Chapter 10. Manual Techniques

At the completion of this chapter, the reader will be able to:

1. Give definitions for commonly used biomechanical terms used in manual therapy (MT).

2. List the criteria that are important for the correct application of a manual technique.

3. Summarize the various types of MT.

4. Apply the knowledge of the various MTs in the planning of a comprehensive rehabilitation program.

5. Recognize the manifestations of abnormal tissue and develop strategies using manual techniques to treat these abnormalities.

6. Categorize the various effects of MT on the soft tissues.

7. Make an accurate judgment when recommending an MT technique to improve joint or muscle function.

Touch has always been and continues to be a primary healing modality. The first written records of massage go back to Ancient China, and wall paintings in Egypt depict hands-on healing techniques that go back 15,000 years. 1From this early “laying on of hands” evolved many of the techniques used today.

The techniques of MT fall under the umbrella of therapeutic touch. MT has become such an important component of the intervention for orthopaedic and neurologic disorders that it is considered by many as an area of specialization within physical therapy. 2– 5

Several MT approaches or techniques have evolved over the years. By their nature, many of these techniques have not been developed with the same scientific rigor as fields such as anatomy and physiology, and much of their use is based on clinical outcomes, rather than evidence-based proof. However, an absence of evidence does not always mean that there is evidence of absence (of effect), and there is always the risk of rejecting therapeutic approaches that are valid. 6

Of the approaches commonly applied, the Cyriax, 7Mennell, 8and osteopathic techniques 9, 10( Table 10-1) originated from physicians, whereas the Maitland, 11, 12Kaltenborn, 13and McKenzie 14approaches ( Table 10-2) were derived by physical therapists. 5, 15, 16

Within these major philosophies, a number of subsets have also emerged, including myofascial release (MFR), positional release techniques, neurodynamic mobilization techniques (see Chap. 11), manually resisted exercise, proprioceptive neuromuscular facilitation (PNF), joint mobilization, and manipulation.

MT techniques have traditionally been used to produce a number of therapeutic alterations in pain and soft-tissue extensibility through the application of specific external forces. 11, 13, 17, 18Although it is generally agreed that manual techniques are beneficial for specific impairments, such as a restricted joint glide and adaptively shortened connective tissue, there is less agreement on which technique is the most effective. The decision about which approach or technique to use has traditionally been based on the clinician's belief, level of expertise, and decision-making processes. This has led to widespread opinions on which tools to use to measure outcome; how to apply a particular technique in terms of patient setup, intensity, and duration; and how to gauge an individual's response to a technique.

Unfortunately, the therapeutic efficacy of many MT techniques remains undetermined, although a number of theories exist. There are numerous concerns with determining the validity of studies addressing the efficacy of manual techniques:

• The selection of a particular technique is typically made on an ad hoc basis.
• The strong placebo effect associated with the laying on of hands.
• Many musculoskeletal conditions are self-limiting so that patients may improve with time regardless of the intervention.
• The difficulty of blinding clinicians and subjects to the intervention the subjects are receiving.
• Clear-cut definitions as to when one technique is more efficacious than another are lacking.
• Overreliance on MT techniques to improve a patient's status is a passive approach in an era when patient independence is stressed.

Indeed, research studies seem to agree and suggest that the most efficacious approach is a combination of manual techniques with other interventions, such as progressive exercises, the use of therapeutic modalities, and patient education about proper body mechanics, positions, and postures. 19– 21Regardless of which MT technique is used, all patients should undergo a full examination/evaluation before any technique is performed.

Despite the varied approaches and rationales, there is general agreement concerning criteria that are important for the correct application of a manual technique. These include 22:

• Knowledge of the relative shapes of the joint surfaces (concave or convex).11– 13, 23If the joint surface is convex relative to the other surface, the joint glide occurs in the direction opposite to the osteokinematic movement (angular motion). If, on the other hand, the joint surface is concave, the joint glide occurs in the same direction as osteokinematic movement.
• Duration, type, and irritability of symptoms11, 12( Table 10-3). This information can provide the clinician with some general guidelines in determining the intensity of the application of a selected technique (see “Indications for MT”later in this chapter).
• Patient and clinician position.Correct positioning of the patient is essential both to help the patient relax and to ensure safe body mechanics from the clinician. When patients feel relaxed, their muscle activity is decreased, reducing the amount of resistance encountered during the technique.
• Position of joint to be treated.The position of the joint to be treated must be appropriate for the stage of healing and the skill of the clinician. It is recommended that the resting position of the joint be used when the patient has an acute condition or the clinician is inexperienced. The resting position in this case refers to the position that the injured joint adopts, rather than the classic resting (open-packed) position for a normal joint. Other positions for starting the mobilization may be used by a skilled clinician in patients with nonacute conditions.
• Hand placement.Wherever possible, contact with the patient should be maximized. The hand should conform to the area being treated, so that the forces are spread over a larger area. A gentle and confident touch inspires confidence in the patient. Accurate hand placement is essential for efficient stabilization and for the accurate transmission of force.
• Specificity.Specificity refers to the exactness of the procedure, and is based on its intent. Whenever possible, the forces imparted by a technique should occur at the point where they are needed. Check one joint at a time, one movement at a time.
• Direction and type of force.When possible work with the force of gravity rather than against it. The direction of the force can be either direct,which is toward the motion barrier or restriction, 24or indirect, which is away from the motion barrier or restriction. 25, 26Although the rationale for a direct technique is easy to understand, the rationale for using an indirect technique is more confusing. A good analogy is the stuck drawer that cannot be opened. Often the movement that eventually frees the drawer is an inward motion, followed by a pull. 22
• Amount of force.The amount of force used depends on the intent of the manual procedure and a number of other factors, including but not limited to
  • age, sex, and general health status of the patient;
  • barrier to motion and end-feel (stage of healing) ( Table 10-4);
  • type and severity of the movement disorder.
• Reinforcement of any gains made.It has been demonstrated that movement gained by a specific manual technique performed in isolation will be lost within 48 hours, if the motions gained are not reinforced. 27Thus, the motions gained by a manual technique must be reinforced by both the mechanical and the neurophysiologic benefits of active movement. 28These active movements must be as local and precise as possible to the involved segment or myofascial structure.

Reassessment is an integral part of any intervention. The clinician must be able to gauge how effective a technique has been so that necessary modifications can be made. Measurement procedures used by the clinician to determine the effectiveness of a manual intervention must adequately reflect changes in pain level, impairments, and functional ability. Although measurements of range of motion (ROM), pain, and strength are valid and reliable, 29– 31the functional measurement selected should be related to the particular functional limitation that the clinician is expecting to change with the intervention. 32Complicating the measurement of outcome and the effectiveness of a technique is the placebo effect (a response resulting from the suggestion that something is beneficial, even though it may be inert). Although MT is not alone in its use of the placebo effect, it is increasingly important that clinicians determine the specific effects of everything they do. 33

MT is indicated in the following cases:

• Mild musculoskeletal pain
• A nonirritable musculoskeletal condition, demonstrated by pain that is provoked by motion but that disappears very quickly
• Intermittent musculoskeletal pain
• Pain reported by the patient that is relieved by rest
• Pain reported by the patient that is relieved or provoked by particular motions or positions
• Pain that is altered by changes related to sitting or standing posture

Contraindications to MT include those that are absolute contraindications and those that are relative. 34, 35

Absolute

• Systemic or localized infection (e.g., osteomyelitis), febrile state
• Acute circulatory condition
• Malignancy
• An open wound at the treatment site, or sutures over the treatment site
• Recent fracture
• Hematoma
• Hypersensitivity of the skin
• Inappropriate end-feel (spasm, empty, and bony), or evidence of joint ankylosis, or joint hypermobility
• Advanced diabetes
• Rheumatoid arthritis (in a state of an exacerbation)
• Cellulitis
• Constant, severe pain, including pain at rest or that disturbs sleep, indicating that the condition is likely to be very irritable or in the acute stage of healing
• Extensive radiation of pain
• Any condition that has not been fully evaluated

Relative

• Joint effusion or inflammation
• Rheumatoid arthritis (not in a state of an exacerbation)
• Presence of neurologic signs
• Osteoporosis
• Pregnancy, if a technique is to be applied to the spine
• Dizziness
• Steroid or anticoagulant therapy

Transverse Friction Massage

Transverse friction massage (TFM) is a technique devised by Cyriax, whereby repeated cross-grain massage is applied to muscle, tendons, tendon sheaths, and ligaments. TFM has long been used by physical therapists to increase the mobility and extensibility of individual musculoskeletal tissues, and to help prevent and treat inflammatory scar tissue. 7, 36– 41

TFM is contraindicated for acute inflammation, hematomas, debilitated or open skin, and peripheral nerves, and in patients who have diminished sensation in the area.

