E N CES O F A B D O MINAL M USCLES Fingertip or thumb glides, as described in Box 14.8, are applied to the intercostal spaces of the posterior, lateral and Like the erector system o f the posterior thorax, the abdomi­ anterior thorax for initial examination as to tenderness and nal muscles play a significant role in positioning the thorax rib aligrunent. A beveled-tip pressure bar or fingertips may and in rotating the entire upper body. They are also now be used to friction the intercostal spaces and more precisely known to play a key part in spinal stabilization and inter­ located trigger points or tender tissue, or to address the tis­ segmental stability, particularly transversus abdominis sue specific to rib approximation when the intercostal space (Hodges 1 999). The rectus abdominis, external and internal is decreased. The pressure bar tip or fingertips can be obliques and transversus abdominis are also involved in pressed into the intercostal space (pressure toward the cen­ respiration due to their role in positioning the abdominal ter of the thorax) or angled superiorly or inferiorly against viscera as well as depression of the lower ribs, assisting in the rib attachments (if space allows) (Fig. 14.27). forced expiration and especially coughing. On the anterior thorax, all breast tissue (including the While the abdominal muscles are discussed in detail in nipple area on men) is avoided with the intercostal treat­ Volume 2 of this text, the following brief NMT assessment ment. Specific lymphatic drainage techniques may be applied of their uppermost fibers and attachments to the ribs will to the breast area but the frictional techniques used in this assist the practi tioner in determining if a more thorough procedure are inappropriate for breast tissue. Additionally, examination is warranted. Stretching and strengthening the area cephalad to the breast is avoided due to the location of the abdominal muscles is indicated in many respiratory and postural dysfunctions, as they are often significantly involved. Additional (to NMT) assessment methods are also detailed in Volume 2 . ---- - \\..' - NMT ASSESSMENT Fig u re 1 4.27 The beveled tip pressure bar can be used in i nter­ The practitioner uses lightly lubricated gliding strokes or costal spaces except where the brachial plexus or breast tissues lie. finger friction on the anterior and lateral aspects of the infe­ rior borders and external surfaces of the 5th through 12th ribs where many of the abdominal muscles fibers a ttach. Caution is exercised regarding the often-sharp tips of the last two ribs. Palpation of the upper 2-3 inches (5-7.5 cm) of the fibers that lie over the abdominal viscera may reveal tenderness associated with trigger points or with postural distortions, such as forward slumping postures, which overapproximate these fibers and shorten them. The upper portion of rectus abdominis and the medial upper fibers of the obliques would be softened with short effleurage strokes or by stretching them manually before the treatment of the diaphragm, which will be treated through the overlying muscles. When these overlying muscles are extremely tender, NMT treatment of the diaphragm may need to be postponed until the tissues have been fully treated.

572 CLI N I CA L A P PLICATI O N OF N E U RO M USCULAR TEC H NI Q U E S : THE U PP E R B O DY When these overlying muscles are hypertonic, they may • By holding tissues in their 'loose' or ease positions and prevent penetration into the underlying diaphragm and waiting for a release (usually 30-90 seconds), the practi­ positional release or muscle energy techniques may be used tioner can encourage changes which will allow more nor­ instead or to prepare for subsequent NMT. mal diaphragmatic function, accompanied by a relaxation of associated soft tissues. � PR OF DIAPHRAGM (FIG. 1 4.28) It M ET R E LEAS E F O R D IAPH RAG M • The patient i s supine and the practitioner stands a t waist level facing cephalad and places the hands over the • The same assessment procedure is carried out as for lower thoracic structures with the fingers along the lower positional release above. However, rather than seeking rib shafts. the direction of ease for rotation and sideflexion of the thorax, the 'tight' (most restricted) directions are • Treating the structure being palpated as a cylinder, the identified. hands test the preference this cylinder has to rotate around its central axis, one way and then the other. 'Does • This time, by sidebending and rotating toward the tighter the lower thorax rotate more easily to the right or the left?' directions, the combined directions of restriction are engaged, at which time the patient is asked to inhale and • Once the rotational preference has been established, the hold the breath and to 'bear down' slightly (Valsalva preference to sidebend one way or the other is evaluated. maneuver). 'Does the lower thorax sideflex more easily to the right or the left?' • These efforts introduce isometric contractions of the diaphragm and intercostal muscles. • Once these two pieces of information have been estab­ lished, the combined positions of ease, so indicated, are • On release and complete exhalation and relaxation, introduced. the diaphragm should be found to function more normally, accompanied by a relaxation of associated soft • For example, the rotation may well be easier toward the tissues. (patient's) right. This is therefore gently introduced by the practitioner, followed, while still in that position, by I NTERIOR THORAX whichever sidebending preference was indicated during testing, possibly toward the left. D I A P H RAG M • In this way a compound (stacked) position of ease (or Attachments: Inner surfaces of lower six ribs and their bind) can be established (see functional technique discus­ costal cartilages, posterior surface of xiphoid process (or sion, Chapter 10). sternum) and the body of the upper 1--4 lumbar verte­ brae, vertebral discs and the arcuate ligaments, thereby forming a circular attachment around the entire inner surface of the thorax Innervation: Phrenic nerves (C3-5) for motor and lower 6-7 intercostal nerves for sensory (Gray's Anatomy 2005, Simons et al 1999) Muscle type: Not established Function: Principal muscle of inspiration by drawing its central tendon downward to stabilize it against the abdominal viscera at which time it lifts and spreads the lower ribs / Remember that the functional status of the diaphragm is probably the most powerful mechanism of the whole body. It not � only mechanically engages the tissues of the pharynx to the Figure 1 4.28 Hand positions for assessment of lower t horacic perineum, several times per minute, but is physiologically tissue preferences. indispensable to the activity of every cell in the body. A working knowledge of the crura, tendon, and the extensive ramification of the diaphragmatic tissues graphically depicts the significance of structural continuity and functional unity. The wealth of soft tissue work centering in the powerful mechanism is beyond compute, and clinically it is very practical. (McConnell 1 962).

14 The thorax 573 Synergists: Accessory muscles of inhalation • The lumbar part arises from two aponeurotic arches Antagonists: Elastic recoil of thoracic cavity and accessory (medial and lateral lwnbocostal arches or arcuate liga­ ments) as well as from the lumbar vertebrae by means of muscles of exhalation two crura (pillars). Indications for treatment • The lateral crus is formed from a thick fascial covering which arches over the upper aspect of quadratus lumbo­ • Dyspnea or any breathing difficulty rum, to attach medially to the anterior aspect of the trans­ • Dysfunctional breathing patterns verse process of L1 and laterally to the inferior margin of • Chronic respiratory problems (asthma, chronic cough, the 12th rib. etc.) • The medial crus is tendinous in nature and lies in the fas­ • 'Stitch in the side' with exertion cia covering psoas major. Medially it is continuous with • Chest pain the corresponding medial crus and also attaches to the • Hiccup body of L1 or L2. Laterally it attaches to the transverse process of Ll. Special notes • The crura blend with the anterior longitudinal ligament The diaphragm is a dome-shaped muscle with a central ten­ of the spine, with direct connections to the bodies and don whose fibers radiate peripherally to attach to all mar­ intervertebral d iscs of Ll, 2 and 3. gins of the lower thorax, thereby forming the floor of the thoracic cavity. It attaches higher in the front than either • The crura ascend and converge to join the central tendon. side or back. When this muscle contracts, it increases the • With attachments at the entire circumference of the tho­ vertical, transverse and anteroposterior diameter of the internal thorax (Kapandji 1974) and is therefore the most rax, ribs, xiphoid, costal cartilage, spine, discs and major important muscle in inspiration. muscles, the various components of the diaphragm form a central tendon with apertures for the vena cava, aorta, Figure 14.29 shows clearly the structural relationship thoracic duct and esophagus. between the diaphragm, psoas and quadratus lumborum. A • When all these diaphragma tic connections are considered, brief summary of some of the diaphragm's key attachments the direct influence on respiratory function of the lumbar and features indicates the complex nature of this muscle. spine and ribs as well as psoas and quadratus lumborum becomes apparent. • The sternal part of the diaphragm arises from the internal • Patients who suffer from hiatal hernia pain may find that surface of the xiphoid process (this attachment is some­ pain is reduced by treatment (and self-treatment) of the times absent). diaphragm, as well as by breathing retraining. Simons et al (1999) note that referred pain from trigger points in • The costal part arises from the internal aspects of the transversus abdominis may be confused with pain from lower six ribs, interdigitating with the transversus abdo­ those associated with the diaphragm and suggest that minis (Gray's Anatomy 2005). transversus trigger points will more likely produce pain on deep inhalation, whereas full exhalation (with added Lateral arcuate Esophageal opening compression from the abdomen near the end of exhala­ �f-- Costal margin tion) will reproduce diaphragmatic trigger point refer­ ligament --='F\"-:c� rals. They also note that diaphragmatic trigger points are �.._. � Median arcuate ligament commonly satellites of primary trigger points found in Right crus ---l'r.tf+P the ipsilateral upper rectus abdominis. ::'>'-\"'I-\"� Medial arcuate ligament �1K7''-\" Left crus � N MT FOR DIAPHRAG M ( F I G . 1 4. 3 0) �-- Quadralus lumborum The patient is supine with the knees flexed and feet resting flat on the table. This position will relax the overlying abdom­ :Sj.!!:-� Psoas major inal fibers and allow a better penetration to the diaphragm. As noted previously, the upper rectus abdominis is treated Fig u re 1 4.29 I nferior view of d iaphragm. Reproduced with before the diaphragm. The trea tment of the diaphragm is permission from Gray's Anatomy for Students (2005). contraindicated for patients with liver and gallbladder dis­ ease or if the patient's right side is significantly tender or swollen. The practitioner stands at the level of the abdomen on the contralateral side and reaches across the person to treat the opposite side of the diaphragm. The fingers, thumbs or a combination of thumb of one hand and fingers of the other may be used.

