At the conclusion of this chapter, the reader will be able to:
Identify the major influences that led to the development of the functional orthopaedics approach to soft tissue mobilization.
Understand the relationship between structure and function and how it relates to the application of soft tissue mobilization.
Conduct an examination including structural evaluation and functional testing consisting of the vertical compression test, elbow flexion test, and lumbar protective mechanism.
Understand the importance of muscle play.
Understand and apply the concept of three-dimensional identification of soft tissue restrictions.
Understand and apply the cascade of techniques for soft tissue mobilization.
Demonstrate entry-level performance of soft tissue mobilization of superficial fascia, bony contours, and myofascial dysfunctions on all regions of the body.
Massage may be the oldest form of medical care. The history of massage dates back to ancient times. In China, as early as 2700 BC, massage was recommended for a variety of ailments in The Yellow Emperor's Classic of Internal Medicine.1 In the 5th century BC, Hippocrates, the father of Western medicine, stated that "the physician must be experienced in many things, but assuredly in rubbing… for rubbing can bind a joint that is too loose and loosen a joint that is too rigid."2 The physician Galen, in the late first century AD, also advocated the use of massage for a variety of maladies.2
In the late 19th and early 20th centuries, clinical interest in the cause and treatment of pain of muscular origin continued in the medical community.3,4 St. George's Hospital in London had a department of massage until 1934.1 It was in 1894 that physical therapists began using massage techniques based on the work done by the Swedish physician, Per Henrik Ling.1 In the mid-1930s, a German physical therapist, Elizabeth Dicke,5 developed a more specific manipulative technique for connective tissue called Bindegewebemasssage. This form of connective tissue massage (CTM) later spread to the Englishspeaking world through the work of another physical therapist, Maria Ebner.6 With the advent of clinical modalities, however, massage fell out of favor within the medical community.7
Today, many forms of sophisticated soft tissue intervention techniques have emerged, bringing us back to a more hands-on approach to the treatment of myofascial pain and dysfunction. Travell and Simons's3 trigger point therapy (see Chapter 16), Cyriax's8,9 deep friction massage (see Chapter 5), Dicke and Ebner's5,6 connective tissue massage, and osteopathic myofascial release (see Chapters 4 and 14), as well as alternative approaches including Rolfing,10,11 Feldenkrais12 (see Chapter 20), Hellerwork, Aston patterning,13 and Trager7,14 have emerged to promote the use of myofascial manipulation for the enhancement of structure and function.
The soft tissue mobilization (STM) principles and procedures described in this chapter represent an eclectic approach (Box 13-1). This approach was developed by the co-author, Gregory S. Johnson, together with his wife, Vicky Saliba Johnson. Johnson developed Functional Orthopedics I (FOI) in 1980 as a way to present an integrated, systematic approach to soft tissue mobilization. FOI became the foundational course in a series of eight courses identified collectively as Functional Mobilization (see Chapter 12). This approach presents STM as an adjunct to other manual physical therapy techniques, neuromuscular reeducation, exercise, and body mechanics training for the purpose of restoring efficient function.
Box 13-1 The Functional Orthopedics Approach to STM
The Functional Orthopedics approach includes concepts from the following:
Cyriax's deep friction massage
Travell's trigger point therapy
Dicke's connective tissue massage
Rolf's concepts of postural efficiency
Feldenkrais's awareness through movement
"The key to optimal function is to balance the system by addressing planes both vertically and horizontally. The body is like a model of blocks or segments that, when misaligned, are unstable…" –Ida Rolf
"Habitual patterns of inefficient movement ultimately lead to inefficient posture. By learning efficient movement patterns, dysfunctional postures can be changed." –Moshe Feldenkrais
In the Functional Orthopedics approach, efficient movement patterns are used to reinforce the changes made through STM. Teaching patients efficient movement patterns following STM will reduce recidivism. In addition, the benefits of STM will be greatly enhanced by retraining patients' postures and breaking habitual patterns of movement.15 A complete description of the Functional Mobilization Approach is provided in Chapter 12 of this text.
"In the Functional Orthopedic Approach, efficient movement patterns are used not as much to change structure, but to reinforce the changes made through STM." –G.S. Johnson and V.L. Saliba-Johnson
The benefits of STM will be greatly enhanced by retraining patients' postures and breaking habitual patterns of movement through the use of a combination of education, neuromuscular reeducation, and exercise. Teaching patients efficient movement patterns following STM will increase the longevity of the results.
ANATOMY AND PATHOANATOMY OF SOFT TISSUE
The Anatomy of Connective Tissue
The properties of connective tissue (CT) are dependent on the extracellular matrix (ECM), which consists primarily of fibers (elastin and collagen), proteoglycans (PGs), and glycoproteins. Proteoglycans are characterized by a core protein covalently bonded to glycosaminoglycans (GAGs). There are six major GAGs, of which chondroitin sulfate 4 and 6 and hyaluronic acid (HA) are the most widely recognized. All GAGs are negatively charged, creating an osmotic imbalance that results in the absorption of water that hydrates the matrix. The proportions of the various ECM components determine the mechanical properties of the CT, which depend on the nature and extent of the loads placed upon them.16-22
The ECM is regulated by the balance between stimulatory cytokines and growth factors and the degradation and inhibition of metalloproteinases. Any alteration of this balance changes the properties of the CT matrix. Connective tissue disease and injury may result in a disruption of this balance.23,24 Refer to Chapter 14 for more details on CT structure and function (Box 13-2).
Box 13-2 Quick Notes! CONNECTIVE TISSUE FUNCTIONS
Tissue fluid transport
Control of metabolic processes
Fascia is comprised of both dense and loose CT and, along with muscle, is the primary focus of STM. Fascia is composed of irregular sheaths of collagen and elastin fibers and a high degree of HA (Fig. 13–1). These fascial sheaths are continuous with one another, creating an interweaving network that extends from the basement membrane of the dermis to the periosteum of the bone.18,22
Dense irregular connective tissue. (Adapted from: Gray H, Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1966, with permission.)
The fascia allows for a relationship between the superficial and deep layers of muscle,11 as well as a relationship between muscles and other structures such as nerves and bones (Fig. 13–2; Box 13-3).25 The superficial fascia is thinner and more delicate, and the deeper sheaths are thick and tough. Fascia serves to compartmentalize structures into functional units.11,22 The space that is created between structures acts as a functional joint or "space built for motion."26 These functional joints require movement, without which the fascia will thicken and harden (Box 13-4).11
Fascial layers surrounding muscle. Fascia functions to compartmentalize structures into functional units.
The space created by the compartmentalization of fascia forms a functional joint "built for motion." As movement specialists, the manual therapist must facilitate movement between the layers of fascia so as to avoid reductions in fascial elasticity, mobility, and adaptability.
Box 13-3 Quick Notes! MECHANICAL PROPERTIES OF CONNECTIVE TISSUE
Properties are determined by the proportions of components in the extracellular matrix (ECM).
Properties are determined by the nature and extent of loading.
Tendons are parallel to the muscle secondary to the line of pull.
Ligaments are primarily parallel, with some multidirectional fibers.
Bone is in orthogonal arrays in alternating sheets.
Fascia and skin are irregular and multidirectional.
Box 13-4 FASCIA IMPACTS MOVEMENT
As active movement increases, a spiraling and narrowing of the fascia occurs, creating elastic recoil, which becomes a factor in regular movement.
Stretch and recoil of the fascia supports the continuity of movement and creates smooth diagonal and spiral movement.
If fascia becomes densely packed or aligned against a typical direction of motion, as might occur with poor posture or holding patterns, then the elastic potential may be lost.
Fascia provides separation between structures that allows independent movement between adjacent structures such as muscle.
Fascia also absorbs shock, assists in the exchange of metabolites, stores energy, and provides protection against the spread of infection.
Cross-sectional dissections show that fascia may exhibit spiral patterns of orientation. In a neutral standing position, the pattern of fascial orientation in the spine is primarily vertical. As active movement increases, a spiraling occurs around the vertebrae and muscles. The elastic recoil that is created greatly influences the subsequent smooth diagonal and spiral movement.11 If fibers become densely packed or aligned in a fashion that resists motion, the elastic potential may be lost.11,27 Fascia also absorbs shock, assists in the exchange of metabolites, stores energy, protects from infection,11,18,22 and enhances active contraction.28 The fascia between two muscles allows each muscle to function independently and glide freely alongside one another during movement. The ability of muscle to move in this fashion is termed muscle play (Fig. 13–3).
Space created between structures through compartmentalization of fascia acts as a functional joint, or "space built for motion."
Connective Tissue and Healing
The synthesis of collagen begins with the alignment of amino acids followed by the assembly of three alpha chains that combine to form tropocollogen. As the process continues, cross-links are formed and more bonding occurs, ultimately resulting in the formation of collagen fibers.22
QUESTIONS for REFLECTION
What type of collagen is typically addressed through the use of STM?
Where is this type of collagen most abundantly found?
What are the primary structural features of this type of tissue and how are these features influenced through the application of STM?
The maturation phase of healing (Box 13-5) begins once levels of collagen reach their maximum at 2 to 3 weeks following injury. Initially, type III collagen, or scar tissue, is laid down. This type of collagen is poorly organized and has inadequate tensile strength. As maturation continues, type I collagen replaces type III, producing an increase in the strength of the injured tissue. Because stress stimulates the maturation process,29 appropriate STM techniques can facilitate healing after connective tissue injury.8,9 The tensile strength of connective tissue will continue to increase for up to 1 year following injury, and these tissues may return to between 80% and 100% of their original strength.30-33
Box 13-5 PHASES OF CONNECTIVE TISSUE HEALING
Reaction phase: This phase is stimulated by physical disruption of the soft tissue, which causes damage to the blood and lymph vessels and results in a transient vasoconstriction in an attempt to slow blood flow as the hemostatic process is activated.
Inflammatory phase: Vasodilation along with chemotaxis is regulated by humoral factors that follow a cascade effect where each successive factor is activated by its predecessor. Neutrophils are the cells to initially migrate to the site, followed by macrophages.
Proliferative phase: This phase is marked by fibroplasia and the development of a vascular network of granulation tissue. There is a concurrent process of angiogenesis that reestablishes the circulatory network. This new vascular system allows delivery of oxygen, amino acids, glucose, vitamins, and minerals necessary for the complete formation of collagen.