TFM is purported to have the following therapeutic effects:

• Traumatic hyperemia.7According to Cyriax, longitudinal friction to an area increases the flow of blood and lymph, which, in turn, removes the chemical irritant by-products of inflammation. In addition, the increased blood flow reduces venous congestion, thereby decreasing edema and hydrostatic pressure on pain-sensitive structures.
• Pain relief.The application of TFM stimulates type I and II mechanoreceptors, producing presynaptic anesthesia. This presynaptic anesthesia is based on the gate theory of pain control (see Chaps. 3and 8). However, if the frictions are too vigorous in the acute stage, the stimulation of nociceptors will override the effect of the mechanoreceptors, causing the pain to increase. Occasionally, the patient may feel an exacerbation of symptoms following the first two or three sessions of the massage, especially in the case of a chronically inflamed bursa. 42In these cases, it is important to forewarn the patient.
• Decreasing scar tissue.The transverse nature of the friction assists with the orientation of the collagen in the appropriate lines of stress and also helps produce hypertrophy of the new collagen. Given the stages of healing for soft tissue (see Chap. 2), light TFM should only be applied in the early stages of a subacute lesion, so as not to damage the granulation tissue. These gentle movements theoretically serve to minimize cross-linking and so enhance the extensibility of the new tissue. Following a ligament sprain, Cyriax recommends immediate use of gentle TFM to prevent adhesion formation between the tissue and its neighbors, by moving the ligamentous tissue over the underlying bone. 7

The application of the correct amount of tension to a healing structure is very important. The tissue undergoing TFM should, whenever possible, be positioned in a moderate but not painful stretch. The exception to this rule is when applying TFM to a muscle belly, which is usually positioned in its relaxed position. 7, 43Lubricant is not typically used with the application of TFM. However, ultrasound can be applied to a tissue before TFM.

Beginning with light pressure, and using a reinforced finger (i.e., middle finger over the index finger), or thumb, the clinician moves the skin over the site of the identified lesion back and forth, in a direction perpendicular to the normal orientation of its fibers. It is important that the patient's skin move with the clinician's finger to prevent blistering.

The amplitude of the massage should be sufficient to cover all of the affected tissue, and the rate should be at two to three cycles per second, applied in a rhythmical manner.

The duration of the friction massage is usually gauged by when desensitization occurs (normally within 3–5 minutes). Tissues that do not desensitize within 3–5 minutes should be treated using some other form of intervention. If the condition is chronic or in the remodeling stage of healing, then the frictions are continued for a further 5 minutes after the desensitization, in an effort to enhance the mechanical effect on the cross-links and adhesions. Following the application of TFM, the involved tissue is either passively stretched or actively exercised, taking care not to cause pain.

Most conditions amenable to TFM should resolve in 6–10 sessions over 2–8 weeks. When possible, patients should be taught how to apply TFM on themselves so that treatments can be continued at home. Tissues that do not show signs of improvement after three treatment sessions should be treated using some other form of intervention.

Myofascial Release

MFR is a series of techniques designed to release restrictions in the myofascial tissue and is used for the treatment of soft-tissue dysfunction. The development of a holistic and comprehensive approach for the evaluation and treatment of the myofascial system of the body is credited to John Barnes, who was strongly influenced by the teachings of Mennell 44and Upledger. 45

According to myofascial theory, the collagenprovides strength to the fascia, the elastin gives it its elastic properties, and the gel functions to absorb the compressive forces of movement. 35Three types of fascia are considered to exist 35, 46:

1. Superficial, lying directly below the dermis.

2. Deep, surrounding and infusing with muscle, bone, nerve, blood vessels, and organs to the cellular level.

3. Deepest, comprising the dura of the craniosacral system, which encases the central nervous system and brain (see Chap. 3).

The theory of MFR is based on the principle that trauma or structural abnormalities may create inappropriate fascial strain, because of an inability of the fascia to absorb or distribute the forces. 46These strains to the fascia can result in a slow tightening of the fascia, causing the body to lose its physiologic adaptive capacity. 46Over time, the fascial restrictions begin to pull the body out of its three-dimensional alignment, causing biomechanically inefficient movement and posture. 46In addition, because of the association of fascia at the cellular level, it is theorized that trauma to or malfunction of the fascia can lead to poor cellular efficiency, disease, and pain throughout the body. 35, 46Three theoretical models for the manifestation of myofascial dysfunction are contraction, contracture, and cohesion–congestion ( Table 10-5).

Thus, the purpose of MFR techniques is to apply a gentle sustained pressure to the fascia, in order to release fascial restrictions, thereby restoring normal pain-free function. 35MFR relies entirely on the feedback received from the patient's tissues, with the clinician interpreting and responding to the feedback. This feedback is based on the Upledger concept of the natural body rhythm, called the craniosacral rhythm. 45It is this rhythm that is theorized to guide the clinician as to the direction, force, and the duration of the technique.

It is not unusual for a patient to experience muscle soreness following MFR techniques. This soreness is thought to result from postural and alignment changes or from the techniques themselves.

Myofascial Stroking

The soft-tissue techniques used in MFR are purported to break up cross-restrictions of the collagenof the fascia. Three of the more commonly used techniques involve stroking maneuvers 35:

• J stroke.This technique is used to increase skin mobility. Counterpressure is applied with the heel of the hand, while a stroke in the shape of the letter J is applied in the direction of the restriction, with two or three fingers, which creates some torque at the end of the stroke.
• Vertical stroke.The purpose of vertical stroking is to open up the length of vertically oriented superficial fascia. As in the J stroke, counterpressure is applied with one hand, while the stroking is performed with the other.
• Transverse stroke.As its name suggests, the transverse stroke is applied in a transverse direction to the body. Force is applied downward into the muscle with the fingertips of both hands, and the force is applied slowly and perpendicular to the muscle fibers.
• Cross-hands technique.The cross-hands technique is used for the release of deep fascial tissues. The clinician places crossed hands over the site of restriction. The elastic component of the fascia is then stretched until the barrier is met. At this point, the clinician maintains consistent gentle pressure at the barrier for approximately 90–120 seconds. Once the release is felt, the clinician reduces the pressure.

It is important to remember that the claimed benefits and effectiveness of MFR techniques are largely anecdotal, because at the time of writing there is no scientific experimental research to validate these claims. 47

Soft-Tissue Mobilization

Soft-tissue mobilizations (STMs) are used in many of the manual techniques described within this chapter, including MFR, muscle energy (ME), and PNF. The techniques of STM described in this section are based on the concept that tissue restrictions occur at different layers, ranging from superficial to deep.

The general principles behind STM are that the superficial layers are treated before deep layers, with the force used applied in the direction of the maximum restriction, and where the choice of technique is dependent on the extent of the restriction, amount of discomfort, and degree of irritability. Deep tissue massage is recommended to reduce spasm 48and promote pain reduction. 49Several well-recognized STM techniques are described next. 50

Sustained Pressure

This technique is applied to the center of the restricted tissue at the exact depth, direction, and angle of the maximal restriction. The sustained pressure technique can be modified by applying a force in either a clockwise or a counterclockwise direction, while maintaining the sustained pressure. This spiral motion increases the tissue tension in one direction, while easing it in the other. Sustained pressure can also be applied perpendicular or parallel to the restriction.

Ischemic Compression

Ischemic compression, a similar technique to sustained pressure, can be used on both active and inactive trigger points. It is believed that the ischemic compression deprives the trigger points of oxygen, rendering them inactive and breaking the cycle of pain–spasm–pain. Usually, the pressure is applied for 8–12 seconds. If the patient reports a lessening of local and referred pain, the clinician can repeat the treatment. However, if the pain does not lessen, the clinician may need to adjust the pressure or choose an alternative technique.

General Massage

Massage can be defined as the systematic, therapeutic, and functional stroking and kneading of the body. 51The French are credited with the introduction of massage into Europe, and many of the terms associated with massage still bear French names. 52Massage has long been a central part of the physical therapy curriculum. Studies have demonstrated that deep massage increases the circulation and skin temperature of the massaged area, as a result of dilation of the capillaries. 53– 56A number of traditional massage techniques are used, including:

• Effleurage.This is a general stroking technique applied to the muscles and soft tissues in a centripetal direction (from distal to proximal), to enhance relaxation and increase venous and lymphatic drainage. The clinician applies a firm contact with the patient using the palms of the hand and, at the end of the stroke, lifts the hands from the patient's skin and replaces them at the starting position. 57Oil or cream can be used to aid the stroking.
• Stroking.Stroking techniques are applied superficially along the whole length of a surface. These techniques are typically applied before the deeper techniques of massage to enhance relaxation. 56
• Petrissage.This term is used to describe a group of techniques that involve the compression of soft-tissue structures and include kneading, wringing, rolling, and picking-up techniques, to release areas of muscle fibrosis and to “milk” the muscles of waste products that collect from trauma or abnormal inactivity. 58
• Strumming.The technique of perpendicular strumming involves the application of repeated, rhythmic deformations of a muscle belly in a strumming fashion.