574 CLI N I CAL APPLICAT I O N OF N E U R O M U SC U LA R TECH N I QUES: T H E U PP E R B O DY The practitioner will work with the flow of the brea th, margins of the ribs and static pressure or gentle friction is sliding the palpating fingers or thumbs under the lower applied toward the diaphragm's attachment. The treatment border of the rib cage. As the patient brea thes out, the fin­ may be applied on full exhalation or at half-breath and is gers will slide further in. As the patient brea thes in, the repeated to as much of the internal costal margins as can be diaphragm will press against the treating d igit(s) and move reached . the fingers out of position unless the practi tioner resists this movement. When penetration appears to be as far as possi­ While it is uncertain if and how much of the diaphragm's ble, the finger ( thumb) tips are directed toward the inner fibers may be reached by this exercise, the connective tissue associated with its costal attachment is probably influenced. Simons et al (1999) describe a similar procedure, which ends in an anterior lifting of the rib cage ( instead of friction or static pressure) to stretch the fibers of the diaphragm. TRA N SV E R S U S T H O RACI S ( F I G . 1 4. 3 1 ) Attachments: Inner surface of the body of sternum and xiphoid process superolaterally to the lower borders of the 2nd-6th costal cartilages Innervation: Intercostal nerves (2-6) Muscle type: Not establ ished Function: Depresses the costal cartilages during exhalation, ribs 2-6 Synergists: Muscles of exhala tion Antagonists: Muscles of inhala tion Figure 1 4.30 Diaphra g m - the th u m bs or fi ng ertips press through I n dications for treatment the u pper rectus a bd o m i nis a n d under the ribs to i n fl u ence the d i a phra g m a n d associated connective tissues. • Inadequate lifting of the sternum during inhalation, if shortened • Inadequate excursion of upper ribs during exhalation ('elevated ribs'), if lax ,-- Sternohyoid Fig u re 1 4.31 Posterior view of transversus thoracis. �J--- Sternothyroid Internal intercostal --,- ltj'ljiO;ji-O!�I Internal thoracic vessels --.-- Transversus thoracicus Diaphragm H�I-;I Sternal part of diaphragm Transversus abdominis --\\- -+-- Aponeurosis of transversus abdominis

1 4 The thorax 575 Specia l notes the practitioner 's other arm or by the use of a seatbelt around the patient's iliac crest. The abdomen should be avoided as This muscle, also called the sternocostalis or triangularis ster­ an area for tills restraining contact as it is likely to be nae, lies entirely on the interior chest and is not available to uncomfortable for the patient. direct palpation. It varies considerably, not only from person to person but also from side to side in the same person (Gray's In order to stabilize the pelvis, so that the practi tioner is Anatomy 2005) and is sometimes absent (Platzer 2004). certain that the majority of rotation is taking place in the trunk, the patient should be seated at the end of a treatment Latey (1996) reports that this muscle has the ability to gen­ table, straddling it, with the back toward the end (i.e. facing erate powerful sensations, with even light contact some­ the length of the table). If the patient cannot straddle the times producing reflex contractions of the abdomen or chest treatment table, then an acceptable if less effective alterna­ with feel ings of nausea and choking, as well as anxiety, fear, tive is to have the patient seated on the edge of the table anger, laughter, sadness, weeping and other emotions. Latey (Fig. 14.32). believes that its closeness to the internal thoracic artery is probably significant since when it is contracted, it can exert Case example of thoracic S NAGs direct pressure on the artery. He believes that physiological breathing involves a rhythmical relaxation and contraction Patient. 23 years old, male, student of this muscle and that rigidity is often seen where 'control' dampens the emotions which relate to it (see Chapter 4). Complaint. Sharp stabbing pain at T4-5 during right rota­ tion. The symptoms had started 7 months previously and T H O RACIC M O B I LIZAT I O N W ITH M OV E M E NT - worsened following manipulation, 4 months previously. SNAGs M ET H O D Presentation. Active movements of the thoracic spine Mobilization with movement (MWM), the modahty in willch were restricted, with left rotation limited . Attempts to rotate joint glide/ translation (sustained natural apophyseal glide ­ left provoked a strong pain at T5, with radiation to the pos­ SNAG) is utilized to assist in pain-free mobilization of terior aspect of the ribs. Extension was limited and painful. restricted joints, is described in Chapter 1 0 . Flexion was slightly restricted . Sidebending to the right was painful. There was evidence of muscle spasm in the right An article published by Edmonston & Singer (1997) paravertebral muscles. explains: Treatment. SNAGs - rotation with slight axial traction The sustained natural apophyseal glide (SNAG) described was applied three times to the right as well as three times to by Mulligan is of particular importance in the context of the left before retesting. painful movement associated with degenerative change. In contrast to most other mobilization techniques, SNAGs are performed with the spine under normal conditions ofphysi­ ological load bearing. Further they combine elements ofactive and passive physiological movements with accessory glides along the zygoapophyseal joint plane. These techniquesfacil­ itate pain-Jree movement throughout the available range and, since movement is under control of the patients, reduce the potential problems associated with end-range passive move­ ments in degenerative motion segments. Horton (2002) published a case report of a student with acute left side back pain adjacent to the level of the TS-9 intervertebral joint. A central SNAG was applied in a cepha­ lad direction to the spinous process of TS . He concluded that the thoracic spine is ideally suited to SNAGs and there­ fore may be the treatment of choice in acute presentations of thoracic pain when the zygapophyseal joints are impli­ cated. Tills case report is illustrated and discussed below. Method Figure 1 4.32 Starting position and a pplication of modified SNAG. Reprod uced with permission from Horton (2002). Because thumb pressure is uncomfortable in tills region, and is difficult to maintain, the ulnar border of the 5th metacarpal (blade of hand) is used in contact with the vertebrae being treated (T3-12) . Patient stabilization is achieved by either

576 C LI N I CA L APPLICATI ON O F N E U R O M USCULAR TEC H N I QU ES : T H E U P P E R BODY Outcome. Mobility increased by about 50% and there was In this volume, we have discussed the foundational plat­ less pain during rotation. No change in pain was noted dur­ form of neuromuscular techniques as well as a number of ing left sidebending. The patient was sent home with self­ treatment instructions. On the following day SNAGs was supporting modalities. Step-by-step protocols have been applied to the ribs at the level of T4-5, bilaterally. offered, together with a full anatomy discussion, to assist Results. After three treatments the patient was pain-free for thoracic movement, except for slight pain at the end of the practitioner in acquiring skiUs to treat myofascial pain range. The patient received another treatment and was syndromes and dysfunctions of the upper half of the body. referred to a spinal stabilization program. One week after The reader is now referred to Volume 2 for the lower half of discharge the patient was pain free. the body and to Clinical Application of Neuromuscular Techniques: Practical Case Study Exercises for comprehensive strategies for chronic pain care. References Denslow J 1944 A n analysis of the variability of spinal reflex thresh­ olds. Journal of Neurophysiology 7:207-216 Arce C, Dohrmann G 1985 Herniated thoracic disks. Neurology Clinics 3(2):383-392 Denslow J, Korr 1, Krems A 1 947 Quantitative stud ies of c hronic facilitation in human motoneuron pools. American Journal of Beal M 1983 Palpa tory testing for somatic dysfunction in patients Physiology 150:229-238 with cardiovascular d isease. Journal of the American Osteopathic Associa tion 82:882 DiGiovanna E 1991 An osteopathic approach to diagnosis and treat­ ment. Lippincott, Philadelphia Beal M 1985 Viscerosomatic reflexes review. Journal of the American Osteopathic Association 85:786-800 Ebner M 1962 Connective tissue massage. Churchill Livingstone, Edinburgh Bogduk N 2005 Clinical anatomy of the l umbar spine and sacrum, 4th edn. Churchill Livingstone, Edinburgh Ed monston S, Singer K 1997 Thoracic spine: anatomical and biome­ chanicaI considera tions for manual therapy. Manual Therapy Bogduk N, Engel R 1984 The menisci of the lwnbar zygapophyseal 2(3):132-143 joints. A review of their anatomy and clinical significance. Spine 9(5):454-460 Elkiss M, Rentz L 1997 Neurology. In: Ward R (ed) Foundations of osteopathic medicine. Williams and Wilkins, Balti more Bogduk N, J u l l G 1984 The theoretical pa thology of acute locked back: a basis for manipulative therapy. Manual Medicine Erwin W, Jackson p, Homonko D 2000 Innervation of the human 1 : 78-82 costovertebral joint: implications for c linical back pain syn­ dromes. Journal of Manipulative and Physiological Therapeutics Boyle J 1999 Is the pain and dysfunc tion of shoulder impingement 23(6) :395-403 lesion rea lly second rib syndrome in disguise? Two case reports. Manual Therapy 4(1) :44-48 Fitzmaurice R 1992 A histo-morphometric comparison of muscle biopsies from normal subjects and pa tients with ankylosing Brismee J-M, Gipson D, Ivie D et al 2006 In terrater reliability of a spondyli tis and severe mechanical low back pain. Journal of passive physiological intervertebral motion test in the mid-tho­ Pathology 163:182 racic spine. Journal of Manipulative and Physiological Therapeutics 29(5):368-3- 73 Fryer G, Morris T, Gibbons P 2004 Paraspinal muscles and interver­ Brugger A 2000 Lehrbuch der Funk tionellen Storungen des tebral d ysfunction: part one. Journal of Manipulative and Bewegungssystems. Brugger-Verlag, Zollikon Benglen Physiological Therapeutics 27:267-274 Gaymans F 1980 Die bedeutung der a temtypen fur Mobilisation der Caso M 2004 Evaluation of Chapman's neurolymphatic reflexes via Wirbelsaule. Manuelle Medizin 18:96 applied kinesiology: a case report of low back pain and congeni­ Gracovetsky S 1997 A theory of human gait. In: Vleeming A, tal intestinal abnormality. Journal of Manipulative and Physiological Therapeutics 27(1):66 Mooney V, Sjniders C, Dorman T, Stoekart R (eds) Movement, Chaitow L 2002 Positional release techniques, 2nd edn. Churchill stability and low back pain. Churchill Liv ingstone, London Livingstone, E d inburgh Gray's anatomy 2005 (39th edn) Churchill Liv ingstone, Chaitow l 2003 Modern neuromusc ular techniques, 2nd edn. Edinburgh Churchill Livingstone, Edinburgh Gray's anatomy for students 2005 ChurchilJ Livingstone� Edinburgh Grice A 1980 A biomechanical approach to cervical and thoracic Chila A 1997 Fascial-ligamentous release. In: Ward R (ed) Foundations of osteopathic medicine. Williams and Wilkins, adjusting. In: Haldeman S (ed) Modern developments in the Baltimore principles and prac tice of chiropractic. Appleton-Centu ry-Crofts, New York Christensen H, Vach W, Vach K 2002 Palpation of the upper thoracic Grieve G 1981 Common vertebral joint problems. Churchill spine: an observer reliability s tudy. Journal of Manipulative and livingstone, New York Physiological Therapeu tics 25(5):285-292 Grieve G 1988 Common vertebral joint problems, 2nd edn. Churchill Livingstone, Edinburgh Coffee J 2006a Is chronic hyperventilation syndrome a risk factor Hides J, Stokes M, Saide M et a1 1994 Evidence of lumbar multi­ for sleep apnea? Part 1. Journal of Bodywork and Movement fidus muscle wasting ipsilateral to symptoms in pa tients with Therapies 10(2):134-146 acute/subacute low back pain. Spine 1 9 : 1 65-172 Hoag M 1969 Osteopathic medicine. McGraw-Hill, New York Coffee J 2006b Is c hronic hyperventilation syndrome a risk factor Hodges P 1999 Is there a role for transversus abdominis in lumbo­ for sleep apnea? Part 2. Journal of Bodywork and Movement pelvic stability? Manual Therapy 4(2):74-86 Therapies 10(2):134-146 Delany J 2003 American neuromuscular therapy. In: Chaitow L (ed) Modern neuromuscular techniques, 2nd edn. Churchill Livingstone, Edinb urgh