Maturation phase: This phase begins once levels of collagen reach their maximum at about 2 to 3 weeks. Initially, type III collagen, or scar tissue, is laid down. This type of collagen is poorly organized and has inadequate tensile strength. As maturation continues, type I collagen replaces type III, producing an increase in the strength of the wound. The maturation process has been shown to be stimulated by stress.
As collagen synthesis proceeds, collagen lysis also takes place. The rate of turnover and the balance between lysis and synthesis determines the nature of the scar. Collagen lysis is stimulated by the enzyme collagenase, which is brought to the site of healing by granulocytes and macrophages. In the event of extreme oxygen deprivation or severe deficiency of protein or vitamins, lysis will continue and synthesis will cease, resulting in incomplete healing of the wound.34 Clinically, this balance is important for the formation of strong, but mobile, scars. In the case of synthesisdominant healing, the potential for hypertrophic and immobile scar tissue exists, often resulting in decreased mobility.35,36 Immobile scar tissue, in the skin or in the deeper connective tissue, will limit mobility of soft tissue structures.
Fibrosis is defined as the laying down of fibrous tissue and is normally considered pathological. Fibrosis, however, occurs as part of the normal wound-healing process. Fibrosis follows a similar pathway to normal wound healing except there is a chronic progression of the fibrotic process characterized by continuous insult or stimulus that is either chemical or mechanical in nature.
Mechanisms and Cellular Processes of Soft Tissue Injury
A detailed manual physical therapy clinical examination provides evidence that myofascial restrictions exist.3,37-41 Various etiologic hypotheses leading to soft tissue dysfunction are often identified.7 Among these are (1) mechanical restrictions in the form of cross-linking of collagen fibers or scar tissue adhesions, (2) ground substance dehydration, (3) interstitial fluid changes such as lymphatic stasis and/or interstitial swelling, (4) neuroreflexive causes, and (5) electrochemical or biochemical causes.7,29,42-44
The most widely accepted etiology of connective tissue pathology is the presence of mechanical restrictions that prevent mobility between fascial layers.35,36,44-47 Postural stresses or continued use of the injured tissue may act as a continuous mechanical insult causing excessive synthesis of collagen and extracellular matrix components resulting in hypertrophic scar tissue.42,49,50
Ida Rolf10 believed that habitual tension leads to an increase in fibroblastic activity and deposition of collagen. Continued mechanical injury results in disruption of sarcomeres with leakage of the cellular components into the ECM, which stimulates tissue scarring.44,47
Connective tissue adhesions are a common by-product of the reparative process following surgery.44-47,50 This suggests that mechanical stimuli can lead to adhesion formation.50 Early passive mobilization using STM may improve the healing process through the initiation of gliding motions that disrupt adhesions and produce a change in the cellular response by alternating between stress and relaxation.51
QUESTIONS for REFLECTION
What is the primary role of proteoglycans (PG) and glycosaminoglycans (GAG)?
Where do these molecules primarily reside?
How would you describe the structure of these molecules?
Against what forces are they effective in resisting?
How does restoring normal mobility to a structure help to maintain the health of this structure?
After a 9-week immobilization period, Akeson et al52,53 found an increase in periarticular connective tissue (PCT) cross-links. In addition, a reduction in water content, hyaluronic acid, and chondroitin suggests a loss of lubrication at the fiber-to-fiber interfaces.
Physical forces produced through motion are able to modulate the synthesis of proteoglycans and collagen in connective tissue. Furthermore, regular movement reduces the formation of collagen cross-linking.
These findings suggest that motion is able to modulate the synthesis of proteoglycans and collagen in connective tissue. Regular movement reduces the formation of collagen cross-linking due to frequent changes in the location of intercept points between fibers, with the converse being true in the presence of immobility (Fig. 13–4). In vivo, animal arthrographic measurements showed significant contracture formation following just 2 weeks of immobilization. The amount of tension increased 10 times, and the area of hysteresis increased by as much as 23 times that of the control group.52-55 In addition to the mechanical causes of soft tissue restrictions, dehydration has also been identified as a factor in cross-linking.52-55
Cross-linking between collagen fibers limits extensibility. When movement is restricted, cross-links form where collagen fibers intercept, ultimately resulting in adhesions and decreased flexibility. Regular movement reduces the formation of collagen cross links. A. In normal muscle that is in a relaxed state, there is no crosslinking present. B. As the fibers are elongated during motion, a normal amount of excursion takes place. C. As a result of immobility and/or injury, cross-linking at intercept points may occur in the relaxed/shortened state. D. This limits the ability of the muscle to elongate leading to deficits in ROM. (From: Akeson WH, Amiel D, Woo S. Immobility effects on synovial joint: the pathomechanics of joint contracture. Biorheology. 1980;17:95-110, with permission.)
QUESTIONS for REFLECTION
What are the current hypotheses regarding the etiologic mechanisms underlying soft tissue dysfunction?
How do our STM techniques address these factors?
Are there specific techniques that are designed to address specific etiologies?
How does poor posture and habitual patterns of activity contribute to soft tissue dysfunction?
The association between HA and scar production has been demonstrated in mouse fetal limb wound repair. Scarless repair occurs in the 14-day fetal mouse limb; however, later in the gestational period, repair with scarring occurs. These results provide support for the notion that hyaluronic acid plays a key role in limiting scar tissue formation.24,52,56
Miller et al57 studied the effect of injecting gel compositions of HA, calcium, and NSAIDs on adhesion formation in chickens. Because water binds to HA, the presence of HA may have allowed for better hydration and fewer adhesions. The addition of NSAIDs and calcium resulted in "less dense" scars. This suggests that inflammation may also affect interstitial flow, which facilitates fibrosis.29
In a study by Ng et al,29 it was suggested that the biophysical environment that precedes fibrosis, such as swelling, increased microvascular permeability, and increased lymphatic drainage plays a role in fibrogenesis. Muscle biopsies of the upper trapezius in assembly line workers with chronic localized myalgia as a result of postural stress demonstrated cellular pathology consistent with localized hypoxia.58 This suggests that localized hypoxia resulting from postural stress could contribute to the production of a fibrotic state.48,49,58
Additional animal studies have shown that HA-treated groups demonstrated higher GAG content and up to 50% decrease in stiffness. HA injections to reduce pain and stiffness in arthritic knees are becoming commonplace. Is the mechanism whereby such positive effects are exerted due to a reduction in the formation of adhesions, or does HA provide the needed lubrication and spacing that enables freer movement? Evidence also suggests that HA may exert a positive feedback on its own production.59
The ECM protein, TN-C, has been shown to be present in regions where high mechanical forces are transmitted, such as the myotendinous and osteotendinous junctions. It is likely that TN-C plays an important role in providing elasticity to the myofascial system, and a reduction in the quantity of this protein may contribute to stiffness.60
Despite the fact that most studies have been performed on animal subjects, collectively they suggest that mechanical, as well as biochemical, processes are involved. Such processes, which affect hydration and interstitial fluid interaction, including swelling and lymphatic stasis, are all involved in the formation of soft tissue restriction. Furthermore, neuroreflexive processes may also play an additional role in the development of soft tissue dysfunction.61,62
Trigger points are myofascial aberrations that present as hyperirritable nodules or bands of myofascial tissue that represent a neuroreflexive dysfunction. Trigger points are thought to occur secondary to sensitization of muscle afferent nerve endings or a convergence of afferent fibers from the TrP and those from the referred pain zone onto a common spinothalamic tract neuron. Intervention must address the neuroreflexive nature of trigger points.
Janda63-65 states that muscle imbalances are reflexive in nature and can be considered a systemic deviation in the quality of muscle function that results from an adaptation to lifestyle. This results in various patterns of muscle tightness and weakness through a region or even throughout the entire body. Janda outlined three specific muscle imbalance syndromes, which are described in Table 13–1. As the manual physical therapist evaluates muscle dysfunction, therefore, it is important to examine the body as a whole, keeping in mind the effect that weakness, posture, and coordination have on a given muscle group. Muscular pain syndromes reflect dysfunction of the entire system and must not be considered in isolation.66
Table 13–1Janda's Classification of Common Muscular Imbalance Syndromes Noted During Structural Observation That Require Closer Examination ||Download (.pdf) Table 13–1Janda's Classification of Common Muscular Imbalance Syndromes Noted During Structural Observation That Require Closer Examination
|MUSCLE IMBALANCE SYNDROMES ||MUSCLES INVOLVED |
|Crossed Pelvic Syndrome || |
Tight: Hip flexors, paraspinals
Weak: Gluteals, abdominals
|Proximal Crossed Syndrome || |
Tight: Upper trapezii, levator scaulae
Weak: Scapular stabilizers
|Layer Syndrome || |
Tight: Hamstrings, thoracolumbarparaspinals, neck, upper trapezii,levator scapulae
Weak: Gluteals, L4-S1 paraspinals, scapular stabilizers
"Muscle imbalances are reflexive in nature and can be considered to be a systemic deviation in the quality of muscle function that results from an adaptation to lifestyle. This results in various patterns of muscle tightness and weakness through a region or even throughout the entire body." –Vladimir Janda
As the manual therapist evaluates muscle dysfunction, it is important to examine the body as a whole, keeping in mind the effect that weakness, posture, and coordination have on a given muscle group. Muscular pain syndromes reflect dysfunction of the whole system and must not be considered simply as a localized affliction.
Muscle tightness, as described by Janda,63,65,66 is the result of chronic overuse or poor posture. Tight muscles are painful when palpated but are not spontaneously painful. Tight muscles have a lower threshold, making them more easily activated, which contributes to their overuse and cycle of pain and tightness.66-68 Over time, strength diminishes in the shortened muscle as active fibers are replaced by non-contractile tissue.63
Muscle adapts to increased length by increasing sarcomeres, and the weight of the muscle increases secondary to changes in protein content. No deleterious biochemical changes have been reported in lengthened muscle.27 Muscles immobilized in a shortened position undergo a decrease in the number of sarcomeres of up to 40%. Biochemical changes also occur in the shortened muscle, which favor catabolism. Shortened muscles show a steep passive tension curve compared to controls, which may indicate that connective tissue loss occurs at a slower rate than does muscle loss. Endomysium and perimysium also become thicker, with immobilization in a shortened range further contributing to the reduction in extensibility.27 Tardieu et al69 found a similar increase in the passive tension curve slope when the triceps surae muscles of humans were immobilized in a shortened position.