Acupressure

Acupressure is based on the ancient arts of shiatsu and acupuncture, involving manual pressure over the acupuncture points of the body, to improve the flow of the body's energy, known as Qi. This energy is thought to circulate throughout the body along a series of channels, called meridians. Traditional Eastern medicine is based on the concept that all disorders are reflected at specific points, either on the skin surface or just beneath it, along these channels. By careful manipulation of these points, the clinician can theoretically strengthen, disperse, or calm the Qi, enabling it to flow smoothly. 59Modern acupressurists use traditional meridian acupuncture points; nonmeridian or extrameridian acupuncture points, which are fixed points not necessarily associated with meridians; and trigger points, which have no fixed locations and are found by eliciting tenderness at the site of most pain. 60When acupressure is applied successfully, the patient is supposed to experience a sensation known as teh chi, defined as a subjective feeling of fullness, numbness, tingling, and warmth with some local soreness and a feeling of distention around the acupuncture point. 60Western scientific research has proposed a number of mechanisms for the effect of acupressure in relieving pain, as follows:

• The gate control theory of pain. 61, 62
• Diffuse noxious inhibitory control. This theory implies that noxious stimulation of heterotopic body areas modulates the pain sensation originating in areas where a subject feels pain. 60
• Stimulation of the production of endorphins, serotonin, and acetylcholine in the central nervous system, which enhances analgesia. 63– 71

Muscle Energy

The origin of ME techniques is credited to Fred Mitchell, Sr. 72ME techniques combine the precision of passive mobilization, with the effectiveness, safety, and specificity of reeducation therapies and therapeutic exercise. 73

ME techniques, which involve positioning a restricted muscle–joint complex at its restricted barrier, can be used to mobilize joints, strengthen weakened muscles, and stretch adaptively shortened muscles and fascia. 75Optimal success with these techniques is more likely in the acute or subacute stages of healing, before prolonged joint changes have had the opportunity to occur.

According to the teachings of ME, muscles function as flexors, extensors, rotators, and side benders of joints, as well as being restrictors or barriers to movement. In other words, muscles both produce and control motion. Although it is obvious that muscles produce motion, it is easy to forget that they also resist motion. This resistance to motion is related to muscle tone, a complex neurophysiologic state governed by both cortical and spinal reflexes and by the afferent activity from the articular and muscle systems. Afferent input from types I and II mechanoreceptors located in the superficial and deep aspects of the joint capsule is projected to the motor neurons (see Chap. 3). 76, 77Exaggerated spindle responses are provoked by any motions that attempt to lengthen the muscle, creating an increase in resistance to those motions. Stretching or lengthening of the muscle also stimulates the Golgi tendon organs, which have an inhibitory influence on muscle tension, leading to muscle relaxation. In addition, it has been demonstrated that cutaneous stimulation of certain areas of the body can produce inhibition or excitation of specific motor neuron pools. 78

It is theorized that the neuromuscular system is “scarred” by pain and impairment, producing asymmetry in the musculoskeletal system and resulting in a disruption of the harmony and rhythm of the body, referred to as somatic dysfunction. 73Somatic dysfunctions can be described or named in one of three ways 24:

1. The direction of increased freedom of motion

2. The position of the lesion

3. The direction of limitation of motion

In the presence of a somatic dysfunction, there is usually an asymmetric pattern of motion, with restriction in one direction and increased freedom in the opposite direction. 24The triad of ART ( asymmetry, range of motion restriction or barrier, and tissue texture) 26helps to describe the characteristics of somatic dysfunction. Primary somatic dysfunctions, which may result from trauma, are reversible, as long as they are treated correctly and do not become chronic in terms of abnormal fibrosis or adhesions. Secondary somatic dysfunctions result from the consequences of visceral pathology, or from the adaptations made by somatic structures in response to forces or stresses imposed on them.

The consequence of a somatic dysfunction can be a change in the length of the tissues that surround a joint. Some of these tissues adaptively shorten, whereas others adaptively lengthen. These changes in length are theorized to produce changes in the neurophysiologic makeup of the muscle, affecting tension development, as well as changes in the angle of pull.

There is some commonality between ME and several procedures used in orthopaedic MT, such as PNF. 79Greenman 26summarizes the requirements for the correct application of ME techniques to be control, balance, and localization.

• The technique, which involves a controlled effort in a controlled direction, commences from a controlled position. Eccentric, concentric, and isometric contractions, at varying levels of effort, are used in ME, within a range of movement controlled by the clinician.
• The clinician balances the degree of force used, depending on the intention.
• The force used is localized as much as possible to the joint in question. The localization of force is more important than the intensity of the force.

The intent of ME is to treat somatic dysfunctions by restoring the muscles around a joint to their normal neurophysiologic state, through either stretching or strengthening the agonist and antagonist. Somatic dysfunctions include those in which the motion barrier is encountered before the physiologic barrier is reached. 73The type of motion barrier is determined by the end-feel.

A normal end-feel would indicate normal range, whereas an abnormal end-feel would suggest abnormal range, either hypomobile or hypermobile, with the latter characterized by a loss of end-feel resiliency and an abrupt approach to the anatomic barrier. All ME techniques are classed as direct techniques because they engage the barrier. 25Indirect techniques form the basis for the strain–counterstrain (positional release) techniques, 80and the functional techniques, 81– 83both of which are discussed later.

The position of the clinician during the performance of the technique must allow easy access to the structures involved, while maintaining proper body mechanics. In each of the following recognized methods of ME, the setup is identical. The clinician positions the bone or joint so that the muscle group to be used is at its resting length. The patient is then given specific instructions about the direction in which to move, the intensity of the contraction, and the duration of the contraction. 75, 79, 84, 85The amounts of force and counterforce are governed by the length and strength of the muscle group involved, as well as by the patient's symptoms. 75The clinician's force can match the effort of the patient, thus producing an isometric contraction and allowing no movement to occur, or it may overcome the patient's effort, thus moving the area or joint in the direction opposite to that in which the patient is attempting to move it, thereby incorporating an eccentric or isolytic contraction. 79There appears to be no consensus as to whether to use the relaxation of the agonist or the antagonist to gain motion. 26, 74, 86– 88

Strain–Counterstrain (Positional Release)

Strain–counterstrain is a passive positional technique used in the treatment of musculoskeletal pain and related somatic dysfunction. According to strain–counterstrain theory, myofascial tender points ( Fig. 10-1) are located and then monitored while a position of comfort, or ease, is established to evoke a therapeutic effect. 80, 89, 90It is worth noting that to date no experimental studies have been published to confirm the existence of these tender points or the effectiveness of strain–counterstrain.

A possible neurophysiologic explanation of how and why these techniques work was first suggested by Korr, 91who postulated that an injured joint and its related tissues behaved differently from those of an uninjured joint in that the γ motor neuron activity in the former became increased. Bailey 92later refined the theory by suggesting that an inappropriate high “gainset” of the muscle spindle (see Chap. 3) resulted in changes characteristic of somatic dysfunction. 93Thus, the techniques of strain–counterstrain appear to serve to effect the muscle spindle–γ loop, by allowing the extrafusal muscle fibers to lengthen to their normal relaxed state, thereby decreasing spindle output and interrupting the pain–spasm cycle. 93– 95Strain–counterstrain is also thought to improve blood flow to the area through a circulatory flushing of previously ischemic tissues. 94, 96

When treating the spine, the first step in the examination procedure is modification of the sagittal posture of the patient to produce a flattening of the lordosis–kyphosis in the region to be examined. 93In the extremities, the body part is placed in a position of relaxation. This position of ease(mobile point), which involves a shortening or folding of the tissues around the myofascial tender point, usually corresponds to the point of maximum relaxation. Any movement from this position produces an increase in tissue tension under the monitoring hand at the selected tender point site. 80, 89, 90Tissue texture abnormalities and areas of tenderness are then sought. The position of greatest resistance and pain is usually the position that is directly related to that of the original mechanism of injury; thus, the position of ease is usually opposite to that direction. For example, if an ankle sustained an inversion injury, the position of comfort is likely to be in eversion. In most cases, the tender point will be in, or near, the area of discomfort. Once the correct position is achieved, it is then maintained for 90–120 seconds before the patient returns slowly to the normal position. 80For example, if the biceps are being treated, the tender point is monitored, while the elbow is flexed and the forearm is simultaneously pronated. If the muscle is being moved in the correct direction, the tenderness should lessen. Slight adjustments from the recommended positions in this text may be needed. If there is more than one tender point, the clinician treats each one at a time, until the dominant one is found.