1 4 The thorax 577 Hodges P, Richardson C 1997 Feedforward contraction of transver­ Norris C M 1995c Spinal stabilisation. 3. Stabilisation mechanisms sus abdomirtis is not infl uenced by direction of arm movement. of the lumbar spine. Physiotherapy 81 (2):72-79 Experimental Brain Research 1 1 4:362-370 Norris C M 1995d Spinal stabilisation. 4. Muscle imbalance and the Horton S 2002 Acute locked thoracic spine: treatment with a modi­ low back. Physiotherapy 81(3):1 27-138 fied SNAG. Manual Therapy 7(2):103-107 Norris C M 1995e Spinal stabilisation. 5. An exercise program to Hruby R, Goodridge L Jones J 1997 Thoracic region and rib cage. In: enhance lumbar stabilisation. Physiotherapy 8 1 (3):138--1 46 Ward R (ed) Foundations of osteopathic medicine. Williams and Norris C M 1998 Sports injuries, diagnosis and management, 2nd Wilkins, Baltimore edn. Butterworths, London Janda V 1983 Muscle function testing. Butterworths, London Jirout J 1969 Movement d iagnostics by X-ray in the cervical spine. Norris C M 1999 Flmctional load abdominal training. Journal of Manuelle Medizin 7:121-128 Bodywork and Movement Therapies 3(3) : 1 50--1 58 Kapandji I 1974 The physiology of the joints, vol. III, 2nd eM. Churchill Livingstone, Edinburgh Owens C 1980 An endocrine interpretation of Chapman's reflexes. Korr I 1970 The physiological basis of osteopathic medic ine. American Academy of Osteopathy, Newark, OH Postgraduate Institute of Osteopathic Medicine and Surgery, New York Parkkola R 1993 Magnetic resonance imaging of the discs and Korr I 1 976 The spinal cord as organiser of disease processes. trunk muscles in patients with chronic low back pain. Spine Journal of the American Osteopathic Association 76:35-45 1 8 : 830-836 Kurz 1 1986 Tex tbook of Dr Vodder's manual lymph drainage, vol 2: therapy, 2nd edn. Karl F Haug, Heidelberg Platzer W 2004 Color atlas/text of human anatomy: vol 1 , locomo­ Kurz I 1987 Introduction to Dr Vodder's manual lymph drainage, tor system, 5th edn. Georg Thieme, Stuttgart vol 3: therapy I I ( treatment manual). Karl F Haug, Heidelberg Latey P 1996 Feelings, muscles and movement. Journal of Ponsetti I 1972 Biomechanical analysis of intervertebral discs and Bodywork and Movement Therapies 1 (1 ):44-52 idiopathic scoliosis. Journal of Bone and Joint Surgery 54:1 993 Lehto M, Hurme M, Alaranta H 1989 Connective tissue changes in the multifidus muscle in patients with lumbar disc herniation. Puckree T, Cerny F, Bishop B 2002 Does intercostal stretch alter Spine 1 4:302-309 Lewit K 1999 Manipulative therapy in rehabilita tion of the motor breathing pa ttern and resp iratory muscle activity in conscious system, 3rd edn. Butterworths, London adul ts? Physiotherapy 88(2):89-97 Liebenson C 1996 Rehabilitation of the spine. Williams and Wilkins, Richardson C, Jull G 1995 Muscle control - pain control. Manual Baltimore Therapy 1 ( 1 ):2-10 Maigne J 1991 Upper thoracic dorsal rami. Surgical and Serizawe K 1980 Tsubo: vital pOints for Oriental therapy. Japan Radiological Anatomy 13:109-1 1 2 Publishing, Tokyo Maitland G 1986 Vertebral manipula tion, 5th edn. Butterworths, London Simons D, Travell j, Simons L 1999 Myofascial p ain and dysfunc­ Mann F 1971 Meridians of acupuncture. Heinemann Medical Books, London tion: the trigger point manual, vol 1 : upper ha l f of body, 2nd Mannino J 1979 Application of neurologic reflexes to treatment of eM. Williams and Wilkins, Baltimore hypertension. Journal of the American Osteopathic Association Singer K P, Giles L G, Day R E 1990 Intra-articular synovial folds of 79:4 thoracol umbar j unction zygapophyseal joints. Ana tomical McConnell C 1962 Yearbook. Osteopa thic Institute of Applied Record 226:1 47-152 Technique, Newark, OH, p 75-78 Solomonow M, Zhou B, Harris M et al 1998 The ligamento-muscu­ Melzack R 1977 Trigger points and acupuncture points of pain. Pain lar stabilizing system of the spine. Spine 3:2552-2562 3:3-23 Testa M 2006 Letters to the Editor. Manual Therapy 1 1 : 83-84 Michelson J 1965 Development of spinal deformity in experimental Timmons B 1994 Behavioral and psychological approaches to scoliosis. Acta Orthopaedica Scandinavica 81 (suppl) breathing d isorders. Plenum Press, New York Morrison M 1969 Lecture notes. Research Society for Naturopa thy, Tro ke M, Moore A, Cheek E 1998 Reliability of the OSI CA 6000 London Spine Motion Analyzer with a new skin fixation system when Myers T 1997 Anatomy trains. Journal of Bodywork and Movement used on the thoracic spine. Manual Therapy 3(1):27-33 Therapies 1 (2):91-101 Tucker A 1994 Shoulder pain in a football player. Med icine and Nichols A 1996 Thoracic outlet syndrome in athletes. Journal of the Science in Sports and Exercise 26(3):281-284 American Board of Family Practice 9(5):346-355 Upledger J, Vredevoogd W 1983 Craniosacral thera py. Eastland Norris C M 1995a Spinal stabilisation. 1 . Active lumbar stabilisation Press, Seattle - concepts. Physiotherapy 81 (2):61-64 ViJensky J, Bal tes M, Weikel L et al 2001 Serratus posterior muscles: Norris C M 1995b Spinal stabilisation. 2. Limiting factors to end­ ana tomy, clinical relevance, and function. Clinical Anatomy range motion in the l umbar spine. Physiotherapy 8 1 (2):64-72 14(4):237-241 Walther D 1988 App lied kinesiology. Systems DC, Pueblo, CO Washington K, Mosiello R, Vend itto M et al 2003 Presence of Chapman reflex points in hospitalized pa tients with pneumonia. Journal of the American Osteopathic Association 103(10): 479-483 White A, Panjabi M 1978 Clinical biomechanics of the spine. Lippincott, Baltimore Yamada K 1971 A neurological approach to etiology a n d treatment of scoliosis. Journal of Bone and Joint Surgery 53A:197

