HEMME Approach Concepts and Tehniques

HEMME APPROACH
CONCEPTS
AND
TECHNIQUES
i
INSTRUCTIONS FOR THE ANSWER SHEET

Thank you for investing in our HEMME APPROACH Concepts and
Techniques Course, the final course in the HEMME APPROACH series.

Now that you're ready to start the course, these instructions will make it
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questions. The answers are clearly stated in the book. Second, the questions
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Feel free to use the manual as you take the quiz. It may be helpful to
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completing this course. Most state boards recommend holding certificates at
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thank you again for taking the HEMME APPROACH series.
ii
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iii
HEMME APPROACH CONCEPTS AND TECHNIQUES
EVALUATION FORM

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iv
HEMME APPROACH
CONCEPTS AND TECHNIQUES

Copyright, David H. Leflet, 1996
Revised 2011
All rights reserved

Published by HEMME APPROACH PUBLICATIONS
502 Armstrong Street
Bonifay, Florida 32425
(850) 547-9320

The author grants permission to photocopy a limited portion of this manual
for personal use. Beyond this consent, no portion of this manual may be
reproduced or copied in any form without written permission from the
author, who can be reached by contacting the publisher.

Although the author has made every effort to ensure the accuracy of the
information herein, medical science is progressive, theories change with
time, and experts often disagree. Practitioners are advised to consult
appropriate information sources if they have questions concerning the
information or principles presented in this manual.

It is the responsibility of the practitioner to determine the appropriateness of
any principle or technique in terms of personal competency, scope of
practice, or relevant laws. Written medical opinions are the best way to
resolve any questions that relate to whether soft-tissue therapy is indicated or
contraindicated, and written legal opinions are the best way to resolve any
questions concerning law.

v
PREFACE

The HEMME APPROACH Concepts and Techniques course was written
for people who plan to become advanced HEMME-APPROACH Practitioners.
Not only does this course summarize material found in previous HEMME
APPROACH courses, but it also provides new information such as how to
prepare evaluation charts and appraisal forms. For people who are not
planning to become advanced HEMME-APPROACH Practitioners, this course
provides an excellent overview of what the HEMME APPROACH is, how it
applies to soft-tissue therapy, and how to use it.
In addition to receiving 16 hours of continuing education credit,
practitioners who complete this course will be able to understand and apply
the basic concepts and techniques that separate the HEMME APPROACH from
other approaches to soft-tissue therapy.
As with other HEMME APPROACH courses, this program focuses on
useful principles and workable techniques more than on general background
information and medical theories. Even though most of the principles used
in HEMME APPROACH courses are based on research that is widely accepted
by doctors who practice physical medicine and rehabilitation, the soft-tissue
techniques that HEMME APPROACH recommends are often more detailed and
more intensive than those commonly used by medical doctors.
Despite a large amount of medical research that supports the value of
using soft-tissue techniques, most medical doctors limit their practices to
medication and surgery. Since they seldom use soft-tissue manipulation as
part of their normal practice, most medical doctors do not have an interest in
learning or developing sophisticated soft-tissue techniques. For this reason,
the soft-tissue techniques used in the HEMME APPROACH are often more
sophisticated and more effective than those used by most medical doctors.
By definition, the HEMME APPROACH is a scientific method that helps
practitioners identify, evaluate, and treat soft-tissue impairments. Most
impairments are caused by internal or external trauma and are characterized
by pain, limited range of motion, and weakness. Soft-tissue refers to any
human structure that is not bone, such as muscles, tendons, or ligaments.
The standard forms of manipulation used in the HEMME APPROACH are
trigger point therapy, neuromuscular therapy, connective tissue therapy, and
range-of-motion stretching. These four types of manipulation address all
four types of tissue found in the human body: nerve tissue, muscle tissue,
connective tissue, and epithelial tissue.
vi
HEMME APPROACH is different from most other medical approaches
to soft-tissue therapy for three basic reasons: balance, scope, and clinical
value. Despite a common tendency for many approaches to focus on
evaluation more than treatment or treatment more than evaluation, the
HEMME APPROACH recognizes that evaluation and treatment are equally
important and both are required to produce positive results. By working
together in harmony, evaluation and treatment can (1) identify real problems
(evaluation), and (2) offer genuine solutions (treatment).
Scope refers to the comprehensive nature of any approach used for
treating soft-tissue impairments. The human body is a complex interaction
of parts that produce many complex problems. Since the problems are often
complex, no single tool, such as trigger point therapy or neuromuscular
therapy, can be expected to deal with every single situation. By using four
methods of manipulationtrigger point therapy, neuromuscular therapy,
connective tissue therapy, and range-of-motion stretchingin addition to
modalities and exercise, practitioners can increase their chances of being
able to treat a wide variety of conditions caused by soft-tissue impairments.
The clinical value of any approach to soft-tissue therapy is not a matter
of scientific theory or academic discussion, but rather a matter of practical
results. Regardless of sourcephysical medicine, osteopathy, chiropractic,
or Swedish massagethe concepts and techniques used in the HEMME
APPROACH produce positive results. Even if medical science cannot always
explain why they work, most HEMME-APPROACH practitioners and other
competent clinicians would be quick to agree they do work.
The final feature that makes HEMME APPROACH unique when compared
with most other approaches is the realization that soft-tissue therapy is both
an art and a science. As an art, soft-tissue therapy requires the caring and
competent use of human touch and as a science, it requires empirical
knowledge, logic, and creative intuition. To practice soft-tissue therapy
without integrating the art with the science can only reduce the quality of
treatment and prevent soft-tissue therapy from reaching its full potential.
Approaching soft-tissue therapy from a medical and scientific perspective
does not limit the options someone has to practice soft-tissue therapy, it
creates opportunities for exploration, creativity, and achievement.

David H. Leflet, MS, LMT
vii
ACKNOWLEDGMENTS

Like most large projects, the HEMME APPROACH Concepts and Techniques
Course is the result of several people working together as a team. The three
team members I would especially like to thank are my wife, Lani Leflet, for
being my loving and supportive better half; my father, Herbert Leflet, for
being my long-term mentor and best friend; and my chief editor, Skip
Rendall, for being my friend and persevering teacher. Without these three
people, this course would still be in the planning stages.
viii
CONTENTS

Preface .......................................................................................... v
Acknowledgments .......................................................................... vii

INTRODUCTION ........................................................................ 1
Soft-Tissue Therapy ................................................................. 1
Basic Goals .............................................................................. 6
Therapeutic Goals .................................................................... 7
Research .................................................................................. 9
Limitations ............................................................................... 9
Chapter Summary ......................................................................... 10

HEMME APPROACH ................................................................. 11
HEMMEGON .............................................................................. 14
Chapter Summary ......................................................................... 15

HISTORY ..................................................................................... 16
Contraindications ..................................................................... 16
Doctor's Opinion ...................................................................... 17
Interview .................................................................................. 17
Whiplash .................................................................................. 22
Chapter Summary ......................................................................... 23

EVALUATION............................................................................. 25
Observation .............................................................................. 25
Palpation .................................................................................. 25
Pain Assessment ...................................................................... 26
Pain Scales .............................................................................. 27
Physical Stress ......................................................................... 28
Spasm ....................................................................................... 30
Electrically Silent Hypertonia ................................................. 30
Contracture .............................................................................. 32
Pain Cycles .............................................................................. 33
Causality ................................................................................. 33
Reactivation ............................................................................ 35
Treatment ................................................................................ 37
Objectives ............................................................................... 40
ix
Contents

Muscle Testing ......................................................................... 41
Active Range-of-Motion Testing ........................................... 43
Passive Range-of-Motion Testing .......................................... 43
Active-Assisted Range-of-Motion Testing ............................ 44
Resisted Range-of-Motion Testing ......................................... 44
HEMME APPROACH Quick Test ............................................... 49
Fibromyalgia Syndrome (FMS) ............................................... 53
Bilateral FMS Tender Points (Anterior) ................................. 54
Bilateral FMS Tender Points (Posterior) ................................ 55
Chapter Summary ......................................................................... 59

MODALITIES .............................................................................. 62
Inflammatory Response ........................................................... 67
Chronic Inflammation .............................................................. 69
Secondary Damage .................................................................. 70
Rehabilitation ........................................................................... 72
Advanced Rehabilitation Model ............................................. 73
CRYOTHERAPY ......................................................................... 75
Wound Healing and Therapeutic Cold ................................... 76
Trial and Error ........................................................................ 79
Ice Packs ................................................................................. 80
Trigger Points and Ice ............................................................. 80
Contraindications for Cold ..................................................... 82
Indications for Cold ................................................................ 83
THERMOTHERAPY .................................................................... 84
Wound Healing and Therapeutic Heat ................................... 89
Infrared Radiation ............................................................... 90
Heliotherapy ....................................................................... 91
Moist Heat .......................................................................... 91
Common Heating Modalities.................................................. 92
Hot Packs ............................................................................ 92
Paraffin Bath ....................................................................... 92
Contraindications for Heat ...................................................... 93
Indications for Heat ................................................................ 93
x
Contents

Physical Properties ................................................................ 94
Thermal Conductivity (Table) ............................................ 94
Specific Heat (Table) .......................................................... 94
COLD OR HEAT ......................................................................... 95
Exceptions ............................................................................... 97
Cryostretch or Thermostretch ................................................. 97
Contrast Bath or Cryokinetics ................................................ 98
Hot-to-Cold Stretch ................................................................ 99
Heat- and Cold-Induced Pain ................................................. 100
Temperatures (Table) ............................................................. 101
Basic Temperature Guide ................................................... 101
Standard Protocol (Table) ....................................................... 101
Protocol for Using Cold or Heat ........................................ 101
Effects of Cold and Heat (Tables) .......................................... 102
Normal Effects of Cryotherapy .......................................... 102
Normal Effects of Thermotherapy ..................................... 102
Normal Effects of Cryotherapy or Thermotherapy ............ 102
VIBRATION ............................................................................... 103
Chapter Summary ......................................................................... 104

MANIPULATION ........................................................................ 109
Principles of Soft-Tissue Therapy ........................................... 110
The Three HEMME Laws ........................................................ 110
Twenty-Two General Laws or Principles ............................... 111
Muscle Imbalance .................................................................... 114
Posture ..................................................................................... 116
TRIGGER POINT THERAPY .......................................................... 118
Trigger Points and Tender Points ........................................... 124
Deep Sliding Pressure (DSP) .................................................. 125
Myoglobinemia ....................................................................... 127
NEUROMUSCULAR THERAPY ...................................................... 128
Inhibition ................................................................................. 132
Proprioceptive Inhibition .................................................... 133
Post-Isometric Relaxation .................................................. 134
Reciprocal Inhibition .......................................................... 135
Stretching to Reset Proprioceptors ......................................... 135
xi
Contents

Facilitation .............................................................................. 136
Activation of Stretch Reflex ............................................... 136
Muscle Spindle Facilitation ................................................ 136
Repeated Contractions ........................................................ 136
Muscle Palpation .................................................................... 137
CONNECTIVE TISSUE THERAPY .................................................. 138
Thixotropy .............................................................................. 139
Hysteresis ................................................................................ 139
Creep ....................................................................................... 140
Adhesions ............................................................................... 140
Skin Rolling ............................................................................ 141
Skin Pulling ............................................................................ 141
Cross-Fiber Friction ................................................................ 142
Layers ..................................................................................... 144
RANGE-OF-MOTION STRETCHING ............................................... 145
Mechanics of Stretching ......................................................... 147
Two Basic Types of Stretching .............................................. 148
Multiple-Repetition Stretching ........................................... 149
Single-Repetition Stretching .............................................. 149
Double-Leg Stretch ................................................................. 150
Over-Head Arm Stretch .......................................................... 150
Fascial Stretching (Myofascial Release) ................................ 151
Cross-Over Stretch ................................................................. 153
Force-Couple Stretch .............................................................. 153
Ballistic Stretching ................................................................. 154
Supplemental Force ................................................................ 155
Isolytic Stretching ................................................................... 156
Deep Breathing ....................................................................... 156
Traction ................................................................................... 156
Aquatic Stretching .................................................................. 157
Indirect (Functional) Techniques ........................................... 157
Neutral Positioning ................................................................. 159
Range-of-Motion Specificity .................................................. 161
Spinal Stretch Reflex .............................................................. 162
Contraindications to Stretching .............................................. 162
xii
Contents

RELAXATION ............................................................................ 163
General Stress ......................................................................... 164
Environment ........................................................................... 165
Lubrication .......................................................................... 166
Activity ............................................................................... 167
Color ................................................................................... 169
Air ....................................................................................... 170
Music .................................................................................. 171
Aroma ................................................................................. 172
Rest ..................................................................................... 174
Attitude ............................................................................... 175
Preliminary Relaxation Techniques ....................................... 177
Autogenic Training ............................................................. 177
Progressive Relaxation ....................................................... 178
Relaxing Massage ................................................................... 180
Chapter Summary ......................................................................... 181

EXERCISE ................................................................................... 187
Exercise Principles ................................................................... 190
The Overload Principle ........................................................... 191
The Intensity Principle ............................................................ 192
The Frequency and Duration Principle ................................... 192
The Specificity Principle ........................................................ 193
The Training Principle ............................................................ 194
Muscle Soreness ...................................................................... 195
Muscle Spasm Theory ............................................................ 197
Osmotic Pressure Theory ........................................................ 197
Tissue Damage Theory ........................................................... 197
Implications ............................................................................ 199
Deconditioning ........................................................................ 201
Motivation ................................................................................ 202
Prevention ................................................................................ 203
Chapter Summary ......................................................................... 205
xiii
Contents

CONCLUSION ............................................................................. 208
Sample HEMME APPROACH Application ................................. 209
General Background ............................................................... 209
History .................................................................................... 210
Evaluation ............................................................................... 211
Modalities ............................................................................... 211
Manipulation ........................................................................... 212
Exercise ................................................................................... 212
HEMME APPROACH Charts and Forms ..................................... 213
HEMME APPROACH Evaluation Chart ..................................... 214
HEMME APPROACH Appraisal and Treatment Form .............. 215
Sample Evaluation Chart ........................................................ 216
Final Considerations ................................................................ 217

SELECTED BIBLIOGRAPHY .................................................... 218

GLOSSARY ................................................................................. 234

HEMME APPROACH QUIZ ....................................................... 258

INDEX .......................................................................................... 268
xiv
ILLUSTRATIONS

Advanced Rehabilitation Model ................................................... 73
Basic Temperature Guide ............................................................. 101
Bilateral FMS Tender Points (Anterior) ....................................... 54
Bilateral FMS Tender Points (Posterior) ...................................... 55
HEMME APPROACH Appraisal and Treatment Form ..................... 215
HEMME APPROACH Evaluation Chart ........................................... 214
HEMMEGON ................................................................................... 14
Normal Effects of Cryotherapy .................................................... 102
Normal Effects of Cryotherapy and Thermotherapy .................... 102
Normal Effects of Thermotherapy ................................................ 102
Pain Scales .................................................................................... 27
Protocol for Using Cold or Heat ................................................... 101
Sample Evaluation Chart .............................................................. 216
Specific Heat ................................................................................. 94
Thermal Conductivity ................................................................... 94

HEMME APPROACH TO CONCEPTS AND TECHNIQUES

1
INTRODUCTION

The HEMME APPROACH has only two main goals: identify and treat soft-
tissue impairments. Identification is accomplished by taking a medical
history and conducting a physical evaluation. Treatment is accomplished by
using modalities, manipulation, and exercise. The basic modalities used in
the HEMME APPROACH are cryotherapy, thermotherapy, and vibration. The
basic types of manipulation are trigger point therapy, neuromuscular
therapy, connective tissue therapy, and range-of-motion (ROM) stretching.
While not considered a separate form of manipulation, relaxation therapy is
used to reduce physical and psychological stress. The main uses for exercise
in the HEMME APPROACH are to increase or maintain (1) range of motion, (2)
muscular strength or endurance, and (3) general fitness.

Soft-Tissue Therapy

Soft-tissue therapy has its roots in Swedish massage that was founded by
Per Henrik Ling (1776-1839). Ling was a Swedish physical education
instructor. Swedish massage is defined medically as a combination of
massage and active or passive physical exercise. In 1916, an institute for
Swedish massage was established in New York.
Soft-tissue therapy is broadly defined as manipulation of superficial
tissue or soft tissue for therapeutic purposes, with or without modalities and
with or without active or passive physical exercise. Since the late 1800s,
soft-tissue therapy has been recognized as being curative, palliative, and
hygienic. Soft-tissue therapy has been practiced by almost every health care
profession at one time or another. The osteopathic profession has probably
done more research on soft-tissue therapy than any other profession.
The type of pain treated by soft-tissue therapy can be broadly defined as
musculoskeletal pain as opposed to visceral pain. When left untreated,
musculoskeletal pain has a tendency to become chronic and cause a loss of
function. In addition to physical impairments, musculoskeletal pain causes
psychological impairments such as anxiety, depression, fatigue, and
irritability. Even though musculoskeletal pain is seldom a matter of life or
death, it can affect a persons happiness, productivity, and quality of life.
Soft-tissue therapy is recognized and widely accepted as a conservative
and cost-effective method for treating soft-tissue impairments. Even though
soft-tissue refers to any tissue other than osseous (bony) tissue, soft-tissue


2
therapy can indirectly affect posture, joint space, and skeletal alignment.
Since the musculoskeletal system constitutes over 60% of the body, any
form of manipulation that affects the musculoskeletal system will also affect
the circulatory, nervous, integumentary, and respiratory systems.
While soft-tissue therapy is practiced in one form or another by almost
every major health care profession, soft-tissue techniques are most
commonly found in physical medicine, osteopathy, chiropractic, physical
therapy, massage therapy, and nursing. Massage therapy is the only health
care profession that specializes specifically in soft-tissue therapy.
By definition, soft-tissue impairments are soft-tissue lesions, defects, or
dysfunctions that cause pain, limited range of motion, or weakness.
Disability results when soft-tissue impairments severely limit a persons
ability to function normally and perform useful activities.
Two common soft-tissue impairments are spasm and contracture. Both
impairments can increase resistance to active or passive stretch, decrease
range of motion, and weaken the affected muscle or opposing muscles.
Spasms are caused by abnormal changes in nerve or muscle tissue and most
contractures are caused by abnormal changes in connective tissue. Since a
muscle is an organ composed of nerve tissue, muscle tissue, and connective
tissue, a muscle can be affected by either spasm or contracture.
In soft-tissue therapy, rehabilitation is the process of restoring normal
function by correcting soft-tissue impairments and allowing the body to heal
itself. Activities typically performed by a soft-tissue therapist focus on pain,
range of motion, and weakness. When viewed as a problem-solving process,
the first part of soft-tissue therapy involves identifying the problem (medical
history and physical evaluation), and the second part involves solving or
treating the problem (modalities, manipulation, and exercise).
Soft-tissue therapy involves the application of manual force that pushes
or pulls soft tissue and produces compression, tension, bending, or shear.
Even though manual contact is made with superficial tissues, deep tissues
are affected by mechanical and reflex effects.
Mechanics is a branch of physics that deals with the way forces act upon
a body. Mechanical effects can produce local changes that affect limited
parts of the body or global changes that affect large parts of the body. Local
effects include neutralizing trigger points, relieving spasm, or stretching
restricted tissue such as adhesions or contractures.
Global effects include changes in lymphatic circulation and release of
endogenous opioids such as endorphins or enkephalins. Endogenous opioids


3
are often released in response to painful stimulus or stress. Other global
effects include sympathetic responses such as copious sweating and
parasympathetic responses such as a decrease in pulse rate.
Reflex effects can activate reflex arcs that connect proprioceptors to the
spinal cord (stretch reflex) or pressure receptors to the medulla oblongata
(baroreceptor reflex). Proprioceptors are sensory end organs such as muscle
spindles or Golgi tendon organs, and baroreceptors are sensory nerve
endings located in the walls of large systemic arteries. Baroreceptors
respond to stretching because of a rise in internal pressure.
The stretch reflex causes muscles to contract when rapidly stretched, and
the baroreceptor reflex causes a decrease in heart rate when mild pressure on
the neck stimulates pressure receptors in the carotid sinus region of the
carotid artery (vagus effect). In people with carotid sinus syndrome, the
baroreceptor reflex can be strong enough to stop the heart. Carotid massage
is normally contraindicated without a prescription.
Manipulation of superficial tissue can also produce psychological effects
such as general relaxation and a sense of well-being. Psychological effects
are possibly related to a decrease in muscle tension or release of endogenous
opioids such as endorphins or enkephalins. Most patients report that human
touch is psychologically more satisfying than mechanical touch and that
slow rhythmic movements, such as slow rhythmic traction, are more
relaxing than rapid movements that lack consistency or regularity.
The medical history and evaluation process are used to determine if soft-
tissue therapy is indicated or contraindicated. Treating a patient when soft-
tissue therapy is not indicated serves no purpose. Treating a patient when
soft-tissue therapy is contraindicated can be harmful to the patient, and in
rare cases, even fatal. If soft-tissue therapy is indicated, the four basic types
of therapy used are trigger point therapy, neuromuscular therapy, connective
tissue therapy, and range-of-motion (ROM) stretching. Modalities may or
may not be used, depending on the case.
While active and passive exercises are medically recognized as part of
Swedish massage (Swedish gymnastics), clinical settings appropriate for
soft-tissue manipulation may not be appropriate for therapeutic exercise.
Although the ideal situation is to have patients be responsible for own health
and exercise at home, some patients require direct supervision during
exercise. For soft-tissue practitioners who do not offer therapeutic exercise
as part of their practice, these patients can always be referred to a hospital,
clinic, or training facility that specializes in therapeutic exercise programs.


4
Twelve activities that may be included as part of soft-tissue therapy:

Take a basic medical history of the patient.
Evaluate posture and symmetry by using observation.
Evaluate condition of soft tissue by using palpation.
Evaluate muscle length by range-of-motion (ROM) testing.
Evaluate muscle strength by muscle testing.
Reduce pain, spasm, or edema by using modalities.
Increase tissue extensibility by using modalities.
Reduce pain by treating trigger points or tender points.
Strengthen muscles by using neuromuscular techniques.
Improve range of motion by stretching restricted tissues.
Provide access to therapeutic exercise programs.
Provide information concerning prevention of injuries.

Soft-tissue therapy has evolved from a collection of manual medicine
and massage techniques that predate recorded history. Unlike classical
Swedish massage that tends to focus on techniques such as effleurage,
ptrissage, tapotement, and active or passive exercise, soft-tissue therapy
incorporates a collection of soft-tissue techniques that are found in physical
medicine, osteopathy, dentistry, and chiropractic.
Since soft-tissue therapy is defined as manipulation of superficial or soft
tissue for therapeutic purposes, with or without modalities, exercise, or
mechanical devices; the high-velocity, low-amplitude thrusting techniques
found in physical medicine, osteopathy, or chiropractic are considered part
of manual medicine, but not part of soft-tissue therapy.
Velocity refers to the quickness of movement and amplitude refers to the
distance of movement. High-velocity, low-amplitude spinal adjustments are
quick thrusting movements that may not move vertebrae more than 1/8 inch.
Most of the movements in soft-tissue therapy are low-velocity push or pull
movements that move tissues or body parts more than 1/8 inch. Since force
and kinetic energy increase with velocity, high-velocity techniques are
considered potentially more dangerous than low-velocity techniques.
Soft-tissue techniques can be used effectively in conjunction with
thrusting techniques. Since thrusting is not recommended while muscles are
in spasm, soft-tissue techniques can be used before thrusting to reduce
spasm. After thrusting, soft-tissue techniques, such as range-of-stretching,
can be used to increase the durability of high-velocity adjustments.


5
Soft-tissue techniques will affect posture to the extent that soft-tissue
components of the body control posture. In terms of function, the skeletal
system provides support and the muscular system controls posture. Both
systems working together provide a series of leversbones and jointsthat
produce movement.
Only in rare cases will the skeletal system, because of a bone deformity
such as scoliosis or a bone disease such as ankylosing spondylitis (spinal
arthritis), have a greater effect on posture than the muscular system. In most
cases, manipulating muscles will have a greater and longer-lasting effect on
posture than manipulating bones.
Beyond the classical benefits of massage such as improved circulation,
removal of waste products, and general sedation or relaxation, soft-tissue
therapy specifically addresses pain, limited range of motion, and weakness.
The typical targets of soft-tissue therapy are trigger points, tender points,
spasms, contractures, adhesions, and restricted scar tissue or fascia. By
working with these targets, soft-tissue therapy can improve muscular
balance, symmetry, and posture, thus reducing the amount of energy needed
to produce movement.
Soft-tissue therapy makes far greater use of the stretch reflex than
classical massage. The gamma system is a reflex arc consisting of anterior
horn cells in the spinal cord, afferent and efferent neurons, and muscle fibers
inside the muscle spindle (intrafusal fibers). When a muscle is quickly
stretched, intrafusal fibers send an afferent signal to the horn cells, which in
turn send an efferent signal back to the muscle spindle that causes a reflex
contraction. One of the most rapid of all reflexes, the stretch reflex is also
called a myotatic reflex or a Liddell-Sherrington reflex. The stretch reflex is
used to strengthen neurologically weak muscles.
While deep relaxation is often considered a reflex effect because of
proprioceptive inhibition involving muscle spindles or Golgi tendon organs,
reflex inhibition is not the only factor that causes relaxation. Neutralizing
trigger points can relax people who are suffering from chronic pain, and
being touched by human hands facilitates psychological relaxation.
Touching may also stimulate low-threshold cutaneous (skin) receptors that
are capable of causing muscles to relax by reflex inhibition.
Deep pressure that causes the release of endorphins or enkephalins
produces deep relaxation. Deep stroking applied to the paravertebral
muscles, soles of the feet, or palms of the hand seem to have a relaxing
effect on most patients. Other patients find deep pulsating pressure more


6
relaxing than deep stroking. The light stroking or tapping (percussion) that
some patients find relaxing is probably caused by reflex effects, not opioids.
Stretching and the relationship between actin and myosin filaments may
also affect relaxation. Myofilaments are capable of developing the greatest
tension when actin and myosin filaments overlap far enough for the myosin
heads to form cross-bridges with the actin molecules. When muscles are
stretched to a point that overlap is minimal, the muscles ability to generate
maximal tension decreases, and the muscle is forced to relax.

Basic Goals

Regardless of methods used, soft-tissue therapy has three basic goals:

Relieve pain.
Restore normal function.
Improve quality of life.

While the first steps to accomplishing these goals focus on restoring a
normal pain-free range of motion, the final steps concentrate on improving:

muscular strength
muscular endurance
coordination
cardiovascular fitness

Patients should also be shown ways to prevent injuries with programs to
maintain work- or sport-related fitness and what activities to avoid. If
prevention fails, patients should be advised to seek professional help.
Once the three basic goals are metrelieve pain, restore normal
function, and improve quality of lifethe final goal is to make patients less
dependent on therapy and more responsible for their own health. The two
most effective ways to accomplish this goal are education and motivation.
Even if long-term therapy is required, showing patients how to prevent
injuries and encouraging patients to exercise at home will often reduce the
number of treatments required.
More than simply treating the symptoms or signs of soft-tissue
impairments, soft-tissue therapy addresses the underlying causes. If the
symptoms or signs of a soft-tissue impairment are pain, limited range of


7
motion, or weakness, the underlying causes are often trigger points, tender
points, spasm, adhesions, or contractures. Pain, itself, can be either a
symptom or a cause. While pain can be a symptom of tissue damage, it can
also be the cause of muscular weakness because of pain inhibition.
To accomplish the three basic goals of soft-tissue therapy, four basic
methods of manipulation are used:

trigger point therapy (relieve pain and reduce pain inhibition)
neuromuscular therapy (inhibit or facilitate muscles)
connective tissue therapy (lengthen adhesions or contractures)
range-of-motion stretching (lengthen restricted tissues)

Even though it is not a separate form of manipulation because it uses a
collection of different techniques to reduce physical or psychological stress,
relaxation therapy is considered a separate type of therapy.
In addition to manipulation, soft-tissue therapy covers the use of
modalities and exercise. Even though modalities and exercise are seldom
curative when used without manipulation, modalities can be used to prepare
the body for manipulation and exercise can be used to improve muscular
strength and endurance or to maintain range of motion after manipulation.

Therapeutic Goals

The most general goal of soft-tissue therapy is to create conditions that
make it possible for the body to heal itself without harming the patient.
During the initial stages of an injury, the bodys natural tendency is to
protect the injured part from movement. Since resting and protecting an
injured body part during the acute stage of an injury appear to be beneficial,
this behavior should be encouraged.
Even though complete immobilization of an injured body part is seldom
recommended because of deconditioning, possible contractures, or
inconvenience; stabilizing, supporting, or compressing an injured body part
during the initial stages of an injury will help to relax hypertonic muscles,
relieve pain, and reduce swelling. Various ways to stabilize and support an
injured body part include bolsters, slings, braces, splints, and tape.
During the subacute stages of an injury, careful positioning of the body
can be used to relieve pain and spasm before, during, and after manipulation.


8
Muscles are normally least painful at or near resting position. Elevating an
injured limb above the heart may also reduce pain.
Protection and rest of an injured body part may become a problem if
patients capable of limited movement during the subacute stage of an injury
refuse to move. Inactivity that continues beyond the acute stage of any
injury can lead to deconditioning, atrophy, contractures, adhesions, and
venostasis. Since the lymphatic system is passive and depends on active or
passive movement to stimulate circulation, inactivity can decrease lymphatic
circulation even faster than venous circulation. While movement may not be
a natural tendency during the subacute stage of an injury, the role of soft-
tissue therapy is to encourage movement.
The basic sequence for encouraging movement has three parts: (1)
passive mobilization, (2) active-assisted mobilization or stretching, and (3)
active movement. When passive mobilization is used, the patient should
avoid contracting any muscles. While passive movements help to improve
the patients range of motion and flexibility, the patients strength and
endurance remain about the same until active movements are used.
Active-assisted mobilization or stretching is a partnership between
practitioners and patients. Practitioners provide part of the force needed to
move a body part, and patients provide the rest. Not only do active-assisted
movements improve range of motion and flexibility, but the active part of
the movement also helps the patient improve strength and endurance.
The goal of any exercise program is to make the patients less dependent
on supervised activity and more dependent on themselves. Although many
professionals such as physical therapists, occupational therapists, exercise
physiologists, athletic trainers, personal trainers, and coaches specialize in
supervising exercise, the final goal is to help patients learn to exercise on
their own and continue exercising even after formal therapy is discontinued.

The six basic goals of a self-directed exercise program include:

increase or maintain range of motion and flexibility
increase or maintain muscular strength and endurance
increase or maintain muscular speed and power
increase or maintain coordination and timing
increase or maintain cardiovascular fitness
increase or maintain general fitness and work capacity


9
While not considered a basic goal of therapy, injury prevention should
be included as part of any rehabilitation program. Patients should be
familiar with concepts such as warming up before strenuous exercise and
cooling down after strenuous exercise. The proper use of body mechanics
(moving and lifting) should be discussed, as well as possible ways to use
safety equipment. Prevention is always more effective than therapy.

Research

One of the most difficult problems facing soft-tissue therapy is a lack of
research to validate what most practitioners realize happens when certain
techniques are applied. Most arguments supporting soft-tissue therapy are
based on anecdotal evidence or clinical observations. To complicate the
problem, the terminology describing soft-tissue therapy is often inconsistent
with standard medical terminology and may have many different meanings.
Despite the problems, a large number of people are using and
recommending soft-tissue therapy. For most patients with soft-tissue
impairments, soft-tissue therapy creates an environment for the body to heal
itself. Many of these people have musculoskeletal problems that are not
responsive to other forms of treatments. Even those who cannot be cured by
soft-tissue therapy may at least find enough relief to improve the quality of
their lives.
Rather than abandon these patients to less effective methods of treatment
because double-blind experiments are difficult to conduct and seldom funded
by the same organizations that often fund medical research, such as drug
companies, practitioners should continue treating patients to the best of their
ability provided these techniques are helpful and do the patient no harm. Even
though research should be encouraged, sometimes it may be enough to know
something works without knowing why it works.

Limitations

Despite a long history of good results, soft-tissue therapy is not without
limitations. First, soft-tissue therapy is not a panacea. Many diseases are not
responsive to soft-tissue therapy and some conditions require medication or
surgery. Second, if soft-tissue impairments are symptomatic of a serious
pathologic condition, treatments are more likely to be palliative than curative
and the patient should be referred to a qualified physician. Recognizing the
limitations of soft-tissue therapy is just as important as recognizing its value.


10
CHAPTER SUMMARY

TWELVE BASIC SOFT-TISSUE THERAPY ACTIVITIES

Take a basic medical history of the patient.
Evaluate posture and symmetry by using observation.
Evaluate condition of soft tissue by using palpation.
Evaluate muscle length by range-of-motion (ROM) testing.
Evaluate muscle strength by muscle testing.
Reduce pain, spasm, or edema by using modalities.
Increase tissue extensibility by using modalities.
Reduce pain by treating trigger points or tender points.
Strengthen muscles by using neuromuscular techniques.
Improve range of motion by stretching restricted tissues.
Provide access to therapeutic exercise programs.
Provide information concerning prevention of injuries.

THREE BASIC GOALS OF SOFT-TISSUE THERAPY

Relieve pain.
Restore normal function.
Improve quality of life.

FOUR BASIC METHODS OF MANIPULATION

Trigger point therapy (relieve pain and reduce pain inhibition)
Neuromuscular therapy (inhibit or facilitate muscles)
Connective tissue therapy (lengthen adhesions or contractures)
Range-of-motion stretching (lengthen restricted tissues)


11
HEMME APPROACH

The HEMME APPROACH is a logical, conservative, and comprehensive
method for treating patients with soft-tissue impairments when soft-tissue
therapy is indicated. The principles and techniques in this approach are
based on scientific research, empirical observation, and clinical experience.
Like most conservative methods, the HEMME APPROACH emphasizes
modalities and manipulation over medication and surgery. The HEMME
APPROACH methodpronounced HEM as in hem and ME as in meis named
after the acronym HEMME that stands for:

HEMME
H HISTORY
E EVALUATION
M MODALITIES
M MANIPULATION
E EXERCISE

More than just a series of steps, the HEMME APPROACH is based on what
system theory refers to as a language model. Language models are used
when complex ideas cannot be formulated mathematically. The purpose of a
language model is to simplify the process of converting knowledge into
action and measuring the results. Language models can be used to (1)
identify problems, (2) collect information, (3) formulate theories, and (4) test
possible solutions by using feedback.
The six connecting steps that hold the model together are

CONNECTING STEPS
1. ENTER PATIENT 4. OBJECTIVES SATISFIED
2. ALTERNATIVES 5. OBJECTIVES NOT SATISFIED
3. FEEDBACK 6. OUTSIDE INFORMATION

In the HEMME APPROACH model (HEMMEGON), the five basic steps
HISTORY, EVALUATION, MODALITIES, MANIPULATION, and EXERCISE are in
bold letters and the other six steps are in outline letters. The starting point,
the step titled ENTER PATIENT, is boxed.


12
Lines and arrows show which directions of movement are possible
within the model. Therapy begins when patients enter the system. Step one
is titled ENTER PATIENT. The first two basic steps in the model titled
HISTORY and EVALUATION define the patient's problem. History refers to
medical history and evaluation refers to physical evaluation.
The next step in the model is titled ALTERNATIVES. This step is a link
between the problem as defined by HISTORY and EVALUATION and possible
solutions as defined by MODALITIES, MANIPULATION, and EXERCISE.
Alternatives should be specifically defined. If modalities, manipulation,
or exercise is needed, practitioners should know specifically which
modalities, manipulations, and exercises are needed. Workable plans for
therapy should include goals, timetables, and measurable results. If therapy
involves more than one practitioner, responsibilities should be assigned.
The steps MODALITIES, MANIPULATION, and EXERCISE are situated on
one line to emphasize that therapy may include one or more of these three
steps. If modalities, manipulation, and exercise are used, a normal sequence
would be (1) modalities, (2) manipulation, and (3) exercise.
The next step is FEEDBACK. Like homeostatic mechanisms that regulate
blood pressure, the HEMME APPROACH uses positive and negative feedback
to regulate the course of therapy. Positive feedback validates the course of
therapy being followed and negative feedback indicates a need for change.
If feedback is positive, it is normally best to continue the same treatment
until all improvements cease. Changes can be made in five basic ways: (1)
change the activities that occur during a step, (2) repeat one or more steps,
(3) change the sequence for using steps, (4) obtain outside information and
reenter the system, or (5) exit the system.
The step for entering new information in the upper left-hand corner of
the HEMMEGON is titled OUTSIDE INFORMATION. Like any living system, the
HEMME APPROACH is capable of receiving and processing input from the
outside. This step can be used to enter outside information from sources
such as consultations, research, or laboratory testing. After receiving and
processing the new information, the knowledge can be entered at four
points: (1) HISTORY, (2) EVALUATION, (3) ALTERNATIVES, or (4) FEEDBACK.
Practitioners can exit the system by using FEEDBACK to reach the steps
titled OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives
of therapy are not satisfied, the patient may exit the system or reenter at any
of the five basic steps. HISTORY and EVALUATION can be reentered directly,
whereas MODALITIES, MANIPULATION and EXERCISE are reentered by using


13
the step titled ALTERNATIVES. If the objectives of therapy are satisfied, the
sequence would go from FEEDBACK to OBJECTIVES SATISFIED and the patient
would exit the system.
From the step titled HISTORY the choices are go directly to OBJECTIVES
NOT SATISFIED or EVALUATION. If contraindications are discovered, the step
titled OBJECTIVES NOT SATISFIED would be used to exit the model. If soft-
tissue therapy is indicated, the next step would be EVALUATION.
From EVALUATION the choices are (1) return to HISTORY if more history
is needed, or (2) go directly to the steps titled OBJECTIVES NOT SATISFIED or
ALTERNATIVES. OBJECTIVES NOT SATISFIED would be used if therapy is
contraindicated and ALTERNATIVES would be used if therapy is indicated.
Even though many combinations are possible, the typical sequence for
soft-tissue therapy is HISTORY, EVALUATION, MODALITIES, MANIPULATION,
and EXERCISE. If modalities and exercise are not used, the sequence would
be HISTORY, EVALUATION, and MANIPULATION. Even if the medical history
and physical evaluation are brief, these two steps are always mandatory.
If the identified problem is solved, OBJECTIVES SATISFIED can be used to
exit the model. If the problem is not solved, OBJECTIVES NOT SATISFIED can
be used to exit the model. Until the objectives are either satisfied or not
satisfied, therapy can be continued by following the lines and arrows.
There is no limit on the number of times a step can be repeated. Even
after a case is closed, the same patient may reenter the system with a new
problem or recurrences of an old problem. Soft-tissue therapy is an ongoing
process that requires enough flexibility to make regular and frequent
changes. To apply the same routine to all patients ignores the fact that each
patient is different and no two cases are exactly the same.
The HEMME APPROACH provides a powerful way to organize the
elements of therapy into a single working model. Unlike the acronym SOAP
(Subjective, Objective, Appraisal, Plan), HEMME APPROACH treats therapy
more like an interactive biological system than a series of steps.
HEMME APPROACH has three basic foundations: (1) scientific method,
(2) systems theory, and (3) medical science. As far as being medically
acceptable, almost all branches of medicine recognize the value of medical
history, physical evaluation, modalities, and therapeutic exercise. While a
few medical doctors would find the HEMME APPROACH more appealing if
the second M in HEMME stood for MEDICATION and SURGERY instead of
MANIPULATION, a large number of medical doctors now consider soft-tissue
manipulation beneficial and worthwhile prescribing to their patients.