Once the tender point has been successfully removed, the clinician should focus on lengthening and/or strengthening the involved muscle.

Functional Techniques

Functional techniques are indirect techniques that use positional placement away from the restrictive barrier, similar to the techniques previously described for strain–counterstrain. The functional techniques were developed in the osteopathic profession in the 1950s, and much credit is given to Dr Andrew Taylor Still 97for identifying the dysfunctions that are treated with these techniques. 81, 98Still considered the somatic lesion to be a mechanical involvement of the structure, and his teachings placed primary emphasis on pertinent anatomy, with palpation used to identify the position and arrangement of a particular structure. 82

Although the term functional techniqueis itself somewhat of a misnomer, the criterion that distinguishes functional techniques from most manual techniques is the emphasis on moving the joint being treated away from, rather than toward, the restrictive barrier. As in the case of strain–counterstrain techniques, the joint in question is moved toward the normal physiologic barrier, at the opposite end of the ROM to that of the restriction.

According to functional technique theory, there is a dynamic balance point located between the restrictive barrier and the opposite physiologic barrier, which is the joint position in which the tensions in the soft tissues around the joint become balanced equally in all three planes. 99If this balance is achieved, the clinician can detect a sense of “ease” under his or her palpating fingers. It is the deep segmental tissues, which support and position the bones of a segment, and their reaction to normal motion demands, that are at the heart of functional technique specificity. 100If motion in any plane is initiated away from the dynamic balance point, the soft tissue tension around the treated segment increases, and there will be an increased sense of palpatory tension, or “bind.” 101

Two theories have been proposed to explain the beneficial effects of these techniques 101:

1. The afferent input from the proprioceptors is inhibited, which, in turn, suppresses the local protective cord reflexes.

2. The techniques stimulate the mechanoreceptors sufficiently to inhibit the pain receptors, allowing the tissues to relax.

Once the patient has been positioned correctly, the clinician can use one of two intervention options:

1. Active.In this method, the clinician initiates movement along the path of least resistance through the sequential release of any soft-tissue tension that occurs, until the restrictive barrier is no longer detectable and normal motion is regained.

2. Passive.In this method, the clinician follows the articular unwinding through sequential releases of the treated joint to the point of full soft-tissue release, until the restrictive barrier is no longer detectable and normal motion is regained.

Craniosacral Therapy

Craniosacral therapy (CST) is an alternative, complementary therapy practiced throughout the United States and around the world by osteopathic and chiropractic physicians; physical, occupational, and massage therapists; and dentists. 102CST is based around the assumption that cranial bone movement occurs through a respiratory mechanism comprising the brain, cerebrospinal fluid (CSF), intracranial and intraspinal membranes, cranial bones, spinal cord, and sacrum. 103CST practitioners are of the opinion that restrictions, misalignments, immobility of the cranial sutures and tension of the intracranial meninges directly impact the health of an individual. In addition, practitioners of CST claim that they can identify alterations in the movement patterns of the sacrum and the cranial sutures through manual palpation. Palpation of the cranium theoretically allows the clinician to perceive the rhythmic impulse resulting from the widening and narrowing of the skull. 102However, the reliability reports of identifying the rhythmic movement of the sutures using palpation have ranged from worse than chance to fair. 102, 104CST is also based on the existence of articular mobility at the cranial bones. According to CST practitioners, 5–10 g of force is recommended to manipulate human sutures. Despite the number of studies and the strong claims made by researchers from a variety of fields regarding the mobility of the cranial bones the research on cranial bone motion done to date is far from conclusive. 102In a study by Downey et al., 102a rabbit model underwent incrementally increasing forces through the skull. Movement within the coronal suture did not occur until 500 g of force was applied. Furthermore, forces up to 22 kg were required to cause 1 mm of movement. 102

It has been suggested that based on the lack of credible evidence, CST should be abandoned as a viable rehabilitative theory (i.e., that cranial sutures move), until such time that the advocates of CST contribute well-designed studies evaluating the efficacy of these techniques to the peer-reviewed literature. 104

Joint mobilization techniques include a broad spectrum, from the general passive motions performed in the physiologic cardinal planes at any point in the joint range to the semispecific and specific accessory (arthrokinematic) joint glides, or joint distractions, initiated from the open-packed position of the joint.

These techniques form the cornerstone of most rehabilitative programs and involve low–high velocity passive movements within or at the limit of joint ROM, to restore any loss of accessory joint motion as the consequence of joint injury. 2Although, theoretically, the joint capsule and articular surfaces are the structures affected by joint mobilizations, other periarticular tissues, such as tendons, muscles, and fascia are also likely affected. However, there are still no studies that identify histological joint changes resulting from joint mobilizations. There is also no conclusive research providing information regarding the optimal type of mobilization, the amount of time a joint should be mobilized, or the optimal amount of force required to treat any of the so-called joint impairments.

The indications for joint mobilizations include those already mentioned for MT techniques, but the evidence-based indications include the following:

• Increasing joint ROM. A number of studies addressing the effect of joint mobilizations on ROM provide evidence of an association. 105, 106
• Decrease pain. A number of studies have shown that hypoalgesia occurs as a result of joint mobilizations, 107– 109although the effect seems to occur regardless of the technique being used, the joint being treated, or the impairment being addressed.
• Promote muscle relaxation. Although there is some evidence that joint mobilizations can reduce muscle activity in muscles, the specific mechanism is unknown. 107
• Improve muscle performance. Evidence suggests that joint mobilization can improve muscle performance, regardless of the presence or nature of the muscle impairment. 110

Joint mobilizations are applied in a direction that is either parallel or perpendicular to the treatment plane, to restore the physiologic articular relationship within a joint and to decrease pain. 99Additional benefits attributed to joint mobilizations include decreasing muscle guarding, lengthening the tissue around a joint, neuromuscular influences on muscle tone, and increased proprioceptive awareness. 112, 113

Three types of mobilizations are recognized, based on the level of participation by the clinician and patient:

1. Active, in which the patient exerts the force

2. Passive, in which the clinician exerts the force

3. Combined, in which the clinician and patient work together

To apply joint mobilizations, the components can be utilized in a variety of ways, depending on the method employed:

• Direct method.An engagement is made against a barrier in several planes.
• Indirect method.Maigne 114postulated “the concept of painless and opposite motion,” in which disengagement from the barrier occurs, and a balance of ligamentous tension is sought.
• Combined method.Disengagement is followed by direct retracing of the motion.

Several other schools of thought have been put forward to address the concepts of increasing joint ROM. Kaltenborn 13introduced the Nordic program of MT, which utilizes Cyriax's 7method to evaluate, and the specific osteopathic techniques of Mennell 8for intervention. Further influence from Stoddard, 9an osteopath, cemented the foundations of the Nordic system of MT. Evjenth, 115who joined Kaltenborn's group, brought a greater emphasis on muscle stretching, strengthening, and coordination training.

Kaltenborn Techniques

Kaltenborn refers to the amount of joint play at a joint as slack. Each joint interface has a plane of motion, an imaginary line lying across the joint surfaces. According to Kaltenborn, all joint mobilizations, when performed correctly, should be made parallel or at right angles to this plane of motion, and are based on the concave–convex rule ( Table 10-6). 13For example, if extension of the tibiofemoral joint is restricted, either the femur (convex) can be stabilized and the tibia (concave) glided anteriorly or the tibia can be stabilized and the femur glided posteriorly. The concave–convex rule cannot be applied to every situation. Exceptions include movements at plane joints, movements for which the axis of rotation passes through the articulating surfaces, and movements at joints in which the concave side of the joint forms a deep socket. 116

Kaltenborn's techniques use a combination of traction and mobilization to reduce pain and mobilize hypomobile joints. Three grades of traction are defined:

• Grade I—piccolo (loosen).This grade involves a traction force that neutralizes pressure in the joint, without producing any actual separation of the joint surfaces. Grade I traction is used to reduce the compressive forces on the articular surfaces, both in the initial intervention session and with all of the mobilization grades.
• Grade II—slack (take up the slack).This grade of traction separates the articulating surfaces and eliminates the play in the joint capsule.
• Grade III—stretch.This grade of traction actually stretches the joint capsule and the soft tissues surrounding the joint to increase mobility. Grade III traction is used in conjunction with mobilization glides according to the convex–concave rules to treat joint hypomobility in the remodeling stage of healing. 13

Australian Techniques

The Australian approach was introduced primarily by Maitland, 12whose grading system is used throughout this text. Under this system, the ROM is defined as the available range, not the full range, and is usually in one direction only ( Fig. 10-2). Each joint has an anatomic limit, which is determined by the configuration of the joint surfaces and the surrounding soft tissues. The point of limitation is that point in the range that is short of the anatomic limit and is reduced by either pain or tissue resistance.