Clinically, patients often present with muscle imbalances and postural dysfunctions that leave certain muscle groups shortened for prolonged periods of time. Clinically, it is important to understand that these muscles may have reduced protein content, increased infiltration of connective tissue, and a thickened endomysium and perimysium, all of which may contribute to the clinical presentation of "tightness."
"Muscle spasm is an involuntary and inappropriate, reversible, prolonged bracing of a muscle or group of muscles, attributable to overactivity of motor units or changes of excitability of muscle fibers." –M. Emre
Janda65 describes muscle tightness as a result of overuse creating physiologic shortening (Box 13-6). Based on this premise, he suggests the use of stretching techniques that are based on the work of Knott70 and to include timing for the contraction and relaxation phases of the stretch.65,70,71
"Tight" muscles are not just in a shortened state. In addition, these muscles may have reduced protein content, relatively increased connective tissue, and a thickened endomysium and perimysium, all of which contribute to the clinical representation of "tightness."
Muscle dysfunction can present in many forms; therefore, intervention should be directed at the specific cause of the dysfunction.
Treating shortened muscles with stretching techniques that include specific timing for the contraction and relaxation phases of the stretch is recommended.
Box 13-6 JANDA'S TYPES OF MUSCLE DYSFUNCTION
Muscle and joint correlation and associated muscle patterns
Muscle coordination, movement patterns, movement programming
Muscle contraction speed
Increased muscle tone or hypertonicity
The accessory motion of muscle, as previously described, is termed muscle play,43,72 that is, the ability of each muscle to move freely in all directions in relation to the surrounding muscles and fascia. Normal gliding motion is possible through adequate hydration of the ground substance provided by water binding to proteoglycans. The mobility of the fascia allows one muscle to move past another as muscles are stretched or contracted. In the dysfunctional state, however, the independent movement between muscle groups is limited or even lost.
Any intervention directed toward increasing muscle length must take muscle play into account. Simply stretching the muscles will not necessarily restore muscle play, and without restoring muscle play, the efficiency of muscle elongation cannot be achieved. Clinically, restoring muscle play through STM can often restore normal length without the need for stretching.43,72 The STM techniques described throughout the remainder of this chapter, are classified as either muscle play techniques, muscle tone techniques, or muscle excursion techniques.
In the same way that the physiologic motion of a joint is determined in part by its accessory motion, the length and function of a muscle is also determined in part by its accessory motion.
The accessory motion of muscle is termed muscle play and defined as the ability of each muscle to move freely in relation to the surrounding muscles and fascia.
Simply stretching muscles will not restore muscle play. Without restoring muscle play, efficiency of muscle elongation cannot be obtained.
PRINCIPLES OF EXAMINATION
The Objective Examination
The Structural Examination
The functional orthopedics approach bases its examination on identifying inefficiencies in both structure and function. The objective examination begins with a structural examination. The goal of this examination is to determine inefficiencies in the patient's structure that may lead to inefficiencies in function. Rolf10 described the body as a model of blocks or segments that, when misaligned, are unstable and therefore inefficient. Rolf contended that many postural dysfunctions and inefficiencies are produced from abnormal tension in the soft tissue.10 These structural inefficiencies present as compensatory postures and can be altered through soft tissue intervention (Figs. 13–5, 13–6).10
The frontal and sagittal alignment of segments are much like the stacking of building blocks. If the blocks are in good vertical alignment, the structure is stable and can support superincumbent weight. (From: Johnson GS, Saliba-Johnson VL. Functional Orthopaedics I, course lecture material. Steamboat Springs, CO: The Institute of Physical Art; 2003, with permission.)
The frontal (A) and sagittal plane (B) postural alignment deviations are identified during the structural examination. If even one block or segment is out of alignment, the structure becomes less stable and therefore less efficient. Intervention is directed toward facilitating functional efficiency through restoring normal alignment. (From: Johnson GS, Saliba-Johnson VL. Functional Orthopaedics I, course lecture material. Steamboat Springs, CO: The Institute of Physical Art, 2003, with permission.)
When examining the structure for vertical and horizontal alignment, the therapist should initially focus only on the bony structure. Using Rolf's analogy of blocks, the examiner can evaluate whether any of the segments are misaligned. Visually, the therapist gets an idea of the efficiency of the structure and estimates where the structure might buckle under pressure.
Once the osseous examination has been completed, the therapist seeks to identify the presence of soft tissue restrictions. During this process, it is important for the therapist to appreciate the three-dimensional components of length, depth, and width of each segment and to evaluate whether each segment is proportional to adjacent segments. For example, in the case of a protruding abdomen, increased anterior length creates excessive lordosis, resulting in compression of the lower lumbar facet joints.
When conducting the structural examination:
Begin observation in a natural setting with the patient unaware that he or she is being observed.
Observe the efficiency of transitional movements.
Look "through" the patient, initially, without focusing on any one specific region.
Observe the pattern of weight-bearing and base of support.
Appreciate the three-dimensional position of each segment.
Focus first on the osseous structures that serve as the structural framework.
Progress to observation of the symmetry, proportions, and contours of the soft tissues.
Visualize how the soft tissue structures may function during movement.
Note any mechanical stress points and patterns of structural dysfunction.
Note any areas of potential compensation.
Examination of the soft tissues includes evaluation of symmetry, proportions, and contours. It is important to observe from caudal to cephalad looking for soft tissue torsions, muscle atrophy or hypertrophy, and any other asymmetries. Posteriorly, the therapist examines the verticality of the Achilles tendons, the position of the calves, and the relationship between the calves and the hamstrings. The contour of the hamstrings and the gluteals, including the presence of any holding patterns or atrophy, should also be determined. Throughout the soft tissue portion of the examination, observation of creases, folds, bands, constrictions, holding patterns, and asymmetries in the soft tissue should be noted. Regions where the skin looks shiny may indicate areas of constant tension or possible autonomic changes. During observation, the therapist should continually visualize how the structure might function during movement.
The two most common postural dysfunctions are the anteriorly rotated pelvis and the anteriorly sheared pelvis.73 An anteriorly rotated pelvis is typically accompanied by hyperextension of the knees, increased lumbar lordosis, a backward bent costal cage, an elevated sternum, and forward head. An anteriorly sheared pelvis causes the sway back posture with the knees flexed, costal cage posterior, a depressed sternum, and forward head.38 The depressed sternum is usually associated with scapular depression and downward rotation, whereas the elevated sternum is more likely to be associated with an elevated or anteriorly tipped scapula.74 The clinician must determine, not only the primary dysfunction, but also any secondary compensations (Table 13–2). The anteriorly tilted pelvis is most often associated with tightness of the iliacus and hip internal rotators. The anteriorly sheared pelvis is associated with tightness of the psoas and the hip external rotators.75
Table 13–2Common Postural Dysfunctions Identified During the Structural Examination and Their Associated Joint and Muscular Involvement ||Download (.pdf) Table 13–2Common Postural Dysfunctions Identified During the Structural Examination and Their Associated Joint and Muscular Involvement
|POSTURAL DYSFUNCTION ||JOINT POSITIONS ||ASSOCIATED MUSCLE IMBALANCES |
|Anteriorly Rotated Pelvis || |
Pelvis: Anteriorly rotated
Lumbar: Increased lordosis
Ribs: Posterior to pelvis
Scapulae: Elevated, anteriorly tilted
Tight: Iliacus, hip internal rotators, paraspinals
Weak: Gluteals, abdominals
|Anteriorly Sheared Pelvis || |
Pelvis: Anteriorly sheared
Ribs: Posterior to pelvis
Scapulae: Depressed, downwardly rotated
Tight: Psoas, hip external rotators
Weak: Gluteals, paraspinals
STM endeavors to address soft tissue dysfunction for the purpose of returning structures to their most efficient neutral state. In neutral, minimal muscle activity is required for erect standing or sitting postures. The key to determining the quality of a particular posture lies in whether the structure functions efficiently.
In the context of examining soft tissue dysfunction, movement tests are performed to identify how these structures fold and elongate during movement.76,77 When examining trunk mobility, pelvic shear or side gliding is a valuable examination tool78 as it involves the use of a complex movement pattern that requires efficient hip, pelvic, lumbar, and thoracic function. Any movement that is limited, inefficient, or painful can be performed following intervention to assess treatment efficacy.
The Vertical Compression Test
The vertical compression test (VCT) (Fig. 13–7) is a useful method of examining the alignment and efficiency of a patient's structure to allow optimal weight transfer.43,72 Vertical compression is applied through the patient's structure in a caudal direction to evaluate how well the inherent structure is aligned. To perform the VCT, the therapist places his or her hands between the patient's first ribs and the acromion process and applies a gentle vertical pressure caudally. To ensure pure caudally directed force, the therapist's forearms should be positioned as vertically as possible. The patient should remain relaxed while the therapist carefully evaluates for the presence of movement within the system or the production of pain. In an efficient posture, force is transmitted to the feet with a springy and stable response without unwanted movement. A hard end-feel may indicate active resistance to pressure (Fig. 13–7a). In an inefficient posture, the patient will buckle or shift, most commonly into lumbar extension, anterior or lateral shear, or rotation (Fig. 13–7b). The test is graded on a 1 to 5 scale using a method found to have 80% interrater reliability by Johnson, anecdotally. Grade 1 indicates no buckling with the amount of pressure needed to contact bony structures. Each subsequent grade requires the addition of the same amount of force used for grade 1. An immediate improvement in the VCT is often realized through subtle modifications in the patient's posture or following minimal cueing. A positive response may suggest the presence of instability.79
The vertical compression test (VCT) is a useful method for examining the alignment and efficiency of a patient's posture. A. In an efficient posture, the clinician will sense the force transmitted through the feet and into the floor with a solid, but not hard, end-feel during the application of vertically directed force. B. In an inefficient posture, the patient will buckle or shift somewhere along the kinetic chain upon application of vertically directed force. Most commonly when inefficient, the patient will shift into lumbar extension.