14


15
CHAPTER SUMMARY

FIVE BASIC STEPS IN THE HEMME APPROACH

HISTORY (medical history)
EVALUATION (physical evaluation)
MODALITIES (thermotherapy, cryotherapy, vibration)
MANIPULATION (soft-tissue manipulation)
EXERCISE (therapeutic exercise)

SIX STEPS THAT LINK THE FIVE BASIC STEPS TOGETHER

ENTER PATIENT
ALTERNATIVES
FEEDBACK
OUTSIDE INFORMATION
OBJECTIVES SATISFIED
OBJECTIVES NOT SATISFIED

FOUR WAYS TO USE A LANGUAGE MODEL

Identify the problem.
Collect information.
Formulate theories.
Test possible solutions by using feedback.

BASIC SEQUENCE TO IDENTIFY AND SOLVE PROBLEMS

HISTORY (identify problem)
EVALUATION (identify problem)
MODALITIES (solve problem)
MANIPULATION (solve problem)
EXERCISE (solve problem)


16
HISTORY

Contraindications

The most general contraindication to soft-tissue therapy is tissue
manipulation during the acute stage of an injury when hemorrhage or
inflammation is present. The characteristics of inflammation are redness,
swelling, heat, pain, and loss of use. Even passive mobilization can be
harmful during the acute stage when tissues are just beginning to heal.
When hemorrhage or swelling are present, ice and rest are more appropriate
than soft-tissue manipulation. The conditions listed below are general
contraindications to soft-tissue therapy. Most of these conditions should not
be treated without a physicians approval or supervision.

Acute inflammation or infection
Anatomically weak or delicate areas
Calcification of a tendon or muscle
Carotid sinus syndrome
Complete insensitivity to pain or touch
Complete rupture or avulsion of a tendon or ligament
Complete tearing or avulsion of a muscle
Conditions requiring surgery or physiatric intervention
Constant, progressive pain or sharp stabbing pain
Constant, pulsating axillary pain
Degeneration that weakens tendons, cartilage, or bone
Dislocations or subluxations
Fever or chills
Hemorrhage or circulatory dysfunction
Highly contagious or debilitating diseases
Hypermobile ligaments or joints
Open fractures, wounds, or lesions
Painful, hot, or swollen joints
Patients with organic or functional psychosis
Poor general health
Referred cardiac pain
Severe skeletal deformity
Unexplained weakness, numbness, or paresthesia
Vertebrobasilar insufficiency


17
Doctors Opinion

Questions regarding indications or contraindications should always be
resolved by the patients physician. Such opinions are most verifiable when
given in writing. In terms of medical hierarchy, physicians are best qualified
to determine (1) the nature of treatment indicated, and (2) who is qualified to
render treatment. This view is normally supported by the medical and legal
systems and the insurance industry.
In the United States, three types of doctors are widely recognized as being
qualified to diagnose and treat musculoskeletal diseases: (1) medical doctor,
MD; (2) osteopath, DO; and (3) chiropractor, DC. Two other types of doctors
who can also diagnose and treat musculoskeletal diseases to a limited extent
are (1) podiatrist, DPM; and (2) dentist, DDS.

Interview

The first step in the HEMME APPROACH is HISTORY. Background
information such as vital statistics, lifestyle, and general health should be
entered by the patient on a standard form before the interview starts. Other
items to include are previous injuries, operations, and past medical treatments.
In particular, patients should advise practitioners if they are currently under
medical care, taking medication, or aware of any conditions that may
contraindicate soft-tissue therapy. There should always be a blank space at the
bottom of each form for patients to add information if needed. The entire
history form should be read prior to interviewing the patient.
During the first few minutes of contact between a patient and practitioner,
both parties form initial impressions that are difficult to change. While patients
evaluate the practitioner's competency, attitude, demeanor, and communication
skills, practitioners evaluate the patient's honesty, intelligence, personality, and
motivation. Negative opinions formed by either party at this time can
adversely affect the entire course of therapy.
If patients decide too early that practitioners are incompetent, uncaring, or
unprofessional, subsequent attempts to regain the patient's confidence may be
futile. Even if patients continue to use the services of a person they dislike or
distrust, their willingness to cooperate will be less, especially in cases that
require home exercise programs or self-care.
If practitioners decide too early that patients are motivated by secondary
gain such as litigation or a need for attention, legitimate signs of injury or


18
illness may not be found or acknowledged. A premature diagnosis of
conversion hysteria has caused more than one physician to identify
psychogenic symptoms but overlook or disregard organic signs.
While it may be difficult to say how much of any treatment is physical
versus psychological, placebo effects cannot be ignored. If a practitioner
believes a treatment will fail and conveys this belief to a patient, some patients
will consciously or subconsciously try to make the treatment fail.
Practitioners should be alert, but open-minded, when trying to evaluate
what they see and hear. Clever patients may be skillful enough to deceive
practitioners during the initial stages of an interview, while other patients may
present totally honest symptoms that give the appearance of deception.
Establishing rapport is one of the first goals when conducting an interview.
The five best ways to establish immediate rapport with a patient are (1) present
a professional appearance, (2) ask non-threatening questions and listen to the
answers (3) be agreeable and empathetic, (4) smile and use appropriate humor,
(5) make eye contact with the patient. Since the importance of eye contact
cannot be overemphasized, the following test may be helpful. After speaking
to a patient for several minutes, look away and try to recall the patient's eye
color. Failure to recall the patient's eye color may indicate a lack of eye
contact or a lack of attention to the patient.
Most patients should be allowed to sit or lie down unless other positions
are more comfortable. If the patient is nervous and prone to movement,
practitioners should seat the patient and remain standing themselves. This
limits the patient's mobility and helps to establish authority. While some
patients respond well to shaking hands or a light touch on the shoulder during
a greeting, others prefer no physical contact. Watching the way patients
conduct themselves may suggest what behaviors are acceptable.
A therapist should be able to empathize with patients, but have enough ego
strength to make difficult decisions. Two of the most important attitudes are
sincerity and caring. Many problems become secondary if patients believe
practitioners truly want to help. As someone once said, "Patients don't care
how much you know until they know how much you care."
Rapport implies trust, confidence, and cooperation. Once rapport has been
established, review the patient's written medical history, ask questions about
the questionnaire if necessary, and listen carefully to what the patient has to
say. A common failing in the health care field is failure to listen. Listening is
a good way to show respect and help patients feel important.


19
When conducting an interview, separate the patient from the problem and
then focus on the problem. Histories are taken to evaluate the patient's
condition and not the patient. The patients personality and lifestyle should
not be allowed to bias the investigation. After reviewing the patient's medical
history form, the examiner should ask questions requiring more than a "yes or
no" answer. Questions concerning the problem or chief complaint and the
quality of past or present treatment will give the examiner a good place to
start. Three basic questions to start a medical history interview are

What is the nature of the problem?
Are you under a doctors care?
If treated before, what was the quality of past treatment?

The acronym PDQ summarizes these first three questions above:

PDQ
P Problem
D Doctor's care
Q Quality of past treatment

Open-ended questions about pain, loss of motion, and changes in lifestyle
will further define the problem. Almost every patient can provide at least
some information that is helpful enough to be recorded as part of the patient's
permanent medical history. Possible open-ended questions for a medical
history interview include:

How do you feel? (problem)
How can I help you? (problem)
How does the problem affect your life? (problem)
Are you seeing any doctors? (doctor's care)
Are you being treated for any other problems? (doctor's care)
Are you taking any drugs or medication? (doctor's care)
Has this problem been treated before? (quality of past treatment)
Has anything helped before? (quality of past treatment)

Interviews should normally proceed from general to specific. After asking
open-ended questions about the patient's condition, the interviewer should


20
continue with questions that are more specific, such as questions about the
quality, intensity, or duration of pain, and a possible mechanism of injury.
The acronym q.i.d., which means quarter in die or four times a day, can be
used to summarize the basic nature of pain.

q.i.d
q quality of pain
i intensity of pain
d duration of pain

Possible open-ended questions relating to pain include:

What is the nature of the pain (quality, intensity, duration)?
Where and when do you feel the pain (location, pattern, time)?
What causes and what relieves the pain (specific movements)?

Even if the patient's information is not complete, the interview provides a
starting point for investigation. Accident investigators follow a standard
principle: "Before investigating the mechanism of injury, always render aid
first." The key wordsAID FIRSTcan be used as an acronym to help
explain the basic factors that are used to reconstruct a mechanism of injury.

MECHANISM OF INJURY
A ANGLE Direction of force
I INTENSITY Magnitude of force
D DURATION Length of time force is applied

F FREQUENCY Number of times force is applied
I IMPULSE Rate of loading or change in momentum
R REBOUND Secondary impact
S SEVERITY Amount of injury or loss of function
T TARGET Body parts affected by the force


21
Reconstructing an automobile accident may help to explain the acronym
AID FIRST. If the front end of a patients automobile strikes the rear end of a
stopped car, the neck was probably flexed or hyperflexed forward during the
impact and then extended or hyperextended back during the REBOUND. A head
striking the front windshield at an ANGLE of 90 degrees is more likely to
sustain serious injury than a head striking the front windshield at 30 degrees.
Backward motions after a head-on collision are sometimes caused by (1) a
stretch reflex, (2) the viscoelastic properties of connective tissue, or (3)
patients pushing themselves back into their seats after the initial impact.
Rebounds often cause additional injuries.
High rates of acceleration increase the magnitude of force (INTENSITY)
and rate of loading (IMPULSE), which in turn increase the potential for serious
injury. If the patient saw the accident coming and used the arms to brace for
impact, then wrist, elbow, and shoulder injuries are possible. The knees and
hips may be injured if the legs were braced against the floorboards or the knees
struck the dashboard or steering wheel during impact.
The same body part (TARGET) can be affected differently by different
types of movement. During the accident, posterior regions of the neck may
have been injured by the initial impact (flexion or hyperflexion) and the
anterior regions of the neck may have been injured by rebound (extension).
Automobile accidents that affect both anterior and posterior regions of the
neck are normally more serious than accidents that affect only the posterior
region. If the head strikes the dashboard or front windshield during impact,
head or facial abrasions and spinal compression injuries may be involved.
Restraining devices can also be a factor if the body is thrown forward against a
seat belt and shoulder harness that injures the lumbar spine or shoulder.
The quality, intensity, and duration of pain, or loss of function after the
accident, may indicate the SEVERITY of an injury. The presence of signs or
symptoms relative to the amount of time elapsed since the accident may also
indicate severity. Seemingly minor injures may become progressively worse
with time. Reflex sympathic dystrophy often occurs after minor trauma.
The DURATION and FREQUENCY of force should also be considered. If an
automobile accident victim remains trapped in a car for a long period of time,
ischemic damage and nerve-compression injuries may be involved. If after the
original accident, the victims vehicle is struck by another vehicle, some of the
injuries may relate to secondary forces applied to the victims body.
Even in the absence of useful information by the patient, reconstructing the
mechanism of injury will make it easier to locate the origins of pain and


22
provide appropriate treatments. Valuable time can be lost by treating areas of
referred pain, if the origins of pain are not treated.
The quality of treatment is one of the main factors that determines whether
a patient will fully recover from an injury or suffer serious disability. When
treatment is inappropriate, even minor injuries can develop into cases of
chronic pain and dysfunction. The three major treatment faults are (1) acute
care such as cryotherapy started too late, (2) aggressive treatment such as
exercise started too soon, and (3) tissues not mobilized or muscles
isometrically contracted during the subacute stage of wound healing.
In the case of an automobile accident, immediate care is normally rendered
on the scene. Acute tissue damage seen weeks after an accident normally
involves exacerbation of the original injury, or some type of re-injury caused
by stretching and tearing weak or poorly formed scar tissue.
If hemorrhage or inflammation is still active, most forms of soft-tissue
therapy are contraindicated except for cryotherapy. Manipulation or exercise
that causes tissue disruption during the early stages of wound healing will slow
the healing process and possibly aggravate the original injury.
Once injuries have reached the subacute stage, failure to mobilize
connective tissues or use appropriate strengthening exercises may adversely
affect wound healing. Treatments started too late can be just as damaging as
treatment started too early. Passive mobilization and isometric contractions
are often the first two methods of treatment when injuries become subacute.
The time since an injury occurred is another important factor. Old injuries
are often more difficult to treat than relatively recent injuries. When a body
part loses mobility because of spasm or pain inhibition, fibrotic changes and
atrophy have a tendency to increase with time. If a muscle remains slack for
extended periods of time, fibrotic changes and a loss of sarcomeres will
shorten and weaken the muscle. If muscle weakness forces the body to
substitute one muscle for another, compensatory changes in movement or
alignment may cause additional problems.

Whiplash

Whiplash is a popular but imprecise term that leaves the exact
mechanism of injury in doubt. Although many writers have suggested the
term be abandoned, this would be difficult since the term is well entrenched.
As commonly used, whiplash refers to any injury of the cervical spine and
adjacent tissue that is caused by hyperextension or hyperflexion of the head.


23
CHAPTER SUMMARY

TWENTY-FOUR SOFT-TISSUE-THERAPY CONTRAINDICATIONS

Acute inflammation or infection
Anatomically weak or delicate areas
Calcification of a tendon or muscle
Carotid sinus syndrome
Complete insensitivity to pain or touch
Complete rupture or avulsion of a tendon or ligament
Complete tearing or avulsion of a muscle
Conditions requiring surgery or physiatric intervention
Constant, progressive pain or sharp stabbing pain
Constant, pulsating axillary pain
Degeneration that weakens tendons, cartilage, or bone
Dislocations or subluxations
Fever or chills
Hemorrhage or circulatory dysfunction
Highly contagious or debilitating diseases
Hypermobile ligaments or joints
Open fractures, wounds, or lesions
Painful, hot, or swollen joints
Patients with organic or functional psychosis
Poor general health
Referred cardiac pain
Severe skeletal deformity
Unexplained weakness, numbness, or paresthesia
Vertebrobasilar insufficiency

FIVE WAYS TO ESTABLISH RAPPORT DURING AN INTERVIEW

Present a professional appearance.
Ask non-threatening questions and listen to the answers.
Be agreeable and empathetic.
Smile and use appropriate humor.
Make eye contact with the patient.


24
THE ACRONYM PDQ STANDS FOR

Problem
Doctors care
Quality of past treatment

THE ACRONYM q.i.d. STANDS FOR

Quality of pain
Intensity of pain
Duration of pain

THREE OPEN-ENDED QUESTIONS RELATING TO PAIN


THE ACRONYM AID FIRST STANDS FOR

Angle: direction of force.
Intensity: magnitude of force.
Duration: Length of time force is applied.
Frequency: number of times force is applied.
Impulse: rate of loading.
Rebound: secondary impact.
Severity: amount of injury or loss of function.
Target: body parts affected by the force.

THREE MAJOR TREATMENT FAULTS

Acute care such as cryotherapy started too late
Aggressive treatment such as exercise started too soon
Tissues not mobilized or muscles isometrically contracted during the
subacute stage of wound healing


25
EVALUATION

Observation

Observation begins when the patient is first seen and is normally the
starting point for evaluation. The use of observation continues throughout
the entire course of therapy and often tells more about the patient than verbal
statements. The old adage"Actions speak louder than words."may
apply if the patient is unwilling or unable to give correct information.
The greatest danger when using observation is forming preconceived
theories that filter out relevant information. During the early stages of
therapy, practitioners should be open to all possibilities until they can focus
more specifically on a workable theory. During treatment, feedback may
occur that invalidates earlier beliefs and forces practitioners to reevaluate the
patients entire condition and possibly formulate new theories.
Careful observation can be used to evaluate shape, contour, posture,
symmetry, movement, swelling, atrophy, perspiration, skin color, tonus, and
twitching (fasciculations). The patient should be observed from several
different angles while sitting, standing, recumbent, and moving. Simple
instruments such as tape measures, mirrors, and goniometers can be used as
aids to observation. Significant observations should always be recorded,
especially posture that indicates pain, weakness, or limited range of motion.

Palpation

Palpation is probably the most useful method of physical evaluation used
in soft-tissue therapy. When soft-tissue impairments occur because of
changes in structure or function, palpation can isolate the offending tissues
by finding pain, tenderness, abnormal tonus, swelling, atrophy, crepitus,
snapping tendons, clicking joints, abnormal shapes or contours, and changes
in temperature. Skin can be palpated for texture, consistency, mobility,
moisture, and thickness. Palpation combined with observation can be used
to locate landmarks and topographic anatomy (regional or surface anatomy).
Algometry is the process of measuring pain, and pressure algometry is
the process of measuring a pain pressure threshold (PPT) by applying
pressure to sensitive tissues. To avoid the subjective nature of palpation
when measuring a PPT, an instrument called a pressure algometer can be
used that applies pressure over a specific area at a constant, uniform rate.


26
While this method may produce reliable and valid measures of a PPT in
some situations, the algometer is not as sensitive to small changes in tissue
consistency as human touch. Since trigger points normally become less
sensitive to pain as the tissue consistency changes from hard to soft, the
same instrument that applies pressure to measure the PPT of a trigger point
may also neutralize the trigger point before the examiner can get a reading.
Unlike manual palpation, the pressure algometer is not able to correlate
changes in tissue consistency with changes in the pressure pain threshold.

Pain Assessment

Since pain is whatever a person experiencing pain perceives it to be,
most measures of pain are based on feedback from the person reporting the
pain. The four most common instruments for measuring pain are

Verbal rating scale: verbally select words that describe the pain.
Numerical rating scale (NRS): select a number between 1 and 10.
Visual analog scale (VAS): select a point on the line.
Graphic rating scale (GRS): select words that describe the pain.

When using a verbal rating scale, the person reporting the pain selects
words that describe the pain such as mild pain, moderate pain, or severe
pain. When using a numerical rating scale, the person reporting the pain
circles a number from 1 to 10 that corresponds with the pain. Zero can
represent no pain and 10 can represent worst possible pain. The visual
analog scale consists of a line with words such as no pain on one end and
worst possible pain on the opposite end. The person reporting the pain
simply marks any point on the line that indicates the intensity of pain.
A graphic rating scale can be made by drawing a horizontal line on a
piece of a paper and then dividing the line into 10 equal parts by using
eleven vertical marks. The first mark on the left can be labeled no pain; the
last mark on the right can be labeled worst possible pain; and the sixth mark
in the middle can be labeled moderate pain. The space between the third
and fourth mark can be labeled mild pain, and the space between the eight
and ninth mark can be labeled severe pain. To use the graphic scale, the
person reporting the pain should circle the words along the line that describe
the pain. The graphic rating scale can be made longer, if needed, by adding
more words to the line such as very mild pain and very severe pain.


27
PAIN SCALES

0 1 2 3 4 5 6 7 8 9 10
Numerical Rating Scale
No Pain Worst
Possible
Pain
Visual Analog Scale
No Pain Worst
Possible
Pain
Graphic Rating Scale
No Pain
Moderate
Pain
Mild
Pain
Severe
Pain
Worst
Possible
Pain


28
Although not commonly used in soft-tissue therapy, the McGill Pain
Questionnaire (MPQ) is one of the most comprehensive instruments for
measuring pain. The four main areas covered by the MPQ are (1) location
of pain, (2) nature of pain, (3) intensity of pain, and (4) frequency of pain.
The McGill Pain Questionnaire was developed by grouping words into
four categories: sensory, affective, evaluative, and miscellaneous. Sensory
words describe the quality of pain by using categories such as punctate
pressure (stabbing pain), incisive pressure (cutting pain), and constrictive
pressure (crushing pain). Affective words describe the quality of pain by
using categories such as tension (tiring pain), autonomic (sickening pain),
and punishment (killing pain). Evaluative words such as mild, distressing,
or unbearable describe the subjective overall intensity of pain. The
miscellaneous category includes words such as cold and freezing.
The MPQ uses pain-location charts, where patients can draw circles on
anatomical charts to mark the internal and external areas affected by pain.

Physical Stress

Tissue damage and soft-tissue impairments are commonly caused by (1)
trauma, (2) disease, and (3) overuse, disuse, or improper use of body
mechanics. Inflammation, a sequence of vascular, cellular, and biochemical
changes, is normally the first indication of tissue damage. Regardless of
cause or contributing factors, tissues can be damaged three ways:

abnormal stress applied to normal tissues
normal stress applied to abnormal tissues
abnormal stress applied to abnormal tissue

While normal stresses, by definition, cannot injure normal tissues, the
term normal implies that tissues are operating at full capacity. If otherwise
normal tissues are not properly warmed-up before strenuous activity, the
tissues are not normal, and normal stresses may cause damage.
The most common forms of abnormal stress are caused by external
forces (trauma) or internal forces (overuse). The two main factors that cause
overuse are (1) repetitions and (2) intensity. All three varieties of abnormal
stress can be seen in tennis players, where injuries are caused by falls
(trauma), multiple repetitions of a single stroke (overuse), or one repetition
of a stroke that requires extreme force (overuse).


29
Overuse injuries from repetition are frequently classified as insidious
because the onset is gradual and patients cannot relate the pain to any single
event. Repetitive overuse injuries occur when the effects of minor insults
accumulate faster than the body can initiate and complete repair. The best
safeguards against repetitive overuse injuries are (1) adequate periods of rest
between exertions, (2) warm-ups before strenuous activity, and (3) proper
conditioning in terms of flexibility, strength, and endurance.
Abnormal stresses may occur when body movements are not properly
coordinated. Based on scapulohumeral rhythm, the humerus cannot be fully
abducted overhead without external rotation. If the humerus is forced into
overhead abduction without external rotation, the movement is likely to
create abnormal stresses and damage the soft-tissue structures that stabilize,
surround, or cross the glenohumeral joint.
When abnormal stresses exceed the elastic limit of a tissue, the tissue
stretches and fails to resume its previous length when tension is released.
When abnormal stresses exceed the plastic limit of a tissue, muscles or joint
capsules may be torn and tendons or ligaments may be ruptured or torn away
(avulsed). The point of damage is often referred to as a lesion.
Normal stresses on abnormal tissues are caused by stressing tissues that
are (1) partially torn or ruptured, (2) contracted or in spasm, (3) ischemic or
edematous, (4) partially desiccated or lacking lubrication, and (5) bound by
adhesions, contractures, or scar tissue. Disuse and immobility may
decondition and weaken tissues to the extent that normal or subnormal
stresses become destructive. Abnormal tissues are characterized by
abnormal changes in cellular function or structure.
After a wound appears to be healed, repaired tissues are frequently the
site of re-injury because of incomplete or defective healing. Two ways to
improve wound healing and reduce the risk of chronic pain and disability are
(1) continuous passive mobilization to improve the alignment, length, and
flexibility of connective tissue, and (2) proper exercise to improve the
strength and endurance of muscle tissue. Beyond the acute stage of an
injury, immobility and disuse decondition the body and perpetuate pain.
Using high-velocity ballistic stretching to lengthen a muscle that is
abnormally short because of spasm or contracture is one way to illustrate the
concept of abnormal stresses being applied to abnormal tissues. Instead of
stretching elastically and returning to its original length or deforming
plastically and becoming longer, the muscle or some related structures may
be torn or ruptured.


30
While abnormal tension on a muscle is not likely to rupture a tendon, the
muscle may tear at the musculotendinous junction, or the tendon may be torn
loose (avulsed) from where it inserts into the bones periosteum.

Spasm

Often the result of tissue damage, a spasm is a sudden involuntary
muscle contraction that results from painful stimuli to a motor neuron.
Spasm can last for seconds, minutes, or years. A tonic spasm is a
continuous, involuntary spasm, and a clonic spasm is a spasm that alternates
between periods of contraction and relaxation. A masticatory spasm is a
convulsive muscular contraction that affects the muscles of mastication, and
a facial spasm is called a facial tic. Spasms that are caused by strong painful
contractions are called cramps. Contracting a muscle that is slack because
the origin and insertion are approximated may cause cramping if the actin
and myosin filaments become excessively overlapped.
Spasms increase muscular tension, shortness, and resistance to active or
passive stretch. If a muscle is in spasm (spasmodic), opposing movements
that are strong enough to cause stretching may also cause tearing. If tearing
occurs, the inflammation caused by tearing may intensity the spasm.
The type of spasm treatable by soft-tissue therapy is normally caused by
a constant stream of nerve impulses that bombard the gamma motor neurons
that innervate the intrafusal fibers within a muscle spindle. Most gamma-
mediated spasms can be eliminated or reduced by using modalities such as
cryotherapy, thermotherapy, or vibration with trigger point therapy,
neuromuscular therapy, or range-of-motion stretching.

Electrically Silent Hypertonia

Hypertonia is defined as extreme muscle tension with an increase in
resistance to passive stretch. The abnormal tension produced by hypertonia
is continuous, not cyclic, and muscles may show an increase in hardness
when palpated. In addition to hypertonia produced by gamma-mediated
spasm, there appears to be another type of hypertonia that is not mediated by
reflex activity, as indicated by electromyographic (EMG) silence.
If the sarcoplasmic reticulum surrounding a muscle fiber tears, the release
of calcium ions (Ca
++
) may increase metabolism and cause a strong attraction
between actin and myosin filaments that results in contraction. While muscles


31
need energy to contract, they also need energy to relax or let go. On a cellular
level, the high-energy phosphate compound adenosine triphosphate (ATP) is a
muscles major source of available energy. If ATP levels within the muscle
are low because of abnormal contractions or ischemia, actin and myosin
filaments will not have the energy they need to disengage and remain separate,
so muscles become hypertonic.
Rigor mortis, a stiffness that occurs in dead bodies within 1 to 7 hours after
death, is apparently caused by:

degeneration of muscle fibers
release of free calcium ions
attraction between actin and myosin filaments
depletion of ATP in muscle fibers

Coagulation of myogen (myosinogen) is another factor that contributes to
rigor mortis. Myogen contains enzymes that promote glycolysis, a series of
enzymatically catalyzed reactions that release energy in the form of ATP.
Muscle biopsies from muscles with trigger points (myofascial pain
syndrome) or tender points (fibromyalgia syndrome) have both shown a low
level of high-energy phosphates with an excess of low-energy phosphates. A
decrease in high-energy phosphates may partially explain why a muscle can be
electrically quiet in terms of electromyographic (EMG) readings, but
nevertheless be hypertonic and highly resistant to active or passive stretch with
occasional bands of taut or indurated tissue.
Besides depleting ATP, prolonged abnormal contractions may cause
vasoconstriction that triggers a sequence of ischemic damage, inflammation,
and ATP depletion that prolongs abnormal contractions. The sequence of
tissue damage, abnormal contractions, and inflammation may partially explain
why trigger points and tender points are often associated with bands of
indurated tissue and pain. This process may also involve colloids.
A colloid is an aggregate of solid particles dispersed in a gas, liquid, or
solid; a sol is a liquid colloid formed by dispersing solid particles in solution;
and a gel is a solid or semisolid colloid formed by removing energy from a sol.
The hardness within a muscle may occur when solid particles related to
myogen (protein) form a liquid colloid (sol) that is later transformed into a
solid or semisolid colloid (gel). The gel represents the hardness in a muscle.
If the conversion of a sol to a gel explains why muscles become hard when

In living tissue, deep
massage is thought to
reduce abnormal muscle
tension by reversing the
energy crisis caused by
depletion of ATP.


32
tender points or trigger points form, the conversion of a gel to sol may partially
explain why digital pressure and stretching reduce hardness. Some sols have a
tendency to become gels when chemical activity causes the sol to lose energy.
Just as a loss of energy may cause a sol to become gel, the input of energy may
cause a gel to become a sol. It seems possible that digital pressure and range-
of-motion stretching produces mechanical energy (friction) that converts hard
muscle tissue (gel) into soft muscle tissue (sol).
Germanic countries use the term myogelosis to describe the modification
of colloids within a muscle. Myogelosis is characterized by indurated nodules
or bands within a muscle that remain unchanged even under deep anesthesia.
The hardness is caused by the localized gelling of muscle proteins. The
nodules or bands are treated by placing the muscle in a relaxed position and
then using manual pressure to reduce the hardness.

Contracture

Contractures are pathologic shortenings of a muscle due to fibrosis or
muscle fiber defects that increase resistance to active or passive stretch.
Contractures may become permanent unless corrected by therapy, and they
often cause physical deformities without discernible changes in nerve tissue
or bone. Most contractures persist whether the patient is conscious or
unconscious. If contractures increase resistance to active stretch, opposing
muscles may be normal, but test weak. Even though they may contribute to
wound healing (remodeling), contractures often prevent normal movement.
Conditions that decrease blood flow and cause ischemic damage, such as
spasms or the pressure from a cast or bandage, may cause contractures.
Other factors that cause contractures include vascular damage, immobility,
and muscle imbalance. Trauma prior to immobilization or excessive slack in
a muscle seems to accelerate the formation of contractures.
In addition to muscles and fascia, contractures frequently involve a
thickening and shortening of tendons and joint capsules. Contractures can
also be caused by the loss of normal skin elasticity due to scarring. If tissue
tension is not maintained by position or movement, scar tissue (collagen) has
a tendency to shorten and cause surrounding tissue to shrink or contract.
The standard treatment sequence for increasing and maintaining range of
motion is (1) passive or active-assisted range-of-motion stretching to
increase range of motion, and (2) active range-of-motion stretching to
maintain range of motion. Therapeutic heat can be used to increase tissue
extensibility and facilitate stretching; cold can be used to reduce pain.


33
Pain Cycles

Pain is normally the first indicator of tissue damage and the main reason
most people seek medical treatment. What complicates soft-tissue therapy is
the circular nature of pain: (1) conditions that irritate or disrupt tissues
such as a neuromuscular junctioncause cellular changes and pain and (2)
cellular changes and pain cause conditions that irritate or disrupt tissues.
Without therapy, pain cycles often become self-perpetuating and chronic.
Not only are the chances of restoring normal function greatly reduced if pain
cycles are not broken, but most patients also consider therapy a failure if
nothing is done to reduce or eliminate their pain.
If the causes of pain and consequences of tissue damage were always
self-limiting, injuries would heal themselves without treatment within
predictable periods of time. Regrettably, this is not the case for most soft-
tissue injuries. Without treatment, soft-tissue impairments have a tendency
to become chronically painful and disabling because of uncontrolled and
self-perpetuating pain cycles. Even though most soft-tissue injuries should
theoretically heal within six to eight weeks, pain cycles can last for months
or years. The four revolving stages of a pain cycle are

Trauma causes pain, spasm, edema, and metabolite retention.
Spasm, edema, and metabolite retention cause ischemic damage.
Ischemic damage restarts the pain cycle by causing additional trauma.

Causality

Pain begins when internal or external factors irritate or disrupt tissues
and cause inflammation. Even though inflammation produces many
beneficial effects during the wound-healing process, such as helping to
stabilize injured body parts and remove dead tissue, it also produces many
adverse effects that slow the healing process and cause secondary damage.
After tissues are damaged, pain-producing (algogenic) chemicals are
released that mediate pain by activating or sensitizing pain receptors
(nociceptors). Sensitizing chemicals lower a nociceptors threshold to pain
and make it extremely sensitive to painful stimuli (hyperalgesia). The pain-
producing chemicals most frequently mentioned are serotonin, substance P
(polypeptide), histamine, prostaglandins, and bradykinin.


34
When blood platelets released by trauma break down, serotonin,
substance P, and mast cells are released. Often listed as a vasoconstrictor,
serotonin sensitizes nociceptors and may act as a vasodilator. Substance P
causes vasodilation, increased vascular permeability, local erythema, and
spasm. The granules in mast cells release histamine, which then causes
vasodilation and edema. The capsaicin found in red pepper counteracts the
effects of substance P, and ice counteracts the effects of histamine.
Normally acting as a vasodilator during inflammation, prostaglandins
mediate pain by sensitizing nociceptors to bradykinin or histamine. While
prostaglandins do not elicit overt pain, they do cause local tenderness and
hyperalgesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as
aspirin (acetylsalicylic acid), ibuprofen, and ketoprofen induce analgesia and
reduce inflammation by inhibiting the production of arachidonic acid, the
biological precursor of prostaglandins.
Bradykinin is a powerful substance that causes overt pain, sensitizes
nociceptors, and stimulates production of prostaglandin. It is also a potent
vasodilator that encourages edema by increasing capillary permeability.
Bradykinin is released during periods of insufficient blood supply (ischemia)
or oxygen deficiency (hypoxia).
After algogenic chemicals mediate pain, vasoconstriction, edema, and
spasm work together to increase metabolite retention. The combination of
vasoconstriction, edema, spasm, and metabolite retention causes (1)
restricted circulation, (2) local ischemia, and (3) restricted movement.
Muscle spasm not only compresses blood vessels and causes local
ischemia, but it also increases the rate of metabolism in muscles, while at the
same time making it difficult for circulation to remove metabolites, the by-
products of metabolism. When metabolites, such as lactic acid, are retained
in muscles and body fluids, pain or fatigue result. Pain-producing chemicals
such as serotonin, histamine, and bradykinin are also retained.
Spasm and edema reduce blood flow by physically compressing blood
vessels, while metabolite retention reduces blood flow by causing
vasospasm that decreases the caliber of blood vessels. Besides causing pain,
congestion, and slowing the healing process, reduced blood flow often
causes ischemic damage that triggers a new round of pain, spasm, edema,
and metabolite retention. The secondary tissue damage caused by ischemia
may be worse than the primary tissue damage caused by the original injury.
Besides damaging muscle tissue, ischemia can reduce the oxygen supply
to nerve tissue and cause hypoxic damage, weakness, referred pain,


35
paresthesia, or sensory dysfunction. Ischemia lasting more than 6 to 8 hours
may cause pathologic death of peripheral nerve tissue (ischemic necrosis).
In addition to ischemic damage, the combination of pain, spasm, and
edema restricts movement. Pain restricts movement by causing physical and
psychological pain inhibition. Spasm restricts movement by causing
guarding or splinting that shortens, tightens, and weakens muscles. Swelling
and edema restrict movement by increasing interstitial pressure. Long
periods of restricted movement cause contractures, adhesions, atrophy,
muscle weakness, and decreases in range of motion and mobility.

Reactivation

Even if pain, spasm, edema, and metabolite retention appear to be
completely resolved, three factors that sometimes reactivate the original pain
cycle are (1) latent trigger points, (2) entrapment neuropathies, and (3)
tearing of fibrous connective tissue such as scar tissue or adhesions.
Some trigger points continue to produce low levels of pain between
major flare-ups in a pain cycle, while others remain latent or subliminal
between flare-ups. When physical or psychological conditions are right,
formerly quiescent trigger points become active and reactivate the pain
cycle. Factors that contribute to reactivation of trigger points include fatigue,
abnormal movements, maximal exertions, psychological stress, disease, rapid
changes in atmospheric conditions, and poor nutrition. Trigger points are
discussed more fully under the section titled Trigger Point Therapy.
Entrapment neuropathies can also restart pain cycles. If nerve entrapments
develop because of swelling, fibrosis, or spasm, neurovascular compression
can irritate nerves and reactivate pain cycles. If the pressure on a nerve is
intermittent, nerve conduction velocities remain intact, and possible symptoms
are pain, paresthesia, or sympathetic hyperactivity.
If pressure is more continuous than intermittent, possible symptoms are
partial paralysis (paresis), complete paralysis, or anesthesia. Continuous
pressure increases the risk of vascular ischemia and decreases nerve
conduction velocities. Even if autonomic continuity is not interrupted,
continuous pressure is more likely to cause sensory or motor loss than pain.
Contractures, adhesions, and scar tissues can also become latent to the
extent they restrict motion without causing pain. Range-of-motion testing
after the patient claims to be fully recovered will often show significant
reductions in range of motion because of connective tissue restrictions.


36
These restrictions often remain asymptomatic for long periods of time until a
forceful movement or strenuous contraction causes tearing.
Connective tissue structures that result from wound healing are more
prone to tearing than normal tissues for several reasons. First, when torn
muscle fibers are repaired by natural healing, only a small percentage of the
dead tissue is replaced by muscle tissue. Most of the wound is repaired by
connective tissue that is very strong, but much less elastic than muscle
tissue. Stresses that would not damage a muscle tissue are sometimes more
than sufficient to damage newly formed connective tissue.
Second, if tissues are ischemic, hypoxic, or if metabolites are present
during the wound-healing process, collagen fibers will have a tendency to
connect or cross-link with each other instead of remaining separate. The
ability of tissues to stretch without tearing is reduced by each additional
connection or cross-link between fibers. Collagen fibers that are properly
formed can crisscross and slide over the top of each other without adhering
because the fibers are separated by distance and lubrication.
Glycosaminoglycans (mucopolysaccharides) are polysaccharides that
form chemical bonds with water. Derived from proteoglycans, this protein-
polysaccharide complex forms the ground substance that occupies the
intercellular spaces between fibrous connective tissue. Even though ground
substance is normally a low-viscosity fluid or semi-fluid gel, water depletion
caused by ischemia or immobility can reduce the volume of
glycosaminoglycans in ground substance and cause stickiness or hardness.
As the quality of lubrication decreases, the drag between fibers increases.
Third, when body parts are immobilized during the wound-healing
process, collagen fibers have a tendency to be poorly aligned. When body
parts are passively mobilized or actively moved, collagen fibers form in
directions that are parallel to the lines of stress (Wolffs Law). This helps to
ensure that flexibility and length are great enough to allow full range of
motion. Movement during the healing process can also prevent adhesions,
fibrous bands of tissue that connect structures that should be separate.
When body parts are injured, pain and protective spasm reduce range of
motion. If the body part is not mobilized after the acute stage of injury has
passed, proliferation of connective tissue and muscle weakness limit range
of motion even more. This tendency can be demonstrated by examining a
body part that was just removed from a rigid cast after six weeks of
inactivity. Immobilization of body parts by casting or splinting encourages
deconditioning, contractures, and atrophy.