Maitland advocated five grades of joint mobilization or oscillations, each of which falls within the available ROM that exists at the joint—a point somewhere between the beginning point and the anatomic limit (see Fig. 10-2). Although the relationship that exists between the five grades in terms of their positions within the ROM is always constant, the point of limitation shifts further to the left, as the severity of the motion limitation increases: 11

• Grade I: a small amplitude technique (about 25%) performed at the beginning of the available ROM
• Grade II: a large amplitude movement in the middle of the ROM (i.e., the middle 50%).
• Grade III: a large amplitude movement at the end of the ROM (i.e., the last 50%).
• Grade IV: a small amplitude movement at the end of ROM (the last 25%)
• Grade V: a movement that exceeds the resistance barrier, commonly referred to as a high-velocity thrust technique or manipulation.

As with the Kaltenborn philosophy, the direction of the glide incorporated is determined by the concave–convex rule, and the joint to be mobilized is initially placed in its open-packed position. Many clinicians use a combination of Kaltenborn's grade III traction with Maitland's grade IV oscillations to decrease pain and increase joint mobility.

Maitland's grades I and II are used solely for pain relief and have no direct mechanical effect on the restricting barrier, although they do have a hydrodynamic effect. Mobilization-induced analgesia has been demonstrated in a number of studies in humans, 117– 119and is characterized by a rapid onset and a specific influence on mechanical nociception. Grade I and II joint mobilizations are theoretically effective in pain reduction, by improving joint lubrication and circulation in tissues related to the joint. 111, 120Rhythmic joint oscillations also possibly activate articular and skin mechanoreceptors that play a role in pain reduction. 77, 121

Maitland's grades III and IV have a mechanical, as well as a neurophysiologic, effect. Grade III and IV joint distractions and stretching mobilizations may, in addition to the above-stated effects, activate inhibitory joint and muscle spindle receptors, which aid in reducing restriction to movement. 77, 111, 120, 121

When joint motion is less than 50% but joint resistance to movement is the dominant dysfunction, a progression from the use of physiologic movements (grade IV; see Fig. 10-2) to stretch the joint limitation, and the use of accessory movements at the limit of the joint, is advocated. 12, 111Grades III and IV have been further subdivided into III+ (+ +) and IV+ (+ +), indicating that once the end of the range has been reached, a further stretch to impart a mechanical force to the movement restriction is given. 122A grade V mobilization, defined as the skilled passive movement of a joint, is a short-duration, small-amplitude, high-velocity thrust that is applied at the physiologic limit of joint range (see Fig. 10-2).

If mobilizing in the appropriate direction according to the convex–concave rule appears to exacerbate the patient's symptoms, the clinician should apply the technique in the opposite direction until the patient can tolerate the appropriate direction. 123

Physiologic movement mobilizations and accessory and distraction mobilizations may be performed at any grade indicated. The mobilizations are performed both at the site of pain and to joints proximal to the site of pain to produce analgesia. 124

The selection of the mobilization technique will depend on the barrier to movement felt by the clinician (the end-feel) and the acuteness of the condition (see Table 10-4). Muscle is usually the first barrier and is treated with light hold–relax techniques. Often some pain follows this initial mobilization, which is treated with grade III or IV oscillations. 122As the pain is reduced, the real barrier to movement is approached. If this barrier is periarticular tissue, then grade IV+ rhythmical oscillations are used to stretch the tissue; if the joint is subluxed, erratic, jerky grade III+ are applied. 122

Whichever technique or grade is employed, a number of further considerations help guide the clinician in addition to those mentioned under Correct Application of Manual Techniques:

• The position of the joint to be treated must be appropriate for the stage of healing and the skill of the clinician:
  • The resting or open pack position is used for the acute stage and/or inexperienced clinician.
  • Other starting positions may be employed by a skilled clinician in the nonacute stages.
• One half of the joint should be stabilized, while the other half is mobilized. Both the stabilizing and mobilizing hands should be placed as close as possible to the joint line. The other parts of the clinician involved in the mobilization should make maximum contact with the patient's body, to spread the forces over a larger area and reduce pain from contact of bony prominences. The maximum contact also results in more stability and increased confidence from the patient. An alternative technique, which produces the desired results, must be sought if the contact between opposite sexes is uncomfortable to either the patient or the clinician.
• The direction of the mobilization is almost always parallel or perpendicular to a tangent across adjoining joint surfaces and is appropriate for the arthrokinematics of the joint being treated.
• The mobilization should not move into or through the point of pain throughout the duration of the technique.
• The velocity and amplitude of movement is carefully considered and is based on the goal of the intervention, to restore the joint motion or to alleviate the pain, or both.
  • Slow stretches are used for large capsular restrictions.
  • Fast oscillations are used for minor restrictions.
• One movement is performed at a time, at one joint at a time.
• The patient is reassessed after a few movements if the joint is in the acute stage of healing, less frequently for other stages of healing.
• The intervention should be discontinued for the day when a large improvement has been obtained or when the improvement ceases.

Muscle reeducation is essential after mobilization or high-velocity thrust techniques and often produces a noticeable reduction in posttreatment soreness. While the joint is maintained in the new range, five to six gentle isometric contractions are asked for from the agonists and antagonists of the motion mobilized. 122Recently, the emphasis has shifted from mobilization of the joint in straight planes to mobilizations that incorporate the combined or congruent rotations that occur with normal motion, in order to take up all of the slack in the capsule.

Mobilizations with Movements

The concept of mobilizations with movements (MWMs) was introduced by Mulligan. 125, 126MWMs are based on the principles of joint mobilization originated by Kaltenborn. 13

With few exceptions, Mulligan's mobilization techniques are applied parallel to the plane of motion and are sustained throughout the movement until the joint returns to its starting position, with the intention of producing no pain when applied. 126Indeed, the golden rule of MWMs is that if pain is produced with an MWM, the techniques are contraindicated. The most common cause of pain with these techniques occurs when the mobilization is not sustained throughout the whole motion. 126

The movements used with MWMs are patient dependent and can include active, passive, and resisted movements. Their success is based on the theory that bony positional faults can contribute substantially to painful joint restrictions, which is similar to the theory behind the success of joint mobilizations. 126

Mulligan's MWM techniques were originally designed for the cervical spine but have since been expanded to include virtually every joint in the body. Several studies 125127– 130that looked at the effects of MWM concluded that MWM is a promising intervention.

Mulligan has devised a number of guidelines when applying these techniques 125, 126:

• The patient is placed in a weight-bearing position.
• Other interventions should be used in conjunction with these techniques.
• When treating hinge joints, the sustained glide or mobilization should be at right angles to the glide that usually occurs with the desired movement. For example, in the case of finger flexion, the glide-mobilization of the distal joint surface is applied in a medial or lateral direction.
• When joint movements involve adjacent long bones, as in the case at the wrist or ankle, it is often necessary for the clinician to adjust the relative positions of the long bones to enable pain-free joint movement to occur.
• The glide-mobilization is always successful in one direction only. The successful glide-mobilization is applied 10 times before reassessing the joint motion.
• Overpressure should be applied at the end range of the available active range of motion (AROM).

Mulligan techniques are described in detail in the relevant chapters of this text.

The earliest physicians to use high-velocity thrust techniques (joint manipulations) were English, and books on the subject were published in the early 1900s. 44, 131– 133

Compared with the four grades of joint mobilization (grades I–IV), high-velocity thrust techniques are given the designation grade V. Recently, manipulative therapy has been broadly defined to include all procedures, in which the hands are used to massage, stretch, mobilize, adjust, or manipulate musculoskeletal tissues for therapeutic reasons. 134However, in this text, high-velocity thrust techniques refer to grade V techniques. Although the grade V technique shares similarities with the grade IV mobilization in terms of amplitude and position in the joint range, grade V differs in the velocity of delivery. Applied at the barrier or point of joint restriction, a grade V technique involves the application of a fast impulse of small amplitude to restore joint play. The terms velocityand amplitudeare used to describe the nature of the final activating force or thrust used. Most grades I–IV joint mobilizations use varying degrees of velocity and amplitude, whereas grade V techniques generally employ a high-velocity (quick) and low-amplitude (short-distance) thrust. Unlike mobilizations, which are applied singularly or repetitively within or at the physiologic range of joint motion, 135high-velocity thrust techniques involve a thrust to a joint so that the joint is briefly forced beyond the restricted ROM. 2The speed, force, and correct application of a high-velocity thrust technique are critical if serious injury is to be avoided. This is particularly true in the craniovertebral region, where an overzealous technique can result in serious consequences. At the time of writing, there is much discussion as to whether or not a patient should be required to sign an informed consent prior to receiving a high-velocity thrust technique. At the very least, the clinician has an ethical duty to obtain at least verbal consent or agreement after explaining the rationale for the technique and the possible side effects. 136