579 I n dex Page numbers in bold refer to boxes, to habits of use, 67 Anterior deltoid, 413, 415 illustrations and tables to trauma, 67 Anterior forearm, 513-522 A d d u c tion A arm, 489 deep muscles, 517 coracobrachialis, 481 NMT for, 5 1 8-519, 518 Abdominal muscles, 551, 571 metacarpophalangeal joints, 510 superficial layer, 514 NMT assessment, 571-572 Patrick's test, 358 trigger points, 514 pectoralis major, 473, 474 Anterior longi tudinal ligament, 251, 253 Abduction, 478 shoulder, 4 1 1 , 412, 478 Anterior neck m uscles, MET for, 299-300, 300 a rm, 489 Adduction restriction, shou lder, 424 Anterior sternoclavicular ligament, 407 bilateral, 412 MET for, 428 Anterior thorax, 550-557 coracobrachial is, 481 PRT for, 428 Antidiuretic hormone (ADH), 132 glenohumeral, 444 Add uctor pollicis, 530-531 Antiinflammatory stra tegies, 130, 167, humeral, 445 Adenosine triphosphate (ATP), 26, 27, 1 00, metacarpophalangeal joints, 511 168-170 pectora lis major, 472, 474 m, 112, 179 nutrients, 129-130 shoulder, 4 1 1 , 4 1 2, 449 energy production, 28, 75 techniques, 470 teres minor, 455 synthesis, 130 Apical ligament, 251 test for hips, 90, 90 Adhesive capsulitis, 402 Apley scratch test, 408, 417-418 Adiponectin (AD), 137 Apoptosis, 146 Abduction restriction, shou lder, 424 Ad ipose tissue, 140 Apoxia see Hypoxia MET for, 427, 428 Adrenal glands, 132 Applied compression, 183 P RT for, 428 Adrenaline, 135, 136 Applied pressure, 383 Adrenocorticotropin (ACTH), 132 Apprehension test, 408 Abductor pollicis brevis, 531 Adson's test for subclavian artery 'Arcade of Struthers', 489 Abductor pollicis longus, 527-528 Ardnt-Sch u l tz's law, 3 Accessory atlantoaxial ligaments, 251 compression, 257 Arm Acetyl-L-carnitine (ALC), 139 Adverse mechanical tensions (AMT), adduction, 484 Acetylcholine (ACh), 1 00, 111 extensor, 54 Acid glycosaminoglycans (AGAGs), 4 223-230 flexor, 54 Acromioclavicular (AC) jOint, 403, 425 Agonists, 35, 267, 413 muscles, 461 Agouti, 137 pectoralis major, 473 MET for, 426 'Ah shi' acupuncture points, 10, 207 range of motion, 411 Acromioc lavicular ligament, 405 Alar ligament, 251 and shoulder pain, 475 Actin, 26-27 Algometers, 117, 117, 118, 1 89-190, 190 see also Forearm Active isolated s tretching (ArS), 236 Alkalosis see Respira tory alkalosis Arthritis, 529 Acture, 248 Allergic myalgia, 168 Arthrography, 407 Acupuncture, 120, 359, 507 Allodyrtia, 144 Articular capsule, wrist, 502 Allostasis, 56 Articulation points, 8, 9-10, 9, 10, 207 Anaerobic energy (ATP) pathways, 28 mobilization and, 217-218 trigger points and, 207 'Anatomy trains', 567 movements, 267 Acute conditions Anconeus, 449-452, 493-494 Assessment definition, 254 NMT framework, 196 inflammation, 1 28, 128 NMT for, 453, 494 protocols, 189-190, 189 injury, 181-182 Anconeus epitrochlearis, 490 tools, 189-190 Acute response (lag) phase, 126 Annular fibers, 244 Atherosclerotic cardiovascu lar disease, Adaptation, 141 Annular ligament of radius, 487 GAS and LAS, 63-64, 64 Annular mertisci, 541 138 posture a nd respiratory function, 64-67 Ann ulus fibrosus, 246, 253 Atlantoepistrophic ligament, 251 slow, 66-67 Antagonists, 35, 37, 267

580 I N D EX Atlantooccipital jOint, 256, 269, 313 Biomechanics, 68, 162-163 Calcium, 100, 139 see also Occipitoa tlantal area cervical, 255 Cancer recovery therapy, 470 insult, 141 Cantu & Grodin Atlantooccipital ligament, 251 laws, 3 Atlas (CI), 248-249, 249, 321 'looseness and tightness', 163-165 deformation characteristics, 6 Atrophy, muscle, 409 shoulder, 409-41 0 fascial dysfunction, 1 6 thoracic spine rotation, 546-547 therapeutic sequencing, 1 9 and chronic back pain, 39 trigger points, 178-179 Capitis, 256 Attachment trigger points (ATrPs), 100, 112, upper chest breathing, 77-78 Capsular liga ments, 251, 511 Capsu le, wrist, 501-502, 501 189, 448 Biopsychosocial model of rehabilitation, Capsulitis, 417 Auditory canal, 346 1 72-173 adhesive, 402 Auditory tube see Eustachian tube Carbon Dioxide (C02), 75 Auricular muscles, 254, 352, 354 Bipennate muscle fibers, 27 loss of, 77 Au ricularis superior, 344 Bitemporal rolling exercise, 347, 347 'Cardiac arrhythmia' trigger points, 472, 472 Au togenic inhibition, 50 Blackbur, Trager®-style approach, 232 Carnosine, 139 Autogenic training, 231 Blood supply Carotid artery, 307, 307 Awad's analysis of trigger points, 109 Ca rpal tunnel syndrome (CTS), 489, 497, Axis (C2), 249-250, 249 to head, 256, 259 Axis-atlas joint, 256 to muscles, 28-29 507-508 Bohr effect, 32, 149 PRT for, 521 B Bolus, 387 tests for, 509 Boyle see also Median nerve, entrapment Babies, newborn, 388 ribs and shoulder pain, 556 Carpi muscles, 513 Back of the arm lines, Myers', 12 2nd rib restrictions, 412-413 Carpometacarpal ligaments, 509-51 0 Back line, M yers' superficial, 11 Bracelet test, 508 Cathie, trigger 'spots', 8 Balaban & Theyer, ba lance control and Brachial plexus, 256, 314 Central nervous subsystem, 31, 67 Brachial pulse, 410 Central nervous system (CNS) anxiety, 74 Brachialis, 54, 480, 493 diseases of, 146 Balance, 24, 74-75, 370 NMT for, 493, 493 signals to muscles, 25 Ballistic movement, 37, 236 Brachioradialis, 494 trigger points and, 8-13 Barbagallo, magnesium and insulin, 130 assessment, 494-495 Central trigger pOints (CTrPs), 101, 112, Barnes, John, MFR, 221, 466 MFR for, 495 Barnes, Mark NMT for, 495 187-188 reflex, 411, 487-488 anterior forea rm, 519 fascial restrictions, 16 Bradley infraspinatus, 448 ground substance, 1 7 key trigger pOints, 110 levator scapula, 437 MFR, 222, 466 pain management, 171 pectoralis major, 471 Bates method, 394-395 Brain electricity activity mapping (BEAM), posterior forearm, 526 Becker, soma tizers, 152-153 teres major, 457 Behavior and persona lity, 71-72 56 thumb muscles, 528 hardiness, 72 Breast cance� 469-470 trapezius attachments, 434 life events, 71 Breathing Centralization mechanisms, 58-59 stages of change in, 171 Cerebral insu fficiency, 257 type A personality, 71-72 cooperation, 218-219 Cerebrospinal fluid (CSF), 373 Bending loading, 166 pattern assessments, 92-94 Cervical column, head balance, 302 Bennett, physical exercise, 172 unbalanced, 149-150 Cervical lamina Beveled-tip pressure bars wave, 93, 547, 548, 548 NMT for, 320, 320 hand, 534 see also Respiratory function prone, 319-320 shoulder, 434, 446, 448, 459 Buccinator, 350, 356, 386 Cervical region, 243-321 thorax, 565-566, 566, 571, 571 Buccolabial muscles, 351-352, 357 assessment, 253-273 Biceps, 413, 480 Buccolabial region, 356-3- 57, 357 circulatory features, 256, 2 57, 259 reflex, 411, 487 NMT for, 357, 357 flexor muscles, 40 Biceps brachii, 482-483 Bucket handle motion, 554, 555 functional features, 255-256 assessment, 483 Bucklew, goal setting and pacing, 172 intervertebral foramina, 256 MET for, 484, 484 Bursitis, 417 landmarks, 255 NMT for, 483-484, 483, 484 B utler & Moseley, nociceptors, 46 ligaments, 251-253 PRT for, 485 muscle strength tests, 260, 262-266, 263 Biceps tendon dysfunction, MET for, 484, 484 c muscular and fascial features, 256 Bicipital tendinitis, 4 1 8-419, 418 neurological features, 256 Bidirectional transverse friction, 320 C-curve observation test, 547 planes and layers, 274-275 Biedermann, 'KISS' children, 388-389 Caffeine, 150-151, 150 posterior see Posterior cervical region 'Bind', 1 63 Cailliet receptors, 51 Bindegewebsmassage, 183, 185 sequencing treatment, 273-321 Biochemical perspectives coHagen, 17 symmetry of movement palpation, 262-264 influences on health, 68 disk nutrition, 247 upper see Upper cervical region neurosomatic disorders and, 55-57 forward head posture, 247 Cervical spine, 246, 546 nutrition, 169-170 lateral epicondyle, 522-523 assessment, 260, 262-266 posture, 245 and pain, 167-170 temporal arteritis, 366 becoming treatment, 266-2- 68 terms relating to fascia, 3 temporomandibular joint (TM]), 362