37
Treatment

Pain cycles are difficult to treat for seven reasons:

The mechanisms that cause pain cycles are difficult to locate.
Pain can migrate from one area to another.
Pain cycles can be chronic and acute at the same time.
Reflex activity perpetuates pain cycles.
Setbacks and reversals are common when treating pain cycles.
Methods for treating soft-tissue injuries are sometimes deficient.
Muscle imbalance perpetuates pain cycles (see page 114).

(1) The mechanisms that cause pain cycles are difficult to locate.

The areas where pain originates and areas where pain is felt are seldom the
same. Pain felt in the shoulder, elbow, or hand is often referred to these areas
by injured muscles in the neck. Treating pain without treating the origins of
pain produces little more than symptomatic relief. The keys to effective
therapy are (1) locate and treat the origins of pain, and (2) locate and treat the
areas where pain is felt. Only in rare cases will the origin of pain and the areas
where pain is felt be the same.

Problems related to locating and treating the origins of pain include:

One origin can produce pain in several different areas.
Pain in one area may be caused by several different origins.
Deep pain is more difficult to localize than superficial pain.
As the intensity of pain increases, the radiation of pain increases.

(2) Pain can migrate from one area to another.

The areas where pain is felt by the patient can migrate during the course of
therapy. As muscles in one area become more functional, antagonistic or
synergistic muscles may experience unaccustomed loading, stretching, or
compression that causes pain. As hypersensitive areas become less sensitive
to pain because of therapy, areas of lower sensitivity become more apparent.
It is also possible that even areas of high sensitivity can be obscured by
widespread pain. If the tissue damage that triggered a pain cycle is confined to


38
a single area, the last tissues to normalize are frequently the tissues that
suffered the initial insult and propagated the widespread pain.
The body is so interconnected by muscles, fascia, and reflex patterns that
treating a single muscle or muscle group is normally pointless, if not
impossible. Most soft-tissue impairments involve agonistic, antagonistic,
synergistic, and compensatory muscles simultaneously. Contralateral or
ipsilateral muscles that share a common reflex pattern, or muscles that cross
the same joint, cannot operate without some degree of interaction.
Approaching the body holistically is the only way to identify and treat pain.

(3) Pain cycles can be chronic and acute at the same time.

Even if pain is classified as chronic because of when the original injury
occurred, any pain that results from re-injuring the same area because of
stretching and tearing scar tissue should be classed as acute, not chronic.
Failure to understand this principle can lead to inappropriate therapy if acute
pain is treated in the same way as chronic pain. While heat may be indicated
for chronic pain, cold is normally indicated for acute pain.

(4) Reflex activity perpetuates pain cycles.

Reflexogenic changes occur because of a neural pathway between a joint
and the muscles that move the joint. It is difficult to say which comes first,
pathologic conditions in a joint that cause muscle splinting or pathologic
conditions in periarticular muscles that irritate the joint. Irrespective of which
comes first, inflammation of the joint and surrounding tissue is likely to
continue until hypertonic muscles that cross the joint relax and lengthen.
Long-term shortness in a muscle that crosses a joint:

reduces joint space
causes abnormal friction
inflames the joint capsule
erodes articular cartilage

High-velocity manipulation techniques that distract a joint, without
relaxing or lengthening the muscles that cross the joint, will seldom do more
than provide temporary relief. If joints and related muscles are not treated
together as a unit, the body cannot heal itself and pain cycles often continue.


39
(5) Setbacks and reversals are common when treating pain cycles.

Even without secondary gain or litigation neuroses, progressive
improvement will sometimes reverse itself for no apparent reason. The
leading cause appears to be higher levels of activity. As patients improve, they
become more active and place more demands on the body. Despite feelings of
well-being, patients should be advised to avoid strenuous activities until the
entire body can handle the added stress. The deconditioning effects of
inactivity are difficult to overcome. Besides pain-free range of motion,
patients need strength, endurance, coordination, and cardiovascular fitness to
function normally. Strength can be affected by either neural or non-neural
elements.
Other considerations that may contribute to setbacks are smoking,
excessive use of alcohol, vitamin or mineral deficiencies, and a lifestyle that
prevents adequate sleep. Any factors that are detrimental to general health will
have an adverse effect on the healing process and may cause setbacks.

(6) Methods for treating soft-tissue injuries are sometimes deficient.

In many cases, soft-tissue therapy begins too late or methods of treatment
are not appropriate for the problem. If an injured body part is not mobilized
early during the subacute stage of injury, pain, spasm, and fibrosis may limit
the victim's range of motion and cause inactivity. Inactivity, in turn, may
cause deconditioning and other pathologic changes, such as trigger points,
contractures, or adhesions, that lay the groundwork for pain cycles. When
used without soft-tissue manipulation, modalities, medication, and exercise are
seldom effective, and splints or braces worn for more than a few days can
retard healing, decondition the body, and decrease range of motion.
Another form of inappropriate treatment is too much focus on reports of
pain by the patient and not enough concentration on restoring function.
Though "train, don't strain" is more popular today than "no pain, no gain,"
some forms of soft-tissue therapy are painful. While any competent
practitioner tries to minimize pain during treatment, patients need to
understand that improvements without pain are not always possible. This
includes pain that occurs during and after treatment. The best ways to help
patients accept unavoidable pain are (1) advise patients that treatments may be
painful, (2) explain why treatments are necessary, and (3) suggest methods for
minimizing or dealing with the pain. The stronger the bond between patients


40
and practitioners, the easier it is for patients to understand that progress may
not occur without some pain.
One of the greatest mistakes made when treating soft-tissue impairments is
viewing the body segmentally instead of holistically. Nerve, muscle, and
connective tissue are so interconnected that one part of the body cannot be
affected without affecting other parts. Because of interconnections between
muscles, bones, and fascia, and the interrelationships between opposing and
synergistic muscles, it would be difficult to affect one muscle or muscle group
without affecting other muscles or muscle groups. If the human body is
viewed holistically as a single unit, not as a series of independent parts, the
obvious course of therapy is (1) evaluate interconnected parts, (2) evaluate the
entire body, and (3) treat accordingly.

Objectives

Understanding pain cycles and the bodys tendency to decrease range of
motion can make it easier to understand the five major therapeutic goals
based on pain cycles:

relieve pain
reduce spasm and edema
improve circulation and mobility
neutralize all trigger points
encourage exercise

Satisfying these five major goals will normally break pain cycles by
altering the basic conditions that cause and perpetuate pain cycles. The
standard tools for satisfying these objectives are (1) modalities, (2)
manipulation, and (3) exercise.
Without therapeutic intervention, pain cycles become self-perpetuating and
may continue for months or years. Once pain cycles become chronic,
precipitating causes are more difficult to identify and treat.
Drugs such as pain-killers, anti-inflammatories, and muscle relaxants are
rarely efficacious, and surgery without definitive laboratory evidence is more
likely to aggravate than negate pain cycles. Unlike conservative, noninvasive
forms of treatment such as soft-tissue therapy, surgery traumatizes the body,
precipitates scar tissue, and often produces serious, irreversible side effects.
At best, soft-tissue therapy is curative; at worst, it seldom causes harm.


41
Muscle Testing

Manual muscle testing is a clinical method for measuring muscular
strength and range of motion (ROM). Another name for muscle testing is
resisted range-of-motion testing. Strength measures the patient's ability to
hold steady or move against resistance. When patients hold against resistance,
muscles contract isometrically without changing in length. When patients
move against resistance, muscles contract isotonically and shorten.
Muscles are organs composed of nerve tissue, muscle tissue, and
connective tissue. Nerves transmit electrical impulses and muscle fibers
produce force by contraction. Tendons and aponeuroses transmit the force to
bones, and deep fascia separates and supports a muscle.
Based on composition, the main factors affecting strength and weakness
are (1) neurologic efficiency, (2) the ability of muscle fibers to contract, (3) the
integrity of tendons and aponeuroses, and (4) the ability of deep fascia to reach
normal length.
Even though joints are not part of a muscle, the integrity of joints can also
affect strength and weakness. If a joint is irritated, locked, or unstable, a
muscle crossing the joint may test weak when the muscle itself is normal. Any
condition that changes joint space above or below physiologic limits will
adversely affect the ability of joints to produce movement.
Range-of-motion testing measures joint movement by degrees of arc in a
circle. The starting position is zero (neutral position) and degrees are added in
the direction the joint moves from starting position. Except for rotation,
starting position is normally the same as anatomical position.
An example of range-of-motion testing is elbow flexion. Starting from
anatomical position with the forearm vertical and the palm supinated
(forward), elbow flexion is about 150 degrees for most people. The active
range of motion normally has fewer degrees of freedom than for the passive
range of motion and both are affected by pain, training, and motivation.
Joint angles can be measured with a goniometer. The accuracy of a
goniometer depends on landmarks. Measurements are most accurate when
landmarks are definite. Range of motion can be approximated by comparing
opposite extremities or using a person of similar age, sex, and physique as a
standard. Active range of motion is normally not tested in goniometry.
If joints and the agonist are normal, the main factor limiting range of
motion is tissue extensibility of the antagonist. If the antagonist fails to
lengthen normally during contraction by the agonist, the joint's range of


42
motion will be limited. This explains why active range-of-motion testing
measures strength and length. Range-of-motion stretching is used to increase
or maintain the amount of motion available to a specific joint.
The following table defines active, passive, active-assisted, and resisted
range-of-motion testing.

Active range-of-motion testing: the force for movement is provided by the
patient without assistance or resistance from the examiner.

Passive range-of-motion testing: the force for the movement is provided by
the examiner without assistance or resistance from the patient.

Active-assisted range-of-motion testing: the force for the movement is
provided by the patient with some assistance from the examiner.

Resisted range-of-motion testing: the force for the movement is provided by
the patient and works against resistance from the examiner.

For the safety of the patient, active, passive, and active-assisted range-of-
motion testing should always be done first, and resisted range-of motion-
testing last. Active range-of-motion testing gives the examiner a chance to
observe the patient's range of motion with gravity as the only outside force. If
the patient's active range of motion is normal, passive and passive-assisted
range of motion testing are optional and the next step is normally resisted
range-of-motion testing.
If a patient fails the active range-of-motion test, the next step is passive
range-of-motion testing. If the patient's passive range of motion is limited, the
probable causes are joint dysfunction, spasm, or contracture. If the patient's
passive range of motion is normal, active-assisted range-of-motion testing can
be used to locate weaknesses that interfered with the patient's active range of
motion. Possible causes for weakness are neurologic dysfunction, lack of
motivation, pain inhibition, disuse atrophy, or fatigue.
If testing reveals a soft-tissue impairment, stop testing, treat the problem,
and then repeat the same test before continuing. If therapy corrects the
problem, further testing of the same movement may not be required. This
follows the EMT acronym: (1) Evaluate the problem, (2) Manipulate to
correct the problem, and (3) Test the results. Modalities can be used before,
during, or after manipulation to increase tissue extensibility or reduce pain.


43
Active Range-of-Motion Testing

If the patient is unable to move a body part against gravity, the same
movement should not be tested against manual resistance. Additional
resistance may traumatize tissue and cause the patient needless discomfort.
The next logical step is passive ROM testing. If active ROM testing is normal,
examiners can normally move directly to resisted ROM testing.

Passive Range-of-Motion Testing

If an examiner applies manual force and finds the patient's passive ROM is
restricted, the three most likely causes are joint dysfunction, spasm, or
contracture. The way body parts feel as they reach the end of their ROM will
often show which structure is most culpable, the joint or muscle. Muscles
prone to tightness include: hamstrings, iliopsoas, piriformis, pectoralis major
and minor, upper trapezius, sternocleidomastoid, and erector spinae.
The end-feel for most joints is either hard like elbow extension or soft like
elbow flexion. End-feels that are soft when they should be hard or hard when
they should be soft indicate joint dysfunction. If the problem appears to be
joint dysfunction, palpate the joint for signs of heat, swelling, or pain. Normal
joints are never swollen or hot, and normal ligaments are not painful when
palpated or stretched.
The next possibility to investigate is spasm or contracture. Spasms can
result from calcium deprivation (carpopedal spasm), sewing or writing
(occupational spasm), spasmodic contraction of a muscle (intentional spasm),
disease (myopathic spasm), or trauma (charley horse). Contractures are
caused by inflammation, macrophages, and tissue fibrosis (ischemic
contracture), sleeping in or maintaining a position that allows a muscle to
shorten (functional contracture), or the effects of heat or chemicals
(physiological contracture). Spasms or contractures can weaken muscles and
restrict joint movement by increasing resistance to active or passive stretch.
The initial end-feel for spasm or contracture is more like stretching a
spring than either hard or soft: the greater the stretch, the greater the
resistance. If properly applied, slow and steady tension will cause a decrease
in resistance. The key points are (1) apply moderate force directly against the
resistance and (2) use slow and steady pressure. Unlike pathologic joints that
normally become more painful with stretching, muscles in a state of spasm or
contracture often become less painful as tissues approach normal length.


44
Active-Assisted Range-of-Motion Testing

If the patient's passive ROM is normal, the next step is active ROM
testing. If full range of motion is possible with assistance by the operator, the
implication is muscular weakness. Having the patient move as far as possible
in one direction and then using manual assistance to complete the range of
motion will help to identify the muscles or muscle groups that are weak.
Different types of muscle weakness are treated by different methods:

Cause for Weakness Possible Treatment
Inhibition Neuromuscular therapy (facilitation techniques)
Pain Trigger point therapy and ROM stretching
Spasm Neuromuscular therapy (inhibition techniques)
Contracture ROM stretching (static)
Disuse atrophy Progressive-resistance exercise
Deconditioning Progressive-resistance exercise
Learned disuse Motor training to force or encourage use

Resisted Range-of-Motion Testing

If the patient's active ROM is normal, the final step is resisted ROM
testing. Even if the active and passive ROM are normal, weakness may still
exist because of injury, disuse, or disease. In resisted muscle testing, strength
is measured by having a muscle hold or move against manual resistance.
Holding against resistance is easier to use than moving against resistance
and less likely to injure joints. If resistance causes joint pain, normal muscles
may test weak. While most muscles can be safely tested at midrange, the
optimal position for testing a one-joint muscle is at the end of a range.
Resistance is normally applied to the distal end of a body part for leverage.
Gravity is often used in place of manual resistance when testing the
abdominal muscles for endurance by using sit-ups. If the trunk is not held in a
curled position during the test, sit-ups measure hip flexor muscles more than
abdominal muscles. Where straight-leg sit-ups allow the psoas muscle to
function during trunk flexion, bent-leg sit-ups exclude the psoas by placing the
muscle at a mechanical disadvantage.
Even though some systems apply percentages to each grade or use pluses
and minuses to create more levels, the most workable grading system for soft-
tissue therapy uses six levels of measurement ranging from 5 to 0.


45
MUSCLE TESTING BY GRADE
NORMAL 5 Hold against gravity and full resistance (N).
GOOD 4 Hold against gravity and some resistance (G).
FAIR 3 Complete range of motion against gravity (F).
POOR 2 Complete ROM with gravity eliminated (P).
TRACE 1 Evidence of contraction only (T).
ZERO 0 No evidence of contraction (0).
Note: Normal is a higher grade than Good.

The difficulty of using this scale is knowing whether to grade a muscle
as normal (5) or good (4). A strong patient with a major disability will
sometimes test higher than a weak patient with a minor disability. A strong
patient can lose a greater percentage of strength than a weak person and still
hold against gravity and give the appearance of normal strength. Bilateral
comparison is one way to cross-check the results of muscle testing.
If only one side of the body is involved, check the muscles on the
impaired side first and then check the same muscles on the opposite side. If
the muscles on the impaired side are the weakest, a grade of 5 for the
impaired side may be too high. If muscles on both sides of the body test the
same, a grade of 4 for the impaired side may be too low.
Because of handedness, the tendency to use one hand in preference to
the other, dominant side muscles are normally stronger than weak side
muscles. If a person is right-handed, the left side testing stronger than the
right side may indicate weakness on the right side.
Muscle testing is based on the premise that no two muscles perform
exactly the same function. Theoretically, each muscle can be tested
separately if the direction and magnitude of force and the patient's position
are correct. The direction of force is normally opposite the direction of pull
for the muscle being tested. Deviation from this direction allows the patient
to substitute other muscles for the muscle being tested. Since appropriate
force will vary from person to person, examiners must learn how much force
to use by experience. Since leverage often favors the examiner, using too
much force is more likely to cause inaccuracy than using too little force.


46
Three types of positioning are used in muscle testing: (1) positioning to
avoid substitution, (2) positioning to reinforce fixator muscles, and (3)
positioning to create active insufficiency.

(1) Positioning to Avoid Substitution

Substitution begins when other muscles attempt to function in place of
the muscle being tested. This often occurs when the muscle being tested is
weak. Placing the patient in a stable position during muscle testing may (1)
isolate the muscle being tested, (2) stop the body from changing position,
and (3) prevent substitution. If the initial body position favors the pull of the
muscle being tested, other muscles cannot function effectively unless their
direction of pull is changed by repositioning the body. If poor positioning
allows substitution to occur, the test results will be invalid.

(2) Positioning to Reinforce Fixator Muscles

Positioning combined with body weight and manual force can be used to
reinforce fixator muscles that allow the insertion to move by locking the
origin of a muscle in place. When a muscle contracts, tension pulls equally
at both the origin and insertion. To produce movement, stabilizing the
origin leaves the insertion, and the bone the insertion attaches to, free to
move. If fixator muscles are weak, muscle testing will not be accurate.
Fixator muscles are often antagonistic to the muscles being tested. The
examiner can use positioning, body weight, and manual force to reinforce
fixator muscles. An example of fixation is using positioning (supine), body
weight, and manual force to fixate the opposite iliac crest when testing the
psoas and iliopsoas for strength.

(3) Positioning to Create Active Insufficiency

Active insufficiency is the failure of any muscle to generate normal
tension because the origin and insertion are too close and the muscle has too
much slack. In certain positions, muscles that cross two joints cannot exert
enough tension to move both joints through a complete ROM at the same
time because of active insufficiency. If a one-joint muscle and a two-joint
muscle both produce the same movement, active insufficiency can be used
to neutralize the two-joint muscle while the one joint-muscle is being tested.


47
As an example, the gluteus maximus and the hamstring muscle both
extend the hip. The gluteus maximus is a one-joint muscle and the
hamstring is a two-joint muscle. When the patient flexes the knee, the slack
hamstring muscle is unable to extend the hip. The gluteus maximus can then
be tested using hip extension without interference from the hamstring.
The same principle applies to the soleus and gastrocnemius. Although
both muscles plantar flex the foot, the soleus is a one-joint muscle and the
gastrocnemius is a two-joint muscle. When the knee is flexed: (1) slack in
the gastrocnemius reduces plantar flexion strength by about 70 percent, and
(2) the soleus can be partially isolated and tested by testing plantar flexion.
If the technique of making a two-joint muscle slack to create active
insufficiency is used, care must be taken to protect the two-joint muscle
from cramping. Two-joint muscles that are strongly contracted while the
muscle is slack have a tendency to cramp. The hamstrings may cramp while
the gluteus maximus is being tested. Because of active insufficiency and
tension being generated at two different joints, two-joint muscles are more
likely to be injured during strenuous activity than one-joint muscles.

Three points are important for the safety of the patient:

Apply resistance slowly and progressively (easy on).
Do not apply excessive force or break the patient's contraction.
Remove resistance slowly and progressively (easy off).

Resistance should be applied slowly to give the patient enough time to
apply a counterforce and removed slowly to avoid a rapid rebound. Applied
too quickly or with too much force, resistance may break the patient's
contraction and cause tissue damage. Resistance should stop when the
patient's contraction changes from isometric to eccentric and the muscle
starts to yield. Repeatedly testing the same muscle may decrease strength
because of pain or fatigue or increase strength because of facilitation.
Isometric resistance is normally applied when a muscle is at or slightly
beyond its normal resting length. Because of the way myofilaments are
arranged in the sarcomere and the viscoelastic properties of a muscle, most
muscles are strongest when the muscle is at or near resting length and
weakest when the muscle is fully stretched or fully shortened. Resting
length is often about midway between full contraction and full extension.
The biceps brachii is close to resting length when the elbow is at 90 degrees.


48
As a caution, testing a muscle when distal and proximal insertions are
not far enough apart to keep tension on a muscle during contraction may
cause cramping. Any condition that allows actin and myosin myofilaments
to overlap without restriction seems to encourage painful spasm. This can
be demonstrated by placing the elbow joint in full flexion (sagittal plane)
and then slowly and carefully contracting the biceps brachii. With only mild
contraction, the biceps will often start to cramp.
Even though high degrees of precision are allegedly required in soft-
tissue therapy, most muscles performing a similar function can be tested as a
group. According to Beevor's axiom, the body knows nothing of individual
muscles but thinks only in terms of movement. Since movements depend on
muscles working in combination with each other, muscles that perform a
similar movement can be tested as a group.
Muscle testing by group is most effective when combined with feedback
and palpation to identify the muscles that are most involved. If contraction
causes pain, both contractile structures and closely related non-contractile
tissues are probably involved. The most likely non-contractile tissues to be
implicated are tendons and aponeuroses.
Palpation can be used to identify offending tissues. Involved muscles
are normally indurated, ropy, and painful. In severe cases, palpation of
irritated muscles will cause fasciculations or twitching and the patient will
show signs of sympathetic response such as perspiration, changes in skin
temperature, or pilomotor activity (erection of hairs and goose flesh).
If contraction is painful, the examiner should palpate for signs of
impairment when the muscle is first relaxed and then contracted. Though
most muscles are easier to palpate when relaxed, impairments are sometimes
more conspicuous when muscles are contracted. When using palpation, start
with light pressure and gradually increase to moderate pressure or heavy
pressure if needed.
Though observation should always be used with palpation, visible signs
are less reliable than kinesthetic signs. Involved muscles may be larger than
normal if swollen or smaller than normal if atrophied. Inflammation may
cause flushing or redness from histamine release and vasodilation. Anxiety
or shock may cause blanching or paleness from sympathetic response and
vasoconstriction. Involved tissues may also appear perfectly normal.
The HEMME APPROACH Quick Test shows how muscles performing a
similar function can be tested as a group. Testing a group of muscles by
testing a basic movement is much faster than testing individual muscles.


49
HEMME APPROACH Quick Test

The Quick Test was developed for quickly testing neck and shoulder
muscles while the patient and examiner are both standing. To conserve
time, the testing sequence is designed to keep positional changes to a
minimum. The first eight tests are done with the examiner facing the patient
and the last four are done with the examiner standing behind the patient.
Within five minutes, the examiner should be able to check:

flexion (forearm)
extension (forearm)
lateral rotation (humerus)
medial rotation (humerus)
extension (humerus)
flexion (humerus)
horizontal abduction (humerus)
horizontal adduction (humerus)
extension (cervical spine)
adduction (humerus from 5 degrees)
adduction (humerus from 90 degrees)
lateral flexion (cervical spine)

The Quick Test evaluates movements more than specific muscles and
the results are fairly accurate because of bilateral comparison. Except for
testing extension and lateral flexion (side-bending) of the cervical spine,
movements on both sides of the body are tested at the same time.
Testing is done with isometric resistance. By making bilateral
comparison and drawing on past experience, examiners can determine if a
movement is normal or weak. Other possible observations include pain
during contraction or substitution. If weakness is detected, standard muscle
testing or muscle-testing devices can be used to quantify muscular strength.
Whenever possible, if movement of the humerus is being tested,
resistance is applied to the humerus above the elbow. If resistance is applied
to the elbow or forearm, pathologic conditions in either of these structures
may invalidate the test because of pain or weakness. When movement of
the forearm is being tested, resistance is applied to the forearm above the
wrist to avoid complications because of pathologic conditions in the wrist or


50
hand. Examiners using the Quick Test should follow the same safety
precautions listed above for standard muscle testing.
For simplicity, neutral position refers to the hand in a semi-pronated,
semi-supinated position, distal forearm refers to the end of the forearm just
above the wrist, and distal humerus refers to the end of the humerus just
above the elbow. To simplify directions of movement, extension is defined
as the opposite of flexion, adduction as the opposite of abduction, and lateral
rotation as the opposite of medial rotation. The basic prime movers of the
shoulder region involved in each movement include:

CERVICAL SPINE

Extension: upper fibers of trapezius.
Lateral flexion: anterior, medius, and posterior scalenes.

FOREARM

Flexion: biceps brachii.
Extension: triceps brachii.

HUMERUS

Flexion: coracobrachialis and deltoid (anterior).
Extension: latissimus dorsi and teres major.
Abduction: deltoid (middle fibers) and supraspinatus.
Adduction: latissimus dorsi, pectoralis major, and teres major.
Medial rotation: pectoralis major and subscapularis.
Lateral rotation: infraspinatus and teres minor.
Horizontal abduction: deltoid (posterior fibers).
Horizontal adduction: pectoralis major.

This list does not include prime movers that are not connected directly
with the shoulder region, such as the forearm flexors brachialis and
brachioradialis. The decision as to what constitutes a prime mover varies
from one reference to another. Some authors list latissimus dorsi as a prime
mover in medial rotation. For clarity, the term humeri (plural of humerus)
has been used below to emphasize that reference is being made to the arm as
medically defined (upper extremity between shoulder and elbow).


51
Examiner Facing Patient (anterior)

1. Flexion (forearm)
A. Patient: arms at sides, elbows flexed to 90 degrees, hands supinated.
B. Examiner: arms along sides, elbows flexed to 90 degrees, hands
pronated and touching superior surfaces of patients distal forearms.
C. Resistance: prevent patient from flexing humeri.

2. Extension (forearm)
A. Patient: arms at sides, elbows flexed to 90 degrees, hands supinated.
B. Examiner: arms at sides, elbows flexed to 90 degrees, hands
supinated and touching inferior surfaces of patients distal forearms.
C. Resistance: prevent patient from extending humeri.

3. Lateral Rotation (humerus)
A. Patient: arms at sides, elbows flexed to 90 degrees, forearms parallel,
hands in a neutral position (vertical).
B. Examiner: arms down at sides, elbows flexed to 90 degrees, hands in
a neutral position (vertical) and touching lateral surfaces of patients
distal forearms.
C. Resistance: prevent patient from laterally rotating humeri.

4. Medial Rotation (humerus)
A. Patient: arms at sides, elbows flexed to 90 degrees, forearms parallel,
hands in neutral position (vertical).
B. Examiner: arms at sides, elbows flexed to 90 degrees, hands in
neutral position (vertical) and touching medial surfaces of patients
distal forearms.
C. Resistance: prevent patient from medially rotating humeri.
D. Option: examiner can draw elbows back (extend arms) and brace
forearms against body for added resistance to internal rotation.

5. Extension (humerus)
A. Patient: humeri flexed to 90 degrees, elbows flexed to 90 degrees.
B. Examiner: arms and elbows flexed, hands touching inferior surfaces
of patients elbows.
C. Resistance: prevent patient from extending humeri.


52
6. Flexion (humerus)
B. Examiner: hands touching superior surfaces of patients distal humeri.
C. Resistance: prevent patient from flexing humeri.

7. Horizontal Abduction (humerus) (forearms of examiner are parallel)
B. Examiner: hands touching lateral surfaces of patients elbows.
C. Resistance: prevent patient from horizontally abducting humeri.

8. Horizontal Adduction (humerus) (forearms of examiner are crossed)
B. Examiner: hands touching opposite medial surfaces of patients elbows.
C. Resistance: prevent patient from horizontally adducting humeri.

9. Extension (cervical spine)
A. Patient: arms at side and cervical spine flexed slightly forward.
B. Examiner: one hand touching parietal region of patients head,
opposite hand touching sternal region of patients chest.
C. Resistance: prevent patient from extending cervical spine.

Examiner Behind Patient (posterior)

10. Abduction (humeri from 90 degrees)
A. Patient: arms abducted to 90 degrees.
B. Examiner: hands touching superior surfaces of patients distal humeri.
C. Resistance: prevent patient from abducting humeri.

11. Adduction (humeri from 90 degrees)
A. Patient: arms abducted to 90 degrees.
B. Examiner: hands touching inferior surfaces of patients distal humeri.
C. Resistance: prevent patient from abducting humeri.

12. Lateral Flexion (cervical spine)
A. Patient: arms at sides (dependent position).
B. Examiner: one ipsilateral hand on lateral surface of patient head,
opposite hand stabilizing shoulder on same side.
C. Resistance: prevent patient from laterally flexing cervical spine.


53
Fibromyalgia Syndrome (FMS)

Various conditions involving inflammation that are often associated with
painful areas or points:

Fascitis: inflammation of fascia.
Fibromyositis: inflammation of fibromuscular tissue.
Fibrositis: inflammation of fibrous tissue.
Myofibrositis: inflammation of the perimysium.
Myositis: inflammation of voluntary muscles.

As part of an effort to identify specific syndromes characterized by painful
points, medical science has now separated tender points from trigger points
and developed a new classification called fibromyalgia syndrome (FMS).
Where myofascial pain syndrome (MPS) is caused by trigger points, FMS is
caused by tender points. In other ways, FMS and MPS are similar.
Since FMS is one of the most common syndromes treated by soft-tissue
therapy, any practitioner evaluating conditions that involve painful areas or
points should be familiar with FMS. Even though FMS, fibrositis, and
fibromyositis have all been used to describe the same syndrome, terms that
imply inflammation, such as fibrositis and fibromyositis, are now considered
obsolete because no one can show that inflammation is part of the syndrome.
Fibromyalgia (FMS) syndrome is characterized by the presence of
palpable fibrocystic tender points that are associated with symptoms such as
generalized muscular aching, stiffness, fatigue, and poor sleep. Other
symptoms may include tension-type headaches, irritable-bowel syndrome,
subjective complaints of joint swelling, and vague complaints of paresthesia.
Tender points are sometimes aggravated by cold, humidity, changes in
weather, immobilization, excessive physical activity, fatigue, and tension. By
definition, unlike trigger points, tender points do not refer pain when palpated.
Pain should be present for at least three months (chronic), and digital palpation
with a force of about 9 lb should cause pain.
The common sites for pain related to fibromyalgia are neck, shoulder,
lower back, arms, hands, hips, thighs, knees, legs, and feet. The concept of
nine paired, anatomically discrete tender-point sites was developed by the
American College of Rheumatology (ACR) in 1990. Since all of the sites
listed below are bilateral, each site is capable of producing two separate tender
point sites for a total of eighteen possible tender point sites.


54
BILATERAL FMS TENDER POINTS (Anterior)

1. greater trochanter: posterior to trochanteric prominence
2. knee: at medial fat pad proximal to joint line
3. lateral epicondyle: about 3/4 inch distal to the epicondyles
4. low cervical: anterior aspects of the intertransverse spaces (C5-C7)
5. second rib: at second costochondral junctions

1
2
3
4
5


55
BILATERAL FMS TENDER POINTS (Posterior)

1. occiput: at suboccipital muscle insertions
2. trapezius: at midpoint of the upper border
3. supraspinatus: at origins above scapular spine
4. gluteal: upper outer quadrants of the buttocks

1
2
3
4


56
To meet the American College of Rheumatology definition for FMS:

Tender points must be present in at least 11 of the 18 tender-point sites.
Pain must be widespread and present for at least 3 months.
Digital pressure with a force of about 4 kg (9 lb) must produce pain.
The patient must state that palpation was painful (tender is not painful).

Classified as a form of nonarticular rheumatism, fibromyalgia syndrome
does not produce signs of connective tissue, musculoskeletal disease, or
inflammation and laboratory tests are normal. Often causing anxiety and
depression as a result of chronic pain and fatigue, FMS may cause even greater
functional disability than rheumatoid arthritis. Often caused by superficial
trauma, FMS appears to affect the central nervous system.
According to ACR, widespread means that pain is present on the right and
left side of the body, above and below the waist. There must also be axial
skeletal pain: anterior chest or cervical, thoracic, or lumbar spine (low back).
While tender points must be present in at least 11 out of the 18 sites for the
ACR definition of FMS to apply, some experts believe the requirement of no
less than 11 tender points is too high and the limit of 18 possible sites is either
too high or too low. One study suggested that 4 regions be used in place of 18
tender point sites. The four regions cited by the study are (1) anterior
shoulder, (2) anterior chest, (3) scapula, and (4) media knee.
Another problem with the definition of fibromyalgia syndrome is trying to
differentiate between tender points that are characteristic of fibromyalgia
syndrome (FMS) and trigger points that are characteristic of myofascial pain
syndrome (MPS). There are four basic reasons why tender points and trigger
points are difficult to separate.

First, tender points and trigger points frequently occur in the same region at
the same time and may produce many of the same symptoms such as
muscle ache, stiffness, fatigue, and difficulty sleeping. Nutritional
deficiencies or inadequacies may also cause muscle ache, stiffness
(ascorbic acid), fatigue, and difficulty sleeping (thiamine or folate).

Second, both tender points and triggers points are painful when palpated, and
patients may withdraw when digital pressure is applied to either type of
point. The act of a patient withdrawing when pressure is applied to a
trigger point is called a jump sign.


57
Third, while it may be true by definition that tender points do not refer pain
when palpated, it is also true by definition that not all trigger points refer
pain when palpated. Unless a trigger point is sufficiently hypersensitive,
compression produces local pain, but not referred pain. A hyperirritable
point that fails to refer pain can be either a tender point or a trigger point.

Fourth, while palpable bands of taut, indurated tissue in a muscle are
characteristic of MPS more than FMS, such bands are often found in cases
of fibromyalgia, but may be absent in cases of myofascial pain. If band-
like structures are found in patients with FMS, palpation should not cause
referred pain. If it does, the syndrome would be classified as MPS, not
FMS.

Perhaps the greatest difference between FMS and MPS is the difference
between generalized pain and localized pain. Where FMS normally produces
widespread pain that affects large percentages of the body, MPS normally
produces local pain that affects limited parts of the body. If the body is
divided into four quadrantsleft side above the waist, right side above the
waist, left side below the waist, and right side below the waistpatients with
FMS should experience pain in all four quadrants. Only rarely will MPS
affect all four quadrants.
While FMS and MPS are clearly different in some cases, in other cases the
two syndromes appear to overlap. In cases where the boundaries between
FMS and MPS are not clear, the number and distribution of points may be
more significant than the classification of points. If any of the points refer pain
when palpated, MPS is at least partially involved. If none of the points refers
pain when palpated, the syndrome could be either FMS or MPS, and other
criteria need to be considered such as location or distribution of pain.
While the ACR's definition makes a good attempt at trying to separate
FMS from MPS, the difficulty in separating tender points from trigger points
prevents a clear distinction. Not only is muscular weakness common to both
tender points and trigger points, the factors that are thought to cause tender
points and trigger points are somewhat similar: microscopic tissue damage,
muscle hypoxia (oxygen deficiency), and pain-producing chemicals.
The 9 pounds of force needed to activate a tender point will also activate a
trigger point. (For clinical purposes, about 9 pounds of force will normally
cause blanching of the patient's skin where the pressure is being applied and
partial blanching of the examiner's thumbnail.)


58
Systematic features such as anxiety, disturbed sleep, deconditioning, and
fatigue probably contribute to both FMS and MPS. Tender points and trigger
points both produce chronic pain that may cause psychological distress. For
patients with FMS or MPS, a good day without pain may be rare.
Despite the widespread aching and stiffness caused by FMS, at least a few
points on the body should not be painful when touched. These points are
called control points. If touching control points such as the tip of the nose or
an earlobe causes pain, the patient is possibly suffering from a psychogenic
illness and may require psychological or psychiatric attention.
Even though there is no definitive strategy for treating tender points or
fibromyalgia syndrome, most tender points can be treated by using trigger
point techniques. These techniques include modalities, manipulation, and
exercise. Passive range-of-motion stretching should be followed by active
range-of-motion stretching, and heat can be used to facilitate stretching. The
basic protocols for treating tender points or trigger points are

digital pressure followed by range-of-motion stretching
cryotherapy (ice) followed by range-of-motion stretching
cryotherapy (ice) followed by heat and range-of-motion stretching
skin rolling to relieve skinfold tenderness (scapular region)

To reduce pain and stiffness, stretching exercises are more effective than
strengthening exercises. It also appears that stretching and cardiovascular
exercises together are more effective than stretching exercises used alone.
Cardiovascular exercises may produce an increase in circulation that helps to
dissipate chemicals that cause or mediate pain. Strengthening exercises are
useful if weakness or joint laxity is present. Although exercise is beneficial,
excessive activity that causes fatigue may also aggravate the symptoms.
Even if exercise is therapeutic, patients with FMS may find it difficult to
exercise because of the pain. Patients who were physically active before they
acquired FMS may have stopped exercising because of the pain. When FMS
occurs, traumatic onsets are more likely to interfere with exercise and cause
disability than insidious onsets. While pain may cause some patients to stop
exercising, inactivity may cause deconditioning that augments the pain. Some
patients find exercising in water less painful than exercising on land.
A stressful life style can make management of FMS difficult. Smoking,
alcohol abuse, caffeine, and psychological stress can aggravate symptoms.
Relaxation therapy, recreation, or psychological counseling may be helpful.


59
CHAPTER SUMMARY

FOUR MOST COMMON INSTRUMENTS FOR MEASURING PAIN

Verbal rating scale: verbally select words that describe the pain.
Numerical rating scale (NRS): select a number between 1 and 10.
Visual analog scale (VAS): select a point on the line.
Graphic rating scale (GRS): select words that describe the pain.