High-velocity thrust techniques may consist of long-lever techniques that exert forces on a point on the body some distance from the treatment area, or short-lever techniques that comprise forces directed specifically at an isolated joint. 137A lesion that might benefit from a high-velocity thrust technique may be defined by movement restriction and pain, especially a joint restriction that elicits pain on provocation. The decision to use a high-velocity thrust technique is made after first identifying the restriction through the end-feel. For example, when significant excessive collagendensity (e.g., chronic capsular fibrosis) is thought to be the cause of the motion barrier, the use of a high-velocity thrust technique is deemed inappropriate. 136In such cases, the technique utilizing a slow, prolonged stretch would be more appropriate. The plane or direction of joint restriction determines the type and direction of the high-velocity thrust technique to be used. The direction of the technique can be delivered either perpendicular to, or parallel to the joint surface to question: 136

• Perpendicular: These techniques, more commonly known as distraction (gapping) techniques, aim to separate the joint surfaces and are usually delivered within the joint's pathological position of ease. This type of technique is only appropriate if the biomechanical assessment suggests an intra-articular inclusion or unstable joint which has become locked upor fixated beyond its neutral zone.
• Parallel: These techniques, aimed at improving the joint glide, are performed at the end of available range

Engaging the barrier, which requires a high level of skill, localizes the force, ensuring it will be applied to the restriction, thereby minimizing the magnitude and amplitude of the force. To successfully engage the barrier, a series of maneuvers called joint locking techniques are utilized. Excessive force or failure to localize the force of a technique results in a dissipation of physical forces, and unless the patient is able to absorb these forces, they may prove to be harmful, especially in the spinal regions. 24These harmful effects can include fracture, spinal cord compression, vertebral artery compromise (see Chap. 24), cerebral ischemia, and even death. 138

The following two methods of locking are commonly cited for the lumbar spine (see Chap. 28): 136

1. Locking from above.This technique places the lumbar spine into rotation and side bending to tighten the ligaments and capsule, thus stabilizing the joint, and can be performed in flexion, neutral, or extension of the lumbar spine. Because the clinician can only adequately control rotation motion when this is away from the edge of the bed, whichever side the patient is lying on the dictates the rotation that can be used—in the opposite direction from the patient side lying position (e.g., left side lying will permit right rotation). The side-bending motion is achieved by using the patient's lower arm to pull the shoulder girdle in either an inferior or a superior direction. For example, if the patient is lying on the left side, pulling the left shoulder girdle superiorly will produce right side bending of the trunk, whereas pulling the patient's left shoulder girdle inferiorly will produce left side bending. Flexion and extension can only be produced unilaterally in combination with the rotation. For example, with the patient in right side lying, flexion can be produced with left rotation by asking the patient to hold onto the edge of the table with their left hand (keeping the left shoulder girdle stationary), while the clinician pulls the patient's right arm horizontally forwards. Extension can be produced with left rotation by placing the patient's left hand onto their waist so that the weight of the patient's arm creates a left rotation with a backward displacement. This can be further enhanced by pulling the patient's right arm as vertical as possible while maintaining the right shoulder in a relatively stationary position. Neutral rotation (i.e., involving either flexion or extension) can be achieved by pulling the patient's right arm forward at a 45 degree angle. These patient positions enable the clinician to combine up to three components in the locking techniques simultaneously.

2. Locking from below.As with locking from above, the direction of the rotation is dictated by whichever side the patient lies on (e.g., the spine is rotated to the right if the patient is then left side lying). The rotation can be enhanced by bringing the nonweightbearing side of the pelvis anteriorly. Flexion and extension of the lumbar segments are produced through motions of the hip and pelvis as is performed with passive intervertebral joint motion (PIVM) testing. The following sequence is recommended:

   • Produce the necessary flexion or extension motion to the appropriate level:
     • Flexion is facilitated by keeping the knees away from full flexion, thus utilizing tension in the hamstrings to rotate the pelvis posteriorly.
     • Extension is facilitated by keeping the patient's knees as flexed as possible, thereby utilizing the tension in the rectus femoris to rotate the pelvis anteriorly.
   • Introduce the necessary side bending using the legs. Side bending is achieved by asking the patient to actively side tilt the pelvis by using commands such as “Push your lower leg down”, or “Make your lower leg longer.”

The clinician then carefully adjusts the position of the hips and knees without moving the pelvis until the upper needed in front of the lower to use rotation for a more secure lock. As with the locking techniques from above, the clinician has seven possible combinations:

• Neutral rotation, flexion, or extension.
• Ipsilateral extension (lower leg extending) or contralateral extension (upper leg extending)
• Ipsilateral flexion (lower leg extending), or contralateral flexion (upper leg extending)

With both locking techniques, the adjacent joints are positioned at the end of the available ROM for flexion/extension, side bending, or rotation. This positioning prevents further movement at these joints because either the ligaments are taut or the articular surfaces are contacting one another so that any further motion induced by a manual technique is likely to occur at the motion segment with the most slack—the motion segment targeted for treatment.

In the cervical spine, two types of locking techniques are also commonly advocated (see Chap. 25): craniovertebral locking and locking through segmental translation. Because of the potential for vertebral artery compromise in the craniovertebral region, the craniovertebral joints are often “locked” first before continuing motion into the middle and/or lower cervical spine joints. In the following example, a left side-bending technique is used. Although this locking technique may be used with the patient positioned in sitting or supine, if it is used in supine it is important to apply a small amount of compression to compensate for the loss of the spinal loading due to the weight of the head.

While palpating the C2 spinous process, the clinician slowly side-bends the patient's head to the left. If the side bending is performed around a sagittal craniovertebral axis, the C2 spinous process should be felt to move to the right, indicating left rotation of the C2 on the C3. Maintaining the left side-bent position, the head is now rotated to the right until the C2 spinous process regains a central position. The head is again side bent slightly to the left, and the C2 spinous process de-rotated back to midline. These motions are continued until a firm end-feel is reached. At this point, motion in the craniovertebral joints has now been exhausted, while the rest of the cervical joints remain in neutral. Being careful to maintain the position of the head, especially the right rotation, the side bending is continued left to the middle or the lower cervical level required. As the cervical joints are prevented from rotating to the left, the middle cervical side bending motion is exhausted very quickly.

When a specific force is applied to the bodily joints, clicking or popping sounds, called cavitations,may be heard. Distraction techniques are undoubtedly the easiest way to get the joint sound, especially from a normal joint. The actual causes of these cavitations or clicks is unknown, but are thought to result from a sudden release of synovial gas during the techniques. The gas is then reabsorbed by the joint over a period of about 30 minutes, which may explain why joints can only be “recracked” every 20–30 minutes. It is quite possible that these cavitations might produce a neuromuscular or neurochemical effect that will lead to temporary generalized changes, including the relief of pain. The mechanism behind the pain relief provided by a high-velocity thrust technique is not yet understood, although attempts have been made to explain the possible effects, including the freeing of an entrapped meniscoid or discal element, 142an alteration in muscle tone, 143and a mechanical disruption of intra-articular adhesions. 144– 146Certainly, it is known that restriction of motion at a joint produces joint adhesions, soft tissue contracture, and degenerative joint disease. 147– 149Therefore, by increasing the motion at a joint, a manipulation is thought to reverse the aforementioned detrimental effects. It is also possible that a high—velocity thrust technique may produce outcomes directly associated with a variety of psychological influences. 150The only true test of a successful technique is by the determination of an objective change in the patient's articular function, as confirmed by active and passive motion tests. 136

Prior to performing a high-velocity thrust technique, the clinician must attempt to determine the natural history of the joint through a subjective assessment or reaction to previous treatments. Ideally, the clinician should initially attempt to regain the lost motion utilizing other techniques such as joint mobilizations, ME, and ROM exercises prior to giving consideration to a high-velocity thrust technique. Unfortunately, a high-velocity thrust technique often becomes the procedure of choice because it carries a certain aura and is, therefore, often erroneously thought of as a panacea. 151The indications and contraindications for high-velocity thrust techniques are the same as those outlined at the beginning of the chapter. Additional contraindications include the following: 136

• Inability of the patient to relax.
• A past medical history that includes any condition that can weaken bone or collagen (e.g., rheumatoid arthritis, osteoporosis), any condition that may create abnormal hypomobility (e.g., Marfan syndrome, Ehlers–Danlos syndrome), any condition involving a joint fusion (surgical or otherwise), or any condition involving chemotherapy or radiotherapy for the treatment of cancer.
• Pediatric patient. The risk of damage to developing growth epiphyses and the question of whether the pretreatment explanation is understood, make children very precarious candidates for manipulation.