Index 581 biomechanics, 255 crosslinkage, 128 sliding filament theory, 26-2- 7 dysfunction, 257-259, 259 fibers, 7, 15 voluntary / involuntary, 33, 38 Collateral ligaments, 510 Contracture, muscle, 38 tests for, 260, 262-266 Colloids, 5 Control, 72 functional features, 255-256 and fascia, 2-3 Coracoacromial ligament, 406 functional units, 248-250, 248, 249, 250 Combined loading, 167 Coracobrachialis, 413, 479, 480 Ligaments, 251-253 Comeaux, facilita ted oscillatory release assessment, 479, 481 mobilization, 272-273 MFR for, 481, 481 (FOR), 231, 232 NMT for, 481, 481 with movement (MWM), 288 'Comfort position', 265 PRT for, 481-482 movements, 250-253, 251, 264 Commitment, 72 Coracoclavicular ligament, 405 muscular and fascial features, 256 Common compensatory pattern (CCP), Coracohumeral ligament, 406 neurological features, 256 Core stability, 75-7- 6 rotation, 288 266 'Corkscrew technique', 285 translation assessment, 269-279, 270 Complex regional pain syndrome (CRPS), Coronoid process, 333 treatment, 266-2- 68 Corrugator supercilii, 342, 355, 356 144 Cortisol, 137 choices, 270-273 Compliance Costal facets, 248 vertebral coluIlU1, 244-250, 244 Costoclavicular liga ment, 407 Cerv icogenic headache (CGH), 252 of muscle, 87 Costotubercular facets, 248 Rectus capitis posterior minor (RCPMin) see also Concordance ___ Costovertebral jOint, 403 Compression, 24 C:ounterstrain, 226, 227 and, 252-253 atlantooccipital joint, 269 see aIso Strain/counterstrain Cerv icothoracic area, 265 biceps brachii, 483 Coupling brachialis, 493 cervical spine, 251, 255, 546 tissue preference, 18-19 brachioradialis, 495 posterior thorax, 542, 547 Chain reactions cervical region, 257-258, 303, 308 segmental, 558-560 deltoid, 443 thoracic spine, 546 facial/jaw pain, 84 infraspinatus, 448 Cozen's test (tennis elbow), 492 shoulder dysfunction, 416 ischemic, 29, 121, 1 94--195, 195, 215 Cranial attaclunents, posteri<lJ:,. NMT for, Challenge, 72 loading, 166 Chemoreceptors, 46 palmar and dorsal hand, 533 320-321, 321 Chikly, lymphatic drainage, 212 pincer, 1 86--187, 186, 302 Cranial base release, 296 Chila, respiration function, 550 and rolling technique, 356 Cranial manipu lation, 359 Children techniques, 1 85-187, 186 Cranial nerves, 334, 336 cranial ca re, 390-392 temporomandibular joint (TMJ), 364 Cranial structure, 326-3- 51, 327, 329 see also Infants tender nodule, 118 Chilling techniques, 120 teres major, 457 bone groupings, 328 Chin protrusion, 553 teres minor, 454 ethmoid, 335-3- 36, 335, 336 Chondroglossus, 382 thenar eminence, 533 frontal bone, 340-343, 341, 342 Chronic conditions trigger points, 112, 119 mandible, 337-340, 337 fatigue synd rome, 210 see also Flat compression maxillae, 35, 349-350, 349 postural stress, 53 Computed tomographic (CT) scanning, occiput, 328-332, 328 pulmonary disease, 417 palatines, 350-351, 351 regional pain syndrome (CRPS), 57 407 parietals, 343-344, 343, 345 Chronic pain Concordance, 173 reCiprocal tension memb ranes, 333 back, 39 sphenoid, 332-335, 332, 335 management, 154 patient advice and, 1 73-174 temporals, 344-347, 346 mechanisms of, 1 26-1- 27 Conductive tissue, 224 terminology, 326 NMT and, 182 Congenital factors, 65 vomer, 336-3- 37 referred muscu lar, research, 98-100 Conjugated linoleic acid (CLA), 139 zygomae, 347-349, 348 Circular muscle fibers, 27 Connective tissue, 4-5- , 224 Cranial treatment, infants, 387-388, 388 Circulatory hypothesis, 227 Cranial-to-caudal friction, 320 Circumd uction definition, 1 Craniocervical link, 388-389 capability with compression, 424, 427 deformation characteristics, 6--7 Craniofacial muscles, 351-352 capability with traction, 424, 427 disorders, 8 Craniomandibular muscles, 365-366 metacarpophalangeal jOints, 511 gel and sol viscosity, 1 7 intraoral palpation, 372 PRT for pain or restriction, 428 hypermobility, 7-8 Creep, 3, 5-6, 221 shoulder, 411 Langevin's research, 9-1 1 , 13 Cricoid cartilage, 308, 312 Circumorbital muscles, 351-352, 355 massage, 1 83, 185 Crista galli, 335 Clarkson, exposure to mercury, 144 as 'sponge', 6 Cross-arm test, 408 Clavicle summary of function, 13-14, 16 Crossed synd rome, 82, 1 62, 409 assessment, 425 trauma and, 17, 19 C rossfiber strumming, 436 attaclunent, 303 Conoid ligament, 406 Crossta Lk, 57-58 head, 413 Contemplation stage of behavior, 171 Cruciate ligament, 251 'Clenched fists', 69-71 Contraction Cryotherapy see Hot and cold applications; 'Clunk' sign, 408 emotional, 69-70 Co-contraction, 54--55, 218 isokinetic, 221 Ice applications Coffee, 150-151 isometric, 33, 199, 219-220, 273, 446, 460 Cytochrome oxidase enzyme, 1 67-168 Cold applications, hot and, 154, 185 isotonic concentric, 33, 220 Collagen, 4-5- isotonic eccentric, 200 continuity, 2 muscle tone and, 33-34 patterns, 69

582 I N DEX D Dommerholt Effleurage, 179, 184, 189, 213, 215-216, 562 chronic regional pain syndrome, 57 see also Gliding techniques Daniels & Worthington, muscle strength, whiplash, 261-262 259-260, 262 Ehlers-Danlos syndrome, 8 Dorsal intercarpal ligament, 502 Davila & Johnston-Jones, 'stiff elbow', 492 Dorsal interossei, 532 Ehrlich, antiinflammatory medication, 130 Decompression Dorsal ligament, 511 Eicosapentenoic acid (EPA), 129, 170 Dorsa l radiocarpal ligament, 502 Elasticity, 3, 5--6, 120, 121 cervical spinal dysfunction, 257-258 'Double-thumb' technique Elbow, 4 85-9-4 8 frontal bone, 342 Deep diagonal cervical muscles, 281 brachialis, 493 dysfunction, 503 Deep front line, Myers', 12 triceps, 494 evaluation, 487--488 Deep heat, upper trapezius, 121 Drag, 3 extension, 452, 484 Deep posterior forea rm, 522 Drop-arm test, 408, 4 18 injuries, 127 Deep transverse ligaments, 510 Dry needling, 154 joint capsule, 486, 487 Defeo & Hicks, common compensatory posterior forearm, 526 Dupuytres's contracture, 514-515 ligaments, 486-84-7, 487 pattern (CCP), 266 Dvorak & Dvorak, radicular pain, 142 motion, range of, 488-84- 9 Deformation, 3 'Dynamic equilibriLUTI', 212 muscles of, 438 Deformational plagiocephaly, 389-390 Dynamic neutral, a tlantooccipital joint, 269 strains and sprains, 489 Degenerative processes, 129 Dysfunction strength tests, 488 DegfutihQ[!, 386-387 biceps tendon, 484, 484 stress tests, 488--489 DeHart, m u l tiple chemical sensitivity (MCS), cervical spine, 257-259, 259, 260, 262-266 structure and function, 485-4-87 chronic soft tissue, 214 surgery, 492--493 148-149 circulatory, 257 treatment, 485, 493--498 Deltoid, 441--442, 442 components, 177 elbow, 498--493, 503 indications for, 489--493 anterior, 413, 415 endplate, 100, 100 Electromagnetic receptors, 46 inflammation, 442 eyes, 393-394 Electromyography (EMG) NMT for, 443, 443 fascia, 16-17 trigger points, 441 forearm, 503 muscle pain and, 33, 38, 40, 110-111 Dens, 249, 249 infraspinatus, 447--448 Dental amalgam fillings, mercury, 145 latissimus dorsi, 458--459 needle, 116 Dentate l igaments, 251 muscle spindle, 110 surface, 116-117 Depression, shoulder, 4 1 1 musculoskeletal, causes, 63-79 Elevation, 128 Depressor a nguli oris, 356 neuromuscular, injury and, 51 shoulder, 411, 4 1 2 Depressor labii inferioris, 356 non-treatment of, 40--41 , 151-154 E l liott, systemiC inflamma tion, 134-135 Depressor septi, 350 organ, trigger points, 106-108 Emotiona l influences, 41, 65, 69-73, 78 Derangement syndrome, 214-215 postural, 469 behavior and personality, 71-72 Diabetes mellitus, 417 proprioception, 52-53 ca utions, 72-73 Diaphragm, 293, 572-573, 573 shoulder, 4 1 7--420 contractions, 69-70 brea thing, 551-552, 553 soft tissue, 166--167, 214 'middle fist' functions, 70 core stability and, 32 subscapularis, 462 problems, 109, 374 MET for, 572 supraspinatus, 446 ' upper fist' functions, 70-71 NMT for, 573-574, 574 temporomandibular joint (TMD), 306, 359, Encircling patterns, 1 65 postural imbalance and, 73-75 End-feel, 163, 217 pressure release for, 572, 572 359-365, 361-362, 374 Endocrine system, 132 tone, 75 three-dimensional pa tterns, 165-166 Endorphins, 132 DiClementi & Prochaska, stages of change in wrist, 503, 521 Endplates, 244 see also Patterns of dysfunction dysfunction, 100 behavior, 171 noise (EPN), 111, 116, 1 1 8 Diet-related metabolic imbalances, 131 E Energy crisis, 65-66 Digastric, 338, 369, 371, 384 theory, 1 11 Eagle's syndrome, 370 attachment, 372 Ear, 51, 370 Energy production, 27, 28 trigger points, 385 Enkephalins, 132 Digest a/ Chiropractic Economics, 1 1 0 bones of, 328 Enthesitis, definition, 492 Digital flexors, 516 disease, 390-391 , 391 Digital pressure, 120 grasping cartilage, 354-355 'Environmental illness', 148 Digiti minimi, 513 'Ease' Environmenta l mercury levels, 145, 145-146 Digitorum muscles, 513 cervical region, 265, 269, 271 Epicondylalgia, 127 Direct techniques, 1 66 therapeutic techniques, 197, 225, 226, 227, Epicondylar region inhibitory pressure, 154 manual pressure, 166 229 pain, 416 manllal variations, 166 thorax, 566, 572 palpation, 526 palpa tion, 454, 454 tight-loose concept, 163, 164 Epicondyles, assessment, 486, 486 'Discomfort scale', 183 see also Tissue preference Epicondylitis, 127 Discs, 246-247, 259 assessment, 492 NMT and, 312 Eating see Mastication, muscles of structure, 244, 244, 248, 541 Epicondylosis, 127 Distal crossed syndrome see Lower crossed Edema, 65 Epicranial aponeurosis, 354 Edmonston & Singer, SNAGs, 575 Epicranial muscles, 351-352 syndrome NMT for, 354-355 EqUilibrium, 24, 74-75, 370 Erector spinae, 280-281, 557, 559, 561 Ernst, relaxation, 231 Esophagus, 387