FOUR CATEGORIES USED BY McGILL PAIN QUESTIONNAIRE

Sensory
Affective
Evaluative
Miscellaneous

THREE CONDITIONS THAT CAUSE TISSUE DAMAGE

Abnormal stress applied to normal tissues
Normal stress applied to abnormal tissues
Abnormal stress applied to abnormal tissues

FOUR REVOLVING STAGES OF A PAIN CYCLE

Spasm, edema, and metabolite retention cause ischemic damage.
Ischemic damage restarts the pain cycle by causing additional trauma.

FIVE BASIC ALGOGENIC CHEMICALS

Bradykinin
Histamine
Prostaglandins
Serotonin
Substance P


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SEVEN REASONS PAIN CYCLES ARE DIFFICULT TO TREAT

The mechanisms that cause pain cycles are difficult to locate.
Pain can migrate from one area to another.
Pain cycles can be chronic and acute at the same time.
Reflex activity perpetuates pain cycles.
Setbacks and reversals are common when treating pain cycles.
Methods for treating soft-tissue injuries are sometimes deficient.
Muscle imbalance perpetuates pain cycles.

FIVE THERAPEUTIC OBJECTIVES BASED ON PAIN CYCLES

Relieve pain
Reduce spasm and edema
Improve circulation and mobility
Neutralize trigger points
Encourage exercise

FOUR RANGES OF MOTION USED IN MUSCLE TESTING

Active range of motion
Passive range of motion
Active-assisted range of motion
Resisted range of motion

SEVEN CAUSES FOR WEAKNESS AND POSSIBLE TREATMENTS

Inhibition: neuromuscular therapy (facilitation techniques).
Pain: trigger point therapy and ROM stretching.
Spasm: neuromuscular therapy (inhibition techniques).
Contracture: ROM stretching (static).
Disuse atrophy: progressive-resistance exercise.
Deconditioning: progressive-resistance exercise.
Learned disuse: motor training to force or encourage use.


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SIX MUSCLE-TESTING GRADES

Normal (5) hold against gravity and full resistance (N).
Good (4) hold against gravity and some resistance (G).
Fair (3) complete range of motion against gravity (F).
Poor (2) complete range of motion with gravity eliminated (P).
Trace (1) evidence of contraction only (T).
Zero (0) no evidence of contraction (0)

THREE MUSCLE-TESTING SAFETY POINTS

Apply resistance slowly and progressively (easy on).
Do not apply excessive force or break the patient's contraction.
Remove resistance slowly and progressively (easy off).

NINE BILATERAL FMS TENDER-POINT SITES

Gluteal: upper outer quadrants of the buttocks.
Greater trochanter: posterior to trochanteric prominence.
Knee: at medial fat pad proximal to joint line.
Lateral epicondyle: about 3/4 inch distal to the epicondyles.
Low cervical: anterior aspects of the intertransverse spaces (C5-C7).
Occiput: at suboccipital muscle insertions.
Second rib: at second costochondral junctions.
Supraspinatus: at origins above scapular spine.
Trapezius: at midpoint of the upper border.

FOUR WAYS TO TREAT TENDER POINTS OR TRIGGER POINTS

Digital pressure followed by range-of-motion stretching
Cryotherapy (ice) followed by range-of-motion stretching
Cryotherapy (ice) followed by heat and range-of-motion stretching
Skin rolling to relieve skinfold tenderness (scapular region)


62
MODALITIES

Wound healing is the key to understanding why modalities, manipulation,
or exercise is needed. The need for soft-tissue therapy normally begins with
some form of injury that causes tissue damage, inflammation, and soft-tissue
impairments. The long-term probability for patients returning to normal
function is largely determined by how practitioners respond to the wound-
healing process.
Inappropriate responses to wound healing because of incorrect procedures
or poor timing can leave patients with chronic pain, limited range of motion,
weakness, and even permanent disability. By understanding the wound
healing process, practitioners will understand why therapy is needed, what
techniques work, and when they should be applied.
Wound healing is a process of inflammation and repair that occurs after
trauma disrupts the continuity of a tissue. Inflammation involves a series of
vascular, cellular, and immune responses that begin the wound-healing
process, while repair involves a series of regenerative responses that replace
injured tissue and close the wound. Inflammation and repair are so closely
related that some writers consider repair part of the inflammation process. If
wound healing is successful, injured tissue is replaced by healthy tissue and
injured body parts function normally.
While full recovery often requires that damaged tissue be replaced by
healthy tissue, the replacement tissue is not always the same as the original
tissue. When muscle tissue is damaged, a small percentage of the new tissue
may be muscle tissue and a large percentage connective tissue. When muscle
tissue is replaced by connective tissue (scar tissue), muscles have a tendency to
become shorter, weaker, and more resistant to passive stretch.
Muscles repaired by connective tissue have a tendency to shorten because
muscle fibers are drawn together by scar tissue as part of the healing process
that closes the open spaces created by a wound. Myofibroblasts are the cells
responsible for closing wounds. These cells have characteristics similar to
smooth muscle, such as contractile fibers, and also seem to produce collagen.
Muscles repaired by connective tissue have a tendency to become weak
because scar tissue is not capable of producing voluntary contractions like
striated skeletal muscle tissue. An increase in resistance to active or passive
stretch occurs because scar tissue has a higher tensile strength than muscle
tissue. By definition, tensile strength measures the maximum longitudinal
(tensile) stress a material can endure without elongation.


63
Since elevations in temperature increase tissue extensibility, heating
modalities are often used with range-of-motion stretching to lengthen scar
tissue after a muscle injury. Until an injured muscle is capable of reaching its
normal length, opposing muscles will not be able to produce full-range-of-
motion movements. Opposing muscles may also test weak because of the
added resistance to active or passive stretch.
Wound healing follows a series of four stages: (1) early acute, (2) late
acute or sub-acute, (3) sub-acute or early chronic, and (4) late chronic. The
number of days an injury is classified as acute, sub-acute, or chronic can vary
depending on the nature of the injury, the rate of healing, and how chronic is
defined. Serious injuries remain acute longer than minor injuries, and three
factors that slow the healing process are inadequate blood supply, infection,
and nutritional deficiencies. Too little rest can retard wound healing, while too
much rest can decondition the body and decrease mobility.
The definition of chronic is so variable that no single definition can be
given. The possibilities include longer than 6 months, longer than 3 months,
and more than 4 weeks past the normal healing time.
During the initial stage of an injury (early acute stage, 1 to 3 days after the
injury), trauma is followed by hemorrhage, inflammation, impaired
circulation, spasm, hypoxic damage, and weakness. One of the early signs of
tissue damage is hemorrhage from broken blood vessels and seepage
(extravasation) of blood into extravascular spaces.
After blood vessels go through a brief period of vasoconstriction, arterioles
and venules vasodilate and cause widespread arterial (active) and venous
(passive) hyperemia. Hemorrhage normally stops within a short period of time
because of clotting. The process of clotting is called coagulation. Clots are
formed as fibrinogen converts to fibrin and creates a mesh that traps red and
white blood cells and platelets. Fibrinogen clots partition off the site of injury
from other tissues and delay the spread of toxic products and most bacteria.

The five classic signs of acute inflammation:

Pain: the result of pain-producing chemicals.
Swelling: the result of fluid accumulation in tissues.
Redness: the result of increased blood flow.
Heat: the result of increased blood flow.
Loss of function: the collective result of inflammation.


64
When related to headaches, inflammation can result in loss of appetite
and a general feeling of discomfort. The three most basic responses to
inflammation are (1) vasodilation that increases the rate of blood flow, (2)
increased capillary permeability, and (3) the escape of leukocytes from
blood vessels into tissues. The migration of leukocytes to the site of an
injury is called diapedesis. The term chemotaxis describes the chemical
attraction of leukocytes into interstitial spaces. Some of the chemicals that
attract leukocytes belong to a group of substances known as kinins. One
member of this group, bradykinin, mediates pain.
Vasodilation and increased blood flow cause redness and heat, while
increased capillary permeability and leakage from small blood vessels cause
inflammatory edema. Even though some swelling, during the initial stage of
injury, may be caused by hemorrhage, most is caused by edema.
By stage two (late acute or sub-acute stage, 2 to 7 days after the injury),
the victim's range of motion is limited by pain, guarding, or splinting. The
differences between acute and sub-acute are hemorrhage and inflammation.
Sub-acute begins when hemorrhage and inflammation are no longer present.
Severe injuries tend to remain acute longer than minor injuries.
In stage three (sub-acute or early chronic stage, 8 days to 6 weeks after the
injury), macrophages (monocytes) remove cellular debris from the site of
inflammation by ingestion and digestion (phagocytosis), and fibroblasts begin
to form collagen fibers. If limitations on range of motion because of pain or
guarding continue, movements become even more restricted as proliferation of
connective tissue produces scar tissue. Newly formed scar tissue is weaker,
more vascular, and more sensitive than mature scar tissue. Improperly
organized scar tissue may cause adhesions or contractures.
Whether stage three is defined as sub-acute or early chronic depends on
what standard is being used: (1) wound healing or (2) chronic pain. When
wound healing is used as a standard, the dividing line between sub-acute and
chronic is 6 weeks. This reflects the belief that soft-tissue injuries normally
heal within 6 weeks. When chronic pain is used as a standard, the dividing
line can be 3 or 6 months, or more than 4 weeks past the normal healing time.
The classical dividing line between sub-acute and chronic has been 6
months. This definition appears to be the most arbitrary and least consistent
with any physical changes. It often implies all standard treatments have failed
and the patient should learn to live with the problem.
Collagen synthesis and proliferation of connective tissue peak sooner in
superficial wounds that affect only the dermis than in deep wounds that affect


65
subcutaneous structures. For most wounds, proliferation of connective tissue
peaks 7 to 21 days after the injury, and scar tissue may take 4 months to
achieve maximum strength. If poorly formed because the affected areas were
not properly mobilized during the healing process, scar tissue may tear before
other connective tissue and cause hemorrhage or inflammation.
The process of reshaping an injured area during wound healing is called
remodeling. As damaged cells are removed by cells or enzymes that digest or
disintegrate (lyse) dead tissue, new cells are laid down as replacements. If the
balance between collagen removal and replacement stays fairly even, wounds
heal without excessive scarring such as hypertrophic or keloid scars.
Hypertrophic scars are elevated scars that stay within the boundaries of a
wound, and keloid scars are elevated scars that extend beyond the boundaries
of a wound. Hypertrophic scars often result from severe burns, and keloid
scars often result from severe trauma.
Regrettably, nature has a tendency to overproduce collagen fibers. As
stated by Weigerts law, the loss or destruction of living tissue is apt to be
followed by overproduction of such tissue during the process of wound
healing. As a consequence, the balance between removal and proliferation of
connective tissue is seldom the case and many wounds heal with adhesions,
contractures, or excessive scarring.
Modalities, manipulation, and exercise are often needed to lengthen
connective tissue, rupture adhesions, and compensate for nature's tendency
to overproduce collagen. Joints produce two types of movement: accessory
and physiological movements. Accessory movements are fine, involuntary
motions such as glide or tilt. Physiologic movements are gross, voluntary
motions such as flexion or extension. In addition to increasing circulation,
soft-tissue extensibility, and joint lubrication, range-of-motion stretching
improves both accessory and physiologic movements.
According to Wolff's law, bone and collagen fibers develop a structure
most suited to resist the forces acting upon them. During remodeling,
collagen fibers normally align themselves in a direction parallel to the lines
of force. Even though the exact mechanism remains unclear, it appears that
collagen fibers use electrical charges to identify lines of force.
Certain materials, such as quartz, tourmaline, and calcite crystals (bone),
produce electrical currents in response to mechanical pressure. Materials
that convert mechanical energy into electric energy are called piezoelectric
substances and the electric currents they produce are called piezoelectricity.
Wound closure and collagen-fiber alignment may involve piezoelectricity.


66
During stage four (late chronic stage, more than 6 weeks after the injury),
small movements are sometimes enough to irritate or rupture tissues and
reproduce physiologic responses characteristic of the early acute stage.
Entrapment neuropathies and myofascial trigger points develop in stage four.
By stage four, disuse atrophy may or may not be present, depending on the
extent of disability. Even if present, atrophy can be difficult to identify if
losses in muscle mass are offset by fluid accumulation. When this occurs, the
circumference of an injured part may be smaller after treatment than before
treatment if therapy dissipates collected fluids. Contractures may also occur
during stage four if inactivity or avoidance of pain causes tissue to remain in a
shortened position without regular stretching.
The optimal conditions for healing depend on a balance between activity
and rest. The normal five-step sequence for early activity during the wound-
healing process is (1) passive mobilization, (2) isometric contractions, (3)
range-of-motion stretching, (4) active-assisted or self-assisted exercise, and (5)
active exercise.
Unlike modalities that can be used at any time to facilitate manipulation or
exercise, soft-tissue manipulation should always be used before exercise if
soft-tissue impairments are present that interfere with normal movement. If
soft-tissue impairments cannot be corrected quickly by manipulation, it may be
appropriate to use exercise after manipulation to prevent deconditioning, if the
patient's condition is not adversely affected by the exercise.

The main uses for modalities during wound healing:

Cryotherapy: reduce pain, control edema, and reduce local metabolism.
Thermotherapy: reduce pain or spasm and increase local blood flow.
Hydrotherapy: same as cryotherapy or thermotherapy.
Vibration: increase circulation and reduce pain or sympathetic activity.
Heliotherapy: kill bacteria and increase local blood flow.
Ultraviolet therapy: same as heliotherapy.

The main uses for manipulation during wound healing:

Trigger point therapy: reduce pain and soften tissues.
Neuromuscular therapy: reduce spasm and facilitate weak muscles.
Connective tissue therapy: rupture adhesions and stretch local scar tissue.
Range-of-motion stretching: lengthen contractures and restricted tissue.


67
The main uses for exercise after wound healing:

Stretching: maintain range-of-motion and flexibility.
Strengthening: improve muscular strength and endurance.
Strengthening: improve muscular speed and power.
Coordination: improve mobility and quality of movement.
Aerobic: improve cardiovascular fitness.

Inflammatory Response

When viewed separately, inflammation (the response of tissues and cells
to injury) can be loosely classified as acute, subacute, or chronic. As
inflammation progresses from acute to subacute, the five classic signs of
inflammation become less visible.
Even though infections can produce inflammation, infection and
inflammation are not synonymous. Unlike infections that are caused by
multiplication of parasitic organisms within a body, inflammations are
caused by cellular injury. While most inflammations related to soft-tissue
impairments produce local responses such as pain, swelling, redness, and
heat, systemic inflammations related to viral infections can produce global
responses such as headaches, muscle aches, sweating, and chills.

The five basic stages of inflammation:

release of pain-producing chemicals
increased blood flow to the inflamed area
edema caused by plasma leaking from capillaries
infiltration of the injury by leukocytes (neutrophils or monocytes)
proliferation of connective tissue and wound healing

If the injury is not too severe, inflammation begins within 30 minutes of
the injury and peaks within 6 to 8 hours. Tissue repair normally begins after
the inflammation peaks. Many of the words denoting inflammation end in
the suffix -itis such as fibrositis (inflammation of fibrous tissue) or myositis
(inflammation of a muscle).
The agents that cause inflammation can be physical, chemical, or
biological. When dealing with soft-tissue impairments, the most common
external factors are trauma and disease, while the most common internal


68
factors are overuse, disuse, or improper body use. Once tissues are
damaged, pain results and psychological or chemical factors increase or
decrease the patients threshold and tolerance for pain. Some chemicals
mediate pain or increase the sensitivity of nerve endings to pain, while other
chemicals such as endorphins or enkephalins mitigate pain.
Despite many of its adverse effects, inflammation has beneficial features
that promote wound healing. One of the cardinal signs of inflammation,
pain warns the body of potential tissue damage and encourages the victim to
avoid contact with any environmental factorssuch as mechanical,
chemical, or electrical agentsthat cause pain. Inflammation causes pain
by releasing chemical mediators that activate or sensitize nociceptors and
lower the pain threshold (hyperalgesia). The psychological avoidance of
movement because of pain is sometimes called pain inhibition.
In addition to psychological avoidance, pain physically protects injured
body parts by causing guarding or splinting. Guarding results from
involuntary muscle contractions that limit range of motion to help victims
avoid pain caused by movement. The effect of splinting is similar to
guarding, only more extreme. When splinting occurs, the range of motion
decreases because of reflex spasm until the injured body part becomes rigid
or fixated. The normal swelling that accompanies inflammation may also
contribute to a limited range of motion, rigidity, or fixation.
The redness and heat that occur with inflammation are caused by an
increase in blood flow. Since increases in blood flow are normally
beneficial to the healing process, redness and heat are two signs of
inflammation that represent beneficial effects. Increased blood flow
accelerates the healing process by transporting oxygen, nutrients, and
leukocytes to the site of injury. Oxygen and nutrients are needed to help the
body generate new tissue, while leukocytes are needed to help the body
defend against invading microorganisms and speed the healing process.
Phagocytes dispose of microorganisms, necrotic tissue, and foreign
particles by a process of ingestion and digestion called phagocytosis.
Phagocytes are divided into two general classes: microphages (neutrophils)
and macrophages (monocytes). Microphages and macrophages are white
blood cells (leukocytes) that kill and phagocytize bacteria or virus and
remove dead or degenerated cells and foreign matter. Whereas microphages
take about an hour to arrive and increase in number (neutrophilia) after the
onset of inflammation, macrophages are normally present in surrounding
tissue and arrive within minutes.


69
Chronic Inflammation

Even though the term inflammation is used, chronic inflammation is a
low-level inflammation characterized more by pain, proliferation of
connective tissue, and loss of function than by swelling, redness, or heat.
Chronic inflammation occurs when the body is unable to completely
overcome the results of an injury and may persist for months or years. Even
without significant loss of function, chronic inflammation can decrease the
victim's quality of life and desire to function normally.
In terms of phagocytic activity, neutrophils are more common than
monocytes during acute inflammation, but less common than monocytes
during chronic inflammation. Within several days or weeks after an injury,
monocytes will outnumber neutrophils. As long as chronic inflammation
continuesmonths or even yearsbone marrow will continue to produce
enormous quantities of neutrophils (20 to 50 times normal production).
In addition to pain inhibition, the two main causes for loss of function
during chronic inflammation are muscle weakness and limited range of
motion. Since collagen is degraded almost as rapidly as it matures, the scar
tissue that forms during chronic inflammation is often weak because much
of the collagen is immature. Because of the rapid degradation of mature
collagen, myofibroblasts have a tendency to overproduce replacement
collagen and cause contractures or adhesions.
Organic contractures shorten muscles, limit range of motion, and cause
muscle weakness. Unlike functional contractures that cease to exist during
sleep or general anesthesia, organic contractures are caused by fibrosis
within a muscle and persist whether the subject is conscious or unconscious.
Many cases of chronic inflammation are caused by repetitive overuse
and microtrauma that damages poorly formed scar tissue. The factors that
may cause poorly formed scar tissue during the acute stage of an injury are
(1) too much activity, (2) infection, (3) insufficient oxygen, and (4) poor
nutrition. During the early subacute stage, body parts should be passively
mobilized to improve the alignment of connective tissue and reduce the
number of abnormal cross-links or attachments. During the late subacute
stage of an injury, range-of-motion stretching should be used to help
connective tissues achieve or maintain adequate length.
While symptoms may not be apparent during the early stages of chronic
inflammation (insidious onset), the later stages of chronic inflammation
often produce pain, stiffness, and various degrees of dysfunction such as


70
muscle weakness or limited range of motion. Symptoms often become
worse with physical activity and may not be relieved by rest. If the effects
of overuse and repetitive microtrauma are cumulative, the symptoms of
chronic inflammation may become worse with time.
While many cases of chronic inflammation are caused by repeated
overuse and repetitive microtrauma, a single trauma can also be the initial
cause for chronic inflammation. If a scar closing a wound is abnormally
weak, normal movements may be enough to tear small portions of the scar
and cause chronic inflammation. If a scar closing a wound is abnormally
tight, normal movements may be enough to tear small portions of
surrounding tissue and cause chronic inflammation. Since most scars are
stronger and less compliant than surrounding tissue, the tissues connected to
scar tissue are more likely to tear than the scar itself.
Since chronic inflammation occurs after the acute stage of injury has
passed, the treatments appropriate for chronic inflammation are similar to
the treatments used for subacute or chronic injuries. Since heat, redness, and
edema are not characteristic of chronic inflammation, heat is normally more
effective than cold. The therapeutic effects from heat that may relieve
chronic inflammation include (1) reduction of ischemic pain, (2) removal of
pain mediators, and (3) elevation of the pain threshold. Unlike cold, heat
has a tendency to improve hemodynamics and increase tissue extensibility.

Secondary Damage

The total damage caused by an injury is not limited to the tissue damage
caused by the original injury. Primary damage is caused by internal or
external forces that disrupt tissue structures and cause a loss of function.
Caused by the wound-healing process itself, secondary damage results from
(1) phagocytosis and lysosomal enzyme damage; (2) ischemic or hypoxic
damage; and (3) hydrostatic pressure damage. Lysosomal enzyme and
hypoxic damage are more significant than hydrostatic pressure damage.
While many of the effects related to inflammation are beneficial during
the early stages of an injury, some of these effects can change from
beneficial to destructive as time progresses. The pain that helps to protect an
injured body part during the early stages of an injury can also prevent the
same body part from regaining normal function after the original injury is
healed. In a sense, pain becomes a disease in its own right.


71
If swelling because of hemorrhage or edema restricts blood flow,
ischemia may cause secondary ischemic or hypoxic damage. The same
increase in blood flow that helps leukocytes migrate to the site of an injury
and remove dead or degenerated cells may also cause secondary damage if
enzymes ingest healthy tissue after the injured tissue has been removed.
Despite its adverse effects, inflammation contributes to human survival.
Without inflammation, wound healing would not occur and humans would
not survive long enough to reproduce and perpetuate the species. While
inflammation may produce several side effects that increase the severity of
an injury, in most cases the inflammation will pass, the wound will heal, and
the victim will survive, with or without loss of function.
Secondary damage is not the same as a re-injury. After an injury is
partially or completely repaired, normal or abnormal forces applied to the
original site of injury will sometimes damage newly formed scar tissue or
adjacent tissues. If a wound-healing environment was deficient because of
inappropriate amounts of movement, ischemia, hypoxia, malnutrition, or
infection, the newly formed scar tissue may be weak or poorly formed
because of improper alignment, cross-linking, or attachments.
If damage is severe, the inflammation that occurs because of re-injury
may be characterized by pain, swelling, redness, heat, and loss of function
(acute inflammation). If damage is not severe, the inflammation that occurs
may be characterized by pain, proliferation of connective tissue, and loss of
function more than swelling, redness, or heat (chronic inflammation). The
difference between acute and chronic inflammation is a matter of degree
more than a sharp line between two entirely different conditions.
Even though the differences between acute and chronic inflammation are
sometimes vague, this decision will determine a starting point for using
thermal modalities. If the inflammation is acute with obvious swelling,
redness, and heat, the starting point would be cryotherapy. Cold is indicated
because it tends to reduce or limit swelling, redness, or heat by decreasing
blood flow (vasoconstriction) and tissue metabolism. Cold also reduces the
risk of secondary hypoxic, enzymatic, or hydrostatic pressure damage.
If the inflammation is chronic with no visible swelling, redness, or heat,
the starting point is thermotherapy. Heat is indicated because it relieves pain
without causing vasoconstriction and promotes new tissue growth by
increasing blood flow (vasodilation) and tissue metabolism. The risk of
chronic inflammation causing significant secondary damage is very small.
Heat is normally contraindicated for acute inflammation.


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Rehabilitation

In soft-tissue therapy, rehabilitation is the process of improving the
quality of life by restoring someone to an optimal, normal, or near-normal
state of health following a soft-tissue injury or impairment. Although some
patients will never fully recover from their injuries, soft-tissue therapy often
produces positive results where other methods of treatment completely fail.
Soft-tissue therapy promotes healing in two ways: (1) it creates or
preserves conditions that allow healing to occur, and (2) it eliminates or
minimizes obstacles that retard healing. Soft-tissue therapy is effective not
because it forces the body to heal, but rather because it allows the body to
heal. While therapy can promote healing, only the body can heal itself.
Using a seven-step rehabilitation model on the next page will make it
easier to understand the relationship between soft-tissue injuries, wound
healing, and soft-tissue therapy. With the exception of cryotherapy and
mobilization that may begin sooner, soft-tissue therapy normally begins after
one or more soft-tissue impairments become symptomatic.

1. Problem: Original injury.
2. Results: tissue damage, inflammation, or pain-producing chemicals.
3. Results: pain, spasm, edema, enzymes, or metabolite retention.
4. Results: restricted circulation, ischemia, hypoxia, or fatigue.
5. Results: restricted motion, inactivity, or fibrosis.
6. Results: adhesions, contractures, trigger points, atrophy, or weakness.
7. Solution: Soft-Tissue Therapy.

Alternatives after soft-tissue therapy is administered:
Acceptable recovery: therapy stopped after the patient recovers.
Secondary injury: therapy continued and the cycle begins again.
Termination: therapy stopped before the patient recovers.

Regardless of the step, patients or practitioners have a right to terminate
therapy at any time. The two main reasons for patients stopping therapy are
lack of funding or poor results. The two main reasons for practitioners
stopping therapy are contraindications and poor results.
Therapy may be temporarily discontinued pending instructions from a
physician, waiting for test results, or waiting for a patient to return after
being referred to another practitioner.


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ADVANCED REHABILITATION MODEL

Original Injury
tissue damage
acute inflammation
pain-producing chemicals
pain or spasm
edema or enzymes
metabolite retention
restricted circulation
ischemia or hypoxia
fatigue
restricted motion
inactivity
fibrosis
adhesions or contractures
trigger points
atrophy
Soft-Tissue Therapy
Acceptable Recovery
Eliminate or decrease pain
Increase range of motion
Increase strength and endurance
Improve coordination and mobility
secondary injury
Termination


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Four important sub-cycles should be noted in the model. First, edema or
enzymes can generate its own sub-cycle and go directly to secondary injury.
Rest, ice, compression, and elevation (RICE) can be used to break the sub-
cycle by reducing edema or enzymatic activity. Second, ischemia or
hypoxia can generate a sub-cycle that leads to secondary injury. The effects
of ischemia or hypoxia can be minimized by reducing pain, spasm, edema,
and metabolite retention with standard modalities or manipulation.
The third sub-cycle is generated by tearing adhesions or contractures.
After an injury heals, improperly formed connective tissue may not be
painful until some forceful movement causes a secondary injury . The best
countermeasure for this problem is passive mobilization during wound
healing and range-of-motion stretching for maintenance. The fourth sub-
cycle results from activating trigger points that cause pain or spasm.
Except for cryotherapy, soft-tissue therapy is started at any point after
the acute stage of injury. Disability is normally reduced by starting therapy
early and continuing therapy until the patient is fully recovered. For various
reasons, many patients are not properly treated until range of motion and
mobility are severely limited by weakness, adhesions, or contractures.
The Advanced Rehabilitation Model shows one problem that is often
ignored: Therapy itself may cause secondary injuries. Even though many
patients feel immediate relief after therapy with no delayed soreness, some
patients will get significant relief after therapy but experience delayed
soreness about 24 hours after a treatment. This soreness often resembles
muscle soreness and may continue for several days. Even the mildest forms
of tissue manipulation may cause some degree of delayed soreness.
To reduce the effects of therapy-induced (iatrogenic) pain: (1) use the
least amount of force necessary, (2) increase the intensity of therapy slowly
and progressively, (3) reduce the intensity of therapy by spacing treatments
out over a longer period of time, and (4) alternate between high-intensity and
low-intensity sessions to allow more time for healing. Pain that continues
for more than an hour after therapy or delayed soreness that causes a loss of
function may indicate that therapy is too intense. Besides pain, overly
aggressive therapy may cause chronic inflammation.
Even with countermeasures, pain and soreness may still occur. In the
interest of honesty, patients should be advised that therapy may cause
immediate pain or delayed soreness. Patients should be encouraged to seek
medical help if low-intensity sessions cause (1) excessive pain during
therapy, (2) long-term persistent pain after therapy, or (3) numbness.


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CRYOTHERAPY

Cryotherapy is a broad term that refers to therapeutic use of cold, and
cooling is the process of removing (abstracting) heat from an object. Cold
can be applied by using ice packs, immersing body parts in ice water, or
using blocks of ice to stroke or press body parts.
The average temperature range for cold modalities is 32F to 65F, and
most of the cold modalities used in soft-tissue therapy involve water. In
addition to local effects such as decreases in local metabolism, blood flow,
and pain, the application of ice to large parts of the body produces global
effects such as decreases in body temperature, pulse, and respiration.
Different parts of the body behave differently when exposed to cold.
Since the face and hands have more cold receptors than the thighs and feet,
the face and hands are more sensitive to cold than thighs and feet. The depth
of a nerve can also be a factor. Superficial nerves in the elbow or lateral
knee become numb faster and rewarm faster than deep nerves in the upper
arm or thigh.
Cooling occurs at different rates. Surface tissues cool much more
rapidly than deep tissues, and total immersion in ice water cools a body part
faster than ice packs or ice massage. Once a body part has been cooled,
rewarming takes about twice as long as cooling. For example, a body part
cooled for 20 minutes takes about 40 minutes to rewarm.
If the amount of change between starting temperatures and final
temperatures is the same, cooled areas take longer to rewarm and reach the
precooled starting temperature than warmed areas take to cool and reach the
prewarmed starting temperatures. The difference between the rate of
rewarming and recooling is a matter of vasoconstriction versus vasodilation.
Blood vessel diameter is the most important single factor that regulates
blood flow. When smooth muscles contract because of cold and reduce the
diameter of blood vessels (vasoconstriction), blood flow decreases. When
smooth muscles relax because of heat and increase the diameter of blood
vessels (vasodilation), blood flow increases. Cold and heat seem to affect
the tonus of smooth muscle by combining direct action with reflex effects.
When body parts are cooled, vasoconstriction reduces blood flow and
prevents warm arterial blood from entering the cooled area. When body
parts are warmed, vasodilation increases blood flow and allows cooler blood
to enter the warmed area and lower the temperature by removing heat.


76
In addition to lowering blood flow by causing vasoconstriction, cold
reduces blood flow by increasing blood viscosity and decreasing production
of pain-producing substances that cause vasodilation. Increasing blood
viscosity reduces blood flow by increasing intravascular resistance to blood
flow. Decreasing production of pain-producing (algogenic) substances, such
as histamine, prevents vasoactive chemicals from causing vasodilation that
would otherwise increase blood flow.
During the acute stage of an injury when stabilization and rest of the
injured body part are advisable, ice packs should be applied for 20 or 30
minutes, removed for 2 hours, and reapplied for 20 or 30 minutes3 to 5
times a day. Injuries can be stabilized by using a splint, brace, or sling.
Most injuries respond favorably when ice packs are applied for 20
minutes. If injuries involve large muscles such as gluteus maximus or if
muscles are covered by thick layers of adipose tissue, ice packs should be
applied for 30 minutes. Ice applied for less than 10 minutes will not affect
intramuscular temperatures at a depth greater than about 1 inch. Ice therapy
for injuries should be started immediately and continued for about 24 to 72
hours or until the swelling stops. Swelling normally stops within 48 hours.
Frostbite is defined as local tissue damage that results from exposure to
extreme cold and skin temperatures below freezing. In mild cases, the skin
becomes red (erythema), swollen, and slightly painful. In severe cases, the
skin becomes pale, cold to the touch, and painless or numb. Because of ice
crystals, ischemia, dehydration, and necrosis, severe frostbite can damage
soft tissues down to the bone and cause gangrene. There is no danger of
frostbite when ice packs are placed directly on the skin for 30 minutes or
less. Frozen gel-packs that produce temperatures below zero may cause
frostbite if placed directly on the skin for even less than 30 minutes.

Wound Healing and Therapeutic Cold

Cold reduces hypoxia by decreasing metabolism and cellular needs for
oxygen. Tissue death from hypoxia (1) attracts phagocytes that release
potent enzymes that attack connective tissue and (2) ruptures lysosomes that
release hydrolytic enzymes that ingest cell material. While phagocytes and
lysosomes both serve a useful purpose by helping to remove dead tissue, the
same process that removes dead tissue can also cause secondary damage by
injuring healthy tissue. Cold reduces secondary tissue damage by slowing
hypoxic cell death that attracts phagocytes and ruptures lysosomes.


77
Since hemorrhage (blood) normally has less effect on swelling than
edema (watery fluid), reducing blood flow has less of an effect on swelling
than decreasing tissue permeability. Of the two basic effects produced by
using coldmetabolic and circulatory effectscirculatory effects are the
most important during the acute stage of injury when bleeding is present.
Cold induces analgesia by (1) decreasing production of pain-producing
chemicals such as bradykinin, (2) slowing nerve conduction velocities to a
point where pain receptors (nociceptors) can no longer transmit painful
stimulus, and (3) reducing protective spasm by decreasing muscle spindle
activity. When acting as a counterirritant, cold raises the pain threshold by
blocking out painful stimuli and causing the release of endorphins.
On the positive side, cold-induced analgesia facilitates exercise by
controlling pain and reducing muscle spasm. Spasticity, a state of increased
muscle tone with exaggeration of the tendon reflexes, can be temporarily
reduced by using cold to decrease the sensitivity of muscle spindles.
On the negative side, cold decreases tissue extensibility and flexibility
by increasing tissue viscosity. Even though cold can be used effectively to
facilitate exercise when pain is the limiting factor, heat can be used more
effectively when the ability to exercise is limited by a decrease in tissue
extensibility and flexibility. Even if heat is used before exercise to reduce
stiffness, cold can still be used after exercise to control pain or edema.
Cold counteracts edema by decreasing tissue metabolism, decreasing
production of inflammatory chemicals such as histamine, and slowing
vascular changes such as vasodilation that cause microscopic bleeding or
edema. Once swelling has occurred, compression and elevation reduce
swelling more effectively than cold by reducing capillary filtration pressure.
If cold is used to prepare body parts for exercise, exposure to cold
should not be longer than needed to induce analgesia. While short-duration
cold appears to facilitate muscles and produce a slight increase in strength,
long-duration cold decreases strength. Long-term exposure to cold may
cause a decrease in strength because (1) blood flow decreases, (2) viscosity
increases, and (3) proprioceptive (muscle-spindle-cell) efficiency decreases.
The acronym RICE emphasizes the four basic steps for using ice:

Rest
Ice
Compression
Elevation


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In the acronym RICE, rest implies the injured body part is stabilized, as
well as rested, and elevation implies the injured body part is elevated above
the level of the heart if possible. RICE is recommended as immediate first
aid for most acute musculoskeletal injuries.
In sports medicine, ice packs are normally applied to stabilized body
parts for about 20 or 30 minutes every 2 hours with compression and
elevation if possible. Ice treatments are continued for about two days.
While ice and compression reduce edema more effectively than cold
alone, combining ice with compression increases the risk of causing
neurapraxia. By definition, neurapraxia is the failure of a nerve to conduct
nerve impulses because of local compression or ischemia. Even moderate
pressure on a nerve may stop nerve conduction, such as a leg falling asleep.
Most cases of neurapraxia do not cause nerve damage and relieving
pressure restores function. If pressure is continued long enough to cause more
than transient ischemia, hypoxia may cause axonal death. Neurapraxia is
characterized by a decrease in proprioceptive sensation and may cause sensory
or motor loss, or paresthesia. Recovery can take a few seconds or 6 months.
One nerve often affected by neurapraxia is the common peroneal nerve
that originates from the sciatic nerve and then merges with the medial
cutaneous nerve to form the sural nerve. From the popliteal space, the
peroneal nerve travels over the lateral head of the gastrocnemius and ends in
the middle third of the leg. Ice packs applied to the lateral border of the
knee have been known to cause peroneal neurapraxia.
Symptoms may include sensory or motor changes that affect the muscles
(and overlying skin) of the lower leg and foot. Drop-foot, a paralysis or
weakness of the dorsiflexor muscles of the foot and ankle, can result from
peroneal neurapraxia.
In one extreme case, ice packs applied around the thigh for about 2 hours
were thought to cause axonotmesis, the interruption of the axons of a nerve
followed by complete degeneration of the nerve distal to the injury. Nerve
degeneration occurs without the nerve or supporting connective structures
being severed. Axonotmesis is normally caused by long-term pinching or
pressure. Regeneration of the nerve is normally spontaneous and return to
normal function can be expected.
After swelling because of edema or subcutaneous bleeding stops,
switching to heat will accelerate the rate of healing by increasing blood flow
and tissue metabolism. Subcutaneous bleeding is less likely to cause


79
swelling than edema, and it may occur with or without visible swelling.
Most edema related to injury (inflammatory edema) is caused by chemical
changes that occur during the inflammation process. The prolonged use of
cold during the subacute stage of an injury can retard wound healing by
restricting blood flow, slowing metabolism, and reducing phagocytic
activity.

Trial and Error

Physical and physiologic responses to modalities are not always fully
explained by simple explanations. Even though cold normally decreases
flexibility by increasing viscosity and decreasing tissue extensibility, cold
does not always decrease flexibility. If muscles are in spasm, and cold
relieves the spasm, the increases in flexibility caused by reduction of spasm
may be great enough to offset the decreases in flexibility caused by
increasing viscosity and decreasing tissue extensibility.
Despite the standard guideline that recommends using cold for acute
pain and heat for chronic pain, acute low back pain often responds better to
heat than to cold, and chronic low back pain often responds better to cold
than to heat. Unfortunately, since many patients dislike cold under any
circumstance, moist heat is often used in place of cold even if cold would
possibly be more effective than heat.
While most responses to therapeutic cold are fairly predictable if the
patient's condition is properly identified, some conditions are difficult to
evaluate. Provided the patient's safety is not compromised, trial and error is
sometimes the only way to find out which methods or modalities work best.
If the trial-and-error method is used, accurate record keeping is essential.
Techniques, time factors, and results should always be recorded for future
reference. Based on feedback from interviewing or physically evaluating the
patient, productive techniques are normally continued as long as the patient
continues to improve and nonproductive techniques are normally
discontinued if the patient stops improving or fails to improve.
While understanding the principles that explain why modalities are used
is always important, results are even more important than understanding. In
the absence of adequate research that fully explains how modalities work,
any technique relating to standard modalities that produces a positive effect
without causing the patient harm is probably acceptable. Regrettably, when
all else fails, trial and error is sometimes the only approach left.