Once the determination is made to perform a high-velocity thrust technique, the clinician should place the joint into a premanipulative position for approximately 10 seconds and assess any change in the symptoms, the patient's reaction, and any localized or distal vascular or neurological signs or symptoms. These include vertebrobasilar artery or spinal cord signs or symptoms. Theoretically, the premanipulative position takes the target joint and its surrounding soft tissues slightly beyond the range through which a high-velocity thrust technique is to be performed. At the end of this hold, the patient is questioned as to the continued willingness of the technique to be performed, and whether this position is comfortable and nonirritating. Under no circumstance should a thrust technique be repeated, if the patient's symptoms are reported to worsen or if the first technique did not succeed with little force.

The evaluation of the effectiveness of high-velocity thrust interventions is difficult because the number of scientific studies on the subject is extremely limited. 152It appears evident that these techniques can cause an immediate relief of low back pain in patients with acute low back pain, 153although the degree of improvement varies between individuals. Some patients respond immediately to a high-velocity thrust technique; however, this population cannot be identified in advance, and there are no strong reasons for recommending high-velocity thrust techniques instead of mobilizations. 152

Proprioceptive Neuromuscular Facilitation

PNF, a manual technique that promotes the response of the neuromuscular mechanism through stimulation of the proprioceptor, was developed at the Kabat Kaiser Institute by Herman Kabat and Margaret Knott during the late 1940s and early 1950s. 154Initially, the approach was developed as a method of treatment for neurologically weak muscles due to anterior poliomyelitis. The techniques were later expanded for use in general muscle strengthening, joint mobilizations, and the stretching of adaptively shortened muscles. 155The PNF stretching techniques are described in Chapter 13.

PNF techniques provide the clinician with an efficient means for examining and treating structural and neuromuscular dysfunctions. 156– 158Structural dysfunctions (myofascial and articular hypermobilities and hypomobilities) affect the body's capacity to assume and perform optimal postures and motions. 159Neuromuscular dysfunctions (an inability to coordinate and efficiently perform purposeful movements) cause repetitive, abnormal, and stressful usage of the articular and myofascial systems, often precipitating structural dysfunctions and symptoms. 159– 161The theory behind PNF is that the human muscular system consists of muscle groups that are classified as agonists, antagonists, neutralizers, supporters, and fixators: 162

• Agonists: work to produce a movement
• Antagonists: relax to allow movement
• Neutralizers: inhibit a muscle from performing more than one action
• Supporters: stabilize the trunk and proximal extremities
• Fixators: hold bones steady

Within specific movement patterns, these muscle groups must contract in the proper sequence for optimal effectiveness. Muscle contractions are classified as static or dynamic. Static contractions are those in which no motion occurs. Dynamic contractions are concentric, eccentric, or maintained isotonic(a PNF term), the latter of which involves the intention to move, but no motion occurs. Theoretically, the facilitation of total patterns of movement will promote motor learning in synergistic muscle patterns and these total patterns of movement and posture are important preparatory patterns for advanced functional skills. These patterns are designed to encourage the stronger synergistic muscle groups to assist the weaker ones during functional movements, and are concerned with gross motions as opposed to specific motions.

According to PNF theory, muscle function occurs three dimensionally around three planes of movement, with each movement associated with an antagonistic motion:

• Flexion or extension
• Adduction or abduction in the extremities and lateral movement in the trunk
• Internal or external rotation.

Combinations of these movements work together in spiral and diagonal patterns. The patterns, which integrate the motions of sport and daily living, are based on the infant developmental sequences such as rolling, crawling, and walking. There are two diagonal patterns for the lower extremity ( Table 10-7), and two diagonal patterns for the upper extremity and scapula ( Table 10-8), which are referred to as the diagonal 1 (D1) and diagonal 2 (D2) patterns. These D1 and D2 patterns are subdivided into those that move into flexion and those that move into extension. In addition to the upper and lower extremity patterns, patterns exist for the upper trunk, lower trunk, and cervical spine.

Knowledge of the normal functional movement patterns of the body allows the clinician to identify altered patterns of motion. Once the clinician has diagnosed impairments or functional limitation, the clinician makes a decision as to which pattern will be used and the goal of the technique. Basic procedures of facilitation include body positioning the mechanics, manual contacts, manual and maximal resistance, irradiation, verbal and visual cueing, traction and approximation, stretch, and timing. 163The position of the patient, which often uses developmental positions, allows for consistency of measurement and plays a major role in influencing postural tone. The exercise pattern is initiated after positioning the patient so that the muscle groups are in the lengthened position. The muscle groups are then moved through their full range to their shortened position. The key to the success of PNF is the ability of the clinician to apply manual contact with appropriate pressure and exact positioning, which allows for a smooth, coordinated motion throughout the pattern. Manual contacts are used to isolate muscle groups, provide tactile cues, and influence the strength of the contraction. Appropriate pressure is described as the amount of resistance that facilitates the desired motor response of a smooth, coordinated, and optimal muscle contraction. 157, 162For example, the clinician can apply maximal resistance at specific points in the range to promote overflow to the weaker components of the movement pattern.

The patient is first taught the diagonal PNF pattern from the starting position to the terminal position, using brief and simple verbal cues, such as “push,” “pull,” and “hold,” as well as visual and tactile input while being careful to avoid exceeding the extensibility limits of the musculotendinous unit.

If a dysfunctional movement is identified in any of the diagonals of motion, the clinician can apply appropriate resistance in conjunction with various PNF techniques ( Table 10-9) to facilitate the relearning and rehabilitative process. 156– 159, 162For example, a quick stretch applied to a muscle before contraction facilitates a muscular response of greater force.

The following PNF techniques can be used for the development of muscular strength, endurance, and coordination.

Rhythmic Initiation

The rhythmic initiation technique is used to teach a patient a specific movement pattern, or with patients who are unable to initiate a movement, or those who have a limited ROM because of increased muscle tone.

The application of the technique involves a progression through the agonist pattern of passive, then active and assistive, then active movement. This technique is applied slowly against resistance through the available ROM, while avoiding activation of a quick stretch.

Repeated Contraction

Repeated contraction is a useful technique for patients who have weakness, either at a specific point or throughout the entire range, and to correct imbalances that occur within the range. The patient is asked to push repeatedly by using the agonist concentrically and eccentrically against maximal resistance, until fatigue occurs in the weaker ranges of the motion. The amount of resistance to motion given by the clinician is modified to accommodate the strength of the muscle group. A stretch can be applied at the weakest point in the range to facilitate the weaker muscles and promote a smoother, more coordinated motion.

Stabilizing Reversal

This technique, also known as an isotonic reversal, can be used for developing AROM of the agonists, while also developing the normal reciprocal timing between the antagonists and agonists that occurs during functional movements. The technique involves a concentric contraction of the agonist followed immediately by a concentric contraction of the antagonist, with the initial agonist push contraction facilitating the pull contraction of the antagonist muscles.

Rhythmic Stabilization

The techniques of rhythmic stabilization, also called stabilizing reversals, emphasize the cocontraction of agonists and antagonists, which results in an increase in the holding power to a point where the position cannot be broken. This effect is achieved by alternating isometric contraction of the agonist with isometric contraction of the antagonist, to produce cocontraction of the two opposing muscle groups. The command “hold” is always given before movement is resisted in each direction. The goals of this technique are to improve stability around a joint, increase positional neuromuscular awareness, improve posture and balance, and enhance strength or stretch sensitivity of the tonic muscles in their functional range. 159

The final step is to integrate the gains from the technique into function.

Myofascial Trigger Point Therapy

The term myofascial trigger pointis a bit of a misnomer, because trigger points can also be cutaneous, ligamentous, periosteal, and fascial. 164

An MTrP is a hyperirritable location, approximately 2–5 cm in diameter, 165within a taut band of muscle fibers that is painful when compressed and that can give rise to characteristic referred pain, autonomic phenomena, tenderness, and tightness. MTrPs, are classified as either active or latent ( Box 10-1). 166The patient's reaction to firm palpation of the MTrP is a distinguishing characteristic of myofascial pain syndrome (MPS) (given later) and is termed a positive jump sign. 167This reaction may include withdrawal, wrinkling of the face, or a verbal response. This hyperirritability appears to be a result of sensitization of the chemonociceptors and mechanonociceptors located within the muscle.