Index 583 Eth01oid, 335-336, 335, 336 Fascia shoulder, 411, 449, 455 Eustachian tube, 380, 381 biochemical ter01s, 3 sphenobasilar, 331 Exaggeration of distortion, PRT, 227 collagenous continuity, 2 sphenoid, 333 Exa01ination findings, 153 colloids and, 2-3 thorax, 540, 542, 548 Excitability of O1uscJes, 33 definition, 1 triceps, 494 Excitotoxicity, 146 dysfunction, 1 6-17 see also Lateral flexion Exercise, physica l, 139, 172 features, cervical region, 256 Flexion restriction, shoulder, 424 Exhalation O1uscles, 550 Langevin's research, 9-11, 13 Expression, O1uscles of see Mi01etic O1uscles lines, continuity, 13 MET for, 427 Extension 010bi l ity, 120 PRT for, 427 Myers' fascial trains, 11-13 Flexion!extension, 558 ar01, 473 myofibroblasts, 181-182 h umeroradial joint, 485-486 atlantooccipital jOint, 269 network, 2 h U 01eroulnar joint, 485-486 aXis-atlas joint, 256 plastic and elastic features, 3, 5-6 Flexor carpi radialis, 515 cervica l region, 250, 255, 262, 264, 272, 313 postural patterns, 1 8-19, 264-266 Flexor carpi u lnaris, 515 craniu01, 293, 304, 333, 346 proprioception and, 2, 46-47 Flexor digitorum profund us, 516, 517, 518 elbow, 488 s0100th O1uscle cell within, 6 Flexor digitoru01 superficialis, 515, 516 interphalangeal joints, 511 summary of function, 1 3-14, 16 Flexor pollicis brevis, 531 longus ca pitis, 312 trigger points and nervous system, 8-13 Flexor poll icis longus, 516-517 O1etacarpophalangeal joints, 510, 510 neck, 295, 304 Fiber Floating ribs, 541, 554 occiput, 269 'Flushing' of tissues, 1 96, 565 shoulder, 411, 478 dietary, 170 Focal hand dystonia (FHd), 503-504 sphenobasi lar, 330-331 see also Muscle fibers 'Focus of disturbance', 223 subscapularis, 464 Fibromyalgia syndrome (FMS), 103-104, 117, Folic acid, 167 thoracic, 542, 540 Follicle-stimulating hor01one (FSH), 132 vertebra, 548 117, 210 Foramen, 259 Extension restriction, shoulder, 423-424 O1yofascial pain and, 105, 105 Foramen transversariu01, 250, 250 MET for, 427 whiplash as trigger for, 256 Forearm, 498, 499, 499 PRT for, 427 Fibrosis, MFR for, 521-522 Extensor carpi radialis brevis, 523 dysfunction, 503 Extensor carpi radialis longus, 523 Fibrotic scar tissue hypothesis, 110 flexors, MET for, 519, 519, 521 Extensor carpi ulnaris, 524 Fine-tuning methods, coracobrachialis, 482 muscles, 512-513 Extensor digiti O1inimi, 525 Finger Extensor digitoru01, 524-525, 524 preparing for treatment, 511-513 Extensor indicis, 528 flat pad pressure, 477 terminology, 512-513 Extensor pollicis brevis, 528, 531 flexors, 516 see also Anterior forear01; Posterior Extensor pollicis longus, 528, 531 friction External auditory O1eatus, 391 forearm Extra-ocular O1uscJes, 394 triceps, 494 Extracellular O1atrix (ECM), 181 triceps tendon, 452 Forehead, rotation on hindhead, 391 Eyes joint, 520 Forward head posture, 247, 293, 362-363, O1uscles of, 392-395 NMT strokes, 569 techniques, 355 technique, Lief's, 193-194, 193 364, 469 see also Palpebral region trigger, 516 Fourth (deep) cervical plane, 274 Fink, occlusal interference, 358 Friction F Fish oil, 139, 170 cervical region, 308, 320 Face Fixator role, 37 coracobrachialis, 481 bones, 328 'Flapping test', 87 craniu 01, 354, 356, 367, 369 O1uscles, 357 Flat compression deltoid, 443 pain, 84 infraspinatus, 448 infraspinatus, 449 latissi01us dorsi, 459 Facet joints, 540-541 palmar and dorsal hand, 533 palmar and dorsal hand, 533 Facet syndro01e, 259 trapezius attachments, 434 pectoralis major, 472 Facilitated oscillatory release (FOR), 231-232 upper trapezius, 432 pectoralis minor, 476 Facilitated positional release (FPR), 229-230 prolotherapy and, 130-131 Facilitated stretching, 235 Flat palpation, 1 85-186, 186 rhomboids, 440 Facilitation, 105-109 deltoid, 443 serratus anterior, 466 lower trapezius, 434 teres major, 457 local in O1uscles, 108 teres minor, 454, 455 neural-threshold and, 109 palO1ar and dorsal hand, 533 thorax, 566, 571 spinal area, 108 for rhomboids, 439 trapezius attachments, 434 trigger points and organ dysfunction, Flexion, 478 Froment's test, 508 atlantooccipital joint, 269 Front of the arm lines, Myers', 12-13 106-108 axis-atlas joint, 256 Front line, Myers' superficial, 11-12 False joint, 401 biceps brachii, 484 Frontal bone, 340-343, 341, 354, 372 False-positive cOO1pression test, 412-413 cervical region, 250-251, 255, 262, 263, 290, decompression treatment, 342 Falx cerebri, 335, 341, 343, 344 Frontooccipital hold, 330, 331 293, 295 elbow, 488 Frozen shoulder syndrome, 402, 417, 462 frontal bone, 342 Fuller, tensegrity, 23, 245 interphalangeal joints, 511 O1etacarpophalangeal joints, 510, 510 Functional pathologies, 400 neck, 438 Functional screening sequence, Janda's, occipitoatlantal restriction, 269 occipitosphenoida l junction, 330 88-92, 410

584 I N D EX Functional teclmique, 228-229, 229 H principles of, 206 atlantooccipital joint release, 269 sitz baths, 210 cervical spine dysfunction, 267 Habits of use warming compress, 206-208 rehabilitation tasks, 172 adaptation to, 67 Hot packs, 154 patterns of dysfunction from, 84-85 'Hot-spots', thermographic, 117 Fusi form muscle fibers, 25 Hou, ischemic compression, 121 Hair Hruby G shafts, 354 facet j oints, 540 traction teclmiques, 354 red reflex assessment, 546 Ganglion, 506-507 thoracic coupling, 558 Garland, breathing patterns, 77-78 Halpern, What's in a Name? Are MSG and Hubbard & Berkoff, dysfunctional muscle GAS and LAS, 63--64, 64 Umami the Same?, 147 Gate theory of pain, 52 spindle, 110 Gel and sol, connective tissue viscosity' 'Hammerlock' position, teres major, 457 Huguenin, radiculopathic model for Hamstrings, 4 1 , 1 63-164, 543 17 Hamulus, 381 muscular pain, 111 General adaptation syndrome (GAS), 63-64, Hand Humeroradial jOint, 486 Humeroulnar joint, 486 64 ligaments, 502-503 Hunter, regeneration phase, 1 28 Genioglossus, 382 muscle treatment, 529-534 Hwang, referred pain, 498 Geniohyoid, 338, 384 NMT for, 533-534, 533, 534 Hydrotherapy, 185, 495, 525 Gerwin palmer aspect, 530, 531 see also Hot and cold applications myofascial pain syndrome, 167 see also Wrist and hand vitamins, 1 67 Hyoglossus, 382 Ghrelin, 137 Hanno, excessive muscular tone, 87 Hyoid bone, 305, 312, 369 Giamberardino, reflexes, 48-50 Hanson & Huxley, sliding filament theory, 26 Hyperabduction, ulnar, 489 Gil Harakal's cooperative isometric technique, Hyperadduction, radial, 489 goaI setting and pacing, 172 Hyperalgesic areas, 144 pain management, 171 272-273, 273 Hyperextension, elbow, 488, 489 Ginger extracts, 170 Hardiness, 72 Hypermobility, connective tissue, 7-8 Glands, 132 Harmonic methods, 231 -233 Hypertonicity, 65-66 Glenohumeral joint, 402 Hau tant's test, disturbed equilibrium, 258-259 Glenohumeral ligaments, 405 Hawkin's test, 408 MFR for, 521-522 G l iding techniques, 184-185, 184 Head Hypertrophy, 39 brachialis, 493, 493 Hyperventilation hand, 518, 519 flexion and rotation, 282, 354, 438 posterior forearm, 526 forward posture, 247, 293, 362-363 biomechanical changes, 77-78, 180 posterior thoracic, 560-562, 562 Head's law, 3, 50 defined, 76 thumb, 121 neural repercussions, 77 trigger points, 112, 1 89, 189 Heart ofListening (Milne), 334-335 summary of effects, 74, 76, 77, 149, 553 wrist, 518, 519, 525-526 Hypocapnia, 32, 150 Heat see Hot and cold, 185, 208-210 Hypoesthesia, l44 see also Effleurage Heberden's nodes, 533 Hypothalamus, 132 Helmet therapy, 389 Hypothenar eminence, 342-343, 342, 529, 532 G l u tamate, 127-128 Herbs, 129-130 Hypothyroidism, 133-134 G l u teus maximi, 543 Herpes zoster lesions, 465 Hypovascular sites, 29 Gluteus maximus and medius, 83 High-velocity, low-amplitude (HVLA) thrust Hypoxia, 32, 102 Goal setting and pacing, 172-174, 173 Hysteresis, 3, 5-6, 222 Gofton & Trueman, osteoarthritis, 66-6- 7 manipulation, 1 64 Goldstein, neurosomatic disorders, 55-57 Ice applications Goldthwaite, postural imbalance, 73 High-velocity thrust (HVT), 1 21 , 217, 267, brachioradialis, 495 Golfer's elbow, 127, 492, 519 packs, 210 Golgi end-organs, 51 268, 269, 416 pronator teres, 497 Golgi tendon organs, 50, 58, 216, 218 Hilton's law, 3, 362, 546 serratus anterior, 466 GoJgi tendon receptors, 52 Hindhead, rotation of forehead on, 390 sprays, 121, 154 Gonads, 132 Hip joint subscapular and bicipital tendons, 483 Goodheart's approach, tender pOints, 228 subscapularis, 462 Gooseflesh, 119 abduction test, 90, 90 superficial posterior forearm, 525 Gracovetsky, gait and, 557 extension test, prone, 89-90 supinator, 496 Granges & Littlejohn, fibromyaJgia and range of movement, 293 teres minor, 455 myofascial pain, 105 Hip-pelvic syndrome see Lower crossed Idiopathic environmental intolerance, 148 Greenman, plastic and elastic features' 3 Iliocostalis cervicis, 286-2- 87 Grieve, decompensation, 85-86 syndrome Iliocostalis group, 280, 557 Ground substance, 4-5, 15, 222 Hoag, red reflex assessment, 546 Iliocostalis lumborum, 558 Group pain management, 171 Hodges, overbrea thing, 76 Gunn, Dr C. Chan expiration function, 552 Holick, Vitamin D, 168 Iliocostalis thoracis, 558 pain management, 154 Holmes & Rahe, life events' 71 radiculopa thic model for muscular pain, respiration function, 552 Home care program, 180 Image posture, 69 111 Hong Guyton's can a l synd rome (GCS), 490 algometer readings, 117 trigger points, 94 Hooke's law, 3, 85, 85 Hormonal influences, 131-133, 140 Hormonal resistance, 135-137 Hot and cold applications, 185 alterna te, 208-210 baths for palmar and dorsal hand' 533 ice packs, 210 neutral bath, 209