The Lumbar Protective Mechanism (LPM)
The lumbar protective mechanism (LPM) (Fig. 13–8) examines the efficient timing of the core and global muscle systems' response to an outside force.80 The patient stands in a diagonal stance with the therapist facing the patient in the same diagonal. To allow initiation of the abdominals to prevent trunk movement, pressure is slowly applied and gradually progressed through the infraclavicular region in a posterior diagonal. The command is "hold, don't let me move you." In the efficient state, the patient should be able to maintain an erect vertical alignment without buckling, shifting, rotating, or developing pain. The therapist continues to provide more force until maximum force is applied without compensation or until movement or pain occurs as initiation, strength, and endurance of the stabilizing contraction is evaluated. LPM should be tested both in anteroposterior and posteroanterior directions and in both diagonals, and graded on a 1 to 5 scale.
Lumbar protective mechanism examines the efficiency of the trunk to stabilize against an outside force. It is a dynamic test of the efficiency of the structure and of the neuromuscular response of the stabilizing musculature. The patient stands in a diagonal stance, and the clinician stands facing the patient in the same diagonal. Pressure is applied by the clinician through the patient's infraclavicular region in a posterior diagonal direction. The command is "hold, don't let me move you." The clinician slowly applies force, evaluating the patient's ability to initiate the abdominals and prevent movement of the trunk.
The Elbow Flexion Test (EFT)
For the elbow flexion test (EFT) (Fig. 13–9), the patient stands with elbows flexed to 90 degrees with palms up as vertical force is applied through the patient's forearms. The therapist evaluates the patient's ability to maintain an erect posture with scapulae correctly positioned on the rib cage. Compensations may include movement of the thoracic cage behind the pelvis; shoulder girdle movement into elevation, protraction, or anterior tipping; or overuse of the upper trapezius. Like the other tests, the EFT is graded on a scale from 1 to 5.
The elbow flexion test is a dynamic test of structural efficiency. The patient stands with elbows bent to 90 degrees and palms facing up. Vertical force is applied down through the patient's forearms. The assessment is of the patient's ability to maintain an erect vertical posture with scapulae correctly positioned on the rib cage. Compensations from an inefficient posture may include movement of the thoracic cage behind the pelvis, shoulder girdle movement into elevation, protraction or anterior tipping (winging), or overuse of the upper trapezius.
The functional squat (FS) is an excellent method to examine movement patterns that involve the entire body. The patient stands with a wide base of support and is asked to squat as far as possible without pain while keeping the heels on the ground. The therapist makes an overall evaluation of the coordination and efficiency of the movement. The efficiency of the lower extremity is often determined by the alignment of the patellae in relationship to the foot. The effort required to keep the patellae tracking correctly is helpful in determining whether the dysfunction is more structural or more functional in nature. In the efficient state, there should be a natural weight transfer. Inefficient movement results in either flexion at the spine or an attempt to keep the spine vertical, causing a loss of balance. General inefficiency during the FS may indicate that this is not the patient's preferred method for bending (Table 13–3).
Table 13-3Special Tests Designed to Examine Postural and Structural Efficiency and Alignment ||Download (.pdf) Table 13-3Special Tests Designed to Examine Postural and Structural Efficiency and Alignment
|TEST ||PURPOSE ||PATIENT/THERAPIST POSITION ||PERFORMANCE ||INTERPRETATION OF FINDINGS |
|Vertical Compression Test (VCT) || || || |
Apply downward force with patient in relaxed posture.
Instruct patient to relax everything but the knees.
Monitor for pain and movement.
Positive: Patient buckles or shifts (lumbar extension, anterior or lateral shear, rotation)
Negative: Force transmitted to floor with solid and springy, not hard, end-feel
Grade 1: Weight of hands produces buckling
Grade 2: Minimum force without buckling
Grade 3: Minimum-moderate force without buckling
Grade 4: moderate-maximum force without buckling
Grade 5: Maximum force without buckling
|Lumbar Protective Mechanism (LPM) || || || |
Pressure applied through the infraclavicular region in an anterior-posterior, posterior-anterior diagonal
Monitor initiation of muscle response and trunk movement
Positive: Poor timing and initiation of the core versus global muscle systems and decreased strength and endurance resulting in loss of erect alignment
Negative: Efficient initiation, strength and endurance of core muscles maintaining an erect position
Strength and Endurance: 1–5 with 1 being poor and 5 being good or efficient
|Elbow Flexion Test (EFT) || || || || |
Positive: Decreased strength of the upper extremity, decreased strength and stability of the shoulder girdle allowing for protraction, firing of global versus core muscles, backward bending of thoracic spine, loss of balance
Negative: Maintain an erect vertical posture with scapulae correctly positioned on the rib cage and efficient balance
|Functional Squat (FS) || || || || |
Positive: Suggests that this is not the preferred method of bending. Excessive pronation, external rotation, or decreased ROM at the ankles. Patellar tracking medial to the great toe with increased effort. Flexion at spine or attempt to keep spine vertical.
Negative: Patellae track in line with the second metatarsal. Natural weight transfer. As knees flex, hips flex, allowing trunk to become horizontal. Spine in neutral, pelvis drops back and down.
Palpation Examination and Localization of Soft Tissue Dysfunction
Once these areas have been identified, the palpation examination allows the therapist to localize the specific dysfunction. Just as joints are evaluated for end-feel, so should soft tissues be evaluated for mobility and end-feel.81-83 Normal soft tissue end-feel is expected to be "springy."
The key to successful STM, within this approach, is threedimensional localization of the restriction, which includes location, depth, and direction. Cyriax advocates the concept that (1) all pain arises from a lesion; (2) to be effective, the technique must reach the lesion; and (3) intervention must exert a beneficial effect on the lesion.
Dividing the body into four layers helps to isolate restrictions. The first layer consists of the skin and superficial fascia. Layers two and three are myofascial layers deep under the skin but short of the underlying bony structures. The fourth layer consists of the deepest myofascial structures that lie against the underlying bone.84,85 Although the layers are not distinct, they aid in the specificity of the examination and intervention.
Superficial restrictions should always be cleared before moving to the deeper layers. The depth at which STM is applied is determined by the angle of the therapist's fingers to the target tissue and does not require an increase in pressure. To address the superficial layer, the treatment hand is nearly parallel to the surface. Deeper layers are reached by increasing the angle of the treatment hand to gradually become more perpendicular to the surface. This method disallows the need to increase force required to exert the desired effect.
A convenient method of indicating the specific direction of a soft tissue restriction is to use the image of a clock as a visual tool for the therapist to determine the specific restricted direction. This method of examination has been identified as tracing and isolating.43 Once specific localization of the dysfunction with regard to depth and direction has been determined, specific intervention may commence.
When addressing soft tissue lesions, the following concepts must be followed:
Be specific in localizing the depth and direction of any given lesion.
Clear the more superficial restrictions before addressing lesions in the deeper layers.
The depth of a technique is determined by the angle of the therapist's fingers, with deeper layers impacted as the angle becomes more perpendicular.
Tracing and isolating involves visualizing the face of a clock and checking soft tissue mobility in all directions.
PRINCIPLES OF INTERVENTION
The Effects of Soft Tissue Mobilization
Improvement in palpatory findings, increased range of motion (ROM), postural changes, and functional improvements can be identified as a result of STM.5,35,72,86-88 Maitland and others89,90 profess that joint mobilization permanently elongates the soft tissues that restrain joint mobility through the use of external force and may also explain the effects of STM on myofascial structures. In the case of postsurgical scars, STM can improve scar mobility and consequently lead to improvement in joint ROM and function.35,36 In the same way, adhesions within the fascial sheaths may also be altered by direct force.
Mechanical stress, in the form of tension or pressure, is thought to facilitate the process of healing by speeding the fibroblastic secretion of collagen.11 In addition, Ng et al29 found that when granular tissue fibroblasts were subjected to tension, in vivo, differentiation into myofibroblasts was increased indicating that mechanical forces facilitate myofibroblastic differentiation. Myofibroblasts in turn secrete hyaluronic acid.
Other effects of STM may be circulatory or neuroreflexive. STM causes mast cells to release a histamine-like substance that leads to vasodilation.63 Because vasodilation is a normal part of the healing process, techniques that facilitate vasodilation could promote healing in tissues that were previously not amenable to such processes.
When treating trigger points (TrPs) or muscle hypertonicity, neuroreflexive changes are thought to play a role in the reduction of pain and hypersensitivity (Box 13-7).3 Some have used dry needling to decrease the hyperirritability that is associated with active TrPs through mechanical disruption of the sensory nerve endings that mediate TrP activity (see Chapter 16).3
Box 13-7 JANDA'S ETIOLOGIES OF MUSCLE HYPERTONICITY
Limbic dysfunction: Not spontaneously painful and presents as a gradual change between the normal and the hypertonic muscle
Interneuronal dysfunction: Rare and exists as an altered balance of antagonistic muscles similar to that found in neural infections
Incoordinated contraction: Causes increased tone in a specific part of the muscle and is commonly referred to as trigger points
Pain irritation: Presents as a guarding or protective action by the muscle and is most often seen following acute injury. Under these circumstances, it is possible to record spontaneous EMG activity, which indicates that the whole reflex arc is activated, making it comparable to a voluntary muscle contraction.
Muscle tightness: Usually a result of chronic overuse or poor posture. Tight muscles are painful to palpation but are not spontaneously painful. Tight muscles present with a lowered threshold, making them more easily activated. This contributes to their overuse, keeping the cycle of tightness going. Initially, strength increases in the shortened muscle; however, in time, strength decreases as the active fibers are replaced by noncontractile tissue.
Lastly, electrochemical influences may also play a role in the effect that STM plays in reducing pain and restriction. The interaction between biological tissues and electromagnetic fields may prove to relate to myofascial dysfunction. In addition, such phenomena as the piezoelectric effect may exist not only in the physical sciences, but also may present in a similar way in biological tissues.
Preparing for Intervention
Beginning the intervention with the patient in the neutral position places tissues on slack, reduces muscle guarding due to pain, and allows the therapist to evaluate without the influence of external forces. As intervention progresses, STM can be performed in more functional positions (see Chapter 12).
CLINICAL PILLAR TIPS FOR PROPER PERFORMANCE OF STM
Place the patent in neutral alignment with adequate support to facilitate comfort and ease of application and progress toward end-range positions.