Healthy tissues do not contain trigger points, are not tender to firm palpation, and do not refer pain. Several possible mechanisms can lead to development of MTrPs, including low-level muscle contractions, an uneven intramuscular pressure distribution, direct trauma, unaccustomed eccentric contractions, eccentric contractions in an unconditioned muscle, and maximal or submaximal concentric contractions. 170Thus, MTrPs are typically located in areas that are prone to increased mechanical strain or impaired circulation (e.g., upper trapezius, levator scapulae, infraspinatus, quadratus lumborum, and gluteus minimus). As with all chronic pain conditions, concomitant social, behavioral, and psychological disturbances often precede or follow their development. 171, 172

Whatever the etiologic factors, it would appear that the development of MTrPs may be a progressive process, with a stage of neuromuscular dysfunction of muscle hyperactivity and irritability that is sustained by numerous perpetuating factors and then followed by a stage of organic dystrophic changes in the muscle bands with MTrPs. 167

According to Simons, 173the diagnosis of MPS can be made if five major criteria and at least one out of three minor criteria are met. The major criteria are

1. localized spontaneous pain;

2. spontaneous pain or altered sensations in the expected referred pain area for a given trigger point;

3. presence of a taut palpable band in an accessible muscle;

4. exquisite localized tenderness in a precise point along the taut band;

5. some degree of reduced range of movement when measurable.

Minor criteria include

1. reproduction of spontaneously perceived pain and altered sensations by pressure on the trigger point;

2. elicitation of a local twitch response of muscular fibers by “transverse” snapping palpation or by needle insertion into the trigger point;

3. pain relieved by muscle stretching or injection of the trigger point.

The major goals of MTrP therapy are to relieve pain and tightness of the involved muscles, improve joint motion, improve circulation, and eliminate perpetuating factors. When treating a patient for a specific muscle syndrome, it is important to explain the function of the involved muscle and to describe or demonstrate a few of the activities or postures that might overstress it, so that the patient can avoid such activities or postures.

A number of manual interventions for MTrPs are available; these include the following. 68, 174– 176

Stretch and Spray or Stretch and Ice 69, 164

Although not technically a manual technique, the spray-and-stretch technique involves a manual stretch during its application.

The patient is placed in a position of maximum comfort to enhance muscle relaxation. The part of the body affected is then positioned so that a mild stretch is exerted specifically on the taut band. Parallel sweeps of the vapocoolant spray or ice are applied unidirectionally; then, while one of the clinician's hands anchors the base of the muscle, the other stretches the muscle to its full length. 173The spray is held approximately 18 inches away from the skin, to allow for sufficient cooling of the spray. One or two sweeps of coolant are sprayed over the area of the involved muscle to reduce any pain. As the muscle is passively stretched, successive parallel sweeps of the spray are applied over the skin from the MTrP to the area of referred pain, covering as much of the referred pain pattern as possible. After each application of the spray-and-stretch technique, the muscle is selectively moved through as full a ROM as possible to normalize proprioceptive input to the central nervous system. 164Intense cold stimulates cold receptors in the skin, which tends to inhibit pain. This technique is supposed to help block reflex spasm and pain, allowing for a gradual passive stretch of the muscle, which decreases muscle tension. Several treatments may be needed to eliminate the pain syndrome; results should be seen after four to six treatments. 164If vaporized coolants are not available, ice may be used in their place, taking care to prevent chilling of the underlying muscles, which is less likely with the use of vaporized coolants. 164

Muscle Stripping

Muscle stripping is used after first applying a lubricant to the skin. The technique involves the slow sliding of the thumb, knuckle, or elbow along the edge of a taut band with firm pressure, while at the same time attempting to bow it out. 164This technique has the effect of applying brief ischemic compression, as the thumb slowly slides over the MTrPs, and of passively lengthening the taut band. Muscle stripping is as effective as the spray-and-stretch technique, although it is somewhat more painful. 164

Massage Therapy

Deep massage mechanically helps break up the fibrous bands of MTrPs. The application of deep pressure produces local ischemia. When the pressure is released, a reactive hyperemia occurs, improving circulation and releasing energy to the area. 177

Myofascial Release

These techniques, discussed in a previous section, combine massage with deep stretch techniques to relax muscle and break up the MTrPs. 46, 69

Ischemic Compression 164

Compression can be applied with a thumb, knuckle, or elbow. The compression serves as the hyperstimulant, and the pain is usually relieved within 20–60 seconds. The technique involves the application of pressure directly on the trigger point, within the patient's tolerance. As the pain subsides, the clinician slowly increases the pressure until, ideally, the painful stimulus is eliminated and a softening of the area is felt.

Stretching

Lengthening of the taut band is an effective form of intervention. It is theorized to disengage the actin and myosin filaments of the skeletal muscle (see Chap. 1), allowing more normal muscle length and increased ROM, and results in normal, patterned proprioceptive input to the central nervous system, which may prevent the resumption of pain. 164Lengthening can be accomplished with gentle stretching of the involved muscles.

Joint Mobilizations

Typically, treatment of a dysfunctional joint leads to spontaneous resolution of soft-tissue tension and the restoration of normal muscle lengths around the joint, thereby allowing the hypertonic muscles to relax. 44, 84, 88, 178

Nonmanual Interventions

The nonmanual interventions for MTrPs are included here for completeness. 68, 174– 176

• Thermotherapy.Moist heat, ultrasound, or a hot-tub session of 5–15 minutes' duration helps relax underlying muscles and increase circulation, thereby improving the supply of nutrients and decreasing tension on the MTrPs. 69Pain relief is theorized to be related to a washout of pain mediators by increased blood flow, changes in nerve conduction, or alterations in cell membrane permeability that decrease inflammation. 166, 179
• Cryotherapy.Brief, intense cold stimulation of the skin overlying the trigger point and its pain referral area is effective in releasing taut bands and inactivating trigger points, particularly when done in combination with a passive stretch. 164
• Trigger point injections.Trigger point injections using various techniques have been widely used to inactivate MTrPs by disrupting the fibrous banding, although the injected local anesthetic agent seems less important for inactivation of the trigger point than the needling itself. 66, 180, 181Trigger point injections should be followed by stretching and the application of heat. 69The effectiveness of ultrasound therapy is comparable to trigger point injections and should be offered as a noninvasive treatment of choice to those patients who want to avoid injections. 166
• Elimination of causative or perpetuating factors, if any.Mechanical and metabolic disorders need to be corrected to prevent further stress and strain on the muscles. Although many people have some degree of imbalanced body structure, structural imbalance is an extremely common contributing factor to myofascial constrictions and trigger points. 65, 174, 175, 182, 183In addition, patients should be encouraged to limit caffeine intake to less than two caffeinated beverages per day and avoid smoking, both of which directly and indirectly aggravate MTrPs. 69Nutrition deficiencies may require correction, and supplements of vitamins C, B 1, B 6, B 12, and folic acid have been advocated because of their essential role in normal muscle metabolism. 164
• Biofeedback and muscle relaxation.Biofeedback and muscle relaxation techniques can be used to avoid chronic muscle tension.
• Exercise.Exercise is important in limiting recurrences of MTrPs. 183
• Counterirritation.This very old method of controlling pain has been used for centuries. Its success relates to the fact that it breaks the pain–spasm–pain cycle that so often perpetuates a painful condition through the gate control mechanism of pain control (see Chap. 3).
• Combination therapy.One study, 166which looked at the combined intervention of ultrasound, trigger point injections, and stretching, found that the combination of these three interventions were effective in the reduction of pain, and improving ROM, independent of the severity or duration of pain present before the treatment. Another study, which examined a combined intervention of ultrasound, massage, and exercise, found that patients who had massage and exercise had a reduction in the number and intensity of MTrPs, whereas ultrasound alone gave no pain reduction. 184
• Electrotherapy.Electrotherapy has also been found to be an effective therapeutic modality to relieve pain from MTrPs, 64, 175, 185although electrotherapy alone is reported not as effective as thermotherapy or intermittent cold with stretching. 175Electrotherapy is thought to work by producing muscle contractions, which squeeze out the edema from needling, increase blood flow to the area, and relax the muscles. 65Two major types of electrical stimulation therapy used for soft-tissue lesions are electrical nerve stimulation (ENS) and electrical muscle stimulation (EMS).
  • ENS is the application of a low-intensity electrical current on the peripheral nerve. In general, ENS, such as transcutaneous nerve stimulation, is used in reducing pain intensity and increasing the pain threshold of MTrPs (no matter how severe the initial pain). 186, 187
  • EMS is the application of electrical current with stronger intensity directly to the involved muscle. EMS can be used to enhance muscle circulation, reduce muscle spasm, eliminate muscle pain, and increase muscle strength. 182, 185, 187

According to one study, ENS was found to be more effective than EMS for immediate pain relief, whereas EMS was more effective than ENS for improving ROM. 187

• 1. Give five indications for the use of MT.

• 2. Give five absolute contraindications to MT.

• 3. Give the three purported benefits of TFM.

• 4. Which manual technique uses the passive positioning of the body in a position of ease (rather than motion restriction) to evoke a therapeutic effect?

• 5. Which manual techniques involve low-velocity passive movements within or at the limit of joint ROM, to restore any loss of accessory joint motion as the consequence of joint injury?

Answers