Index 585 Immobilization, 65 NMT for, 571, 571 Jaw pain, 84 Interleukin-6 (IL-6), 137 Jeng & Su, sternalis, 479 Impingement syndrome test, 412 Interna l rotation Joint hypermobility syndrome, 8 ribs and shoulder pa in, 556 Joints, 404 restriction Incisivus inferior, 356 MET for, 428-429 false, 401 PRT for, 429 mechanics, muscular imbalance and, 165 Incisivus superior, 356 motion, 263 of shoulder, 412, 478 pain, 143 Indicis, 513 Interneurons, 52 restriction, trigger points, 114, 114 Interosseous ligaments, 502 spinal stability, 31-32 Indirect approaches, 166 Interosseous membrane, 499, 502 trick pa tterns, 40 Induration technique, 542, 566-567, 566 Interphalangeal joints, range of motion, 511 true, 401-402 Infants Intersegmental muscle (ISM), 104 see also Mobilization; Mobilization with Interspinales, 281, 287, 558 cranial treatment, 326, 387-388, 388 movement (MWM) craniocervical link, 388-389 NMT for, 289 deformational plagiocephaly, 389-390 Interspinous ligament, 253 Jones sleeping position, 389 Intertransversarii muscles, 281, 289 'ease', 225, 226-227 Inferior border, 335 Intertransverse ligament, 253 strain and counterstrain, 54 Intervertebral discs see Discs tender points, 228 Inferior head of lateral pterygoid (ILP), 375 Intervertebral ligaments, 253 wrist, 521 Inferior longitudinal, 382 Intraabdomin a l pressure (lAP), 75 Jugular vein, 346 Inflammation, 125-131 Juhan acute phase, 128, 128 Intraarticwar synovial folds (IASFs), 541 adaptive changes, 65 Iron, 167-168 posture, 247-248 adipose tissue and, 140 Irritable bowel syndrome (IBS), 1 07-108 tensegrity, 15 controlled scarring, 130-131 Ischemia, 65, 179 'Jump' sign, 119 degenera tive processes, 129 deltoid, 442 fibromyalgia syndrome (FMS) and, 103-104 K elbow, 127 muscle pain and, 101-1 02 trigger point evolution, 1 02-103 Kapandji global, 131-140 Ischemic cardiac disease, 477 curvatures, 245 hormonal lllfluences, 131-133, 140 Ischemic compression, 29, 121, 194-195, 195, hand, 498 respiratory model, 551 pain management, 154 215 water imbibition, 247 regeneration phase, 128 Ischemic fibers, 495 lsokinetic contraction, 221 Kappler & Ramey, thumb, 511 remodeling phase, 1 28-129 Isometric contraction, 33, 21 9-220 Keefe, pain management, 171 Keese, carpal tlUUlel syndrome, 515 sinus, 336 latissimus dorsi, 460 Kerr & Grahame, hypermobility, 7 pain and, 273 Kershaw & Flier, leptin hormone, 135 subscapularis, 462 postisometric relaxation, 199 Key trigger pOints, 112-113, 113 systemic, leptin and, 134-140 reCiprocal inhibition, 199 Kinesthetics, 46, 90 teres minor, 455 supraspinatus, 446 'KISS' children, 388-389, 390 see also Muscle energy technique (MET) Kneading, 215 vomer, 337 Isotonic concentric contraction, 33, 220 Knebl, Spencer sequence, 422, 425, 429 see also Antiinflammatory strategies Isotonic eccentric contraction, 33 Koo & Szabo, carpal tlUelU l syndrome, 497 Infrahyoid muscles, 304-305, 305 Isotonic stretch Korr NMT for, 307-308, 307 rapid eccentric, 220-221 Infraspinatus, 402, 415, 420, 420, 447 slow eccentric (SEIS), 221 neural eXCitabili ty, 57-58 assessment, 447, 448 'Itching' patterns, 565 neu rological lens, 106 MET for, 448-449, 448 neurotrophic influences, 47 MFR for, 449, 449 J proprioception, 45 NMT for, 448, 448 PRT, 226 PRT for, 449 Jacob & McKenzie, repetitions, 254-255, 408 red reflex assessment, 546 Ingber's structural continuum, 23-25 Janda, V1adimir spinal cord, 53 strain and coun terstrain, 55 Ingram-Rice, carpal runnel syndrome, 507 adaptation sequences, 66 Kuchera & McPartland Inhalation muscles, 550 biceps brachii, 483 clinical fea tures, myofascial trigger points, Inhibition, 141, 215 chain reactions, 84 classification of tense and tight muscles, 36 118 of pain transmission, 154-155 excessive muscular tone, 87 clinical symptoms, trigger point activi ty, functional screening sequence, 88-92, 410 Inhibitory soft tissue techniques, 120 layer syndrome, 83 120 primary and secondary responses, 85-86 trigger points, joint restriction, 114 Injection, 120 proprioception, 46, 53 Kyphosis, 474 posterior forearm, 526 reeducation, 59-{i0 scapulohumeral rhythm test, 410 l Injury cycle, 129 trick patterns, 39 Injury, neuromuscular dysfunction and, 51 two-joint muscle, 413 Labyrinthine receptors, 51 Inner range e�durance tests, 37 upper crossed syndrome, 409-410 Labyrinthine test, 370 Instantaneous axis of rotation (lAR), 558 upper and lower crossed syndromes, 82 Insulin, 135 resistance; 136-137, 139 Integra ted neuromuscular inhibition technique (INIT), 121, 197, 210-212, 435 combination procedures, 569 Ruddy's reciprocal antagonist facilitation (RRAF), 201, 212 Interclavicular ligament, 407 Intercostal muscles, 552, 570, 570 Lief's NMT for, 569