The therapist's body generates the pressure and creates movement, which is accomplished by placing the therapist's shoulders and hips in the direction of movement, with the feet positioned in a diagonal stance so that movement is produced by weight shifting from one foot to the other.
Identify specific parameters to evaluate the success of STM, keeping in mind specific goals that are commensurate with the stage of the condition.
Acute stage: Reduce pain, muscle tone, spasm
Subacute stage: Reduce tone, improve mobility
Chronic stage: Address soft tissues and associated compensations in more lengthened ranges and during functional motions
Maintain constant communication with the patient regarding his or her comfort and response to intervention.
The patient must take responsibility and become an active participant in his or her own care. The primary role of the manual therapist is to facilitate an efficient postural state and to teach patients how to maintain and care for themselves.
The Soft Tissue Mobilization Cascade of Techniques
Intervention should proceed in a methodical fashion, continuously searching for specificity while focusing on function. Most of the cascade of techniques that follow require both hands; therefore, descriptions consist of details regarding the treatment hand and the assisting hand (Box 13-8).
Box 13-8 CASCADE OF STM TECHNIQUES
Sustained pressure with assisting hand either shortening or lengthening the surrounding tissues
Unlocking spiral performed by treatment hand
Sustained pressure with shortening or lengthening of a body part
Sustained pressure with associated oscillations
Direct oscillations with the treatment hand
Soft Tissue Mobilization for the Skin and Superficial Fascia
Collagen fibers within the integument run in all directions. However, there is usually a predominate fiber direction that runs parallel to the direction that the skin is folded (shortened) and becomes stretched during normal movements. The skin is loosely attached and moves easily in relation to the underlying tela subcutanea or superficial fascia.22,91
Scar tissue is the extreme example of skin/superficial fascial immobility. More commonly, minor adhesions form between these layers, resulting in limitations in movement. To examine the skin and superficial fascia, the clinician places one or both open hands with palms down on the area to be examined with enough pressure to "tack" down the skin. As the hands are moved, the skin slides along the underlying tissues. This form of examination is called skin sliding and is typically performed around the image of a clockface.43
Because tissues in various regions move differently, the focus of the examination is on identification of end-feel rather than excursion. Once the slack is taken up, overpressure is applied to assess end-feel. Dysfunctional tissues are identified as having a hard end-feel. By moving into all directions of the imaginary clock, the direction of hardest end-feel and greatest restriction can be identified. Finger gliding of one finger along the skin normally reveals that the finger glides easily, creating a wave of skin in front of it (Fig. 13–10).43 Dysfunctional tissues will cause a slowing down of the finger glide or resistance. The therapist then moves along the surface in parallel, adjacent rows as though mowing a lawn, while ensuring that the finger remains on layer one by remaining parallel to the surface of the skin.
Finger gliding in order to trace and isolate a single dysfunctional region. A. In normal tissue, the finger glides easily. B. In dysfunctional tissue, resistance is noted under the finger. The therapist then moves along the surface in parallel, adjacent rows (A). Remaining on the proper layer is accomplished through attention to the angle of the finger and arm (B).
The manual physical therapist must be careful to maintain contact with the patient at all times in order to instill in him or her a feeling of confidence and security. Intervention begins with sustained pressure from the treatment finger, making sure the restriction remains isolated and is taken to its end range. Pressure is applied gently and follows the direction of greatest restriction, which may change as the restriction releases. With the assisting hand, the tissues around the restriction can be shortened, creating slack around the restriction, or lengthened, producing traction on the restriction. Shortening of the tissues can be applied in any direction around the restriction, whereas lengthening is usually performed along the direction of the restriction (Fig. 13–11).
Shortening or lengthening of superficial fascia, may be applied with A. the assisting hand, as B. the treatment hand releases the restriction. Tissues around the restriction can be shortened, creating slack around the restriction, or lengthened, producing traction on the restriction. Shortening of the tissues can be applied in any direction, whereas lengthening is performed along the direction of the restriction.
If sustained pressure combined with shortening or lengthening of tissues fails to provide a release, then a rotational force from the treatment hand may be used. This technique is called the unlocking spiral. This is performed by maintaining pressure on the restriction and superimposing a clockwise or counterclockwise motion through the treatment hand. The rotation is produced by the therapist's forearm moving toward pronation or supination. The tissue's resistance to the rotation is evaluated in both directions, and the spiral is performed in the direction of greatest ease until the restriction releases.
The more aggressive techniques are typically reserved for the deeper layers. The only exception to this is scar tissue, which is more resistant to intervention and may require more aggressive techniques to gain mobility. Following intervention of the superficial fascia, reexamination is required. Releasing the skin and superficial fascia may have profound effects on deeper structures as well. Not only will ROM improve, but these techniques may also produce changes in the aforementioned functional tests.
Soft Tissue Mobilization for Bony Contours
Because soft tissues attach to bone, clearing restrictions at the site of attachment is a good starting point. By improving mobility along these bony contours, release of tissue tension in the muscles that attach to the same site is facilitated (Fig. 13–12).64 For example, clearing restrictions along the iliac crest can impact the thoracolumbar fascia, paraspinals, quadratus lumborum, latissimus dorsi, and oblique abdominals.7 In addition, clearing bony contours is necessary since fascial sheaths may become "snagged" on bony hooks such as the coracoid process, resulting in a modified flow of the fascia from the neck to the hand. The coccyx may also interrupt the continuity of fascial tissue both inside and outside the pelvis.
By improving mobility along bony contours, release of tissue tension can occur in all of the muscles that attach there. For example, clearing restrictions along the A. lower border of the rib cage or B. iliac crest can affect muscles throughout the trunk. Once a restriction is identified, further localization is accomplished by angling the finger toward or away from the bone. The assisting hand can then shorten or lengthen the surrounding tissues.
The bony contours that frame the lumbar spine consist of the iliac crest, 12th rib, sacral sulcus, coccyx, and spinal groove. Once the superficial fascia is cleared, the therapist evaluates the deeper layers by changing the angle of the treatment hand. For example, when treating along the iliac crest, progression from layer one to layer two is accomplished by angling the hand and forearm about 30 degrees from the horizontal. Depth can also be accomplished by curling the hand so that the fingers themselves become more perpendicular to the structures that are being addressed. Once a restriction is identified, further localization of the restriction is accomplished by angling the finger toward or away from the crest as the assisting hand shortens or lengthens the surrounding tissues. In order for intervention to be successful at deeper layers, the assisting hand must be kept at the same layer as the treating hand.
Releasing recalcitrant restrictions may require more aggressive techniques, which may not necessarily require more force. If unsuccessful with shortening or lengthening, the clinician moves down the cascade of techniques, which leads to shortening or lengthening of a body part. In the example of the iliac crest, the obvious option is to shorten by pushing up on the ischial tuberosity or lengthening by pulling down on the iliac crest while maintaining the direction and depth of the restriction with the treating hand. Active movement such as hip rotation, for example, can be effective in facilitating tissue tension changes.
With progression, the patient advances from basic to more complex movements.12,92 Feldenkrais12 used repeated coordinated movements, which resulted in the development of efficient movement patterns that ultimately improve structure (see Chapter 20). By adding STM to these functional movement patterns, the process of releasing soft tissue restrictions is accelerated while simultaneously teaching the patient to move efficiently within the newly acquired ROM.92
The next intervention technique that uses the concept of shortening and lengthening of a body part in conjunction with gentle oscillations is called associated oscillations. The oscillations used within the FO approach derive their origin from the Trager method.14 In this form of "body work," oscillatory movements are incorporated at various locations throughout the body. The use of repetitive movement induces relaxation of the muscles. Although no direct manual contact to the muscle occurs, these oscillations are effective in reducing tightness.
The key to performing associated oscillations is rhythm. Using the previous example, the clinician's hand is placed on the ischial tuberosity, and pressure is applied cranially. Once the pelvis reaches its end range cranially, the pressure is released, allowing the pelvis to return to its initial position. The therapist's hand must remain in contact with the ischial tuberosity both during the shortening (or lengthening) and the relaxation phase of the oscillation. The oscillatory force is produced through movement of the therapist's body, which moves with the patient, creating a smooth, rhythmic motion. Associated oscillations can be performed in any region of the body and can be done either along the longitudinal axis of the body or the transverse axis, which creates a greater rotational force.
The most aggressive technique, reserved solely for unyielding restrictions, is the direct oscillation. Once the restriction has been isolated, direct oscillations are performed through the treatment hand directly into the restriction. Although the technique is considered to be direct, the force is produced through the body and is simply transmitted through the hand. This technique is similar to a grade III or IV joint mobilization and, as with associated oscillations, the patient's body should move along with the oscillation.
Soft Tissue Mobilization for Myofascial Restrictions
When addressing muscle play restrictions, the treatment hand performs (1) perpendicular deformation, (2) strumming, and (3) parallel mobilization. Examination of muscle play is typically performed by perpendicular, or transverse, deformation of the muscle (Fig. 13–13). In the lumbar spine, for example, the therapist should place the heels of his or her hands on one side of the spine with the fingers in a relaxed and slightly flexed posture, allowing the fingertips to rest on the opposite side of the spine. In this way, both hands come together to produce a single "tool" consisting of a row of fingertips that engages the border of the muscle. Other options include using the heel of the hand or thumbs, which is a more general technique. Movement of the spinalis muscle away from the spine allows the clinician to evaluate its capacity for deformation, the extent of its excursion, and most importantly, its end-feel. As with the intervention of bony contours, the process of examining myofascial structures must proceed from superficial to deep.
During perpendicular deformation, the heels of the hands are placed on one side of the spine, with the fingertips resting on the opposite side of the spine. Both hands come together to produce a single "tool," consisting of a row of fingertips that engages the border of the muscle. The set up for strumming is similar; however, once the perpendicular deformation is performed, the therapist allows his or her fingers to slide over the muscle belly. Muscle deformation is generated by the therapist's body, not his or her hands.