80
Ice Packs

The easiest way to make an ice pack is to fill a plastic bag with 2 pounds
of crushed or shaved ice, squeeze or suck out the excess air, and tie the end
in a knot. A properly constructed plastic ice pack should not leak. Elastic
wraps can be used to hold ice packs in place and generate moderate pressure.
Ice packs can be placed directly on the skin or wrapped in a towel and then
placed on the skin. Since water is a better conductor of heat than air, moist
towels allow faster cooling than dry towels. Ice packs can also be made by
placing ice in a terry cloth towel. When properly used, ice packs are less
likely to cause frostbite than cold-gel packs or ethyl chloride spray.

Trigger Points and Ice

When ice is used to neutralize trigger points, most patients can perceive
and distinguish between four basic stages: (1) cold, (2) burning, (3) aching,
and (4) numbness. While most patients can differentiate between cold and
numbness, the difference between burning and aching is less clear. Some
patients report stages two and three as aching-burning instead of burning-
aching. A few patients report cold or painful sensations when cold is
applied, but not burning or warming sensations. Many patients report
burning sensations after ice has been removed, and some report a cutting-
burning sensation when ice is stroked across the back.
The burning sensation felt after ice has been removed is possibly the
result of vasodilation and rewarming. The burning effect felt when ice is
stroked across the back is more related to the way the body interprets painful
(nociceptive) stimulus than to cold-induced vasodilation (CIVD).
There are two basic methods for using ice to neutralize trigger points:
the ice-massage method and the ice-pressure method. The ice-massage
method is similar to stretch and spray except that vapocoolant sprays such
as ethyl chloride or Fluori-Methane are replaced by ice massage. Ethyl
chloride is flammable and Fluori-Methane contains fluorocarbons. The ice
massage strokes are applied like a spray: parallel and unidirectional.
The two steps in the ice-massage method are (1) slowly stroke the edge
of the ice across trigger points until the skin is slightly desensitized, and (2)
use range-of-motion stretching to stretch the affected body part. Although
stroking with ice is unlikely to produce numbness or analgesia, it can reduce
pain by acting as a counterirritant.


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1 Ice-Massage Method for Treating Trigger Points

Stroke several times across the trigger points with ice.
Apply passive range-of-motion stretching to affected body part.

In the ice-pressure method, ice should be applied with light pressure
long enough for superficial numbness to occur. This takes about 5 to 7
minutes. After numbness occurs, use the ice to apply moderate (ischemic)
pressure until the trigger point directly under the ice is neutralized. Once the
tissues are numb, most trigger points can be neutralized within 1 to 3
minutes. Trigger points covered by adipose tissue may take longer.
As soon as the trigger point is neutralized, slowly remove pressure on
the trigger point and apply moist heat for several minutes to stimulate
circulation and increase tissue extensibility. After the tissues are rewarmed,
apply range-of-motion stretching to the affected body part.
If the passive range of motion appears normal, have the patient complete
3 cycles of active range-of-motion stretching. The patient should inhale
slowly and deeply, pause for several seconds, and then exhale slowly and
deeply while at the same time stretching the affected muscles. Some
patients will find it easier to use deep breathing if they inhale while looking
up and exhale while looking down. Even when trigger points are not
involved, ice massage appears to facilitate range-of-motion stretching by
stimulating mechanoreceptors or reducing pain inhibition.

2 Ice-Pressure Method for Treating Trigger Points

Apply light pressure with ice until local numbness occurs.
Apply moderate pressure with ice until trigger points are neutralized.
Remove pressure on trigger points slowly.
Apply moist heat for several minutes to rewarm tissues.
Have patient complete 3 repetitions of active range-of-motion stretching.

Applied for less than five minutes, ice massage increases muscle tone by
reflex action and cools the skin. Since ice normally produces a burning
sensation or pain before numbing takes effect, ice can be classified as a
counterirritant and may cause the release of endorphins. Based on the gate
control theory of pain and inhibition, counterirritants reduce pain by


82
stimulating large-fiber proprioceptors that inhibit small-fiber nociceptors.
Applied for twenty minutes or more, the effects of ice massage are
vasoconstriction, analgesia, and loss of tonus.
To make ice for ice massage, fill a small paper cup with water and then
freeze the water. To use the ice, simply peel back the top of the cup until
part of the ice is exposed and use the bottom part of the cup as a holder. To
create a handle for the ice similar to the handle on a popsicle, place a tongue
depressor vertically in the cup before freezing. To use the ice, simply
remove the entire paper cup and hold the ice by the handle. Ice cubes
rounded by partial melting and handled with a rubber glove or partially
wrapped in a towel can also be used for treating trigger points with ice.

Contraindications for Cold

Contraindications for cold include:

compromised local circulation
heart disease
hypertension
cold hypersensitivity
acrocyanosis
Raynauds disease
cryoglobulinemia
areas affected by frostbite in the past
open lesions or rashes

Compromised local circulation can affect the body's ability to regulate
blood flow and consequently temperature. If circulation is compromised,
cooling may occur at a faster rate than normal, penetration may be deeper
than normal, and the risk of frostbite will be greater than normal. Peripheral
artery insufficiency is often found in elderly or diabetic patients. Heart
disease and hypertension are listed as contraindications because cold causes
a transient increase in systolic and diastolic blood pressure.
When people with cold hypersensitivities are exposed to cold, hives
(cold urticaria) and edema are caused by the abnormal release of histamine.
As a simple test, apply cold to a small area of skin and look for signs or
symptoms of cold hypersensitivity before starting a regular treatment. While
the area used for testing should not be part of the region being treated, if a


83
single hand or foot is being treated, the opposite (contralateral) hand or foot
should be used for testing.
Acrocyanosis is a circulatory disorder in which the hands, and possibly
the feet, are persistently cold and blue. Possibly related to Raynaud's
disease, the arterial spasm that characterizes acrocyanosis is precipitated by
cold or emotional stress.
Raynaud's disease is a vasospastic disorder that can be idiopathic (not
related to any known disease) or associated with pathologic conditions such
as systemic lupus erythematosus or systemic scleroderma. Systemic lupus
erythematosus is an inflammatory connective tissue disease that often
produces diffuse erythematosus (red) skin lesions on the face, neck, or
extremities. Systemic scleroderma is a disease characterized by thick skin
that results from the swelling and thickening of fibrous tissue. Raynaud's
disease causes excessive vasoconstriction when extremities are exposed to
cold and the digits (fingers or toes) often become cyanotic.
Cryoglobulinemia is characterized by the presence of abnormal plasma
protein (cryoglobulin) in the blood plasma. When exposed to low
temperatures, the plasma protein changes to a gel that can lead to ischemia
and possibly tissue death (necrosis) or gangrene. Cryoglobulinemia is often
found in association with pathologic conditions such as leukemia and certain
forms of pneumonia and may be associated with Raynaud's disease.
Even if a medical history and physical evaluation fail to identify any
contraindications, the patient's skin should be constantly monitored for
changes in color. If the skin turns blue or purple (cyanotic), cryotherapy
should be discontinued immediately and medical help should be requested.
A final consideration is whether patients like the use of cold. If both
heat and cold modalities are acceptable, let the patient make the final
decision. If cold is used, explain that even though some patients experience
minor discomfort, the benefits far outweigh the pain. To make cryotherapy
more acceptable, keep body parts that are not being treated warm and dry.

Indications for Cold

Indications for Cold
1 Muscle spasm
2 Pain
3 Edema
4 Trauma


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THERMOTHERAPY

Common methods for applying therapeutic heat include silicon gel
packs, whirlpools, hot baths, paraffin baths, and infrared light. Since moist
air conducts heat more rapidly than dry air, moist heat is generally more
penetrating than dry heat. Certain electric heating pads produce moist heat
by trapping vapor that escapes from the body during the heating process. As
a rule, the greater the temperature differences between the heating agent and
the tissues being exposed, the greater the magnitude of physical and
physiologic changes.
After swelling and subcutaneous bleeding have stopped, normally about
48 hours after the acute stages of an injury, heat relieves pain by reducing
protective spasm, dispersing pain-producing chemicals, and producing a
relaxing effect for most patients. The application of heat promotes healing
by stimulating circulation that is needed to supply nutrients or oxygen and to
remove debris or chemical toxins. By reducing the viscosity of viscoelastic
collagen, heat increases tissue extensibility and makes connective tissue less
resistant to active or passive stretch. Both heat and cold can act as
counterirritants to reduce perception of pain.
By reducing tissue viscosity, heat discourages collagen fibers from
adhering to each other during the healing process. The intersection points
between normal collagen fibers crisscrossing over the top or bottom of each
other are not attached because distance and lubrication separate the fibers
during movement. When collagen fibers adhere to each other at intersection
points, or if they connect tissues that should not be connected, flexibility is
reduced and moderate stress may cause tearing. Though heat and cold both
relieve pain and spasm, most patients seem to prefer heat over cold. Unlike
cold, heat also reduces joint stiffness and stimulates circulation.
While the broad statement that heat increases blood flow is generally
true, the increase in blood flow that occurs in the skin is far greater than the
increase in blood flow that occurs in muscles. Exercise normally produces a
greater increase in skeletal muscle blood flow than heat, and exercise and
heat together produce a greater increase in skeletal muscle blood flows than
exercise or heat alone. During vigorous exercise, a person's skin may feel
cool to the touch because blood is being diverted to skeletal muscles.
Even though most studies agree that heat reduces spasm, the
mechanisms involved are not fully understood. One theory contends that
superficial heat increases the firing rate of Golgi tendon organs (inhibitors)


85
and decreases the firing rate of muscle spindles (facilitators). When reflex
inhibition exceeds reflex facilitation, muscles relax.
The belief that heat relieves spasm by reducing pain appears to have
some merit, since heat reduces pain by elevating the pain threshold, and pain
is known to cause conditions such as muscle guarding or splinting that
involve spasm. Even so, many patients experience pain without spasm or
spasm without pain. Of the two possibilities, finding pain without spasm is
more common than finding spasm without pain.
Pain is an unpleasant sensation often associated with tissue damage and
pain-producing chemicals. Even though, during the acute stage of an injury,
heat has a tendency to increase production of pain-producing chemicals by
increasing metabolism, during the sub-acute stage of an injury, heat reduces
the concentration of pain-producing chemicals by dilating capillaries and
causing active hyperemia. When new blood enters a lesion, pain-producing
chemicals are dissipated in almost the same way that pain-producing
chemicals are dissipated by digital pressure and reactive hyperemia.
If tissue damage is causing pain, using heat during the subacute stage of
an injury may help to eliminate the cause of pain by accelerating the wound-
healing process. Heat accelerates the wound healing by increasing local
blood flow and making nutrients and oxygen more available to tissues at the
site of injury. Until tissue damage is at least partially healed, the pain relief
from trigger point therapy or neuromuscular therapy is more likely to be
temporary and palliative than permanent or curative. Applying heat to acute
injuries may increase or perpetuate pain by causing secondary damage.
Even if the frequency and duration of heat treatments is the same, the
biophysical changes that occur may be different because:

target tissues are different (depth or thermal conductivity)
heating agents are not at the same temperature (intensity)
amounts of tissue being exposed to the heat are different
rates of tissue temperature increase are not the same
distances between the source and target are different (radiant energy)
angles between source and target are different (radiant energy)

When superficial heat is used, superficial tissues normally reach peak
temperatures before deep tissues. While skin and subcutaneous tissues may
reach peak temperatures within 10 minutes, muscles may require 30 minutes
or more to reach peak temperatures.


86
While maximum penetration for superficial heat into a muscle is about
1.2 inches (3 cm), penetration may be less if layers of fat are situated above
the muscle. Thermal conductivity is the rate at which heat passes through a
material. Because of a low thermal conductivity value, fat insulates against
heat and may prevent maximum penetration.
When treating body parts, the temperature range of therapeutic heat is
104F to 113F. Blood flow, as indicated by hyperemia, is not significantly
increased until tissue temperatures reach 104F to 113F, and connective
tissue extensibility is not substantially increased until tissue temperatures
reach 105F to 110F. The upper limit for therapeutic heat is about 113F,
since the risk of tissue damage and pain increases rapidly beyond this point.
The total amount of tissue exposed to a heating agent affects physical
and physiological changes in two ways. First, increasing the amount of
surface area in contact with a heating agent increases the amount of heat
transferred to the body. Second, mechanisms for cooling the body, such as
blood flow and evaporation, become less efficient as larger parts of the body
are exposed to heat. Because of a general decrease in cooling efficiency,
immersing a large part of the body in water at 110F can be more dangerous
than immersing a small part of the body in water at 115F.
Although pain and tissue damage normally start at tissue temperatures
above 113F, most patients can tolerate immersing their feet in a hot foot
bath that reaches temperatures as high as 115F. Despite the high local
temperatures produced by the heating agent, tissue temperatures (TT) in the
feet seldom exceed 113F because of the body's ability to dissipate heat and
the relatively small amount of tissue in contact with the heating agent.
As the percentage of body surface exposed to a heating agent increases,
the temperature of the heating agent tolerated by the body decreases.
General applications are applications of a modality that affect all or most of
the body and local applications are applications that affect a smaller part of
the body. Since a large part of the body's cooling mechanism involves
dissipation of heat via blood flow through the skin and evaporation, general
applications of heat expose more of the body to heat than local applications
and reduce the efficiency of basic cooling mechanisms.
Regardless of the heating agent used, reflex activity causes an increase
in skin blood flow that transports warm blood away from the body parts
being heated. Part of the heat is later dissipated through the skin or lungs.
The other mechanism that dissipates heat is evaporation. As water changes
from a liquid to gas, thermal energy is absorbed during the conversion.


87
When the heating agent is water, as opposed to radiant heat, evaporation will
be difficult for body parts above the water because humid conditions created
by hot water retard evaporation. For body parts below the water line,
evaporation will not be possible.
For complete immersion of the lower body in a hot bath, temperatures
beyond 110F are considered unsafe. For full body immersion in a hot bath,
water temperatures should not exceed 100F. While exposing large portions
of the body to temperatures between 100F and 110F should not cause
superficial tissue damagethe upper limit for tissue damage is 113F
there is a risk of interfering with vital functions such as blood pressure,
circulation, or respiration.
Even if the final temperatures are the same, the body can tolerate a slow
increase in tissue temperature better than a rapid increase in temperature. If
tissue temperatures (TT) rise slowly, the circulatory system can often keep
pace with the rise in tissue temperature by replacing warm blood with cool
blood. As warm blood is circulated through the body, thermal energy is lost
and the blood cools. If the tissue temperature rise (TTR) is rapid, the body
may not have time to dissipate excess thermal energy and the buildup of heat
may cause adverse local or systemic reactions.
If more than one body part requires treatment, each body part should be
heated separately. Since tissue temperatures drop rapidly once a body part is
no longer in contact with a heating agent, treatments such as stretching that
require a temperature range of 104F to 113F should begin shortly after the
body part is no longer being heated. If more than one body part is heated at
the same time, the tissue temperatures in the last body part treated may drop
below optimal levels before the body part is stretched.
One way to avoid heat loss while stretching a body part is to keep the
heating agent in continuous contact with the body part. This can be
accomplished by stretching a body part while the body part is still immersed
in hot water or stretching a body part that is wrapped in a hot pack, electric
heating pad, or electric heating blanket. Infrared radiation can also be
applied while a body part is being stretched.
Even though many patients find that soaking in a hot bath (100F to
104F) produces feelings of relaxation, sedation, and well-being, these
effects are probably more psychological than physical or physiological. One
effect from soaking in a hot bath that is not psychological is a change in
reflex activity that decreases muscle tonus by increasing proprioceptive
inhibition and decreasing proprioceptive facilitation. This combined with a


88
brief period of lower than normal blood pressure may help to explain why
many patients report feelings of weakness when rising from a hot bath.
After the body cools, feelings of weakness are normally reversed and
strength returns to the same level it was before the bath. In some cases,
muscular strength may be greater than before the bath if soaking in hot water
relieves pain that was causing pain inhibition and weakness. Other factors
related to hot water that may contribute to an increase in strength include:
(1) increase in blood flow, (2) decrease in spasm, (3) decrease in tissue
viscosity, and (4) increase in tissue extensibility.
Soaking in hot water on a continuous basis can produce both positive
and negative effects. On the positive side, by causing decrease in pain and
spasm, and a slight decrease in tissue viscosity, heat decreases resistance to
active and passive stretch. Tissues that are heated before stretching show a
greater permanent increase in length with less cellular damage than tissues
that are not heated before stretching. This makes it easier for a body part to
execute full-range-of-motion movements with less force.
On the negative side, most patients do not stretch after soaking in hot
water and tissues cooled at or below resting length have a tendency to
remain short and become more resistant to active or passive stretch. This
tendency relates to a property found in thermoplastics called set. If soaking
in hot water is used as a long-term method of pain relief, range-of-motion
stretching should be used to lengthen tissues while the body cools to reduce
the risk of increasing stiffness or pain because of thermoplastic set.
To achieve the greatest amount of permanent increase in tissue length
possible with the least amount or force or tissue damage:

Heat tissues to a therapeutic temperature of at least 104F.
Slowly stretch tissues with just enough force to overcome elasticity.
Hold tissues in a fully stretched position until cooling is complete.

Some patients report good results soaking in a hot bath before and after
range-of-motion stretching. Soaking before stretching makes collagenous
tissues easier to stretch and reduces general stiffness. Soaking after
stretching helps the body stay flexible and reduces general soreness.
For patients recovering from soft-tissue injuries involving stiffness more
than pain, a good routine is (1) soak in a hot bath for 20 minutes, (2) use
active or passive stretching to increase the injured body part's range of
motion, (3) ice the injured body part to accelerate cooling, (4) soak in a hot


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bath within 24 hours after stretching, and (5) hold the injured body part in a
fully stretched position until the body feels cool. While the first three steps
are designed to increase range of motion and reduce stiffness, the last two
steps are designed to preserve range of motion and reduce soreness.
After an adequatebut not excessiveROM has been achieved, the
problem becomes preserving, not increasing, flexibility. Stretching a body
part beyond the range needed to ensure normal flexibility may cause
instability. There is no simple protocol for treating joints that become
unstable (hypermobile) because of excessive stretching. Rest, stabilization,
strengthening exercises, medication, and surgery are the main methods used
for treating hypermobile joints. Heat may increase hypermobility.
Ironically, if left untreated, hypermobility can lead to a sequence of
tissue damage, inflammation, infection, avoidance of movement, fibrosis,
and ossification that causes a progressive decrease in mobility. Ankylosis is
the stiffening or fixation of a joint caused by deposits of fibrous or bony
material across the joint. Factors that may contribute to ankylosis include
trauma, inflammation, infection, and lack of movement.

Wound Healing and Therapeutic Heat

While heat has a tendency to accelerate healing during the subacute
stage of an injury, cold has a tendency to retard healing during the subacute
stage. The two main differences between therapeutic heat and cold are

vasodilation: an increase in the caliber of a blood vessel.
vasoconstriction: a decrease in the caliber of a blood vessel.

While heat produces vasodilation that increases blood flow, cold
produces vasoconstriction that decreases blood flow. Heating modalities
promote healing by increasing blood flow and making it easier for nutrients,
the cellular components of healing such as fibroblasts, and oxygen to reach
the injury site. Oxygen, in particular, plays a major role in wound healing.
Increasing blood flow to a wound prevents ischemic or hypoxic damage
and reduces the risk of infection by making oxygen available to bacteria-
killing phagocytes. By definition, phagocytes are special cells that ingest or
digest invading microorganisms, foreign particles, or other cells, and
bacteriostatic phagocytes are phagocytes that retard the growth of bacteria.


90
When the partial pressure (tension) of oxygen (PO
2
) n tissues drops
below normal, bacteriostatic phagocytes become less effective and the risk
of infection increases. Even though phagocytosis often occurs normally in
the presence of severe hypoxia, phagocytes such as neutrophils (mature
leukocytes) kill engulfed bacteria that are not digested by using a process
called oxidative killing. This process involves the production and release of
powerful oxidizing agents that kill bacteria. In the cycle that produces
bactericidal oxygen, strong acids (superoxides) are reduced to hydrogen
peroxide and hydrogen peroxide is reduced to oxygen. Hypoxic conditions
severely limit a neutrophil's ability to use oxidative killing. Like ischemic
damage and nutritional deficiencies, infection retards wound healing.
Increasing the PO
2
during the wound-healing process will also decrease
the risk of abnormal cross-linking between collagen fibers. Excessive cross-
linking reduces connective tissue extensibility and may cause adhesions,
contractures, abnormal shortness, or limited range of motion after the
wound-healing process is complete.

Infrared Radiation

There are two types of infrared radiation: near infrared and far infrared.
After traveling from a warmer source, most infrared radiation is then
absorbed by a cooler target. Used as a measure of wavelength, a nanometer
(nm) is one-billionth of a meter. Near-infrared radiation emits light within
the 800 nm to 1500 nm range of the electromagnetic spectrum, and far-
infrared emits light within the 1500 nm to 15000 nm range. Near-infrared
lamps emit visible light and are called luminous lamps. Far-infrared lamps
emit practically no visible light and are called nonluminous lamps. While
both types of lamp produce superficial dry heat, near infrared penetrates
about 0.4 inches (1 cm) and far infrared penetrates about 0.08 inch (0.2 cm).
Infrared treatments normally last about 20 to 30 minutes. Treatments
less than 20 minutes may not be sufficient to increase tissue extensibility or
dilate cutaneous arteries enough to improve circulation. While increasing
capillary circulation will have a tendency to accelerate wound healing, the
drying effect produced by infrared radiation will have a tendency to retard
wound healing by causing tissues to lose water (dehydration or dessication).
Dehydration or dessication may cause tissue death and possibly an eschar.
By definition, an eschar is a mass of thick, crusty tissue that results from a
thermal or chemical burn.


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Heliotherapy

Heliotherapy is defined as exposure to sunlight for therapeutic purposes.
Sun bathing has been used to promote wound healing since the time of
Hippocrates (460 to 400 BC). In addition to heat, sunlight produces
significant amounts of ultraviolet radiation. Beyond the basic physiologic
effects of ultraviolet lighterythema, pigmentation (tanning), hyperplasia
that thickens the stratum corneum (outer layer of epidermis), and production
of vitamin Dultraviolet light with a wavelength of 253 to 260 nm kills
bacteria by interrupting DNA, and possibly RNA, synthesis. Bactericidal
ultraviolet light reduces infection without causing tanning or skin damage.
Whether the erythema caused by ultraviolet radiation promotes wound
healing remains to be proven. Erythema is the inflammatory redness of the
skin that results from dilation or congestion of superficial capillaries. While
erythema may relieve pain by acting as a counterirritant and promote healing
by increasing blood flow and phagocytosis, it also can retard healing by
causing excessive phagocytosis or swelling.
Excessive phagocytosis may cause production of lysosomal enzymes
that damage healthy tissue, while excessive swelling because of edema may
cause a decrease in blood flow that precipitates ischemic or hypoxic damage.
If pain is excessive during the subacute stage of an injury, pain inhibition or
spasm (guarding or splinting) may cause a decrease in activity that retards
the healing process and prevents tissue from healing normally.

Moist Heat

Unlike infrared radiation or ultraviolet radiation, moist conductive heat
promotes wound healing without the adverse effects caused by infrared
radiation or ultraviolet radiation. Moist heat increases circulation without
causing dehydration (infrared radiation) or erythema (ultraviolet radiation).
It also penetrates more deeply than dry conductive heat, and most patients
respond more favorably to moist heat than dry heat. Often produced by hot
packs, moist heat penetrates about 1.2 inches (3 cm).
One benefit of moist heat is relaxation. The basic causes are probably
reflex inhibition and a decrease in muscle tonus more than a drop in blood
pressure. Even though heat initially increases blood pressure by increasing
heart rate and then decreases blood pressure by causing vasodilation, after
fluctuating and making adjustments, blood pressure often returns to normal.


92
Common Heating Modalities

Hot Packs

Most hot packs consist of a canvas or nylon case filled with a
hydrophilic substance, such as silicon gel, that attracts water. Since
hydrophilic substances have a lower thermal conductivity value than water,
they conduct heat more slowly and retain heat longer than water. Hot packs
come in a variety of sizes and shapes and are normally heated to about
165F in hot water or a microwave oven before use. Hot packs are normally
wrapped in six or more dry terry cloth towels to insulate the patient from
excessive heat. If more heat is needed, one or more towels can be removed.
Hot packs can be secured in place by using the weight of the hot pack or by
wrapping towels around the hot pack and the body part being treated.
Rapid changes from normal skin color to blotchy areas of pink and red,
pink and white, or light and dark colors may indicate the temperature is too
high. Feedback from the patient is possibly the best indication that
temperatures are too high or too low. Hot packs should be easy for the
patient to remove if they become too hot, and patients should not be allowed
to place enough body weight on hot packs to force water out.
Hot packs retain heat for about 20 minutes and should be monitored for
at least the first 10 minutes. Because they are relatively inexpensive to
purchase and can be reused, hot packs are considered economical. Hot
packs leaking hydrophilic material should be thrown away. Most patients
find heat more relaxing than cold and seem to prefer moist heat over dry
heat. Patients should not be allowed to sleep while a hot pack is being used.

Paraffin Bath

A paraffin bath is prepared by heating a mixture of wax and mineral oil
to a temperature of about 130F. A commercial paraffin mixture is about 6
parts wax to 1 part mineral oil. Specific heat is the amount of heat required
to raise the temperature of 1 gram of any substance 1C. Heat is measured
in calories, and water with a specific heat of 1.0 is the standard. Because of
its lower specific heat than water (0.69), paraffin requires less heat to raise
the temperature 1C and releases less heat as the temperature drops 1C. At
the same temperature, paraffin does not feel as hot as water and is less likely
to cause a burn. The specific heat for wax with mineral oil is about 0.45.


93
There are three basic ways to use a paraffin bath. The first method is
using 5 or 10 cycles of (1) dip the body part in melted paraffin, (2) remove
the body part from the melted paraffin, and (3) allow enough time for the
paraffin to stop dripping and solidify. After the paraffin solidifies, the body
part treated should be held fairly steady to avoid cracking the wax. Each
time the body part is immersed in wax, the thickness of wax will increase.
After the last immersion, the body part should be placed in a plastic bag and
covered with a terry cloth towel. Heat retention is about 20 minutes.
The second method is similar to the first except that after the last layer of
wax solidifies, the body part is placed back in the paraffin bath for about 10
to 20 minutes. This method produces the highest increases in tissue
temperatures and is not recommend for patients who are prone to edema. As
a third method, paraffin wax can be painted on body parts with a brush.
By acting as a lubricant, a paraffin bath improves the pliability of skin.
In one study involving patients with rheumatoid arthritis, hot paraffin was
shown to relieve hand pain just as effectively as ultrasound used with or
without electrical stimulation.
Jewelry should be removed before body parts are immersed in hot wax.
In addition to general contraindications for heat, contraindications that apply
specifically to immersion in hot paraffin include open lesions, skin
infections, and contagious diseases.

Contraindications for Heat

The contraindications for heat include bleeding, blood clots, edema,
malignancy, infection, acute inflammation, peripheral vascular disease, poor
circulation, burns, fever, tuberculosis, general weakness because of age or
infirmity, and debilitating conditions such as heart disease. Heat is
contraindicated for patients who are unable to perceive pain (dysesthesia or
anesthesia) or communicate perception of pain.

Indications for Heat

Indications for Heat
1 Muscle spasm
2 Pain
3 Contracture
4 Vascular stasis


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Physical Properties

THERMAL CONDUCTIVITY (k)

air (27C) ................................................................................ 0.026
bone ......................................................................................... 2.78
copper ..................................................................................... 401.0
glass ........................................................................................ 2.60
ice ............................................................................................ 0.592
muscle ..................................................................................... 1.53
rubber ...................................................................................... 0.372
silver (poor insulation) ........................................................... 429.0
skin .......................................................................................... 0.898
subcutaneous fat...................................................................... 0.45
vacuum (maximum insulation) ............................................... 0
water (20C)............................................................................ 1.4

Specific Heat

SPECIFIC HEAT

air ............................................................................................ 0.23
alcohol (ethyl) ......................................................................... 0.58
bone ......................................................................................... 0.38
ice ............................................................................................ 0.50
mercury ................................................................................... 0.033
muscle ..................................................................................... 0.895
paraffin (may be lower if mixed with mineral oil) .................. 0.69
rubber ...................................................................................... 0.45
skin .......................................................................................... 0.9
steam ....................................................................................... 0.48
subcutaneous fat...................................................................... 0.55
water (standard for comparison) ............................................ 1.0


95
COLD OR HEAT

Cold decreases bleeding by causing vasoconstriction. If pain, edema, and
subcutaneous bleeding are present, cold is safer to use than heat. Heat
causes vasodilation and stimulates circulation. While cold is normally
recommended for acute inflammatory conditions, chronic inflammatory
conditions, such as chronic low back pain, often react favorably to heat.
Where time is a factor and subcutaneous bleeding is not present, heat
reduces muscle spasm faster than cold. Heat works by reflex effect on the
gamma system and requires only enough time for shallow penetration. Deep
cold works by slowing nerve conduction velocities and requires enough time
for deep penetration. When nerve temperaturesnot surface
temperaturesdrop below 50F, nerve conduction velocities normally stop.
Unlike deep cooling that requires about 20 minutes and slows nerve
conduction velocities, superficial cooling requires 10 minutes or less and
produces reflex effects. When briefly applied for about 30 seconds, ice can
trigger a stretch reflex that aggravates spasm and makes treatment difficult.
When applied for about 10 minutes, ice can generate a reflex effect that
decreases tonus in underlying muscles even though cooling is superficial.
Creating the best environment for wound healing requires a delicate
balance between (1) early treatment and (2) protecting injured body parts.
During the acute stage of an injury, body parts need rest and cryotherapy can
be used to reduce inflammation by reducing tissue metabolism. Once
swelling, inflammation, and subcutaneous bleeding are no longer present,
cryotherapy and gentle stretching (passive mobilization) can be used to
promote wound healing.
For the best results, cold should be applied as quickly as possible to
acute injuries. Even though cold can prevent swelling or reduce the rate of
swelling by decreasing metabolism and lowering vascular permeability, once
swelling has occurred, cold will not reduce swelling. Since swelling has
normally stopped by the time an injury reaches the subacute stage, cold
applied to subacute injuries will have little or no effect on swelling.
The two basic ways to reduce swelling are (1) elevation, and (2)
compression. If swollen body parts are elevated above the heart, gravity
causes a decrease in capillary hydrostatic pressure that reduces swelling.
Compression reduces swelling by encouraging the reabsorption of fluid.
When cold and compression are used together, the cold prevents swelling
and the compression reduces any existent swelling.


96
Since mobilization that begins too early can retard wound healing by
increasing inflammation or disrupting newly-formed connective tissue,
injured body parts should be rested during the initial stage of an injury.
Once inflammation is no longer present and tissue integrity is partially
restored, injured body parts should be passively mobilized to improve tissue
alignment, strength, and flexibility. Passive mobilization will also improve
arterial, venous, and lymphatic circulation.
Passive mobilization that begins too late can increase the occurrence of
adhesions or contractures that decrease range of motion. Because of pain,
many patients resist having injured body parts mobilized, even when
movement would be beneficial. Even if signs of inflammation are not
present, significant pain that continues after a body part has been mobilized
may indicate the injury is ready for movement.
As a general rule, heat is used only during the subacute stage of an injury
and cold is used during the acute or subacute stage. By increasing
microvascular hydrostatic pressure, heat exacerbates hemorrhage and edema
during the acute stage of an injury. Cold, on the other hand, encourages
reduction of hemorrhage and edema.
Cold is preferred over heat when treating myositis or tendonitis because
it reduces three types of secondary damage: (1) lysosomal enzyme damage,
(2) ischemic or hypoxic damage, and (3) hydrostatic pressure damage.
Lysosomal enzyme damage occurs when hydrolytic enzymes are released
during phagocytosis. Ischemic or hypoxic damage is caused by a decrease
in blood flow, and hydrostatic pressure damage is caused by swelling.
Thermotherapy should not be attempted until the vascular system is
repaired and swelling and subcutaneous bleeding are no longer present. If
swelling is present, the application of heat may increase swelling, restrict
blood flow, and cause ischemic, hypoxic, or hydrostatic pressure damage. If
subcutaneous bleeding is present, heat may increase hemorrhage.
Since cold causes vasoconstriction that decreases circulation and blood
flow to injured tissues, continuing cryotherapy beyond the acute stage of
injury may retard wound healing. Heat, on the other hand, accelerates
wound healing by causing vasodilation that increases circulation and blood
flow to injured tissues. Heat also promotes lymphatic circulation that is
needed to remove tissue debris from injuries. While heat seems to relieve
the dull aching pain that accompanies subacute sprains and chronic low back
pain more effectively than cold, long-term exposure to cold can produce
anesthesia.


97
Exceptions

There is one exception to the general principle of not using heat during
acute inflammation. Superficial heat can be applied to soft-tissue infections
such as boils to accelerate inflammation and help the body create an abscess
that can be drained. Since infections normally contraindicate soft-tissue
therapy, the general principle of not using heat during active inflammation
would still apply within the scope of soft-tissue therapy.
While deep heat (ultrasound or diathermy) is not recommended for
rheumatoid arthritis during any stage of inflammation because it increases
the enzymatic destruction of cartilage, superficial heat does not produce the
same adverse effects. Hot packs may even cause a decrease in joint
temperature as blood is shunted away from joints into muscles.

Cryostretch or Thermostretch

Even when wound healing is subacute, the guidelines for when to use
heat or cold during the wound-healing process are not always clear.
Although heat and cold can each be used to facilitate range-of-motion
stretching, the reasons for using heat or cold are quite different.
If pain is the main limiting factor, cryotherapy can be used to relieve
pain and prepare tissues for stretching. If tissue extensibility is the main
limiting factor, thermotherapy can be used to increase tissue extensibility
and prepare tissues for stretching. If pain and tissue extensibility are both
limiting factors, cryostretch (alternating cold applications with stretching) is
normally used before thermostretch (alternating heat applications with
stretching). Ice massage can be used to numb tissues before stretching.
If spasm is present, either cryotherapy or thermotherapy can be used to
reduce spasm and prepare muscles for stretching. Since the risk of
subcutaneous bleeding is always present during spasm, cold is preferred over
heat when treating spasm. Cold packs can be used to reduce spasm.
In the absence of subcutaneous bleeding, edema, spasm, or joint
dysfunction, the main factors that restrict the passive ROM are connective
tissue adhesions or contractures. Where cold increases connective tissue
viscosity (stiffness) and resistance to passive stretch, heat decreases tissue
viscosity and makes it easier to lengthen connective tissue without causing
tears or ruptures. While cold increases the risk of tears or ruptures more
than heat, it may also make it easier to break subcutaneous adhesions.


98
Thermotherapy is often preferred when dealing with chronic injuries
where connective tissue restrictions are the main cause of limited ROM.
While not as effective as cold, heat can be used to reduce pain and spasm.
Heat tends to relax patients more than cold, and most patients seem to prefer
heat over cold. Heat should not be applied to any tissues that are stretched.
When used to prepare patients for active-assisted range-of-motion
stretching during the subacute stages of an injury, cold is normally preferred
over heat. Cold reduces pain more effectively than heat and discourages
edema. Treating injured body parts with ice packs after range-of-motion
stretching helps to control pain or edema caused by movement.
Ice packs applied for 20 to 30 minutes relieve pain by analgesia, not
anesthesia. Unlike anesthesia that produces a partial or complete loss of
sensation, analgesia produces a decrease or absence of sensibility to pain
because nociceptive stimuli are perceived, but are not interpreted as pain.
While cold-induced analgesia can be used safely to facilitate movement,
ice-induced anesthesia is not recommended because it prevents the body
from sensing potentially dangerous movements. When cold-induced
anesthesia (cryoanesthesia) is used to prepare patients for surgery, body
parts become insensitive to pain as temperatures approach freezing.

Contrast Bath or Cryokinetics

Contrast applications produce large changes in body temperature that
range from hot at one extreme to cold on the other. The cycle for treatment is
normally 4 minutes of heat (104F) followed by 1 minute of cold (55F). This
cycle is repeated four times, always starting with heat and ending with cold.
At the same time that contrast applications improve circulation, reduce edema,
increase local metabolism, and hasten healing, they also act as a tonic and a
neuromuscular stimulant. This creates a problem in terms of soft-tissue
manipulation, since modalities that relax muscles are more conducive to soft-
tissue manipulation than modalities that stimulate muscles.
A second problem with contrast applications relates to exposure. Four
minutes of heat is not long enough to increase tissue extensibility, and 1
minute of cold will not produce analgesic effects. Though frequently
acclaimed as one of the most potent procedures in hydrotherapy, the ability of
contrast applications to prepare the body for manipulation is limited. At best,
contrast applications, such as a contrast bath, reduce muscle spasm and relieve
pain by improving circulation and reducing edema.


99
Cryotherapy followed by exercise (cryokinetics) is possibly a better way to
stimulate circulation than a contrast bath. A normal sequence for cryokinetics
is (1) chill the affected body part for 20 minutes, and (2) exercise slowly and
smoothly with moderation until the body part is rewarmed. This should take
less than 40 minutes, since rewarming without exercise normally takes about
twice as long as cooling. The exercises should not be painful.
Even though cold does not seem to affect proprioception or agility, cold
increases viscosity and decreases tissue extensibility. A short stretching
warm-up will decrease joint stiffness and increase tissue extensibility. The
stretching should be done long enough to give tissues time to lengthen. If
chilling decreases strength because of decreases in neurologic efficiency, a
stretching warm-up will increase strength by increasing neurologic efficiency.
Cryostretching can be used to prepare body parts for cryokinetics.
While using a contrast bath may produce a vascular pumping action, as
sometimes suggested, the pumping action produced by exercise is more
efficient because of more pumping cycles per hour. The pumping cycle for a
contrast bath begins with 4 minutes of heating and ends with 1 minute of
cooling. This produces 12 pumping cycles per hour. The pumping cycle for a
muscle begins with contraction and ends with relaxation. One muscle alone
could produce hundreds of pumping cycles per hour. Several muscles working
together could produce thousands of cycles per hour.
Lymph is a clear, colorless or slightly yellow fluid that flows through
lymphatic vessels called lymph nodes. Since lymphatic circulation is more
responsive to muscular activity than to hot or cold, exercise following 20
minutes of ice is more likely to stimulate lymphatic flow than a contrast bath.
Lymph flow can be stimulated after exercise by using manual pressure to
produce stroking or pumping movements in the direction of lymph flow.