586 I N D EX Lamina groove, 250 functional pathologies, 400 weakened, 82, 409 Langevin & Yandow, acupuncture points, low back pain, 1 72 Lubricant, 194 muscular pain, 141 Lumbar lordosis, 542 10-11 neuropathic pain, 143 Lumbosacral area, 266 regeneration phase, 128-129 Langevin, fascial cellular structures, 2, 9-11, tissue preference, 19 13 spinal rehabilitation, 170 Lumbricales, 532 Lief's NMT, 191-194, 222, 274 Lundberg, psychological stress, 431 LAS, GAS and, 63-64, 64 Luschka's joints, 250 Lateral epicondyle, 526 finger technique, 193-194, 193 Luteinizing hormone (LH), 132 Lateral epicondylitis (tennis elbow), 127, 492, intercostal muscles, 569 Lymph nodes, 301, 430 suboccipital region, 297 Lymphatic drainage, 29, 259 522, 526 upper thoracic area, 549 Lateral flexion upper trapezius, 278, 434-435 anterior forearm, 519 see also Neuromuscular techniques (NMT), pectoralis major, 476 cervical region, 262, 264 posterior forearm, 526 European pump, 429 head, 438 Life events, 71 techniques, 31, 102, 212-213, 470, 571 Lateral ligament, elbow, 511 L ifestyle management, 139 Lymphatic system, 29-31 Lateral line, Myers', 12 Ligaments in neck, 248, 260 Lateral pterygoid, 338, 358, 375-378, 376 cervical, 251-253 M NMT for, 369, 369, 378-379, 378, 379 collagen deposition, 4 elbow, 486-487, 487, 511 McConnell trigger points, 380 diaphragm, 572 Lateral tracts, 280, 557 hand, 502-503 red reflex assessment, 545-546 Latex a llergy, 371 posterior atlantooccipital, 248 respiratory dysfunction, 78 Latey, 'clenched fists', 69-71 shoulder girdle, 405-407 Latissimus dorsi, 413, 415, 458 source of referred pain, 142 McGill, overbreathing, 75-76 McKenzie methods, 166, 213-215 assessment, 458-459 thumb, 511 McNulty, emotional stress, 109 MET for, 460, 460 McPartland & Brodeur, rectus capitis MFR for, 459, 459 wrist, 501-502, 501 Ligamentum flavLUll, 253 posterior minor, 294 NMT for, 459, 459 Ligamentum nuchae, 248, 253 McQuade & Smidt, scapulohumeral rhythm, PRT for, 460, 460 Limbic system, 55 respiration, 552 Lippman's test, 418 402 shortness, 553 Lips, movements of, 356 Magill & Suruda, multiple chemical Layer (stratification) syndrome, 83-84, 83 Lederman see also Buccolabial region sensitivity (MCS), 149 adaptation to trauma, 67 Magnesium, 129-130 collagen deposition, 4 'Liquid electric model', 334 MagneticResonance Imaging (MRl) direct treatment forces, 1 66-167 Listening hand, 229, 269 muscle tone, 33 Litchfield, hypocapnia, 150 arthrography, 407 proprioception, 52 Litigation, 171 Maigne's test for vertebral artery-related Local adaptation syndrome (LAS), 63-64, 64 Lehman, prone leg extension, 89 Loca I anesthetics, 154 vertigo, 257 Leptin Local pain, 142 Mandible, 337-340, 337 Local twitch responses (LIRs), 116, 118 resistance, 136 Long-axis compression, teres major, 457 movement of, 84, 358, 359, 371, 377 rules to regain normal levels, 139 Long-term potentiation (LIP), 57, 58-5- 9, 126 ramus of, 333 systemic inflammation and, 134-140 Longissimus capitis, 286, 303, 345, 370 Mandibular condyle, 360 Levator anguli oris, 350, 356 Longissimus cervicis, 286 Mandibular disc, 360 Levator ani syndrome (LVAS), 107-108 Longissimus muscle group, 280, 557 Mandibular fossa, 346 Levator labii superioris, 348, 350, 356 Longissimus tnoracis, 558 Manipulation Levator labii superioris alaeque nasi, 356 Longitudinal muscle fibers, 25 cranial, 359 Levator muscles, 381 Longitudinal paraspinal MFR, 222-223 minimal impulse, 390 Levator scapula, 256, 289-290, 290, 321, 415, Longus capitis, 309-311, 329, 346 reporting station, 58 tissue, 166-167, 216 435-436 MET stretch, 312 Manual pressure release, 118 assessment for shortness, 436 NMT for, 311-312, 311, 312 Manubrium, 541 MET for, 291 , 291, 420, 421, 438 Marfan syndrome, 8 NMT for, 290-291, 291, 436-437, 437 Longus colli, 256, 308--309, 309, 310-311 Ma rking tender spots, 559 PRT for, 291-292, 292 NMT for, 311-3 1 2, 311, 312 Masked depreSSion, 41 shortened, 82, 409 Massage, 215-217 Levin, tensegrity, 15-16 Looseness, 165, 266 brachioradial is, 494 Levoratores costarum longus and brevis, deep pressure, 1 21 tightness and, 163-165 effects of, 216 568--570 Lorscheider, amalgam fillings, 145 masseter, 368 Lewit Low back pain (LBP), 41, 141-142 techniques, 267, 354 Massete� 338, 348, 350, 358, 373-374, 373 cervical pattern, 259 chronic, 162 myofascial stretch, 368, 368 'loose-tight' thinking, 164 rehabilitation, 172 NMT for, 367-368, 367, 368, 375, 375 PRT for, 368-369 masked depression, 41 Lowe, Guyton's canal syndrome, 491 'no man's land', 216 Lower cervical ligaments, 253 Lower crossed syndrome, 82-83, 83 pain, 46, 415-416 Lower trapezius shoulder-arm syndrome, 409 whiplash, 262 flat palpation, 434 Lewit & Olsanska, scar tissue, 223 NMT for, 433-434, 433 Liebenson trigger pOints, 433 dysfunctional pa tterns, 211

Index 587 Mastication, muscles of, 351-352, 358-359 Motor endplate hypotheSiS, 111 imbalance, 165, 416 Mastoid Motor units, 33, 78-79 layers, 274-275 motor control and respiratory alkalosis, palpa tion, 371-372 types, 34 process, 248, 296, 371 Mouth see Suprahyoid muscles 31-32 Maxillae, 35, 349-350, 349, 351 Mu lligan's mobilization techniques, 217, 520 organization detail, 25, 33 Mechanical interface (MI), 224 Mu ltidirectional instability (MOl), 441 pain and, 40-41 Mechanoreceptors, 46 planes, 274-275 Mechanotransduction, 24 Multifidi, 281, 287, 557, 558, 563, 564-565, 564 range of motion, 87 Medial epicondyle, 492, 519 Multipennate muscle fibers, 27 somatization and, 41-42 Medial epicondylitis (golfer'S elbow), 127, Multiple chemical sensitivity (MCS), 148-149 spasm, 37-39 Muscle energy technique (MET), 199-200, strength, 259-260, 262 492, 519 Medial p terygoid, 338, 350, 358, 376, 379-380 218-221, 219 tests, 39, 260, 262-266, 263 acromioclavicular (AC) joint, 426 structural continuum and, 23-25 NMT for, 369, 369, 379, 380 anterior neck muscles, 299-300, 300 subsystems, 31, 67 Medial scapula, 440 biceps brachii, 484, 484 Medial tracts, 281, 557-558 cervical region, 267, 270, 272 terminology, 33 Median nerve diaphragm, 572 tone, 65, 86-87 fascia, 6 entrapment, 489, 491, 507 assessment, 87-88 forearm flexors, 519, 519, 521 trick patterns, 39-40 seealso Carpal tunnel syndrome Golgi tendon organs, 58, 216 paralysis, 509 iniraspinatus, 448-449, 448 two-joint, 39 Melanotropin, 132 internal rotation restriction, 428-429 types of, 25, 27, 34-35, 35 Melatonin, 139 latissimus dorsi, 460, 460 vulnerable areas, 34 Melzack & Katz, pain rating tools, 190-191 leva tor scapula, 291, 291, 421, 438 weakness, 39, ll8 Meniscoids see Intraarticular synovial folds Musculoskeletal dysfunction, causes, 63-79 longus capitis, 312 postural and emotional influences, 69-73, (IASFs) occipitoatlantal restriction, 269 Meniscus extrapment theory, 541 pectoralis major, 472-473, 473-474, 473 69 Mense posterior forearm, 526 Musculus uvula, 381 p rotocols, 547 Myalgia, allergic, 168 dysfunctional muscle spindle, llO-lll rectus capitis anterior, 313 Myers trigger point connection, 102 rhomboids, 440-441 Ruddy's pulsed, 201 fascial trains, 11-13, 567 Mentalis, 356 scalenii, 318-319, 319 shoulder muscles, 404 Mercury, 144, 145-146 semantic confusion, 178 Metacarpal muscles, 529, 532-533 serratus anteriol� 466, 466-467 tensegrity, 15 Metacarpophalangeal joints, 510 shoulder, 416, 427, 428 Mylohyoid, 338, 384 soft tissue, 66, 164 Myocardial infarction, 417 range of motion, 51O-5ll Spencer's sequence, 427-429 Myofascial pain and FMS, 105, 105 Metacarpophalangeal ligaments, 510 spiral, 478 Myofascial pain syndrome (MrS), 167 Middle deltoid, 415 sternoclavicular, 426 Myofascial release (MFR), 221-223, 'Middle fist' concept, 69, 70 Middle trapezius sternocleidomastoid (SCM), 303-304, 304 222, 466 stretching, 235 active, 267 NMT fOl� 433, 433 subscapularis, 463-464, 463 adherent tissue, 186 weakened, 82, 409 supina tor, 496 Mills test, 492 supraspinatus, 421, 446 brachioradialis, 495 Milne teres minor, 448-449, 448, 455 coracobrachialis, 481, 481 mandible range of motion, 339 triceps, 452-453, 453 epicranial tissues, 354 newborn babies, 388 trigger points, 120 tissue separation, 334-335 upper cervical dysfunction, 268 hypertonicity, 521-522 M imetic muscles, 351, 351-352, 352, 353 upper trapezius, 278-279, 422, 435 latissimus dorsi, 459, 459 buccolabial region, 356-357, 357 wrist and hand extensors, 521 masseter, 368, 368 circumorbital and palpebral region, 355 Muscle fibers, 27, 218 pectoralis major, 472, 474, 474 of the epicranium, 352 parallel, 25 pectoralis m inor, 477, 477 nasal region, 356 postural, 218 posterior forearm, 526 Minimal impulse manipulation, 390 types, 28, 34-35 postmastectomy, 470 Mobilization Muscle spindle, 5 1-52 pronator teres, 498 adverse mechanical tensions (AMT), hypothesis, llO-I11 serratus anterior, 223, 466 Muscles, 23-42 soft tissue, 166 223-230 alternative categorization, 36-37, 554 and articulation, 217-218 atrophy, 37-39, 409 subclavius, 477, 479 of cervical spine, 272-273 blood supply and, 28-29 supinator, 496 Mobilization with movement (MWM), 166, central nervous system signals, 25 supraspinatus muscle, 447, 4467 contraction see Contraction trigger points, 121, 164 217, 520, 575 cooperative activity, 35, 37 upper trapezius, 279, 280-281, 435 thoracic spine, 757-756 Myofascial therapy, 359 wrist and hand, 520 energy production, 27, 28 Myofascial tissue problems, guidelines, Mock, MFR, 222, 466 essential information, 25 facilitation in, 108 183 Monosodium glutamate (MSG), 146, 147, 148 Mood disturbances, 153 Myofascial triggerpoints (MTrPs), 8, 38, Motion palpation, ear disease, 390 1 1 3-114, 1 1 8-122, 119, 154-155, 164, Motor control 374 injury prevention and, 67-68 Myofibroblasts and fascia, 181-182 Myosin, 26-27 see also Respira tory a Ika losis Myotendinoses, 142