A progression of the perpendicular mobilization is a technique called strumming. Strumming can be used both as an examination and mobilization technique for muscle play dysfunctions. The setup for strumming is the same as that for perpendicular mobilization. However, once the perpendicular deformation is performed, the therapist allows the fingers to slide over the muscle belly and then back to the starting position. The therapist may strum repeatedly at a given location to assess the mobility and end-feel of the muscle and then repeat the process along the entire length of the muscle. As with all techniques, the muscle deformation is generated by the therapist's body, producing an oscillatory effect on the patient's body. Strumming takes time to master, but it can be an excellent method for treating muscle play dysfunctions and identifying areas of increased tone.
The third examination and intervention option is the parallel technique. This technique is performed by applying finger pressure parallel to the muscle, either between the bone and the muscle or between two adjacent muscles. The therapist slides his or her finger along the muscle, attempting to separate it from the surrounding tissues. Dysfunctions will present as a "stitch" in the tissues that makes continued gliding of the finger difficult. The therapist will trace and isolate to the specific depth and direction and treat accordingly.
Muscle tone dysfunctions present as tight nodules or bands of sensitivity within a muscle belly. Because of their neuroreflexive nature, these dysfunctions are often more resistant to lasting improvement72,73,92; therefore, intervention requires patient participation and retraining of posture and movement.15 The patient's feedback is helpful in localizing the exact "epicenter" of the dysfunction.
Intervention is applied with sustained pressure at the exact point and direction of the dysfunction. As relaxation occurs, the therapist takes up the slack by moving farther into the tissue. The emphasis of intervention is to allow the patient to recognize the increased tone and reduce it by using various "self-relaxation" techniques such as (1) breathing into the pressure, (2) breathing through the pressure, (3) attempting to "let go," (4) using visualization or imagery, and (5) contracting the isolated point followed by relaxation. Muscle belly dysfunction can also be treated by localized strumming or general ironing techniques that broaden the muscle.
Muscle Excursion Techniques
Muscle tightness may exist in isolation65,93 or in conjunction with muscle play/tone dysfunctions. Stretching in conjunction with soft tissue techniques are more effective than stretching alone.10 To examine muscle length passively, the segment is brought to end range along its primary plane of movement followed by moving diagonally to isolate the direction of maximal restriction. For example, when testing hamstring length, the patient is asked to perform passive straight leg raising. Further isolation may be accomplished by slightly abducting and adducting, then medially and laterally rotating the leg in order to identify maximal threedimensional tension.94,95 STM during passive stretching and in conjunction with proprioceptive neuromuscular facilitation (PNF) may also be performed (Table 13–4).
Table 13–4Soft Tissues Typically Targeted for Mobilization Techniques Including a Description of Their Mechanical Properties and Recommended Principles of Examination and Intervention to Be Implemented for Each Tissue ||Download (.pdf) Table 13–4Soft Tissues Typically Targeted for Mobilization Techniques Including a Description of Their Mechanical Properties and Recommended Principles of Examination and Intervention to Be Implemented for Each Tissue
|TARGET TISSUE ||TISSUE PROPERTIES ||PRINCIPLES OF EXAMINATION ||PRINCIPLES OF INTERVENTION |
|Skin and Superficial Fascia || |
Collagen run in all directions. Primary fiber direction is parallel to direction that skin is folded and stretched.
Easy gliding between skin and fascia and stretching of the skin occurs during normal movement.
Large amount of elastin allows stretching, deformation.
Place one or both open hands with palms down. "Tack" down the skin so that the skin slides along the underlying tissues. This form of examination is called skin sliding.
Excursion of the tissues varies in different regions and directions.
Identify end-feel rather than excursion. Once the slack has been taken up, apply gentle overpressure.
Slowly move the hand in all directions, looking for the hour on the clock with the hardest end-feel.
Take one finger and slide along the skin in the established direction, a technique called finger gliding.
Move along the surface in parallel adjacent rows with the finger in layer one.
Sustained pressure from the assessing finger isolates the restriction and takes it to end range.
Pressure applied gently and follows direction of greatest restriction
With assisting hand, tissues around the restriction are shortened or lengthened, producing traction on the restriction.
Unlocking spiral is performed by maintaining pressure on the restriction and superimposing a clockwise or counterclockwise motion through the treating hand. Rotation produced by the therapist's forearm moving toward pronation or supination. Spiral performed in the direction of ease until the restriction releases.
Scar tissue is more resistant to intervention and may require more force and more aggressive techniques.
|Bony Contours || |
Type I fibers that present in orthogonal arrays in alternating sheets to resist multidirectional forces, including shear.
Clearing restrictions along the iliac crest can affect the thoracolumbar fascia, paraspinals, quadratus lumborum, latissimus dorsi, and oblique abdominals.
Fascial sheaths may become "snagged" on bony hooks like the coracoid process.
The coccyx may also interrupt the continuity of fascial tissue.
The tissue-layering concept is important because multiple layers of muscle and fascia attach to these bony contours.
| || |
Isolation occurs by angling the finger toward or away from the crest to further localize the restriction. The assisting hand shortens or lengthens the surrounding tissues.
Keep the assisting hand at the same layer as the treating hand.
Shorten the region by pushing up on the ischial tuberosity or lengthening it by pulling down on the iliac crest while maintaining specific direction and depth with the treating hand.
Simple active movements are performed, including hip internal and external rotation progressing to more complex movements, including functional movements.
Associated oscillations are performed with treating hand on the ischial tuberosity with pressure applied cranially, followed by a release of the pressure without removing the hand. The oscillation is produced by movement through the clinician's whole body, not just the hands. Oscillations into hip or shoulder rotation are used to create rotational forces.
Once the restriction has been isolated, direct oscillations are performed through the treating hand.
|Myofascia || |
Includes both dense and loose connective tissue
Composed of irregular sheaths of collagen and elastin and a high degree of HA
Fascial sheaths are continuous, creating a network that extends from the dermis to the periosteum.
Muscles are covered by endomysium, perimysium, and epimysium, which are considered fascial sheaths and allow for independent movement between each structure.
Intervention for muscle play dysfunction will usually be maintained once treated; the muscle tone dysfunctions are more resistant to lasting intervention.
Examine the body as a whole, keeping in mind the effect that weakness, posture, and coordination have on a given muscle group.
Examination of muscle play is performed by perpendicular or transverse deformation of the muscle.
In the lumbar spine, therapist places heels of hands on one side of the spine with fingers in a relaxed posture, allowing fingertips to rest on the opposite side of the spine; this allows both hands to produce a single "tool" that engages the border of the muscle.
Examining myofascial structures proceeds from superficial to deep. Once a restriction is identified, angle fingers slightly caudally and then cranially to further trace and isolate to establish the three-dimensional location of the restriction.
Examination then progresses between any two muscle bellies.
To examine muscle length, passively stretch the muscle to the end of its range. Then isolate the direction of maximal restriction by moving diagonally.
Muscle play techniques include the following:
Maintain sustained deformation pressure with the intervention hand with the assisting hand shortening or lengthening tissues or lengthening the body part by pulling down on the iliac crest.
Direct oscillation in combination with assisting hand techniques to rhythmically deform the muscle in the direction of the restriction.
Strumming can be set up the same as that for perpendicular mobilization. Once the perpendicular deformation is performed, the therapist allows fingers to slide over the muscle belly, strumming repeatedly at a given location, then repeating along the entire length of the muscle.
Parallel technique is performed by applying finger pressure parallel to the muscle, either between the bone and muscle or between two adjacent muscles. The therapist slides finger along the muscle, attempting to separate it from the surrounding tissues.
Muscle tone techniques include the following:
Intervention must include patient participation, which includes the retraining of posture and movement.
Intervention is applied with sustained pressure at the exact point and direction of the dysfunction. The pressure should begin at a level that does not cause the surrounding muscles to contract. As relaxation occurs, the therapist takes up the slack by moving further into the tissue. The emphasis of intervention is to allow the patient to recognize the increase of tone and learn to reduce it by using various "self-relaxation" techniques. While sustained pressure is maintained by the therapist, several techniques can be applied by the patient. These include (1) breathing into the pressure, (2) breathing through the pressure, (3) attempting to "let go," (4) using visualization or imagery and (5) specifically contracting that isolated point of muscle followed by relaxation. Muscle belly dysfunction can also be treated by localized strumming or by general ironing techniques that attempt to broaden the muscle. These techniques should also be performed with patient involvement.
Muscle excursion techniques include the following:
General Myofascial Techniques
General techniques are performed using a broader contact. They are still performed specific to the location, depth, and direction of the restriction. They are effective when large muscle groups are involved and can effectively "iron out" the muscle. In the lumbar spine, general techniques can be performed along the paraspinals, using the heel of the hand, knuckles, or proximal ulna. The stroke should be applied cranial to caudal and medial to lateral to facilitate lymph drainage and is most effective with a posterior tilt of the pelvis. Using the elbow or knuckles on the piriformis with hip rotation is often effective.
Circumferential techniques are typically performed on the extremities for the purpose of restoring muscle play so that soft tissue is able to move circumferentially around long bones. Hands are placed posteriorly and anteriorly and enough pressure is provided to take up slack and prevent hands from sliding over the skin. The soft tissues are then rotated clockwise and counterclockwise around the bone until full excursion is accomplished. End-feel is assessed, and the most restricted direction is established. The therapist then angles the pressure proximally and distally to isolate the exact angle of the restriction. To progress, the patient attempts to rotate the extremity against the therapist's pressure. Following relaxation, the therapist takes up the slack and the process is repeated.
Soft Tissue Mobilization Techniques for Selected Regions
Soft Tissue Mobilization for the Abdominal Region
In the abdominal region, examination of the superficial fascia should be performed first along with assessment of the umbilicus mobility through a 360 degree range. Specific attention should be given to surgical scars, which are common in the abdomen and can significantly affect the mobility of the spine and create locomotor dysfunction and associated pain syndromes.35 The bony contours of the abdomen consist of the lower border of the rib cage and the anterior aspect of the ilium. Both of these bony contours lead directly to examination and intervention of the diaphragm and iliacus muscles. The diaphragm is mobilized by placing both hands on the upper abdomen with the fingers resting laterally on the rib cage (Fig. 13–14). As the patient inhales, the therapist's hands move cranially and into ulnar deviation to spread the rib cage. During exhalation, the therapist maintains the spread of the rib cage, providing a stretch to the diaphragm.96 The iliacus can be palpated by sliding the fingers posteriorly along the iliac fossa.