Hot-to-Cold Stretch

Rather than being stretched after heating pads or silicon gel packs are
removed, tissues can be stretched while heating devices are held in place by
loosely wrapped elastic bands. This method prevents tissues from cooling
during the stretching process. Body parts such as joint capsules can also be
stretched while still immersed in hot water.
Once stretching is complete, apply ice and hold the stretch at maximum
length until the affected tissues cool. Using heat to decrease viscosity during
stretching and ice to increase viscosity after stretching will encourage tissues


100
to remain at maximum length. In thermoplastics, the tendency for the length
during cooling to become the permanent length is called set.
Thermoplastics and viscoelastic materials like muscles often behave in
similar ways. The normal protocol for a hot-to-cold stretch is

Apply moist heat for about 15 to 20 minutes.
Stretch tissues while heating devices are still in place.
Hold stretch and apply cold for about 15 to 20 minutes.
Release tension after tissues are cold.
Allow patient to rest for about 5 minutes without moving.

Heat- and Cold-Induced Pain

Despite the therapeutic effects, the application of heat or cold will
sometimes cause pain. Overheating can upset the body's electrolyte balance
and cause cramps or fatigue. Temperatures above 113F will cause tissue
damage and pain. If a patients skin is extremely sensitive to painful stimuli
(hyperalgesic), the threshold for pain may be lower than 113F.
Cold produces pain in two ways: (1) vasoconstriction causes a decrease
in blood flow and ischemic pain, and (2) increases in tissue tension and
viscosity cause an increase in stiffness and joint pain. For pain to occur, the
temperatures must be cold enough to induce pain, but not cold enough to
cause analgesia. Some patients report that pain and spasm increase when
cold is applied to hypertonic neck or shoulder muscles. Cold and damp
weather seems to increase muscle ache and joint pain, whereas warm and
dry weather seems to decrease pain.
Cold-induced pain is one of the main reasons practitioners give for not
using cryotherapy. While most patients seem to agree that cold causes more
discomfort than heat, many patients are willing to endure the pain if they
clearly understand the benefits of using cold instead of heat. There appears
to be some degree of adaptation to cold, since many patients report
cryotherapy is less painful after the first or second session.
Although not part of soft-tissue therapy, when a body is cooled in a
mixture of water, salt, and cracked ice (ice jacket) for several hours, cold-
induced pain is replaced by cold-induced anesthesia. The loss of sensation
from cold-induced anesthesia is so complete that surgeons are able to
amputate gangrenous legs with the patient conscious or unconscious. Cold-
induced anesthesia is also called refrigeration anesthesia.


101
Temperatures

BASIC TEMPERATURE GUIDE

Very hot .............................................................. 104F and above
Hot ......................................................................... 100F to 104F
Warm ....................................................................... 96F to 100F
Neutral ....................................................................... 92F to 96F
Tepid .......................................................................... 80F to 92F
Cool ............................................................................ 70F to 80F
Cold ............................................................................ 55F to 70F
Very cold ................................................................... 32F to 55F

Standard Protocol

PROTOCOL FOR USING COLD OR HEAT

1. When treating injuries, use cold until hemorrhage and swelling
stop (about 24 to 72 hours), and then use heat.

2. When using cold or heat to restore normal function:

If pain is present, use cold to relieve pain.
If pain is not present, use heat to increase tissue extensibility.

3. To relieve chronic aches, pain, and stiffness, use heat.

Since pain and tissue damage normally start at 113F,
a thermometer is a saferand more reliablemethod
of determining the temperature than human touch.


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Effects of Cold and Heat

The following tables summarize the effects of cold and heat.

NORMAL EFFECTS OF CRYOTHERAPY

1. Vasoconstriction ------------------------------------------ cold only
2. Decrease in local metabolism --------------------------- cold only
3. Decrease in local circulation ---------------------------- cold only
4. Decrease in edema ---------------------------------------- cold only
5. Decrease in inflammation -------------------------------- cold only
6. Decrease in tissue extensibility ------------------------- cold only
* While cold decreases production of edema, compression and elevation
decrease existing edema.

NORMAL EFFECTS OF THERMOTHERAPY

1. Vasodilation ----------------------------------------------- heat only
2. Increase in local metabolism ---------------------------- heat only
3. Increase in local circulation ----------------------------- heat only
4. Increase in edema ----------------------------------------- heat only
5. Increase in inflammation --------------------------------- heat only
6. Increase in tissue extensibility -------------------------- heat only

NORMAL EFFECTS OF CRYOTHERAPY OR THERMOTHERAPY

1. Reduce muscle spasm --------------------------------- cold or heat
2. Reduce pain --------------------------------------------- cold or heat


103
VIBRATION

Vibration is used to relax or stimulate muscles, relieve pain, increase
lymphatic or venous circulation, and decrease sympathetic activity. By
improving circulation, vibration reduces edema and hastens wound healing.
Oscillating vibrators that move back-and-forth are less likely to cause tissue
damage than percussion vibrators that move up-and-down. Mechanical
vibration is more effective and less tiring than manual vibration.
When patients cannot tolerate compression or stretching because of pain,
vibration can be used to desensitize the offending tissues. Vibration of a
normal muscle reduces pain in three ways (1) large-fiber inputs block out the
deep pain that is transmitted by small-fiber inputs, (2) prolonged low-
frequency vibration (60 Hz to 75 Hz) inhibits the muscle spindles and causes
relaxation, and (3) activation of pacinian corpuscles may cause a decrease in
muscle tonus and pain, especially at frequencies near 60 Hz.
At frequencies above 100 Hz, vibration of a normal muscle facilitates
muscle spindles and causes contraction. If high-frequency vibration (100 Hz
to 150 Hz) is used to facilitate an agonist, the antagonist may relax because
of reciprocal inhibition. When hypertonic muscles are treated with
vibration, the belly of the muscle should be slightly stretched before
vibratory stimulus is applied, and the frequency should be about 60 Hz.
To relax muscles and relieve pain, vibratory treatments should be at least
3 minutes long. Treatments less than 3 minutes may stimulate more than
sedate. The most popular targets for vibration are (1) the belly of large
muscles, (2) the paraverbal region, (3) the hands or feet, and (4) the scalp.
Practitioners using mechanical hand-held vibrators for long periods of
time may experience musculoskeletal problems themselves. There are no
standards for acceptable levels of exposure, but people using hand-held
vibrators should take frequent breaks and avoid positions that cause fatigue
or discomfort. For general safety, vibrators should not exceed 150 Hz.
Vibration can be used effectively over the muscles of mastication, such
as the masseter and temporalis, to relieve temporomandibular joint pain
(TMP) and prepare the muscles for range-of-motion stretching.
Contraindications for vibration include: inflammation, heart disease,
open lesions, blood clots, hemorrhage, infection, malignancy, cerebellar
dysfunction, infants, and overly sensitive or inelastic skin. Applying
mechanical vibration with too much downward pressure can increase the
risk of tissue damage and decrease the frequency of vibration.


104
CHAPTER SUMMARY

THE FIVE CLASSIC SIGNS OF INFLAMMATION

Pain: the result of pain-producing chemicals.
Swelling: the result of fluid accumulation in tissues.
Redness: the result of increased blood flow.
Heat: the result of increased blood flow.
Loss of function: the collective result of inflammation.

FOUR USES FOR MODALITIES DURING WOUND HEALING

Cryotherapy: reduce pain, control edema, and reduce local metabolism.
Thermotherapy: reduce pain or spasm and increase blood flow.
Vibration therapy: reduce pain or spasm and increase blood flow.
Heliotherapy: kill bacteria and increase blood flow.

FOUR USES FOR MANIPULATION DURING WOUND HEALING

Trigger point therapy: reduce pain and soften tissues.
Neuromuscular therapy: reduce spasm and facilitate weak muscles.
Connective tissue therapy: rupture adhesions and stretch local scar tissue.
Range-of-motion stretching: lengthen contractures and restricted tissue.

FIVE USES FOR EXERCISE AFTER WOUND HEALING

Stretching: maintain range-of-motion and flexibility.
Strengthening: improve muscular strength and endurance.
Strengthening: improve muscular speed and power.
Coordination: improve mobility and quality of movement.
Aerobic: improve cardiovascular fitness.


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FIVE BASIC STAGES OF INFLAMMATION

Release of pain-producing chemicals
Increased blood flow to the inflamed area
Edema caused by plasma leaking from capillaries
Infiltration of the injury by leukocytes (neutrophils or monocytes)
Proliferation of connective tissue and wound healing

THREE TYPES OF SECONDARY DAMAGE

Lysosomal enzyme damage
Ischemic or hypoxic damage
Hydrostatic pressure damage

SEVEN-STEP ADVANCED REHABILITATION MODEL

The cycle starts with original injury or restarts with a secondary injury.
Results: tissue damage, inflammation, or pain-producing chemicals.
Results: pain, spasm, edema, enzymes, or metabolite retention.
Results: restricted circulation, hypoxia, ischemia, or fatigue.
Results: restricted movement, inactivity, or fibrosis.
Results: contractures, adhesions, atrophy, or weakness.
Options: possible early intervention with cryotherapy or mobilization.
Soft-tissue therapy: modalities, manipulation, or exercise.
Alternatives:
Acceptable recovery: therapy stopped after the patient recovers.
Secondary injury: therapy continued and the cycle begins again.
Termination: therapy stopped before the patient recovers.

FOUR SUB-CYCLES THAT MAY CAUSE SECONDARY INJURIES

Edema or enzymes may cause secondary injuries.
Ischemia or hypoxia may cause secondary injuries.
Adhesions or contractures may cause secondary injuries.
Soft-tissue therapy may cause secondary injuries.


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THE ACRONYM RICE STANDS FOR

Rest
Ice
Compression
Elevation

FOUR BASIC PHASES OF ICE MASSAGE

Cold
Burning
Aching
Numbness

ICE-MASSAGE METHOD FOR TREATING TRIGGER POINTS

Stroke several times across the trigger points with ice.

ICE-PRESSURE METHOD FOR TREATING TRIGGER POINTS

Apply light pressure with ice until numbness occurs.
Apply moderate pressure with ice until trigger points are neutralized.
Remove pressure on the trigger point slowly.
Apply moist heat for several minutes to rewarm tissues.
Have patient complete 3 repetitions of active range-of-motion stretching.

INDICATIONS FOR COLD

Muscle spasm
Pain
Edema
Trauma


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SIX FACTORS THAT AFFECT BIOPHYSICAL CHANGES

Target tissues are different (depth or thermal conductivity)
Heating agents are not at the same temperature (intensity)
Amounts of tissue being exposed to the heat are different
Rates of tissue temperature increase are not the same
Distances between the source and target are different (radiant energy)
Angles between source and target are different (radiant energy)

THREE-PART SEQUENCE TO INCREASE TISSUE LENGTH

Heat tissues to a therapeutic temperature of at least 104F.
Slowly stretch tissues with just enough force to overcome elasticity.
Hold tissues in a fully stretched position until cooling is complete.

TWO DIFFERENCES BETWEEN THERAPEUTIC HEAT AND COLD

Vasodilation: an increase in the caliber of a blood vessel.
Vasoconstriction: a decrease in the caliber of a blood vessel.

FOUR INDICATIONS FOR HEAT

Muscle spasm
Pain
Contracture
Vascular stasis

SIX STEPS FOR A HOT-TO-COLD STRETCH

Apply moist heat for about 15 to 20 minutes.
Stretch tissues while heating devices are still in place.
Hold stretch and apply cold for about 15 to 20 minutes.
Release tension after tissues are cold.
Allow patient to rest for about 5 minutes without moving.


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SIX NORMAL EFFECTS OF CRYOTHERAPY

Vasoconstriction
Decrease in local metabolism
Decrease in local circulation
Decrease in edema
Decrease in inflammation
Decrease in tissue extensibility

SIX NORMAL EFFECTS OF THERMOTHERAPY

Vasodilation
Increase in local metabolism
Increase in local circulation
Increase in edema
Increase in inflammation
Increase in tissue extensibility

TWO EFFECTS OF BOTH CRYOTHERAPY OR THERMOTHERAPY

Relax muscle spasm
Reduce pain


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MANIPULATION

Manipulation implies skilled and dexterous treatment by using the
hands. The manipulations used in the HEMME APPROACH are low-velocity
pushing or pulling movements that correct soft-tissue impairments by
repositioning soft-tissue components of the body. They are not high-
velocity thrusting movements, as found in some forms of manual medicine
that seek to adjust or reposition bones. The main goals of soft-tissue
manipulation are (1) correct soft-tissue impairment and (2) restore normal
function in terms of strength, endurance, flexibility, pain-free movement,
coordination, and mobility. These goals should be accomplished with
minimal force and without doing the patient harm.
A good manipulator has a wide variety of techniques to select from and
uses flexibility in selecting the most workable techniques. The four basic
types of therapy used in HEMME APPROACH include (1) trigger point
therapy, (2) neuromuscular therapy, (3) connective tissue therapy, and (4)
range-of-motion stretching. Despite hundreds of different names and
techniques, any form of soft-tissue therapy involving physical contact with
the patient can be classified under one of these four basic categories.
Trigger point therapy involves hypersensitive areas of the body known
as trigger points, tender points, or trigger zones. Neuromuscular therapy
involves nerve and muscle tissue, while connective tissue therapy involves
connective tissue and epithelial tissue. Range-of-motion stretching affects
trigger points and all four types of tissue found in the human body: nerve
tissue, muscle tissue, connective tissue, and epithelial tissue. Modalities and
exercise are supplements or adjuncts to soft-tissue therapy, but not
substitutes. Neither modalities nor exercise is fully effective in treating soft-
tissue impairments without manipulation.
Practitioners are responsible for sequencing manipulations to produce
the best possible outcomes. The normal sequence for treating soft-tissue
impairments is (1) trigger point therapy to control pain, (2) neuromuscular
therapy to inhibit spasm or facilitate weak muscles, (3) connective tissue
therapy to lengthen adaptively-shortened tissues or break adhesions, and (4)
range-of-motion stretching to normalize muscle tonus, lengthen connective
tissue, and maximize range of motion. A competent practitioner should be
skilled in all four methods of manipulation and should be flexible enough to
alter the normal sequence based on feedback from the patient (symptoms),
physical evidence (signs), and clinical experience.


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Principles of Soft-Tissue Therapy

Soft-tissue therapy is based on a series of scientific principles that are
sometimes called axioms or laws. Even though principles can make it easier
to simplify complex ideas, they do change. Pflger's Laws of Unilaterality,
Symmetry, Intensity, and Radiation are classical examples.
Written in 1853 by the German physiologist Edward Pflger, these laws
were widely accepted for more than 50 years. Pflger developed these laws
by observing frogs and reading clinical cases of spinal lesions in man.
When all four laws were shown to be invalid by Dr. Charles Sherrington in
1915, the laws became scientific history. This explains why none of these
laws is found in medical textbooks or dictionaries today.
Another law that has recently been questioned is the Arndt-Schultz Law:
Weak stimulus causes activity, moderate stimulus increases activity, strong
stimulus retards activity, and very strong stimulus stops activity. While this
law seems to explain the sequence that occurs when digital pressure is
applied to trigger pointspain increases with increases in pressure until
numbness occursother situations involving painful stimulation produce
continuous pain instead of numbness. Stedmans Medical Dictionary (26th
ed.) shows the Arndt-Schultz Law as obsolete.

The Three HEMME Laws

The HEMME APPROACH is based on three fundamental laws:

HEMMEs 1st law: Most conditions treatable by soft-tissue therapy are
characterized by pain, limited range of motion, or weakness.

HEMMEs 2nd law: Most conditions treatable by soft-tissue therapy can
be identified and treated by using five basic steps: History, Evaluation,
Modalities, Manipulation, and Exercise.

HEMMEs 3rd law: Always be ready, willing, and able to disregard any
law, principle, axiom, or belief that proves to be incorrect.

The following principles are still accepted by medical science and shown
in medical dictionaries. These principles explain why forces applied to the
human body produce various physical and physiological changes.


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Twenty-Two General Laws or Principles

1. All-or-none law: The weakest stimulus capable of producing a
response causes skeletal muscle fibers to contract maximally.

2. Beevor's axiom: The brain knows nothing of individual muscles, but
thinks only in terms of movement.

3. Bells law: Anterior spinal nerve roots are efferent (motor) nerves and
posterior spinal nerve roots are afferent (sensory) nerves.

4. Creep: Deformation of viscoelastic materials when exposed to a slow,
constant, low-level force for long periods of time.

5. Facilitation-Inhibition:

A. When a nerve impulse passes once through a set of neurons to the
exclusion of other neurons, it usually takes the same path in the future
and resistance to the impulse becomes less.

B. As opposites, facilitation encourages a process and inhibition restrains
a process.

6. Head's law: If painful stimulus is applied to areas of low sensibility
in close central connection with areas of high sensibility, pain may be
felt where sensibility is high.

7. Hilton's law: The nerve trunk that supplies a joint also supplies the
muscles that move the joint and the skin that covers the insertions of
the muscles that move the joint.

8. Hookes law: The stress applied to stretch or compress a body is
proportional to the strain or changes in length thus produced,
provided that the elastic limit of the body has not been exceeded.

9. Houghtons law of fatigue: When muscles or muscle groups are kept
in constant action until fatigue sets in, the total amount of work done
is the same, regardless of rate.


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10. Hysteresis: Energy loss in viscoelastic materials subjected to stress or
to cycles of loading and unloading.

11. Inverse square law: The intensity of radiation (heat) is inversely
proportional to the square of the distance between the point of the
source and the irradiated surface.

12. Jacksons law: The nerve functions that evolve last are the first to be
lost when the brain is damaged by disease.

13. Law of denervation: When a structure is denervated, sensitivity to
certain chemical agents is increased (denervation supersensitivity).

14. Law of referred pain: Referred pain arises only from irritation of
(visceral) afferent nerves that are sensitive to the same stimuli that
produce pain when applied to surface (cutaneous) afferent nerves.

15. Meltzer's law (Contrary Innervation): All living functions are
continually controlled by two opposing forces.

16. Sherrington's laws:

A. Every posterior spinal root nerve supplies one particular region
on the skin, though fibers from segments above and below can
invade this region.

B. Reciprocal Inhibition: when the agonist receives an impulse to
contract, the antagonist relaxes.

C. Irradiation: nerve impulses spread from a common center and
disperse beyond the normal path of conduction. Dispersion tends to
increase as the intensity of stimulus becomes greater.

17. Stokes law: A muscle situated above an inflamed mucus or serous
membrane is often affected by paralysis.

18. Stretch reflex: A muscle contracts in response to passive longitudinal
stretch. (also called myotatic reflex or Liddell-Sherrington reflex)


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19. Thixotropy: Certain gels liquefy when agitated and revert to gel upon
standing.

20. Webers law: The increase in cutaneous stimulus necessary to
produce the smallest perceptible increase in sensation bears a
constant ratio to the strength of the stimulus already acting.

21. Weigerts law: The loss or destruction of living tissue is apt to be
followed by overproduction of such tissue during the process of
regeneration or repair.

22. Wolff's law: Bone and collagen fibers develop a structure most suited
to resist the forces acting upon them.

In addition to the above principles, there are seven basic concepts
relating to pain that are normally true and deserve mention.

Pain will continue if at least one source of pain is active.
Pain may cause spasm and spasm may cause pain.
Pain stimulus applied to skin may cause flexion of a limb.
Pain is often referred from a damaged region to a healthy region.
Pain is often referred to structures that share the same spinal segment.
Pain can result from stretching, compressing, or contracting muscles.
Pain can result when strong tissues try to compensate for weak tissues.

There are two basic ways to identify the origins of pain: (1) stimulate a
point that intensifies or reproduces the pain, or (2) neutralize a point that
reduces or eliminates the pain. Digital ischemic pressure can be used to
stimulate a trigger point or tender point, and ice can be used to neutralize a
point. Many points that refer pain are trigger points.
If pain perceived at one point can be intensified or reproduced by
stimulating the same point or a different point, the point being stimulated is
probably one of the origins of pain. Stimulating the scalene muscles in the
neck will often intensify or reproduce shoulder pain.
If pain perceived at some point can be reduced or eliminated by
neutralizing the same point or a different point, the point being neutralized is
probably one of the origins of pain. Neutralizing trigger points in the
scalene muscles will often reduce or eliminate shoulder pain.


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Muscle Imbalance

Even though muscle imbalance is more of a concept than a principle, the
implications of this concept apply directly to all forms of manipulation
trigger point therapy, neuromuscular therapy, connective tissue therapy, and
range-of-motion stretching. The concept of muscle imbalance emphasizes
the need for examining, and possibly treating, any antagonist or synergist
that interacts with a muscle that is known to be defective.
Since most muscles or muscle groups work in pairs, a muscle imbalance
develops when opposing muscles are not equal in terms of (1) length, (2)
resistance to passive stretch, or (3) strength. While small amounts of muscle
imbalance are normally asymptomatic, large amounts of imbalance can affect
posture, movement, or locomotion. While differences in muscle length and
resistance to passive stretch can be determined by using passive ROM testing,
differences in strength can be determined by using resisted ROM testing.
When muscles work in pairs, the muscle contracting and producing
movement is called the agonist, and the opposing muscle is the antagonist.
Unless muscles are cocontracting to stabilize a joint, contracting the agonist
will normally relax the antagonist because of reciprocal inhibition. If an
agonist is short and tight because of spasm, the antagonist often becomes
stretched and weak because of stretch weakness or inhibition. Spasm in the
iliopsoas may weaken the gluteus maximus because of reciprocal inhibition.
Muscular strength is the amount of force or tension a muscle can exert
during contraction, and maximum strength is the maximum amount of force a
muscle can exert during contraction. Since force may or may not produce
movement, strength can be subdivided into static or dynamic strength.
Static (isometric) strength is measured by a muscles ability to exert force
against an immovable or relatively immovable object. Instruments such as a
tensiometer or dynamometer can be used to measure static strength.
Dynamic strength can be measured by a 1-repetition maximum or a 10-
repetition maximum. A 1-repetition maximum is the greatest amount of
weight a muscle can lift once through the full range of motion of a given joint.
A 10-repetition maximum is the greatest amount of weight a muscle can lift 10
times through the full range of motion of a given joint.
A short or tight muscle can be strong or weak, depending on the amount of
force it generates during contraction. Muscles that are short because of
contracture are highly resistant to active or passive stretch, but they often test
normal or good during muscle testing. Muscles that are short because of


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hypertonia or spasm are highly resistant to active or passive stretch, but they
often test fair or poor because neurologic inefficiency or pain inhibition
prevent the muscle from exerting normal force (tightness weakness).
The normal sequence for treating muscle imbalance is (1) lengthen short
muscles, and (2) strengthen weak muscles. If a muscle is short because of
spasm, use trigger point therapy or neuromuscular therapy to reduce spasm,
and then use range-of-motion stretching to readjust proprioception. If a
muscle is short because of contracture or adhesions, use connective tissue
therapy or range-of-motion stretching to lengthen restricted tissues.
When muscles are being treated to improve the balance between opposing
muscles, a muscle of normal length should not be stretched beyond its normal
length. Overstretching a normal muscle can lead to instability and cause the
opposing muscle to shorten because of insufficient tension.
Once muscles become symmetrical in terms of length, the next step is
using manipulation to strengthen weak muscles. If muscles are weak because
of pain inhibition, then trigger point therapy, neuromuscular therapy, and
range-of-motion stretching can be used to reduce pain. If muscles are weak
because of neurologic inefficiency, neuromuscular therapy and range-of-
motion stretching can be used to facilitate weak muscles.
Once muscle balance is achieved, therapeutic exercise can be used to help
patients maintain the balance. A therapeutic exercise program should include
range-of-motion stretching exercises to preserve length and strengthening
exercises to preserve or improve muscular strength and endurance. Aerobic
exercises seem to reduce some types of musculoskeletal pain as well as
improve cardiovascular and pulmonary fitness.
Using exercise without manipulation to relieve pain and correct muscle
imbalance is normally ineffective at best and dangerous at worst. Except for
minor injuries that are often self-limiting, manipulation should be used to
reduce pain and normalize tissue tonus and length before exercise. In many
cases, modalities should be used before and during manipulation to reduce
pain or increase tissue extensibility.
Using opposing muscles during vigorous exercise to forcefully stretch
muscles that are short or tight is more likely to cause tissue damage than help
the patient achieve muscle balance. The same applies to self-assisted
stretching, using one or more body parts such as the arms to stretch another
body part such as a thigh. Even though active exercise may be cost-effective
in terms of not requiring someone to perform soft-tissue therapy, it is not
results-effective in terms of helping the patient recover.


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Posture

Posture refers to position of body parts or attitude of the body. Perfect
posture is not realistic since most people, whether healthy or unhealthy, are out
of alignment or asymmetric in one or more respects. Because of handedness
(a tendency for people to be right- or left-handed) one shoulder is normally
lower than the other, one hip is normally higher than the other, and muscles on
one side of the body are normally larger than on the opposite side.
Even though anatomical leg length is normally about the same for most
people, physical demands on the body encourage a functional difference in leg
length because of rotation or elevation of the hip. Despite sometimes heroic
efforts to analyze posture and force people to conform with one or more
standards, most changes in symmetry are lost shortly after postural therapy is
discontinued and people return to normal activities.
Discrepancies in leg length can be functional or anatomic. Functional
discrepancies result from physical activities that alter the body's posture.
Anatomical discrepancies result from differences in physical structure.
Functional leg length can be estimated by measuring the distance between
the anterior superior iliac spine (ASIS) and the medial malleolus. The most
accurate way to measure anatomical leg length is by using an X-ray.
With the patient supine, applying traction to the short leg will
temporarily lengthen the short leg and give the appearance of equalizing leg
length. With normal activity, the short leg will normally return to its
previous length. There is no justification for treating differences in leg
length that are (1) asymptomatic or (2) not considered a risk factor.
Even though traction can be used to temporarily lengthen the functional
short leg, with normal activity the short leg will return to its previous length.
Although some doctors treat leg-length discrepancies as small as 1/4 inch,
differences of less than 1/2 inch are seldom significant.
Rather than work for perfect symmetry, which is probably unrealistic,
unobtainable, and pointless, a practitioner should work to improve posture in
ways that help a patient become pain-free and functional. Of all the postural
defects, a forward-head posture is probably the single most common serious
defect. A forward-head posture (especially when combined with increased
upper cervical lordosis and increased cervicothoracic flexion) contributes to
headaches, temporomandibular joint pain, neck and shoulder pain, low back
pain, and even extremity pain.


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Since posture is more a function of the muscular system than the skeletal
system, most treatments combine soft-tissue manipulation with exercise and
postural training. The general goals for soft-tissue manipulation and exercise
are (1) lengthen muscles that draw the shoulders forward, and (2) strengthen
muscles that draw the head and shoulders back.
If a patient is placed supine on a narrow bench with the arms perpendicular
to the body, gravity can be used to pull the arms down, open the chest, and
draw the shoulders back. Stretching an elastic band across the front of the
chest with the arms perpendicular to the body is a good way to strengthen the
muscles that adduct the scapulas and draw the shoulders back. If the patient is
sitting with the hands placed behind the head, muscles that draw the head back
can be isometrically contracted against the hands to strengthen the muscles
that draw the head back.
The goals for postural training are (1) improve the vertical alignment
between the head, neck, and shoulder, and (2) improve the vertical alignment
between the upper and lower body. When these alignments are correct,
muscular and ligamental stress are reduced. Walking with a bag of rice or a
book balanced on top of the head is still considered good postural training.
Other methods of postural training include (1) having patients practice
good posture in front of a mirror, or (2) having patients look up at the sky or
ceiling several times a day to remind themselves to keep their heads vertical.
From a forward-head posture you cannot look directly overhead. Some
patients report that looking overhead elevates their mood. This may partially
explain the expression, Things are looking up.
In a search for a reflex that helps the body assume and maintain an upright
posture, early investigators discovered what they thought was a righting reflex.
Recent studies now suggest the righting reflex is not a true reflex, but a
conscious, learned reaction of orienting the head in response to visual cues.
While the optical righting response may be helpful when the environment
provides numerous vertical and horizontal lines for reference, it has no value
in the dark where visual cues are absent.
To assume or maintain an upright posture in the dark, the body uses the
labyrinthine righting reflex that is based on the position of utricles in the inner
ear and responds to gravity. Amusement park fun houses are built to create a
conflict between the optical righting response that responds to visual cues and
the labyrinthine righting reflex that responds to gravity. To improve the
sensitivity of the labyrinthine righting reflex, create a safe environment where
postural exercises can be practiced in the dark or while blindfolded.


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TRIGGER POINT THERAPY

By definition, trigger points are hyperirritable spots or zones that
produce pain when stimulated by pressure or compression. The basic cause
for trigger points appears to be mechanical stress that causes macroscopic or
microscopic trauma to the body. Trigger points can appear as nodules or as
palpable bands of tense, indurated tissue. Though trigger points can occur in
cutaneous, ligamentous, or periosteal tissue, the majority of trigger points
occur in muscle or fascia (myofascial trigger points).
Trigger points can produce local pain or tenderness, refer pain to other
areas, and reduce range of motion by causing spasm or pain inhibition. The
mechanisms that cause trigger points normally include disruption of muscle
tissue or connective tissue, inflammation, abnormal metabolic activity, or
some form of hypertonia. Contributing factors include psychological stress,
nutritional inadequacies, changes in temperature (hot to cold), sleep
disturbances, muscle imbalance, chemical irritants, and postural defects.
Trigger point therapy is a progression from one trigger point to another
until all remaining trigger points are neutralized. Though muscles normally
become progressively less sensitive with each treatment, trigger point
therapy should be continued until all trigger points are neutralized. When
myofascial trigger points are present, most of the following signs or
symptoms will be present:

points or zones that are tender when pressure is properly applied
distinct patterns of referred pain or radiated pain
the presence of taut, indurated, or ropy bands within a muscle
tremors or fasciculations when pressure is properly applied
jump signs or local twitch responses when pressure is properly applied
abnormal weakness, shortness, tightness, or spasm within a muscle

Trigger points can be palpated, but not biopsied. From all indications
they are physiological or molecular, but not cellular. In many respects they
appear to be a highly localized collection of fluids and pain-producing
chemicals such as histamine, prostaglandins, and bradykinin.
The hardness of trigger points is probably caused by spasm, edema, or
changes in tissue viscosity. This would explain the rapid change from hard
to soft when trigger points are treated with digital pressure. Digital pressure


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inhibits spasm by dispersing pain-producing chemicals and reduces edema
by compressing tissues with excessive fluid. The fact that trigger points
become soft and pliable directly after treatment makes it unlikely that
contracture, fibrous connective tissue, or fatty infiltration are the main
causes for palpable hardness.
Spasm and edema partially explain why trigger points are painful.
Spasm produces pain by causing ischemic damage and allowing noxious
metabolites such as lactic acid or adenosine diphosphate to accumulate,
while edema causes pain by causing secondary tissue damage because of
swelling and lowering the threshold to pain. By reducing spasm and edema,
trigger point therapy helps to reduce pain.
Though commonly referred to as points, trigger points are more likely to
affect zones or bands within a muscle than small discrete points within a
muscle. Sometimes large portions of a single muscle behave like a single
trigger point. Treating several trigger points within a hypersensitive muscle
will often neutralize other trigger points and relax the entire muscle.
Trigger points normally produce deep aching pain as opposed to
superficial pain. When pressure stimulates trigger points, the patient may
recoil or experience autonomic responses such as vasoconstriction,
perspiration, or dizziness. Autonomic responses can also affect heart rate,
skin temperature, and respiration rate. Activation of trigger points can also
cause severe spasm, muscular weakness in surrounding muscles, involuntary
tremors, and difficult breathing (dyspnea).
Trigger points can produce changes in skin temperature, as evidenced by
palpation or shown by thermograms. Temperatures higher than normal may
indicate active inflammation or rapid metabolism. Temperatures lower than
normal may indicate circulatory insufficiency or sluggish metabolism.
Spasm and edema are two of the main causes for circulatory failure in
soft tissue. High rates of metabolism and low rates of circulation produce
ischemic damage that corresponds with pain and weakness. When trigger
points are properly treated, temperatures normalize, circulation improves,
pain diminishes, and muscles become stronger. Though trigger points are
sometimes inactive for long periods of time, trigger points are not self-
limiting, and complete neutralization without treatment is rare.
Locating trigger points depends on the identification of certain
characteristic signs. The most common signs are (1) pain when pressure is
correctly applied, (2) referred pain, (3) a jump response, (4) a local twitch
response, and (5) hardness or ropiness within a muscle.


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The simplest test for trigger points is the appearance of pain when
pressure is correctly applied to sensitive tissues. Light pressure is normally
more discriminating than heavy pressure when locating trigger points. Light
pressure can be applied by using the fingers or thumb to compress or pinch
suspect tissues.
Stretching a muscle can sometimes be used to locate trigger points. If
stretching produces a dull pain, palpate the muscle for trigger points. If
trigger points are not found, the pain may be joint pain. Where trigger
points often produce intermittent pain, joints often produce continuous pain.
If trigger points are treated while a muscle is held in a stretched position, the
muscle may lengthen even more as the trigger points are neutralized.
If a patient recoils while pressure is being applied, the jump sign is
positive. If the trigger point is in a muscle, slight pressure will sometimes
cause spontaneous contraction of the entire muscle. This contraction may or
may not be strong enough to move the affected body part. A positive jump
sign combined with simultaneous radiation of pain to other parts of the body
is strong evidence of trigger point involvement.
Cutaneous tissue responses and a positive twitch response can be used
for additional verification. If skin that is pinched and pulled away from the
body feels coarse, granular, and inelastic, the cutaneous tissue response is
positive. If taut bands of indurated tissue within the muscle respond
elastically by snapping back into place after plucking the tissues like a guitar
string, the twitch response is positive. The twitch response is caused by
muscle fibers contracting in response to transverse stretching.
The amount of pressure used during palpation is critical because too
much pressure can obscure physical signs. Responses produced by light
pressure are sometimes canceled by heavy pressure that restricts tissue
movement and deadens pain. Light pressure is also more sensitive to
differences in tissue consistency than heavy pressure. In some cases, heavy
pressure will change tissue consistency before differences in tissue
compliance can be felt. In trigger point therapy, it is not uncommon for
evaluation and treatment to occur simultaneously. Even light palpation will
at times neutralize trigger points.
Muscular weakness and resistance to passive stretch are consistent with
trigger point activity, but they are not definitive because spasm, contracture,
and various neurologic conditions can produce similar conditions. If taut
bands of muscular tissue caused by trigger point involvement compress a
nerve, the physical signs are similar to those caused by fibrous or


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osseofibrous entrapment. In both cases, nerve conductivity may be reduced
and the patient may experience weakness, aching pain, or paresthesia. If
trigger points are indirectly causing the entrapment, trigger point therapy and
stretching should eliminate the signs and symptoms of entrapment.
Satellite trigger points are trigger points activated by another trigger
point in the same reference zone. When left untreated, satellite trigger
points can become primary trigger points and develop their own satellite
patterns of distribution. Untreated satellite trigger points can also reactivate
primary trigger points that became clinically quiescent after treatment
Secondary trigger points develop in synergistic or antagonistic muscles
because of compensatory overload. When active trigger points weaken the
agonist and make it more resistant to passive stretch, synergistic muscles
compensate for weakness in the agonist by substitution, while antagonistic
muscles work harder than normal to stretch the agonist because of passive
resistance. This creates an overload that encourages secondary trigger points
to form in synergistic or antagonistic muscles. Primary, secondary, and
satellite trigger points should always be treated together.

Three factors seem to explain why trigger point therapy reduces pain:

Digital pressure disperses pain-producing chemicals.

Digital pressure stimulates production of endogenous opioids.

Trigger points stimulated by pressure act as a counterirritant.

First, when digital pressure disperses blood and pain-producing
chemicals away from trigger points, surrounding tissues become ischemic,
as indicated by blanching or whiteness of the skin. A decrease in electrical
conductivity after a treatment indicates that pressure has dissipated pain-
producing electrolytes such as potassium ions. Immediately upon release of
pressure, blood reacts to a decrease in hydrostatic pressure by reentering
ischemic areas, as indicated by flushing or redness of the skin. The redness
is caused by hyperemia. The net effect of ischemic pressure and reactive
hyperemia is a lower concentration of pain-producing chemicals. Since
pain-producing chemicals such as potassium ions, serotonin, and bradykinin
activate or sensitize nociceptors, decrease local circulation, and contribute to
spasm or vasospasm, lowering their concentration may reduce pain.


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Second, trigger point therapy relieves pain by stimulating the body to
produce endogenous opioids such as endorphins that affect the limbic
system and brain stem, enkephalins that affect the central nervous system,
and dynorphins that are active in the brain and pituitary gland. Endogenous
opioids produce analgesia by binding to the opiate receptor sites involved in
pain perception. Opioids produce a type of analgesia that is similar to that
produced by opiates, and the effects of both substances can be canceled by a
drug called naloxone that prevents or reverses the effects of morphine and
other opioid drugs. When patients receive naloxone, the pain-relieving
effects of trigger point therapy and acupuncture are greatly reduced.
Third, trigger point therapy relieves pain by acting as a counterirritant.
According to Melzack and Wall's gate-control theory of pain, the large
diameter A-beta nerve fibers that transmit superficial pain can inhibit the
small diameter A-delta and C nerve fibers that transmit deep pain. Since
most people find the superficial pain more tolerable than deep aching pain,
counterirritants such as trigger point therapy and chemical irritants are
sometimes useful. The most common chemical irritants are those that feel
hot or cold when applied to the skin. Some people refer to superficial pain
as a "good hurt."