The diaphragm release is performed by placing both hands on the upper abdomen with the fingers resting laterally on the rib cage. As the patient inhales, the therapist's hands move into ulnar deviation to spread the rib cage. During exhalation, the therapist attempts to maintain the spread of the rib cage.
After the diaphragm and iliacus have been treated, the rectus abdominis should be evaluated for muscle play. Its lateral borders, indicated by the lineae semilunares on each side of the linea alba, should be palpated. The therapist then slides the fingers medially to slide under the rectus, which is then lifted and glided from right to left.
Before progressing to the psoas, the abdominal contents are assessed. The viscera is surrounded by fascia and can therefore develop restrictions. With hands on either side of the abdomen, the entire abdomen is moved to the left and right. Isolation of the restricted direction through angling the pressure is critical. Intervention is most easily performed by having the patient shorten or lengthen the region by rotating the spine through the lower extremities. Lastly, the therapist should treat the psoas. Soft tissue restrictions of the psoas can refer pain to the back and impact movement.97-99 The psoas is palpated by moving deeply into the abdomen approximately midway between the umbilicus and the anterior superior iliac spine. The therapist verifies position by flexing the hip. Any of the previously mentioned techniques can be used to treat the psoas. Lengthening or shortening a body part can be performed by changing the hip angle, moving the pelvis into rotation, or rotating the spine through the legs, all of which can be performed passively or actively (Fig. 13–15).
The psoas release is performed by moving deeply into the abdomen midway between the umbilicus and the anterior superior iliac spine. Gentle strumming of the psoas allows for assessment of both muscle play and tone. Once the muscle is palpated, the therapist can move more cranially and caudally to isolate restrictions.
Soft Tissue Mobilization for the Anterior Chest Region
Addressing soft tissue restrictions of the anterior chest is vital to the outcome of most neck and shoulder dysfunctions. Treating soft tissues in the anterior chest can be beneficial at improving posture and the efficiency of the cervical and thoracic spine and shoulders. In supine position, the manual physical therapist should evaluate the position of the scapulae and the breathing pattern. Intervention begins with intervention of superficial fascia. Bony contours include the manubrium, sternum, costosternal junctions, clavicle, and anterior/lateral ribs. The deep and superficial cervical fascia attaches to the clavicle, and shoulder movement into rotation is an effective way of altering fascial tension. The lateral border of the scapula should also be assessed because many of the involved muscles attach to this region. The myofascial structures treated in this region may include the pectoralis major/minor, subscapularis, teres major/minor, serratus anterior, latissimus dorsi, infraspinatus, intercostals, sternocleidomastoid, scalenes, upper trapezii, levator scapulae, platysma, and the longus colli.
Soft tissue mobilization as a means of addressing myofascial pain has been in existence since the beginning of time, and through the years, many clinicians and researchers from a variety of disciplines have contributed to the existing body of knowledge. The approach to STM delineated in this chapter represents a unique system developed by Gregory S. Johnson. This approach uses STM as an integrated component of Functional Manual Therapy for the reduction of pain, the enhancement of efficient function, and the restoration of myofascial mobility in preparation for the application of joint mobilization, neuromuscular reeducation, and motor control training.
To effectively implement STM, it is vital that the manual physical therapist has an appreciation for normal soft tissue anatomy and healing, as well as a complete understanding of the mechanisms that may contribute to soft tissue impairment. Effective use of STM requires the manual physical therapist to localize the soft tissue dysfunction three-dimensionally, that is, by location, direction, and depth. Localization is best accomplished through a method called tracing and isolating. Once localization of the dysfunctional lesion has occurred, a cascade of STM techniques may be implemented. These techniques should be used to address soft tissue dysfunctions, first of the skin and superficial fascia, followed by clearing of bony contours, and ultimately they should address myofascial dysfunction, more specifically, limitations in muscle play.
Soft tissue restrictions may need to be addressed in order to allow other interventions to have a more profound effect. The prevalence of soft tissue lesions requires the manual physical therapist to possess a thorough understanding of soft tissue anatomy and potential mechanisms, along with examination and intervention strategies designed to restore structural efficiency and symptom-free function.
History of Present Illness (HPI): The patient is a 29-year-old male with a history of degenerative disc disease at L4-L5 and L5-S1 and multiple episodes of low back pain and bilateral buttock and posterior thigh pain. This current episode began a couple of days ago for no apparent reason and has progressively worsened. Currently, he complains of nearly constant pain, difficulty walking, and the inability to forward bend.
Past Medical History (PMH): The original onset of symptoms was approximately 5 years ago during a ski trip. Since that time he has had five episodes of low back pain, with each resolving in response to physical therapy.
Observation: The patient presents with a 50% right lateral shift, reduced lumbar lordosis, positive pelvic anterior shear, and pelvic asymmetry with the left ilium postured superiorly.
Active Range of Motion (AROM): Backward bending = 10%; left shear = 80%; right shear = −40%.
Based upon observation and the AROM findings, within what muscle groups would you expect to find myofascial impairment? Be specific and explain your rationale. Where would you expect this patient to buckle upon performance of the VCT? Explain your rationale. What other examination procedures would you perform to confirm your suspicions?
Describe in detail how you would examine the lumbar spine to determine the most appropriate soft tissue mobilization techniques. Assuming you identified the presence of muscle spasm, what soft tissue techniques might be most beneficial? Include direct and indirect techniques and explain your rationale. What would you monitor to determine the success of your intervention, both during the intervention and immediately after?
After two visits, the patient no longer presents with a lateral shift; however, the rest of the observational assessment remains the same. He now presents with left shear 80% and right shear 60%. At this time, he is not complaining of difficulty walking and complains of a general ache in the lumbar region. What tests would you now perform to determine function?
During soft tissue palpation, you discover decreased muscle play on the left at L4, level 3, in the direction of 10 o'clock. Explain how this restriction might limit his right shear. Describe two myofascial techniques you could use to treat this restriction. Be specific and include the position of both the treatment hand and the assisting hand. What could you have the patient do to assist you in releasing the restriction?
What other interventions would you use to complement the STM techniques described above?
HPI: The patient is a 35-year-old female complaining of an insidious onset of right shoulder and arm pain. She complains of pain with lowering of the arm from an elevated position. In addition, she reports an episode of right neck pain about 2 months ago, with pain into the right lateral brachial region. She reports awakening with pain, with a worsening of symptoms throughout the day. She reports resolution of symptoms in response to medication.
PMH: The patient reports similar symptoms in the left shoulder approximately 2 years ago. At that time, she was diagnosed with calcific tendonitis of the supraspinatus tendon. Symptoms resolved completely in response to physical therapy.
Observation: The patient presents with forward head and rounded shoulders, increased upper thoracic kyphosis, depressed sternum, and increased internal rotation of both upper extremities. In the supine position, the right scapula rests 4 inches above the table, the left 3 inches. The patient is a chest breather.
AROM: Cervical rotation right = 60%; left = 50%. Shoulder abduction in internal rotation right = 120 degrees; left = 160 degrees.
EFT: Elbow flexion is positive with anterior tilting of the scapulae and excessive anterior cervical muscle activity.
Based on the above presentation, how might you explain the development of this patient's widespread symptoms over time? Where would you begin your palpation of the soft tissues, keeping in mind restoration of function rather than reduction of pain? Provide your rationale. Explain in detail how you would progress your examination.
List several soft tissue groups that you would expect to find dysfunctional in this patient. Explain your rationale. What specific areas would you examine and treat with soft tissue mobilization to improve respiration?
During further examination, you discover that the first rib on the right is elevated. What soft tissues could you treat that may help to resolve this dysfunction? In examining the upper thoracic spine, what specific bony contours would you clear?
Soft tissue palpation reveals decreased muscle play of the right upper trapezius from anterior to posterior. Describe how you might use shortening and lengthening of at least two body parts to assist in improving muscle play. What might the patient do to assist during this process? If muscle play techniques are not successful in improving ROM of the cervical spine, what other myofascial dysfunction may be present that could be preventing full cervical ROM? Describe how you might treat this dysfunction.
What other interventions would you use with this patient to complement the soft tissue mobilization techniques described above?
With a partner, perform the following activities:
1 Perform a structural examination of your partner and note any dysfunctions in structure as well as soft tissue contours. Then perform the three functional tests, VCT, EFT, and LPM, on your partner and grade each test using the 1 to 5 scale. Use any other movement examination techniques with which you are familiar to further identify dysfunctional areas.
2 Identify three superficial restrictions within your partner's thoracolumbar spine based on where you would suspect to find dysfunction. Identify the specific location, direction, and depth of each restriction. Treat the dysfunctions using direct pressure, direct pressure with shortening or lengthening of tissues, and/or unlocking spiral. Once you have cleared the restrictions, retest VCT, EFT, and LPM and note any changes.
3 Identify a restriction along the iliac crest of your partner. Apply direct pressure with your "treatment hand." Use your assisting hand on your partner's ischial tuberosity to apply associated oscillations. It may be helpful to practice the associated oscillation prior to attempting to use it in conjunction with intervention. Continue to locate restrictions on other bony contours and use the cascade of techniques for intervention. Be sure to solicit feedback from your partner while treating. Pay particular attention to the specificity of pressure and your body mechanics. Following this intervention, retest your partner for changes in structure, movement, and the results of functional testing (VCT, EFT, LPM).
4 Use the technique of strumming to evaluate soft tissue dysfunctions along the thoracic and lumbar paraspinal musculature. Identify the location of a muscle play restriction three-dimensionally (direction, depth, and angle). Continue to use strumming to treat the dysfunction. Have the patient perform active movements of lower trunk rotation (or any other movement pattern you choose) to assist in clearing the dysfunction. If the dysfunction is not responding to intervention, try another muscle play technique, or evaluate for the presence of tone and apply techniques as needed. Retest following intervention.
5 Locate your partner's psoas muscle and compare bilaterally. Treat the most dysfunctional side using the cascade of techniques.
6 Choose another body part, preferably one not outlined in the chapter, and attempt to examine and treat the most significant superficial fascia, bony contour, and myofascial dysfunctions.
R. Historic descriptions of massage. Massage Magazine. 2005;111.
DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vols. I and II. Baltimore, MD: Williams & Wilkins; 1992.
JH. Observations on referred pain arising from muscle. Clin Sci. 1938;3:175–190.
A. A Manual of Reflexive Therapy of Connective Tissue (Connective Tissue Massage) "Bindegewebsmassage" Scarsdale, NY: Sidney S. Simone; 1978.
N. Connective tissue massage. In: Grieve
G, Modern Manual Therapy of the Vertebral Column. London: Churchill Livingston; 1986.
B. Manual therapy for myofascial pain and dysfunction. In: Rachlin
ES, ed. Myofascial Pain and Fibromyalgia. St. Louis, MO: Mosby; 2002.
J. Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions. 8th ed. Baltimore: Williams & Wilkins; 1984.
P. Illustrated Manual of Orthopaedic Medicine. Bourough Green, UK: Butterworths; 1983.
R. Rolfing. Santa Monica, CA: Dennis-Landman; 1977.
R. The Endless Web-Fascial Anatomy and Physical Reality. Berkeley, CA: North Atlantic Books; 1996.
M. Awareness Through Movement. New York: Harper & Row; 1977.
J. Aston Patterning. Incline Valley, NV: Aston Training Center; 1989.
M. Trager Mentastics: Movement as a Way to Agelessness. Barrytown, NY: Station Hill; 1987.
PW. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. J Electromyogr Kinesiol
MJ. Connective tissues: matrix composition and its relevance to physical therapy. Phys Ther
M. Basic Biomechanics of the Skeletal System. Philadelphia: Lea & Febiger; 1980.
R. The Dynamics of Human Biolgic Tissue. Philadelphia, F.A. Davis; 1992.
MI. Bone biology and the clinical implications of osteoporosis. Phys Ther. 2006;86:1.
Akeson W. Wolff's law of connective tissue: The effects of stress deprivation on synovial joints. Arthritis Rheum. 1989;18(suppl 2):1.
KS. Tissue adaptation to physical stress: A proposed "physical stress theory" to guide physical therapy practice, education and research. Phys Ther
H. Anatomy of the Human Body. Philadelphia: Lea & Febiger; 1966.
S. Immobility effects on synovial joint: the pathomechanics of joint contracture. Biorheology
S. Effects of nine weeks immobilization of the types of collagen synthesized in periarticular connective tissue from rabbit knees. Trans Orth Res Soc. 1980;5:162.
D. Mobilization the Nervous System. New York: Churchill Livingstone; 1991.
CM. Air injection of the fascial spaces. Am J Roentgenol. 1936;35:750.
SJ. Review of length-associated changes in muscle. Phys Ther
F. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Med Hypothesis. 2005;65:273–277.
MA. Interstitial fluid flow induces myofibroblast differentiation and collagen alignment in vitro. J of Cell Sci. 2005;118:4731–4739.
M. A tissue response. In: Donatalli
R, and Wooden
M. Orthopaedic Physical Therapy. Philadelphia: Elsevier; 2001.
JA. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1988.
JW. Effects of stress on healing wounds. Intermittent noncyclical tension. J Surg Res
Van der Muelen
JCH. Present state of knowledge on processes of healing in collagen structures. Int J Sports Med
M. Twenty-year old pathogenic active postsurgical scar: a case study of a patient with persistent right lower quadrant pain. J Manipulative Physiol Ther. 2007;20:234–237.
S. Clinical significance of active scars: abnormal scars as a cause of myofascial pain. J Manipulative Physiol Ther
MR. Orthopedic Physical Therapy Series: Vol 1: Tissue Changes in Contractures. Atlanta: Strokesville; 1983.
DA. Posture and Pain. Huntington, NY: Krieger Publishing; 1977.
JA. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: American Academy of Orthopedic Surgeons; 1988.
R. Soft Tissue Pain and Disability. Philadelphia: FA Davis; 1977.
HF. Mechanical factors in the genesis of low back pain. In: Bonica
D, eds. Advances in Pain and Research and Therapy. Vol 3. New York: Raven Press; 1979.
IA. Cell interaction in post-traumatic fibrosis. Clin Symp. 114;1985:128–149.
VL. Functional Orthopaedics I. Course Outline. Steamboat Springs, CO: Institute of Physical Art; 2003.
et al. The ultrasonic localization of abdominal wall adhesions. Surg Endos. 1995;9:283–285.
F. Spinal epidural fibrosis following lumbar diskectomy and antiadhesion barrier. Neurocirugia (Astur)
C. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol. 1998;85:269–272.
P. Surgical technique to reduce scar discomfort after carpal tunnel surgery. J Hand Surg (Am)
JG. Fibrosis and intercellular collagen connections from 4 weeks of muscle strains. Muscle Nerve
R. Disruptions of muscle fiber plasmamembrane: role in exercise-induced damage. Am J Pathol
H. Factors in the adherence of flexor tendon after repair. J Bone Joint Surg. 1976;58B:230.
WH. Flexor tendon healing and restoration of the gliding surface. J Bone Joint Surg. 1983;65A:70.
et al. Collagen cross-linking alterations in periarticular connective tissue collagen after nine weeks of immobilization. Connect Tissue Res
JV. Biomechanical and biochemical changes in the periarticular connective tissue during contracture development in the immobilized rabbit knee. Connect Tissue Res. 1974;l2:4.
et al. Connective tissue response to immobility: correlative study of biomechanical and biochemical measurements of normal and immobilized rabbit knees. Arthritis Rheum
et al. The relationship of immobilization and exercise on tissue remodeling. Biorheology
TM. Hyalurion induces scarless repair in mouse limb organ culture. J Ped Surg. 1998;33:4.
SW. Efficacy of hyaluronic acid/ anti-inflammatory systems in preventing postsurgical tendon adhesions. J Biomed Mater Res
PA. Chronic trapezius myalgia: morphology and blood flow studied in 17 patients. Act Orthop Scand. 1990;61:394–398.
et al. Value of hyaluronic acid in the prevention of contracture formation. Clin Orthop 1985;196:306.
et al. Tenascin-C in the pathobiology and healing process of musculoskeletal tissue injury. Scand J Med Sci Sports
H. The Stress of Human Life. New York: McGraw-Hill; 1978.
B. The neurology of joints. Ann R Coll Sur 1967;41:25.
V. Muscle weakness and inhibition (pseudoparesis) in back pain syndromes. In: Grieve
G, ed. Modern Manual Therapy of the Vertebral Column. New York: Churchill Livingstone; 1986:198.
V. Pain in the locomotor system, a broad approach. In: Glasgow
EF, ed. Aspects of Manipulative Therapy, Melbourne, Australia: Churchill Livingstone; 1984.
V. Muscles and Back Pain: Assessment and Intervention, Movement Patterns, Motor Recruitment. Course notes. 2nd ed. 1994;4.
V. Muscle spasm-a proposed procedure for differential diagnosis. J Manual Med 1991;6:136–139.
M. Symptomatology of muscle spasm. In: Emre
H, eds. Muscle Spasm and Back Pain. Carnforth, UK: Parthenon; 1988.
K. Management of muscular pain associated with articular dysfunction. In: Fricton
EA. Advances in Pain Research and Therapy. Vol 28. Myofascial Pain and Fibromyalgia. New York: Raven; 1990.
et al. Adaptation of sarcomere numbers to the length imposed on muscle. In: Gubba
O, eds. Mechanism of Muscle Adaptation to Functional Requirements. Elmsford, NY: Pergamon Press; 1981:103.
DE. Proprioceptive Neuromuscular Facilitation. 2nd ed. New York: Harper & Row; 1968.
C. Proprioceptive neuromuscular facilitation. In: Basmajian
R, eds. Rational Manual Therapies. Baltimore: Williams & Wilkins; 1993:243.
VL. Soft tissue mobilization. In: Donatelli
MJ, eds. Orthopaedic Physical Therapy. 2nd ed. New York: Churchill Livingston; 1994.
VL. Back Education and Training: Course Outline. Steamboat Springs, CO: Institute of Physical Art; 1997.
S. Diagnosis and Intervention of Shoulder Movement System Impairment Syndromes. Course notes. St. Louis, MO: Washington University; 2004.
J. Manual Therapy and Movement. Course notes. 1992.
T. Stretching Scientifically: A Guide to Flexibility Training. Island Pond, VT: Stadion; 1994.
Y. The Feldenkrais Method. San Francisco: Harper & Row; 1974.
RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Lower Hutt, New Zealand: Spinal Publications; 1981.
S. Physical signs of instability. Spine. 1985;3:277–279.
G. Lumbar protective mechanism. In: White
R, eds. The Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins; 1991;112.
et al. Palpation of the upper thoracic spine: An observer reliability study. J Manipulative Physiol Ther
P. Spinal motion palpation: a review of reliability studies. J Man Manip Ther. 2002;10:24–39.
et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine
G. Specific soft tissue mobilization in the management of soft tissue dysfunction. Man Ther
MR. Soft Tissue Mobilization Techniques for the Hand Therapist. J Hand Ther
K. Shifts in pelvic inclination angle and parasympathetic tone produced by rolfing soft tissue manipulation. Phys Ther. 1988;68.
D. The immediate effects of soft tissue mobilization with proprioceptive neuromuscular facilitation on glenohumeral external rotation and overhead reach. J Orthop Sports Phys Ther. 2008;33:713–718.
A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc
GD. Vertebral Manipulation. 5th ed. London: Butterworths; 1986.
AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72.
WH. Textbook of Anatomy. 3rd ed. New York: Harper and Row; 1974.
VL. Functional Orthopaedics II. Course outline. Steamboat Springs, CO: The Institute of Physical Art; 2004.
J. Muscle Stretching in Manual Therapy: A Clinical Manual. Alfta, Sweden: Alfta Rehab Forlag; 1985.
VL. PNFI: The Functional Approach to Movement Reeducation. Steamboat Springs, CO: Institute of Physical Art; 1997.
K. Manipulative Therapy in Rehabilitation of the Locomotor System. 2nd ed. Boston: Butterworths; 1992.
A. Manual of Osteopathic Practice. London: Hutchinson & Co; 1959.
J. Lumbopelvic Integration. Course notes; 1999.
W. Clinical implications of iliopsoas dysfunction. J Man Manip Ther. 1993;1:41–46.
RS. Ilipsoas myofascial dysfunction: a treatable cause of LBP. Arch Phys Med