Though digital pressure is normally effective in treating trigger points,
the amount of pressure needed varies from case to case. Moderate to heavy
pressure is normally more effective than light pressure. Trigger points in
large deep muscles or muscles that overlay soft tissue often require more
pressure than trigger points in small superficial muscles or muscles that
overlay bone. Lighter than normal pressure can be used if the same trigger
point is treated repeatedly on successive days.
Compared with moderate to heavy pressure, light pressure is more likely
to cause facilitation than inhibition. When trigger points in muscles are
stimulated by light pressure, hypertonia and spasm increase as the muscle
attempts to guard itself against the insult. With light pressure, pain tends to
increase and then remain constant. This differs from moderate to heavy
pressure that normally causes the pain to intensify and then diminish as the
pressure continues and the muscles relax.
When moderate to heavy pressure is used, pressure should be applied
slowly and released slowly. Slowly applied pressure causes less trauma
because tissues have more time to absorb force and accommodate the
changes caused by pressure. Slowly released pressure lessens the recoil


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effect that normally occurs after pressure is removed. Both measures will
increase the patient's comfort and improve the probabilities that treatments
will have a longer-lasting effect. The principle of "easy on, easy off" applies
to both muscle testing and trigger point therapy.
The best method for gauging time is continuing pressure until the tissue
changes in consistency and softens or melts down. Feedback from the tissue
and the patient is a better way to estimate treatment time than arbitrary
numbers such as 20 or 60 seconds. In a large, indurated muscle such as the
gluteus maximus, changes in tissue consistency may take several minutes.
Regardless of duration, digital pressure should not be used in the presence of
inflammation as indicated by pain, swelling, redness, and heat.
The normal sequence is a sharp increase in pain followed by a gradual
decrease in pain. If the patient reports no reduction in pain after one minute
of pressure, stop the pressure and look for signs or symptoms that indicate
the trigger point being treated is not causing the pain. If the pain is being
referred from another trigger point, then find and treat the origin of the pain.
If the pain is being caused by inflammation, acute trauma, or nerve
entrapment, trigger point therapy will not be effective.
If pain continues to decrease as pressure is being applied, continue the
pressure until the affected tissues become less resistant to pressure. Changes
in tissue consistency normally coincide with pain relief. If trigger point
therapy is successful, the patient will experience less pain and greater
mobility within minutes after treatment.
If patients cannot tolerate digital pressure, it may be possible to pinch the
skin directly over the trigger point and partially desensitize the area by reflex
effect. Once the skin is desensitized, trigger points are normally less
sensitive to pressure. It is not uncommon to find that skin pinching will
sometimes neutralize trigger points in a muscle without further treatment.
Trigger points can be treated with tissues stretched, at normal resting length,
or slack.
The final phase of trigger point therapy is stretching. If tissues are not
stretched to normal length, trigger points are likely to recur. Low-velocity
stretching helps to restore normal length without causing a stretch reflex or
tearing tissues. Even though stretching in some cases will eliminate trigger
points without digital pressure, it can also irritate trigger points and cause
spasm. Stretching is normally safer and much less painful if trigger points
are neutralized first. Heat can be applied before stretching to increase tissue
extensibility and reduce any existing spasm.


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It is common to treat identifiable trigger points during one session and
have the patient return for the next session with entirely different trigger
points. It is possible that elimination of primary points during the first
session makes secondary trigger points more discernible during the second
session. In any event, treatment should be continued until all trigger points
are eliminated as completely as possible. It is common to find great
improvement after one treatment.
When trigger points and spasm are widespread, the origin of pain is
difficult to localize. Every muscle in the body has a potential for developing
trigger points. The origins of pain can be obscured by trigger point zones
that represent areas of referred pain. Autonomic, sensory, or motor
responses caused by trigger point activity can be observed anywhere within
the zone.
As spasm recedes, the origins of pain will be more apparent. Tissues
that caused the original involvement are often the last tissues that respond to
therapy. Though most soft-tissue impairments cannot be resolved until all
trigger points are neutralized, in many cases comprehensive trigger point
therapy followed by range-of-motion stretching will give the patient
complete pain relief.

Summary of trigger point classifications:

Active trigger point: symptomatic with characteristic behavior.
Associated trigger point: caused by trigger points in another muscle.
Latent trigger point: symptomatic only when palpated or compressed.
Primary trigger point: caused by mechanical strain in a muscle.
Satellite trigger point: caused by trigger points that share the same zone.
Secondary trigger point: caused by compensating for another muscle.

Trigger Points and Tender Points

Of all the different points, trigger points and tender points seem to be the
closest. Both points both produce a similar type of paina dull constant
aching pain or a sharp, stabbing, shooting painand neither point normally
produces a burning sensation. It is also common for trigger points and
tender points to occupy the same region at the same time and both types of
point can be activated by changes in temperature (hot to cold), chemical
irritants, and psychological stress. The main differences between trigger


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points and tender points are based on definition: trigger points refer pain
and cause myofascial pain syndromes (MPS), whereas tender points do not
refer pain and cause fibromyalgia syndrome (FMS).
Palpation is the most reliable way to identify the exact location of either
trigger points or tender points. Although charts are sometimes useful when
trying to approximate where various points should occur, there is no
substitute for palpation. Palpating an entire muscle, muscle group, or region
is often faster than trying to use a chart. To save time, muscle testing and
feedback from the patient can be used to narrow the search parameters.
Palpation can be used to locate trigger points or tender points within a
muscle while tissues are stretched, relaxed, being lengthened, or being
shortened. Rapid movements are more likely to cause pain than slow
movements. Palpating a tissue during movement is called motion palpation.
Even if trigger points and tender points are not identical, they often
respond to the same treatments. This adds to the belief that trigger points
and tender points share a similar pathogenesis (origin) and may not deserve
to be separated. While both points may respond to the same treatments,
points that refer pain (trigger points) are often easier to neutralize than points
that do not refer pain (tender points). Other points that may respond to
similar treatments include: acupuncture points, acupressure points, reflex
points, motor points, neurovascular points, and wobble points (osteopathy).

Deep Sliding Pressure (DSP)

Deep sliding pressure (DSP) is used for treating taut, indurated zones or
bands within a muscle. Sliding movements can be linear, curved, circular,
or spiral, depending on where the zones or bands are located. DSP starts by
treating a single point within a zone or band until the tissues melt down or
soften. Once this change occurs, the next step is sliding forward to another
point within the zone or band without releasing pressure. Even though
patients may experience an increase in pain, if the sliding movements are
slow and gradual, some patients will not realize that new points are being
treated. Lubrication can be used to reduce friction.
The key to using deep sliding pressure is moving very slowly and
waiting for tissues to soften slightly before moving in a new direction. This
requires much less force than pushing through hard or indurated tissue
without waiting for tissues in the direction of movement to melt down and
become more compliant to pressure. Even though areas being treated will be


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blanched (white) because of ischemic pressure, once pressure is released,
these same areas become flushed (red) because of reactive hyperemia.
When used properly without too much force or velocity, deep sliding
pressure is more effective and less painful than treating zones or bands point
by point. If the first sweep through a zone or band fails to release tension,
several more sweeps can be made. Deep sliding pressure is very effective
when treating any skeletal muscle with hard or indurated bands.
Deep sliding pressure can be used for treating the upper fibers of the
trapezius by slowly pinching the fibers together at opposite ends of the ridge
created by the upper fibers and then working slowly toward the center. The
fibers can be pinched together by using the first finger and thumb or the first
and second fingers with the thumb. Using deep sliding pressure that
converges toward the belly of the muscle will have a tendency to relax
hypertonic muscles because of proprioceptive inhibition.
Several sweeps are often needed to relax the upper fibers of the
trapezius. After treating one side, use palpation to compare the treated side
with the untreated side. Differences in tissue consistency should be apparent
if both sides were equally hard before treatment. Because of reductions in
tissue tension or pain, patients will normally notice an immediate difference
between the treated and untreated side. Deep sliding pressure should
always be followed by range-of-motion stretching.
One alternative to using deep sliding pressure along the upper fibers of
the trapezius is using a pincer-like grip to apply digital pressure. With the
patient supine, place the fingers on the posterior surface of the upper fibers
and wrap the thumb around until it touches the anterior surface. Pressure is
applied by approximating the fingers and thumb to create a pincer-like
movement. Once tissues between the fingers and thumb soften, pressure can
be reapplied somewhere else along the upper fibers if needed. It is often less
painful to start with lateral fibers near the acromioclavicular joint and work
in a medial direction toward the neck. When standing over a patient, body
weight can be used to increase downward pressure. The point-to-point
method works best when indurated bands are not present.
When deep sliding pressure is applied between the medial borders of the
paravertebrals and the lateral borders of the thoracic spine, the pressure often
produces a state of sedation that resembles a drug-like state. Some patients
fall into deep sleep, while others report extreme relaxation and feelings of
well-being. Pulse and respiration are slow. When aroused, some patents
become slightly incoherent, and the eyes appear to be unfocused. From all


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indications, DSP along the spine relaxes muscles, decreases sympathetic
outflow, increases parasympathetic activity, and causes the release of
endogenous opioids such as endorphins or enkephalins.
DSP can be applied with the patient sitting and upper spine flexed
forward over a padded table or supine with the arms parallel along the sides.
The direction for DSP is normally toward the head (cephalad), although
pressure in the opposite direction (caudad) also seems to work. Lubricant
reduces friction and makes it easier to treat both sides of the spine at the
same time. DSP applied between the medial borders of the scapulas and the
lateral borders of the paravertebrals may neutralize trigger points, produce
inhibitory pressure, and relax muscles, but fails to produce a drug-like state.
When applied to a tendon, DSP encourages a muscle to relax. DSP
should start at the musculotendinous juncture and move along the tendon
toward the bony attachment. Vibration applied to a tendon may produce a
similar effect by activating Golgi tendon organs or pacinian corpuscles.
DSP and vibration will also cause inhibition and relaxation when applied to
the palms, soles of the feet, and peroneal region along the lateral leg.

Myoglobinemia

Myoglobin is the oxygen-transporting and storage protein of muscle that
resembles hemoglobin, the oxygen-transporting and storage protein in blood,
and myoglobinemia is the presence of myoglobin in blood plasma. Muscle
degeneration is the main factor that causes the release of myoglobin into
blood plasma or urine (myoglobinuria)
If deep sliding pressure (DSP) is applied to areas of abnormal tension or
tenderness, myoglobin may appear in blood plasma. After abnormal tension
and tenderness are relieved by treatment, deep sliding pressure does not
cause myoglobinemia. Based on the transient nature of myoglobinemia,
three conclusions can be drawn:

(1) Since most areas of abnormal tissue tension and tenderness in a muscle
are caused by acute injury or chronic microtrauma, some of the tissues
in these areas have already undergone at least partial degeneration.
(2) While DSP may accelerate degeneration if tissues are already damaged,
it will not cause degeneration if tissues are normal.
(3) Even though the initial use of DSP may disrupt degenerated tissue,
continued use improves local metabolism and promotes healing.


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NEUROMUSCULAR THERAPY

The key to understanding medical neuromuscular therapy is realizing
that muscles contract or relax because of the complex relationship between
inhibition and facilitation. Muscles contract when (1) facilitation is strong
enough to cause contraction, and (2) facilitation is stronger than inhibition.
Muscles relax when there is (1) there is no facilitation, or (2) inhibition is
stronger than facilitation. Facilitation is the sum of all facilitatory synaptic
events and inhibition is the sum of all inhibitory synaptic events.
Because the human nervous system is more complex than most other
animals, human skeletal muscles are not controlled entirely by reflexes that
facilitate or inhibit contraction. Higher centers such as the cerebral cortex,
cerebellum, or brainstem can influence the intensity of either facilitation or
inhibition. Both the stretch reflex (facilitation) and Golgi tendon organ
response (inhibition) can be modified by training, memories, or emotions.
When exteroceptors in the skin are stimulated by noxious stimuli, such
as a hot stove, the reverse stretch reflex causes the affected body part to
withdraw. This reflex can also be modified by higher centers.
While most conditions involving hypertonia, such as spasms or cramps,
can be corrected by standard neuromuscular techniques, conditions that are
not responsive to neuromuscular therapy (1) may require static stretching
and active movement to dampen spinal reflexes, (2) motor training to
unlearn or modify previous learned responses, or (3) cognitive-behavioral
conditioning to address psychological issues.
Four other reasons why neuromuscular therapy may not be effective are
(1) the injury being treated is still acute or poorly healed, (2) acute
inflammation or infection are present, (3) trigger points are reversing the
effects of neuromuscular therapy, and (4) hypertonia is being caused by the
abnormal release of calcium ions (Ca
++
), not aberrant reflex activity.
The first problem can often be avoided by not treating an injury with
neuromuscular therapy until the classic signs of acute inflammation have
disappeared. Except for passive mobilization to improve the alignment of
connective tissue and isometric contractions to prevent muscle atrophy, most
forms of soft-tissue therapy will not be productive during the early subacute
stages of wound healing. To treat hypertonia caused by trigger points or the
abnormal release of calcium ions, trigger point therapy and deep sliding
pressure are often more effective than neuromuscular therapy.


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The complexity of the human nervous system partially explains why
simple solutions, such as always use trigger point therapy or always use
neuromuscular therapy, are not feasible. Even to treat a common condition
such as hypertonia, a competent practitioner must be able to use a wide
variety of tools. Since hypertonia is one of the main causes for muscle pain,
joint pain, limited range of motion, and weakness, any method or sequence
of treatment that reduces hypertonia deserves attention.
Neuromuscular therapy is characterized by manual techniques that
facilitate or inhibit muscles. The primary tissues acted upon are nerve and
muscle tissue. Inhibition encourages elongation; facilitation encourages
shortening. Extensibility is the ability of a muscle to lengthen and
contractility is the ability of a muscle to shorten. Theoretically, muscles can
lengthen to about 50 percent more than resting length and shorten to about
50 percent less than resting length. Inhibition lengthens hypertonic muscles
by relaxation and facilitation shortens hypotonic muscles by contraction.
Neuromuscular techniques strengthen a muscle by eliminating factors
that cause weakness. This allows the patient to attain the greatest amount of
strength possible without using exercise to increase potential strength. By
using inhibition and facilitation to balance opposing muscles in terms of
length and strength, neuromuscular therapy restores function and prepares
the patient for the next stage of therapy, which is normally exercise.
As the opposite of inhibition, facilitation stimulates reflex activity that
causes contraction. The least amount of stimulus that causes a muscle to
contract is called the absolute threshold. When stimulation exceeds the
absolute threshold, muscles contract and produce force. If the force of
contraction is greater than resistance, muscles contract isotonically and body
parts move. If the force of contraction is not greater than resistance, muscles
contract isometrically and body parts remain stationary.
Inhibition encourages relaxation by decreasing reflex activity. Two
basic principles are (1) deactivating of any facilitating mechanism tends to
inhibit facilitated muscles and (2) deactivating any inhibitory mechanism
tends to facilitate inhibited muscles. After inhibitory mechanisms have been
deactivated, facilitated muscle fibers will contract maximally if the level of
stimulation is greater than the absolute threshold for activation. If
stimulation is below the absolute threshold, muscle fibers will not contract.
The immediate goal of neuromuscular therapy is muscular balance. This
means balancing and normalizing opposing muscles or muscle groups in
terms of length and strength. The effects of muscular imbalance are pain


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and limited range of motion. Pain results when muscles and joints are
abnormally stressed by asymmetrical forces. Limited range of motion is
caused by agonistic muscles that are too weak to initiate movement or
antagonistic muscles that are too short to allow movement.
Though pathologic joints can produce pain and limit range of motion,
dislocations, loose bodies, and menisci tears are less common than muscular
imbalance. Even when joints are implicated, muscular imbalance may have
caused the joint to become dysfunctional.
First, asymmetrical forces acting on the joint may cause one side of the
joint to wear more rapidly than the other and become irritated. Second,
when both muscle pairs are too short, excessive tension reduces joint space
and limits range of motion. If restoring muscular balance normalizes the
joint, muscles are more likely than joints to be the cause of disability.
Meltzer's Law of contrary innervation states that all living functions are
controlled by two opposing forces. This law relates to the Chinese concept
of yin-yang, which states that opposing and complementary forces control
all nature. In neuromuscular therapy, the opposing forces are inhibition and
facilitation. Inhibition restricts and facilitation promotes.
Muscles move joints by facilitating the agonist and inhibiting the
antagonist. They restrict joint movement by facilitating the agonist and
partially facilitating the antagonist. Muscles stabilize a joint or maintain
posture by facilitating both the agonist and the antagonist (cocontraction).
Facilitating both the agonist and the antagonist prevents movement.
When neuromuscular techniques are used to balance muscles, inhibition
and facilitation have the following uses:

Inhibition:

Lengthen hypertonic muscles (decrease hypertonia and muscle tension)
Strengthen weak muscles (decrease the rate of abnormal contractions)

Facilitation:

Shorten stretched muscles (increase hypertonia and muscle tension)
Strengthen weak muscles (increase the rate of normal contractions)

The standard protocol for using neuromuscular therapy to balance
muscles or muscle groups has six steps:


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1. Evaluate length by range-of-motion testing.
2. Use inhibition to lengthen restricted tissues.
3. Evaluate strength by muscle testing.
4. Use facilitation to strengthen weak muscles.
5. Evaluate length first and then strength.
6. If needed, treat again with inhibition or facilitation.

The underlying principle that applies to almost any method of soft-tissue
therapy is (1) lengthen first, and (2) strengthen second. Rarely would it be
advisable to strengthen a muscle with a limited range of motion. Even if the
muscle becomes stronger, any rapid movement that encourages the muscle
to achieve its normal length could result in tearing.
If one muscle is too short, the opposing muscle is too long, and both
muscles are weak, lengthen the short muscle first. This will decrease tension
on the longer muscle and help it assume its normal length. After the short
muscle is lengthened, strengthen the long muscle to increase tension on the
short muscle. If two opposing muscles test long and weak, which is unlikely
except in cases of hypermobility, strengthen both muscles and then monitor
length to ensure that both muscles shorten to a normal length.
If a muscle is abnormally short and weak but correcting the shortness
may require extensive treatment, lengthening and strengthening can be
combined to avoid deconditioning the muscle and possible atrophy. The
first half of the treatment should focus on lengthening restricted tissue, and
the second half of the treatment should focus on strengthening the muscle.
Neuromuscular therapy deals with muscle function more than trigger
point therapy, connective tissue therapy, or range-of-motion stretching. The
three main neurologic conditions that contribute to loss of muscle function
are (1) hypotonia or loss of tone, (2) decrease of contractile strength, and (3)
changes in activation or recruitment patterns. All three of these conditions
relate directly to proprioceptors called muscle spindles or Golgi tendon
organs (GTOs). (Muscle spindles and GTOs are also mechanoreceptors.)
Tone is caused by slight, continuous, partial contractions of a muscle
while a person is conscious. Tonic contractions increase a skeletal muscles
resistance to passive elongation and help postural muscles stay at a fairly
constant length. Muscle spindles and GTOs regulate tone at the reflex level.
Without tonus, muscles become flaccid and the body cannot maintain
posture. With too much tonus, the body becomes rigid and cannot move.
Greater than normal tone is called hypertonia and less than normal tone is


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called hypotonia. Resulting from hypertonia with exaggerated tendon
reflexes, spasticity causes movements to be awkward or stiff.
The force generated by a muscle is determined by the number of motor
units contracting within the muscle. This number is controlled by two
factors: (1) the number of motor units contracting at the same time, and (2)
the frequency at which motor units are contracting. Recruitment controls the
number and frequency of motor units contracting and also the order of
activation. If recruitment patterns are defective, a muscle may not be able to
generate normal strength and movements may not be smooth.
In a broader sense, recruitment also controls the proper sequencing of
individual muscles. When body parts move, muscles normally follow a
specific sequence of activation. Synergists and stabilizers are normally
activated before the agonist, and the antagonist normally relaxes when the
agonist contracts. If a synergist or stabilizer becomes dysfunctional,
movements may not be strong, smooth, or continuous. If two opposing
muscles both contract (cocontraction), the body part may not move.
In addition to pain, fatigue, and nerve damage, abnormal changes in
proprioceptive input can adversely affect recruitment. If they occur without
pain, changes in recruitment may not be obvious to the patient. Mirrors,
videos, or photographs can often be used to demonstrate abnormal changes.
Inhibition caused by changes in joint space may also occur without pain.
If muscle tension decreases joint space enough to slightly irritate the joint,
mechanoreceptors may cause weakness without causing significant pain. It
is not uncommon to find joints that are weak and swollen, but not painful.
Proprioceptors respond to stimulus such as pressure, equilibrium, or
stretch and give information concerning movements or positions. Because
they are easy to activate and control, muscle spindles and GTOs are often
used to facilitate or inhibit muscles. While both respond to passive stretch,
GTOs are more sensitive to active stretch than muscle spindles.

Inhibition

The three main ways to inhibit a muscle are (1) proprioceptive
inhibition, (2) post-isometric relaxation, and (3) reciprocal inhibition.
Proprioceptive inhibition includes direct manipulation of muscles spindles
and Golgi tendon organs. Since hypomobility and limited ROM are more
common than hypermobility and increased ROM, proprioceptive inhibition
is normally used before proprioceptive facilitation.


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Proprioceptive Inhibition

Soft-tissue therapy uses two methods of proprioceptive inhibition: (1)
compression of muscle spindles, and (2) activation of Golgi tendon organs.
While compressing muscle spindles is often easier and more effective than
stretching GTOs, both techniques are useful.
To use the first method, compress the belly of a muscle toward the
center until the intrafusal fibers in the muscle spindle become slack and
cause reflex inhibition. This can be done by grasping the muscle near the
musculotendinous junctures and using convergent force to compress the
belly of the muscle until both hands meet near the center.
The direction of push is parallel to the muscle and the rate of push is
slow enough for tissues to thin out, melt down or dissolve as the fingers
move toward the center of the belly. The need for anything more than
moderate force indicates that movements are too fast. Hypertonic muscles
will normally relax and test weak after muscle-spindle inhibition.
To use the second method of proprioceptive inhibition, apply tension to
GTOs by using range-of-motion stretching that increases the distance
between the distal and proximal insertion of a muscle (origin and insertion).
This activates GTOs by increasing tension on the tendons. It appears that
GTOs protect muscles against overstretching. Extremity muscles are often
easier to inhibit by stretching than torso muscles. Inhibition and stretch
weakness may also be caused by decreasing the overlap (interdigitation)
between actin and myosin filaments in a sarcomere or by activating the joint
receptors in ligaments that are almost identical to GTOs .
In addition to stretching, direct pressure seems to activate GTOs and
cause reflex inhibition. If a muscle is hypertonic, heavy digital pressure
applied to the tendon where it attaches to the muscle will often decrease
tonus. The concentration of GTOs is greater near the musculotendinous
junction than where the tendon inserts into periosteum or bone. Pressure
applied across the longitudinal axis of a tendon may also cause inhibition.
Where inhibition caused by stretching GTOs is called stretch weakness,
inhibition caused by pressure on GTOs is called pressure inhibition.
Pressure on a tendinous insertion may also cause pressure inhibition by
activating pacinian corpuscles. Other terms that are often used to describe
GTO inhibition are lengthening reaction and autogenic inhibition. Since
autogenic implies self-induced, autogenic inhibition refers to inhibition
caused by contraction more than inhibition caused by passive stretching.


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Post-Isometric Relaxation (Inhibition)

Fatigue can be used to inhibit contraction. If hypertonic muscles
contract isometrically for about 10 seconds and then relax, the refractory
period that follows contraction decreases neurologic efficiency. According
to the rebound phenomena, muscle should have a tendency to relax after
being strongly contracted. During the refractory period, muscles become
hypotonic and easier to stretch. Isometric contractions may also cause
autogenic inhibition because of tension on the Golgi tendon organs. The
technique of stretching a muscle after an isometric contraction is called post-
isometric relaxation. The sequence is contractrelaxpassive stretch.
If isometric contractions are too strong, accessory muscles may contract
and irritate the muscles that need to be stretched. Moderate contractions will
discourage other muscles from being recruited. Contractions can still be
effective at 10% maximal effort with a 5-second hold. Muscle should be
held in a slightly stretched position during contraction. Cycles of contract-
relax-stretch can be repeated up to 5 times with stretches 30 seconds long.
If post-isometric relaxation is used, breathing cycles should correspond
with periods of contraction against isometric resistance and relaxation. The
best method is having the patient (1) exhale during contraction, (2) inhale
during the first stage of relaxation, and (3) exhale during the second stage of
relaxation as muscles are being slowly stretched by low levels of force.

1. Patient exhales and contracts (practitioner applies counterforce).
2. Patient inhales and relaxes (practitioner stops counterforce).
3. Patient exhales and deepens relaxation (practitioner stretches muscle).

After the basic three-part sequence of contractrelaxpassive stretch, the
patient should be encouraged to actively stretch the target muscle. The
sequence would then become contractrelaxpassive stretchactive stretch.
While most advocates of post-isometric relaxation recommend using
moderate contractions before stretching, a few recommend using maximal
contractions. After placing a muscle about midway between full contraction
and full extension, the patient is told to contract with maximum effort for
about 10 seconds and then relax. After the patient relaxes, the slack is
quickly taken up and the muscle is stretched for about 30 seconds. This
sequence can be repeated 5 times. Normally used for chronically shortened
muscles, maximal contractions increase the risk of tissue damage and pain.


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Reciprocal Inhibition

When muscles work in pairs, facilitation of the agonist causes reciprocal
inhibition of the antagonist. As the agonist contracts, the antagonist relaxes
to allow stretching by the agonist. Relaxation of the agonist is apparently
caused by a reflex activity that allows proprioceptors in the agonist to
interact with proprioceptors in the antagonist.
If the antagonist fails to relax, the agonist may test weak despite normal
strength. Coordinated movement is possible because one muscle relaxes
when the opposing muscle contracts. Anything less than total relaxation of
the antagonist restricts shortening of the agonist.
If a flexor muscle is hypertonic, contracting the opposing extensor
muscle should cause the flexor muscle to relax. If a flexor muscle such as
the biceps brachii is in spasm, contracting the triceps brachii should cause
the biceps brachii to relax. If contracting the triceps brachii stretches the
biceps brachii, the stretching may help to relax spasm in the biceps brachii.

Stretching to Reset Proprioceptors

After relaxing a muscle that is abnormally short because of spasm or
hypertonia, the final step is stretching the muscle to reset proprioceptors and
prolong the effects of therapy. Once reset, a proprioceptors old memory is
replaced by a new memory. If the old memory represents hypertonia and
limited length, range-of-motion stretching can be used to establish a new
memory that represents normal tonicity and length.
The mechanism that muscles use to store memory is poorly understood.
Unlike viscoelastic materials, such as connective tissue, that have an elastic
memory based on physical properties, proprioceptive memory seems to
involve a complex interaction between proprioceptors, muscle tissue, spinal
nerves, and the brain. Whereas elastic memories respond to physical force,
proprioceptive memories respond to physical force and psychological stress.
In soft-tissue therapy, the normal sequence for using inhibition with
ROM stretching is (1) relax muscles by using inhibition, and (2) lengthen
tissues by using ROM stretching. If ROM stretching is used to reset
proprioceptors, using inhibition techniques before ROM stretching reduces
the risk of tissue damage. Although ROM stretching is not considered a
method of inhibition, when used slowly and progressively, it does produce
some degree of inhibition and can be used to reduce hypertonicity or spasm.


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Facilitation

Most facilitation techniques are based on activation of muscle spindles.
Forces that reduce the tension on muscle spindles have a tendency to inhibit
contraction, while forces that increase tension on muscle spindles have a
tendency to facilitate contraction. Facilitation can be used without inhibition
if muscles test weak but are able to achieve full range of motion when tested
passively. The three main ways to facilitate a muscle are (1) activation of
the stretch reflex, (2) muscle spindle facilitation, and (3) repeated
contractions.

Activation of Stretch Reflex

Muscle spindles react to sudden stretching by a reflex contraction called
a stretch reflex, myotatic reflex, or Liddell-Sherrington reflex. What is often
called a tendon reflex is actually caused by activating a stretch reflex.
Sharply striking the patellar tendon rapidly stretches the quadriceps muscle
and causes a "knee jerk." The stretch reflex is a protective mechanism that
guards muscles from being actively or passively stretched too quickly.

Muscle Spindle Facilitation

The highest concentration of muscle spindles is found in the belly of the
muscle. The safest way to facilitate a skeletal muscle is by grasping the
belly of a muscle near the center and using divergent force to stretch the
muscle in opposite directions away from the belly. The direction of pull is
parallel to the muscle and the rate of pull is faster than pulling to lengthen a
muscle, but not fast enough to cause pain. Weak muscles will normally test
stronger after facilitation. Other ways to facilitate a muscle are plucking,
tapping, rapidly shaking, and briefly applying ice to the belly of the muscle.

Repeated Contractions

If a muscle is capable of reaching its full range of motion, repeated
isometric or isotonic contractions will facilitate and strengthen the muscle.
While facilitation reverses the effects of inhibition, improves neurologic
efficiency, and helps a muscle achieve its normal strength, only progressive-
resistance exercises can strengthen a muscle beyond its normal limit.


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If a muscle is bilateral, such as the biceps brachii, contracting the biceps
muscle on one side of the body will sometimes facilitate the biceps muscle
on the opposite side of the body. Through a process called irradiation,
strong contractions can spread nervous impulses and recruit synergistic
muscles that directly or indirectly help the agonist.
The breathing sequence for quick repeated contractions is (1) exhale
during contraction, and (2) inhale during relaxation. The sequence for slow
repeated contractions is (1) exhale during the initial stage contraction, (2)
inhale during the final stage of contraction, and (3) exhale during relaxation.
Even though individual muscles are sometimes facilitated to improve
neurologic efficiency, the brain thinks in terms of movement, not individual
muscles (Beevors Axion). If one muscle contracts to produce a movement,
other muscles are normally acting synergistically to enhance the movement.
Patients who try to move by consciously contracting individual muscles
often develop a condition that resembles ataxia, the inability to coordinate
muscles during a voluntary movement. In sports training this condition is
sometimes called paralysis by analysis. To avoid incoordination, encourage
patients to think in terms of movement, not in terms of individual muscles.

Muscle Palpation

Palpation can be used to determine the presence of contraction or to
monitor the strength of contraction. Touching a muscle, along with verbal
instructions or mirrors, can be used to help patients focus on a particular
muscle. Touching a muscle is very effective when patients cannot follow
verbal commands or see the target muscle. If touching is done with a series
of solid taps, the tapping itself may help to facilitate the muscle.
Touching the muscle during contraction and giving verbal or visual
feedback can be used to enhance contraction or relaxation. Light pressure
seems to encourage facilitation and deep pressure seems to encourage
relaxation. A workable sequence is (1) apply light pressure as the muscle
contracts, and (2) apply moderate to heavy pressure as the muscle relaxes.
Palpation can also be used to determine the absence of contraction or to
monitor a muscles ability to relax. If muscles are bilateral, both muscles can
be palpated simultaneously to compare one with the other.
If contraction in one muscle is weaker than in the other, measure both
muscles and compare size. If the patient is right-handed, and the muscle on
the right side is weaker and smaller, atrophy may be present.


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CONNECTIVE TISSUE THERAPY

Connective tissues support and connect other tissues. Compared with
most other types of tissue, connective tissues have very few cells. The bulk
of connective tissue is composed of an intercellular substance or matrix that
gives each type of connective tissue its own particular properties. With the
exception of cartilage, most connective tissues are highly vascular.
Examples of dense fibrous connective tissue are tendons, ligaments,
aponeuroses, deep fascia, and dermis. Other forms of connective tissue are
bone, adipose tissue, and cartilage.
Connective tissues have three main components: cells, fibers, and
matrix or ground substance. The most common mechanical properties of all
connective tissues except bone are elasticity and plasticity. Elastic materials
yield to stress and then resume normal shape. Plastic materials yield to
stress and remain permanently deformed.
Immobilization after an injury increases the density of collagen and the
frequency of cross-bridging between fibers. The cross-bridging makes
collagen fibers more resistant to passive stretch and less mobile. Stretching
and exercise increase flexibility by reducing the number of cross-links.
The ability of ground substance to hold water allows for diffusion of
metabolites between capillaries and cells. The presence of hyaluronic acid
in ground substance reduces friction by increasing water retention.
Hyaluronic acid molecules form large random chains that are filled with
water. Proteoglycans such as hyaluronic acid give tissues elasticity and
resistance to compression.
Excessive water retention produces higher tissue tension and greater
resistance to pressure. Tissue tension is a palpable sign that frequently
occurs during inflammation or after trauma. High degrees of edema reduce
mobility by increasing tissue tension and causing spasm.
Reduced water retention, on the other hand, increases friction between
fibers and causes cross-bridging. Friction and cross-bridging irritate tissues
and reduce mobility. Without water retention, tissues lose elasticity.
Three principles explain the mechanics behind connective tissue therapy:

1 Thixotropy
2 Hysteresis
3 Creep


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Thixotropy

Thixotropy is a two-part property of certain gels: (1) the gels become
liquid when agitated by any force that puts energy into the system, and (2)
the liquids revert to gels when the energy dissipates. The energy input from
manipulationcompression, tension, or shearis friction or heat.
The gel-sol (gelatum to solution) theory proposes that aqueous (watery)
solutions within connective tissue become highly viscous during long
periods of inactivity and produce a sticky gelatinous substance (gel) that
limits tissue mobility. A gel is the solid or semisolid phase of a colloidal
solution, and a sol is the liquid phase. Colloidal solutions are formed by
dispersing submicroscopic particles, such as proteins, in a liquid.
Because of thixotropy, connective tissue manipulation is thought to
increase tissue mobility by liquefying viscous gels, decreasing tissue
viscosity, and reducing tissue tension. Viscosity is a stickiness that causes
tissues to bind with each other and tissue tension stimulates reflex activity
that facilitates muscle contractions. Reducing viscosity allows tissues to
slide freely over each other and decreasing tissue tension reduces reflex
facilitation that causes hypertonia. Because of thixotropy, tissue may give
the appearance of thinning out or melting down after manipulation.

Hysteresis

According to the concept of hysteresis, cyclic loading causes viscoelastic
materials to soften and change shape because energy is lost in the form of
friction and heat. Cyclic loading refers to cycles of loading and unloading
such as pullandrelease or pushandrelease. Connective tissue (collagen)
is considered a viscoelastic material because of two properties: viscosity
and elasticity. Even with low magnitudes of force, connective tissue will
lengthen progressively without tearing or rupture if cyclic loading reduces
the energy that binds the tissues together.
Hysteresis can be used to lengthen abnormally short connective tissue by
following a sequence of (1) slow stretch, (2) 5-second hold, and (3) slow
release. This sequence should be repeated about 10 times. Repeated bouts
of stretch, hold, and release should cause a permanent increase in tissue
length without significant tissue damage. Because of hysteresis, cyclic
loading can also be used to relieve tissue congestion by improving vascular
flow and lymphatic drainage.


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Creep

Creep is defined as deformation of viscoelastic materials when exposed
to a slow, constant, low-level force for long periods of time. When
individuals stand on their feet all day long, they become shorter by the end
of the day because of creep. Even though body weight does not change, the
steady load from body weight causes deformation of intervertebral disks and
subsequent loss of height. The principle of creep applies directly to
myofascial release as found in osteopathy. The application of heat tends to
accelerate lengthening because of creep in muscles and tendons.
After the patient is properly positioned for access and comfort, tissues
are stretched carefully until solid resistance is felt. Small degrees of
constant tension are then applied steadily until the tissues start to relax and
lengthen. The point at which tissues start to lengthen is sometimes referred
to as a meltdown or release. Constant tension is continued until the tissues
are fully elongated or no further stretching is needed. The keys to using
creep effectively are (1) minimize force and (2) maximize time.
Once a tissue is fully elongated, the body part should be held in this
position long enough for the tissue to fully relax. This can be done without
using additional force. According to biomechanics, when deformation is
held constant, internal stresses within a structure will decrease with time.
Holding tissues in position long enough for total relaxation to occur will
increase the probability that changes in tissue length will be permanent.

Adhesions

Range-of-motion stretching and topical stretching will sometimes break
the adhesions that form during the wound-healing process. Adhesions are
abnormal fibrous bands that connect tissues that are normally separate.
Adhesions that form between the dermis and superficial fascia in
response to inflammation or trauma are fairly common. Depending on how
the attachments form, adhesions may or may not be symptomatic.
Adhesions that irritate nerves or restrict mobility are symptomatic.
Adhesion and skin restrictions frequently occur over the scapulas. If
adhesions prevent the dermis from sliding freely over the top of underlying
structures, limited loss of mobility and pain are possible. When adhesions
break, relief from pain is almost immediate and the skin starts to move freely
again.


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Skin Rolling

Skin rolling is a combination of tension, compression, and bending
applied to skin and subcutaneous fascia. The reasons for skin rolling are (1)
break adhesions, (2) increase tissue mobility, and (3) improve fluid
dynamics. Skin rolling can be used effectively over the scapulas and lower
back because superficial tissues in these areas are often loose and pliable.
Using both hands together, the sequence for skin rolling is (1) use the
balls of the thumbs and forefingers to pull skin away from the patients body
and create a skin fold, and (2) use the forefingers to pull the skin fold back
toward the practitioner and bend it skin over the ball of the thumbs.
Once created, the skin fold is moved forward by (1) using the balls of
each thumb to push the skin fold forward while (2) the finger tips of each
hand pull new skin back over the thumbs. If adhesions are detected in areas
where skin is loose, skin rolling will normally generate enough tension to
break the adhesions. If adhesions are not released by skin rolling, the
thumbs and forefingers can be used to pull the skin fold farther away from
the patients body. When adhesions break, the rupture can often be heard as
a popping or snapping sound or felt as a sudden release of tension.
Skin rolling is used to release fibrous adhesions that connect skin or
superficial fascia to deep fascia. If skin is too sensitive for skin rolling,
gently pinching the skin until the thickness decreases will often reduce
tenderness enough to allow skin rolling. After skin rolling, deep, slow
stroking with the fingertips or thumbs can be used to disperse fluids, sedate
muscles, and neutralize hyperalgesic (overly sensitive to pain) skin zones.
Tender points characterized by an increased thickness in skin or
subcutaneous tissue will often respond to skin rolling. Once these tender
areas are located, the skin should be pinched and held in place until the
tissues palpably soften enough to allow skin rolling. This technique may be
painful, and superficial edema or subcutaneous fat often make it difficult to
even form a skin fold. Tender points of this nature may be aggravated by
heat and are often found adjacent to the lumbar spine and sacrum.

Skin Pulling

Even though the low back seems to be more sensitive to skin rolling than
the shoulder, some patients will find skin rolling anywhere painful and
difficult to tolerate. For these patients, pulling loose skin directly away from


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the body can be used in place of skin rolling. Body parts can be repositioned
to reduce cutaneous tissue tension in the areas being treated.
Skin pulling begins by using minimum force to pull loose tissue away
from the body and hold the position long enough for tissues to relax (creep).
The pressure generated by holding the tissues in place will cause some
degree of tissue thinning (thixotropy). The process is repeated several times
to maximize tissue mobility (hysteresis). For breaking adhesions, range-of-
motion stretching is not as effective as skin rolling or skin pulling. Once
tissue mobility is restored, ROM stretching will help to preserve mobility.
Adhesions and restrictions are less likely to reform if body parts are
mobilized on a regular basis. Without continuous passive mobilization,
adhesions and restrictions have a tendency to recur in the same place.

Cross-Fiber Friction

Cross-fiber friction combines digital pressure with perpendicular force to
produce local friction as fingers or thumbs move back-and-forth across a
tissue such as a tendon or ligament. Normal treatments are 10 to 20 minutes,
twice a week. Because of the need for deep friction, lubricants are not used.
Another name for cross-fiber friction is transverse friction.
Linear force can be produced in two ways: digital stroking over the top
of a stationary body part or stationary digital pressure over the top of a
moving body part. Cross-fiber friction is applied to the subscapularis tendon
by stroking back and forth with the thumb, whereas cross-fiber friction is
applied to the biceps tendon along the bicipital groove by holding the fingers
stationary and rotating the humerus back and forth.
The justifications for cross-fiber friction are that it should (1) break
adhesions, (2) reduce cross-links between connective tissue fibers, and (3)
align scar tissue parallel to lines of stress in accordance with Wolffs law.
Cross-fiber friction may produce hyperemia that promotes healing and
reduces pain by dispersing pain-producing chemicals, acting as a counter-
irritant, or stimulating the body to produce endorphins.
With the exception of breaking adhesions or helping to align scar tissue,
the effects produced by trigger point therapy and cross-fiber friction are very
similar. Since trigger point therapy is faster and less painful than cross-fiber
friction, the main justification for using cross-fiber friction relates to
adhesions and scar tissues.


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What cross fiber-friction does more effectively than trigger point therapy
is shear the cross-links between collagen fibers that form during the early
stages of wound healing. Where trigger point therapy tends to focus on
muscles and fascia, cross-fiber friction is normally applied to connective tissue
structures such as tendons or ligaments.
Since trigger point therapy combined with range-of-motion stretching
seems to be more effective in preventing adhesions and helping to align scar
tissue than cross-fiber friction, the best time for using cross-fiber friction is
during the early stages of an injury when even passive mobilization is not
recommended because of pain, spasm, or tissue disruption.
During the early stages of wound healing, friction should be light and
superficial to avoid disrupting properly placed scar tissue. Though some
degree of passive mobilization should begin as early as possible, applying
cross-fiber friction directly over a lesion may improve wound healing.
Trigger point therapy can also be used in combination with cross-fiber
friction. When used together, trigger point therapy desensitizes hyperesthetic
(sensitive) tissues and cross-fiber friction moves and stretches connective
tissue. Ice can be used before trigger-point therapy or cross-fiber friction to
induce analgesia.
Though cross-fiber friction can produce some degree of anesthesia, the
process is normally more painful than trigger point therapy. To induce
anesthesia, the treatment should begin with light pressure and limited
movement and progress to heavier pressure and deeper movement. Instead of
anesthesia, many patients report that pain intensifies during the initial minutes
of treatment and continues without abatement until cross-friction is stopped.
The recommended frequency for cross-fiber friction, like most forms of
soft-tissue manipulation, is twice a week. This allows tissue enough time to
recover between treatments. Cross-fiber friction should not be used for more
than about two weeks. After two weeks, other forms of manipulation such as
trigger point therapy and neuromuscular therapy are normally more effective.
Cross-fiber friction tends to be ineffective when used alone. Before a
tendon is treated, the muscle attached to the tendon should be treated with
trigger point therapy or neuromuscular therapy to reduce pain and spasm.
Cross-fiber friction is not recommended for the belly of a muscle. After cross-
fiber friction, partial or complete range-of-motion stretching will help to
relieve muscle tension on the tendon if tissues are stable enough to permit
stretching. Icing contact points for about 20 minutes after manipulation
reduces the possibility of therapy-induced (iatrogenic) pain or swelling.


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To avoid digital fatigue when using cross-fiber friction, practitioners can
use fingers from the same or opposite hand to reinforce the fingers that are
doing the actual stroking. (Finger is defined as any one of five digits on the
hand, including the thumb.)
To avoid excessive joint compression, digits should not be elevated more
than about 30 degrees above the surface of the patients skin. Below 45
degrees, more force is directed horizontally than vertically. At 45 degrees,
vertical and horizontal forces are equal. At angles greater than 45 degrees but
less than 90 degrees, vertical force is greater than horizontal force. At 90
degrees, all force is directed downward with no horizontal component. The
higher the angle, the greater the downward pressure on the patient and the
greater the pressure on the practitioners digital joints.
Whether finger-shaped objects made of wood, metal, plastic, or rubber
with various types of handles are used in place of fingers or thumbs when
administering cross-fiber friction or trigger point therapy is a matter of
personal choice. The advantage of using devices such as a T-bar is being able
to generate high degrees of pressure without causing digital stress. The
disadvantage is losing the sensitivity of human touch.
Since the need for high degrees of force in soft-tissue therapy is minimal if
pressure is applied slowly and correctly, the disadvantages of using special
devices to administer cross-fiber friction or trigger point therapy may outweigh
the advantages. Despite the popular trend in therapy that favors replacing
manual medicine with machines, there is still no substitute for the sensitivity
of human touch.

Layers

A general practice in connective tissue therapy is to view the body as a
series of layers. When muscles are placed in a stretched position, working
superficial layers first will make it easier to reach the deeper layers. After the
tissue consistency of a superficial layer changes from hard to soft, the next
layer below should be easier to palpate, and the amount of force needed to
work the deeper layer should be about the same as the amount of force needed
to work the layer above. While the primary purpose of this technique is to
reach and work deep connective tissue such as fascia, possible secondary
benefits include neutralization of trigger points and release of endorphins.
The concept of layers also applies to palpation where superficial tissues are
palpated before deeper tissues. The process is called layer palpation.


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RANGE-OF-MOTION STRETCHING

Range-of-motion (ROM) stretching is the fourth and final method of
manipulation. The soft tissues affected by ROM stretching include muscles,
tendons, fascia, ligaments, and joint capsules. ROM stretching lengthens
muscles and tendons by increasing the distance between the origin and
insertion. The direction of pull is opposite that of the muscle's action.
A muscle is an organ composed of three types of tissue: muscle tissue,
nerve tissue, and connective tissue. If a muscle is normal and the joints the
muscle crosses are normal, connective tissue such as fascia is far more likely
to restrict active or passive stretching than muscle tissue. If a muscle is
hypertonic and the joints the muscle crosses are normal, muscle tissue is
more likely to restrict active or passive stretching than connective tissue.
When the body is functioning normally, the resistance to movement
caused by muscles and tendons is about equal to the resistance caused by
joint capsules, ligaments, and skin. Pathologic joint conditions involving
inflammation, infection, bony anomalies, or connective tissue disease may
increase or decrease the amount of resistance produced by joints
Since connective tissue is both viscous and elastic, it follows the same
laws of physics that apply to other viscoelastic materials. These laws
include hysteresis and creep. Because of proprioceptors such as muscle
spindles and Golgi tendon organs, muscle tissues are controlled more by
neuromuscular properties than by viscoelastic properties. The main
principles that apply to muscle tissue are based on inhibition or facilitation.
Dehydration or calcification can reduce the elasticity of any soft tissue.
The reason for therapeutic range-of-motion stretching is to help joints
achieve or maintain a normal range of motion by lengthening pathologically
shortened tissues. A joint is biomechanically most efficient when a joint is
neither too stable (rigid) nor too mobile (loose). Increasing a joint's ROM
beyond normal decreases stability and may cause dislocation. Decreasing a
joint's ROM to less than normal decreases mobility and may cause rigidity.
If trigger point therapy is used to reduce pain or neuromuscular therapy
is used to lengthen a muscle by reducing tonus (inhibition), range-of-motion
stretching should be used afterward to reset the gamma motor neurons and
help the muscle spindles readjust to the muscles new length. Range-of-
motion stretching can also be used to relieve or prevent cramps, reduce
muscle soreness, improve posture, and promote general relaxation.


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Because of human touch and the ability to measure the direction and
magnitude of resistance, manual stretching is normally safer and more
effective than mechanical stretching by machine. Patients have the option of
verbally or physically resisting a stretch when stretching is done by the
dexterous use of the hands and not by machine.
Although range-of-motion stretching is normally safe because patients
have the ability to stop the tension at any time, caution must be used not to
overstress healing tissues. Stress applied early during the wound-healing
process (1) promotes remodeling and proper alignment of scar tissue, (2)
increases lubrication that allows glide between fibers, and (3) improves
flexibility by reducing cross-links and breaking adhesions. Excessive stress,
on the other hand, can disrupt tissues and slow the healing process.
Stretching is seldom beneficial until the acute stage of injury is over, as
indicated by the absence of swelling or subcutaneous bleeding. Since scar
tissue production is greatest during the first three weeks of wound healing,
stretching to improve mobility should begin shortly after the acute stage.
Two general factors that promote stretching are relaxation and heat.
Patients should be as physically and mentally relaxed as possible before,
during, and after stretching. Techniques that encourage relaxation include
light massage, supportive conversation, and deep breathing. Environmental
factors such as soft music, warm temperatures, and pleasant aromas may
also encourage relaxation. The treatment environment should not distract
the patient and the patients posture should be conducive to relaxation.
Heat increases tissue extensibility and promotes stretching, while cold
decreases tissue extensibility and retards stretching. Heat can be produced
by heating agents or warm-up exercises. Where most heating agents elevate
deep or superficial tissue temperatures, exercise elevates core temperatures.
After a tissue is heated and stretched, cooling the tissue before tension is
released may help to increase the amount of permanent elongation.
To increase ROM stretch, some muscles can be positioned in ways that
partially stretch a muscle before active or passive movements are used to
increase the distance between the origin and insertion. Although the biceps
brachii is almost fully stretched when the arm is hanging downward and
elbow is fully extended, extending the arm before the elbow is fully
extended will cause even greater stretch. The same principle can be applied
to the hamstrings. Even though the hamstrings are almost fully stretched
when the knee is fully extended, fully flexing the thigh before (and also
after) the knee is fully extended will stretch the hamstrings even more.


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Mechanics of Stretching

The basic factors that control the nature of stretching can be defined by
the acronym DAVID.

Duration: holding period.
Angle: direction of pull.
Velocity: rate of loading.
Dosage: repetitions and frequency.

The duration of the holding period after tissues are stretched can be used
to separate static stretching from dynamic stretching. The holding period for
static stretching is normally several seconds to several minutes. The holding
period for dynamic (ballistic) stretching is practically nonexistent.
The two basic angles of pull are longitudinal or parallel to the tissue
being stretched and lateral or perpendicular to the tissue being stretched.
ROM stretching is longitudinal because tension is applied by separating the
origin and insertion of a muscle. When digital pressure is used, a muscle
can be stretched in either a lateral or longitudinal direction.
The two basic velocities used in stretching are fast and slow. While
these terms are far from exact, ballistic stretches that involve jumping or
bouncing are considered fast and stretches where the lengthening of tissue is
barely perceptible to the eye are considered slow.
The two basic intensities used in stretching are high and low. Intensity is
difficult to quantify because the same amount of force considered low when
stretching a large muscle may also be considered high when stretching a
small muscle. Many practitioners use pain to indicate force. The presence
of pain indicates high force and the absence of pain indicates low force.
Dosage refers to the number of stretches per session (repetitions) and the
number of sessions per day or week (frequency). Multiple-repetition
stretching normally use 3 to 12 repetitions per session, and single-repetition
stretching normally uses 1 repetition per session. The frequency can be as
high as 2 sessions per day or as low as 2 sessions per week. The frequency
is often higher for subacute injuries than chronic injuries.
By using the five basic factors identified by the acronym DAVID
Duration, Angle, Velocity, Intensity, and Dosagefive basic concepts
relating to range-of-motion stretching can be stated.


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Duration A long-duration stretch is more likely to produce a permanent
increase in tissue length without causing tissue damage than a short-
duration stretch.

Angle Longitudinal range-of-motion stretching is more likely to produce
a permanent increase in tissue length than longitudinal or lateral
stretching produced by local pressure with the hands or elbows.

Velocity Low-velocity static stretching is more likely to produce a
permanent increase in tissue length without causing tissue damage than
high-velocity dynamic (ballistic) stretching.

Intensity Low-intensity stretching is more likely to produce a permanent
increase in tissue length without causing tissue damage than high-
intensity stretching. (Low intensity implies a low load or low force.)

Dosage It is safer and more effective to increase the number of stretches
and make smaller gains per stretch with less force than to decrease the
number of stretches and make larger gains per stretch with more force.

Two Basic Types of Stretching

There are many varieties of stretching, and each method seems to have
its own merits. A competent practitioner should be familiar with at least
three types of preliminary manipulation and two basic types of stretching.
The three main types of preliminary manipulation that prepare tissue for
range-of-motion stretching are (1) trigger point therapy to relieve pain and
reduce spasm, (2) neuromuscular therapy to inhibit muscles and reduce
spasm, and (3) connective tissue therapy to break adhesions.
In addition to standard neuromuscular techniques such as proprioceptive
inhibition and reciprocal inhibition, other methods of inhibition include: (1)
rocking motions applied slowly and rhythmically to the body, (2) stroking,
pinching, or tapping techniques applied gently to the skin that overlies
hypertonic muscles, and (3) mechanical or manual vibration applied to body
parts affected by hypertonic muscles.
The two basic types of ROM stretching used in HEMME APPROACH are
(1) multiple-repetition stretching, and (2) single-repetition stretching. While
both methods use slow, progressive force to generate tension, the holding


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period between stretch and release is shorter in multiple-repetition stretching
than in single-repetition stretching.
Both multiple-repetition and single-repetition stretching are considered
static stretching because tension is mostly isometric and produces very little
movement. Ballistic stretching uses isotonic tension and produces a rapid,
rhythmic movement that is often described as bouncing or bobbing. While
ballistic stretching has practically no holding period, multiple- and single-
repetition stretching have at least a few seconds between stretch and release.

Multiple-Repetition Stretching: This method is based on hysteresis
and uses multiple repetitions of low-force stretching with a short holding
period to permanently increase tissue length. Viscoelastic materials, such as
connective tissue, lose energy and become more pliable when subjected to
multiple cycles of stress and relaxation. To reduce the risk of causing tissue
damage, the stretch should be slowly applied and slowly released.
Although the average number of repetitions is normally 3 to 12, the
numbers of repetitions can be increased if the intensity of each repetition is
decreased. The holding period for multiple-repetition stretching should be
long enough for tissue tension to decrease at the end of each stretch, about 3
to 15 seconds. While 3 sessions of stretching per week is about average, the
intensity can be decreased and the number of sessions per week increased if
stretching is causing too much pain or discomfort for the patient.

Because the first stretch in multiple-repetition stretching is more likely
to break adhesions or loosen restricted tissue than subsequent stretches,
the force needed for the first stretch may be greater than the force needed
for the following stretches. If heating modalities are used before the first
stretch, the need for greater force during the first stretch may be less.

Single-Repetition Stretching: This method is based on creep and uses
low and continuous force with a long holding period to permanently increase
tissue length. Tissues are held under constant tension until the internal
stresses dissipate and the tissues relax and lengthen. While the holding
period for single-repetition stretching is always longer than 15 seconds,
holding periods longer than 3 minutes are common. More than 1 repetition
per session is seldom required and 3 sessions per week should be adequate.
Because of a longer stationary period, heat is easier to use with single-
repetition stretching than with multiple-repetition stretching.


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Double-Leg Stretch

Single-repetition stretching can be used to stretch two body parts at the
same time. With patients supine and their knees extended, practitioners can
lift one ankle with each hand and then step back until the arms are fully
extended. Traction is then applied to both legs at the same time by stepping
away from the patient. Practitioners should be careful not to hyperextend
their own backs when stepping away from the patient to apply traction.
This stretch can be applied with patients on a table or on the floor.
Although some patients will find it easier to get on or off a table than use the
floor, treating patients on the floor eliminates the risk of having patients fall
from a table while being treated. If the floor is used, exercise mats are
recommended and care should be taken to maintain hygienic conditions.
The double-leg stretch helps to realign soft tissues and bring the iliac
crest on the high side into alignment with the iliac crest on the low side. It
also stretches soft-tissue structures surrounding the head of the femur, which
at times becomes tight enough to reduce joint space and irritate the hip joint.
While minor differences in leg length are seldom symptomatic, this
stretch will sometimes correct apparent differences in leg length. Since most
differences in leg length are functional as opposed to anatomical, corrections
are usually temporary and disappear with normal usage.

Over-Head Arm Stretch

The overhead-arm stretch is another instance of two body parts being
stretched at the same time. To execute an overhead arm stretch, the arms of
the patient should be fully extended overhead and parallel. If the patient is
on a table, the angle between the arms and table should be about 30 degrees
or less depending on the patients comfort. If the patient is on the floor, the
angle will be about the same if the practitioner is sitting on the floor. Many
practitioners find it easier to apply tension while sitting on the floor as
opposed to standing on the floor.
With the palms of the patient facing each other, practitioners should use
a wrist hold on the patient that is similar to the way someone would hold the
handles of a wheelbarrow: firmly but not too tight. Practitioners can apply
tension by leaning back slowly until there is no slack in their arms or the
patient's arms and then hold the stretch long enough for tissue to lengthen
(about 1 to 3 minutes). Even with low force and slow, steady tension, most


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practitioners will feel restricted tissues release and lengthen as the stretch
continues. To avoid using arm strength, practitioners should keep their
elbows fully extended and their arms parallel to those of the patient.
While this technique is sometimes recommended as a method for
improving shoulder symmetry where one shoulder is lower than the other,
small differences in shoulder symmetry are almost universal and normally
asymptomatic. The differences in shoulder symmetry are often caused by
handedness, a preference for the use of one hand, most commonly the right,
over the other. Although handedness is often associated with dominance of
the opposite cerebral hemisphere, it can also result from training or habit.
Because of handedness, the dominant shoulder is often larger, stronger,
and lower than the non-dominant shoulder and may have a greater range of
motion and slight increase in the humeral head retroversion (backward tilt).
Like minor leg-length discrepancies, since most differences in shoulder
symmetry are functional as opposed to anatomical, most corrections can be
expected to disappear if the patient resumes normal usage.
If the overhead-arm stretch is successful, patients will be able to stand
more erect and placing both hands directly overhead should be less difficult.
Many patients find the overhead stretch extremely relaxing and pleasant.
Some patients will feel the effects of overhead stretching all the way down
to their lower back.
As with all stretches, caution should be taken not to injure any joints that
are located within the line of pull. Though traction, in general, seems to
improve joint mobility, any complaints of joint pain while tension is being
applied may contraindicate further stretching.

Fascial Stretching (Myofascial Release)

If a muscle is unable to achieve normal length and muscle tissues are
functioning normally, the restriction is probably caused by abnormally short
fascia. By definition, fascia is a sheet of fibrous connective tissue that (1)
envelops the body beneath the skin, (2) encloses muscles and groups of
muscles, and (3) separates muscle layers or muscle groups. Fascia also
forms sheaths for the nerves and vessels, envelops various organs and
glands, and becomes specialized around joints where it forms or strengthens
ligaments. Superficial fascia lies directly below the skin, and deep fascia is
any fascia that lies below superficial fascia.


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Even though fascial stretching can be accomplished by using deep
pressure with the hands or elbows, range-of-motion stretching is generally
less painful and more effective. The key to fascial stretching is slow, steady
tension with low force. As the duration of stretching increases, the amount
of tension needed to lengthen fascia decreases. Even if the same amount of
lengthening occurs, a 3-minute stretch with low force is less likely to cause
tissue damage than a 1-minute stretch with high force.
When a muscle is stretched, the different bundles of deep fascia
surrounding or separating a muscle do not always lengthen at a uniform rate,
for two reasons. First, the bundles of fascia themselves are not uniform, and
therefore do not always lengthen at a uniform rate. Second, based on
Hookes law, tension is proportional to changes in length until the elastic
limit of a material is exceeded. When stretched below the elastic limit,
fascia returns to its original length when tension is removed. Changes in
fascial length are not permanent until the tissue is stretched beyond the
elastic limit and deforms plastically. Once fascia is stretched beyond the
elastic limit, less force is needed to continue lengthening the same tissue at
the same rate. Stretching fascia beyond the plastic limit will cause rupture.
When fascial stretching is done with slow manual traction, the body part
being stretched may give the impression of lengthening or unwinding by
stages. A similar effect can be produced by flexing the trunk forward and
letting the arms hang freely from the shoulders. As gravity pulls the upper
body closer to the floor, the rate of descent will normally vary by multiple
stages of tightness and release that some people perceive as a twisting or
unwinding of the trunk. Since a standing straight-leg toe touch may cause
back pain, flexion should be stopped well before the fingers touch the toes.
Increases in fascial length are permanent only to the extent that other
forces operating in the body do not reverse the change in length and cause
shrinkage or contraction. Immobility and allowing fascia to remain slack for
extended periods of time are two conditions that encourage fascia to shorten.
If fascia is not maintained by frequent range-of-motion stretching, fascial
length is more likely to decrease than to remain constant.
When fascial stretching is used to improve muscular balance, the
standard sequence is (1) lengthen short muscles by stretching, and (2)
shorten stretched muscles by using facilitation. Since there is no easy way
to shorten fascia, tissues that are not overly short should not be stretched.
Overstretching can decrease stability or coordination, increase the risk of
injuries, decrease mechanical or neurologic efficiency, and cause pain.


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Cross-Over Stretch

Even though cross-over stretching is normally used as a local stretch to
improve tissue mobility, it can also be used for range-of-motion stretching
when applied between the neck and shoulder. To apply the cross-over
stretch with practitioner standing and patient seated, cross the forearms
several inches above the wrists and simultaneously push on: (1) the lateral
surface of the neck and (2) the superior surface of the shoulder. This push-
push movement will increase the distance between the neck and shoulder.
When the forearms are crossed, the contact point becomes a pivot point
or fulcrum between the forearms. Leaning down, while keeping the
forearms crossed, will increase the distance between neck and shoulder by
causing the hands to move apart. As the hands separate, the pivot point will
have a tendency to slide upward toward the elbows.
The cross-over stretch can be used to separate (abduct) the scapulas.
With the patient prone, stand at the patients head (cephalic) and lean over
the scapulas to apply the cross-over stretch. The hands will be pushing
against the medial (vertebral) borders of the scapulas.

Force-Couple Stretch

A force couple can be defined as two equal, opposite, and parallel forces
separated by distance and applied simultaneously to an object to produce
rotation. If hands are placed on opposite sides of a steering wheel and one
hand pushes up while the other hand pulls down, the steering wheel rotates
because the hands have created a force couple. The same push-upand pull-
down principle applies to force-couple stretching.
If hands are separated by distance and placed on the body with one hand
pushing up while the other hand pulls down, tissues, and possibly underlying
structures, will twist or rotate. In physics, forces that produce rotary motion
are called torque and the process of twisting or rotating is called torsion.
In scapulohumeral rhythm, the scapula rotates upward when the upper
trapezius pulls up and serratus anterior pulls down. Since muscles can pull
(contract) but not push, force couples created by internal forces are based on
pulling movements only (pull-pull). When force couples are created by
external forces, push-pull or push-push movements may be easier to use and
biomechanically more efficient than pull-pull movements.


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By placing one hand on the scapula where the upper trapezius attaches and
the other hand on the scapula where the serratus anterior attaches, a
practitioner can use a force couple to mobilize the shoulder and tissues above
the scapula by pushing up with one hand and pulling down with the other.
This technique works best when the patient is prone and the arms are touching
the sides of the body. Force-couple stretching applied to loose tissues over
the scapulas will sometimes break adhesions or release scar tissue faster than
skin rolling.
Once the tissues are mobilized, the scapula can be rotated by abducting the
arm directly overhead and then returning the arm to its original position along
the side of the body. While the arm is overhead, the shoulder joint can be
stretched by gently pulling the arm. The patients hand should be palm down
and the elbow fully extended.
Just as all muscles that cross a joint should be treated when movement
around the joint is deficient, all muscles involved in a force couple should be
treated when rotation of a bone is deficient. Force-couple stretches are
normally followed by range-of-motion stretches.

Ballistic Stretching

In ballistic stretching, muscles are stretched by bouncing movements
with no hold at the end of the movement. Because of a stretch reflex that
causes muscles to contract when suddenly stretched, ballistic stretching has a
tendency to increase resistance to active stretch and cause soreness. When
ballistic movements force a muscle to contract and lengthen at the same
time, the end result can be tissue damage and pain. Because ballistic
stretching is harder to control and more likely to trigger a stretch reflex,
static stretching is often safer and more effective than ballistic stretching.
While not considered the safest or most effective way to permanently
lengthen a muscle, ballistic stretching can be a practical method of stretching
for athletes who participate in sports that require high-velocity ballistic
movement. Training a body part with low-velocity stretches only may not
be sufficient to prepare the body part for competition that requires high-
velocity stretches such as gymnastics, wrestling, or martial arts.
Plyometric training uses ballistic movements and quick muscle stretches
followed by contractions to increase speed and power. Despite the potential
dangers caused by using the stretch reflex and the elastic potential energy in
a muscle to increase explosive power, the method appears to be effective.


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Supplemental Force

Although most forms of ROM stretching rely on manual force, different
ways to supplement manual force include (1) mechanical stretching devices,
(2) passive-assisted stretching, (3) active-assisted stretching, and (4) gravity.
Mechanical stretching devices that are sometimes used by athletes to
increase range of motion are not recommended for therapy because
machines, unlike human touch, cannot measure changes in tissue tension or
respond to complaints of pain by the patient.
One variant of mechanical stretching that can be useful is having the
patient actively stretch a muscle as far as possible and then use a wall, table,
chair, or some other device to hold the body part in place until the muscle
being stretched relaxes. The patient must have the ability to safely
discontinue the stretch at any time if pain becomes too severe. This
approach works well when stretching exercises are done at home.
Passive-assisted or active-assisted stretching can be used if spasm,
contracture, or pain is too severe for active stretching. In passive-assisted
stretching, an external force stretches a restricted agonist to the greatest
length possible within safe and normal limits, and then the patient uses
active contraction by antagonistic muscles to hold the stretch for about 12
seconds. This helps to strengthen antagonistic muscles that may be weak if
shortness in the agonist has caused chronic stretching and stretch weakness.
Passive-assisted stretching is very effective when the active stretch
follows a passive post-isometric relaxation stretch. The sequence would be
(1) the patient contracts and then relaxes the agonist, (2) the practitioner
stretches the agonist, and (3) the patient uses antagonistic muscles to stretch
the agonist. The stretch should be executed slowly with minimal force.
When active-assisted stretching is used, the patient actively contracts
antagonistic muscles during the entire stretch. This not only strengthens
antagonistic muscles, but also helps to improve neurologic efficiency and
coordination. Active-assisted stretching seems to encourage patients to
work harder than they would if they were using active stretching alone.
Gravity is an excellent way to supplement manual force when a body
part can be positioned so that gravity works to stretch the target muscle.
Light manual force combined with gravity or gravity alone can be used to
produce a slow, progressive stretch. Adding weights to increase the weight
of a body part may not be advisable. Joints that tolerate the normal weight
of a body part may not tolerate the weight of a body part with added weight.


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Isolytic Stretching

Stretching a muscle against active resistance by the patient can be used
to lengthen a muscle severely shortened by contracture. To perform isolytic
stretching, the patient slowly contracts the muscle being stretched while the
practitioner uses manual force to overcome the patients resistance and
lengthen the muscle. On the positive side, isolytic stretching increases
muscle length by stretching and breaking down fibrotic tissues. On the
negative side, the risk of torn muscles and ruptured or avulsed tendons
makes isolytic stretching potentially more dangerous than static stretching.
Another positive: isolytic stretching may cause greater reflex inhibition
than static stretching. The Golgi tendon organs that cause reflex inhibition
are more sensitive to the active tension generated by muscle contractions
than the passive tension generated by static stretching. Unlike static
stretching, isolytic stretching produces both active and passive tension.

Deep Breathing

When used properly, breathing facilitates stretching. Deep abdominal
breathing produces general relaxation and the normal sequence for breathing
and stretching is (1) apply tension (stretch) while the patient exhales, and (2)
hold or release tension while the patient inhales. In most cases, breathing
should be slow, smooth, rhythmic, and regular, and patients should be
discouraged from holding their breath. Many patients need several practice
sessions with direct supervision to learn the technique.

Traction

Longitudinal traction is a form of stretching that affects ligaments and
joint capsules more than muscles or tendons. Just as synovial joints have
normal ranges of motions, they also have normal amounts of joint space
between the articulating surfaces. Decreasing joint space can decrease range
of motion, and increasing joint space can increase range of motion.
Using manual traction (distraction) along the longitudinal axis of a joint
to increase joint space encourages mobility. Using approximation along the
longitudinal axis of a joint to decrease joint space encourages cocontraction
and stability. Cocontraction is a muscular state in which opposing muscles
around a joint contract simultaneously to increase stability.


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Aquatic Stretching

Some patients find stretching in water enjoyable and useful. Buoyancy
is the upward force water exerts on a partially or fully immersed body.
Because buoyancy can be used to counteract the effects of gravity, the body
is able to move and stretch with less effort. As range of motion and strength
improve, the patient can move farther out of the water to increase the effects
of gravity. Active or self-assisted stretchingusing one or more body parts
to stretch another body partis easier to use in water than passive or active-
assisted stretching. Swimming is also considered an excellent exercise for
improving or maintaining a patients range of motion.
While many patients enjoy exercising in water, travel time, changes in
weather, and a shortage of good facilities make long-term aquatic stretching
programs difficult. Because of personal safety, aquatic stretching or
swimming programs should always be supervised.

Indirect (Functional) Techniques

In terms of range-of-motion stretching, a barrier is any obstacle or
impediment to further movement within a single plane. A joints total range
of motion from one extreme to another is limited by anatomical structures
such as bone, muscles, tendons, fascia, ligaments, skin, or the joint capsule.
Abnormal features (pathologic barriers) that can limit a joints range of
motion include pain inhibition, spasms, contractures, swelling, and bony
projections. Each joint has three standard ranges of motion:

Active range of motion: up to physiological barrier.
Passive range of motion: up to anatomical barrier.
Anatomical range of motion: beyond anatomical barrier.

The active range of motion describes the entire range of motion patients
are able to achieve by using their own muscles. The active range of motion
stops at the physiologic barrier and may be called the physiologic range of
motion. The active range of motion is the range most affected by pain
inhibition. Range-of-motion stretching has a tendency to increase the active
range of motion, whereas aging has a tendency to decrease the active range
of motion. The frequent goal of soft-tissue therapy is to increase or maintain
the active range of motion.


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The passive range of motion describes the entire range of motion
possible when external forces are used to move a body part. In soft-tissue
therapy, the most common type of external force is manual pressure. The
passive range of motion stops at the anatomical barrier.
Within the passive range of motion, there are two regions: the elastic
region where tissues resume their previous shape when external forces are
removed and the plastic region where tissues remain permanently deformed
when external forces are removed. The dividing line between elastic and
plastic deformation is the elastic barrier. To produce a permanent increase
in range of motion, tissues must be stretched beyond the elastic barrier.
The anatomic range of motion describes the entire range of motion
possible without causing tissue damage. Exceeding the anatomical barrier
will cause fractures, dislocations, ruptures, or soft-tissue tears.
The restrictive barrier at the end of the passive range of motion is
normally characterized by an increase in tension or pain. The feel when
approaching the end of this range of motion (end feel) can be hard as in the
bonetobone contact felt during complete elbow extension or soft as in the
muscletomuscle contact felt during complete elbow flexion.
The restrictive barrier that prevents a range of motion from becoming
larger is called the outer barrier, and the barrier that prevents a range of
motion from becoming smaller is called the inner barrier. The theoretical
point within a range of motion where the agonistic muscles are in a resting
positionneither stretching nor contractingis called a neutral point.
When a body parts range of motion increases beyond the neutral point,
tension increases until the outer barrier stops any further movement.
Techniques that increase tension (bind) by moving in the direction of the
outer barrier are called direct techniques. Range-of-motion stretching is a
direct technique. Techniques that decrease tension (ease) by moving in the
direction of the inner barrier are called indirect techniques. Slacking a
muscle, the opposite of stretching a muscle, is an indirect technique.
Indirect techniques are analogous to pushing a stuck drawer closed
before trying to open it again. Like a drawer, pushing a body part into a
position of less stress before pulling it into a position of greater stress may
help to align contact surfaces or move particles such as joint mice out of the
way that are interfering with normal movement. Joint mice are defined as
small fibrous, cartilaginous, or bony loose bodies in the synovial cavity of a
joint that may interfere with normal joint movement.


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While direct techniques that apply force directly against abnormal or
pathologic barriers are more common than indirect techniques that move a
body part in the direction of greatest comfort, slacking a muscle before
stretching it will sometimes produce a greater increase in range of motion
than stretching alone. A similar effect can be achieved by separating joint
surfaces with longitudinal traction before using direct techniques, such as
range-of-motion stretching, to increase range of motion.
One theory to explain why indirect techniques work contends that
moving in the direction of the inner barrier stimulates mechanoreceptors in
the joint that inhibit muscle contraction. Mechanoreceptors are a special
type of receptor found in joints that respond to mechanical deformation or
pressure. If a muscles range of motion is being restricted by spasm, this
may explain how indirect techniques decrease resistance to passive stretch.
Another possibility is that indirect techniques improve joint function in
four ways: (1) increase joint space, (2) reduce internal resistance, (3)
improve metabolism, and (4) reduce afferent impulses. Afferent (sensory)
nerves conduct the impulses from pain receptors in a joint to the brain.
Since musculoskeletal pain is often caused by abnormal contractions,
any technique that has the potential for relaxing muscle tissue needs to be
considered. Because they move in directions that decrease tissue tension,
indirect techniques can be used to relax hypertonic muscles and increase
range of motion when direct techniques cannot be used because of pain.

Neutral Positioning

Neutral positioning is a method for increasing ROM when stretching a
muscle in spasm is not advisable because of pain. When muscles are in
spasm, increasing tension (bind) will normally increase pain. Increasing the
distance between the origin and insertion of a muscle will normally increase
tension, and decreasing the distance will decrease tension.
Neutral positioning begins by slowly moving in the direction that
increases tension on the muscle until the patient reports mild pain and then
moving in the opposite direction just far enough to reduce tension (create
slack) and stop the pain. This position should be held for about 90 seconds.
After about 90 seconds, the affected body part should be slowly moved
in the same direction to create maximum slack. This can often be done by
approximating the origin and insertion. What may be the position of greatest
ease or comfort, this position should be held for about 90 seconds.


160
After about 90 seconds, the affected body part should be moved slowly
in the direction that increases tension until the patient reports mild pain and
then moved in the opposite direction just far enough to reduce tension and
stop the pain. The point between pain and no pain is called a neutral point.
If neutral positioning is effective, the ROM between maximum slack and
the second neutral point will be greater than the ROM between maximum
slack and the first neutral point. Continue the 3-step sequence as long as the
pain-free ROM continues to increase and approach normal:

1. Establish a neutral point and hold for about 90 seconds.
2. Create maximum slack and hold for about 90 seconds.
3. Reestablish a neutral point and hold for about 90 seconds.

Despite the occasional good results, the scientific justification for using
neutral positioning remains unclear. Putting a body part into a position that
reduces pain before trying to increase the ROM may (1) reduce abnormal
proprioceptive input, (2) reduce pain inhibition, (3) increase joint space, or
(4) improve local circulation. It is also possible that decreasing painful
stimulus for even a short period of time gives nociceptors, proprioceptors, or
mechanoreceptors a chance to reset and return to normal sensitivity.
Neutral positioning does not always work, and in some cases, may even
exacerbate the problem. First, hypertonic muscles that become slack may
contract instead of relax. This explains why people with musculoskeletal
pain are often told to stretch frequently and not remain in one position for
extended periods of time. Second, if neutral positioning is used, patients
should be carefully instructed not to contract muscles that are in a pain-free
position. If the pain-free position creates slack, contracting the muscle may
cause spasm or cramping. If this situation occurs, slow stretching with heat
or cold can be used to relieve spasm or cramping and lengthen the muscle.
Even though neutral positioning is often combined with trigger point
therapy, digital pressure can be used to neutralize trigger points or tender
points while muscles are slack or stretched. When combined with neutral
positioning, trigger point therapy that reduces pain inhibition or spasm will
normally improve the active and passive ranges of motion.
Even if neutral positioning does not increase the ROM, finding a neutral
position where the patient is at maximum comfort or ease is often a good
starting point for other methods of therapy. Starting therapy with the patient
in any position that is not relatively pain-free is often difficult.


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Range-of-Motion Specificity

ROM and flexibility are specific to a particular joint. If a movement
involves more than one joint, each joint contributes degrees of freedom to
the movement. A kinematic chain represents a collection of all joints that
contribute degrees of freedom to a single movement. A movement cannot
be normal unless each joint in the kinematic chain is functioning normally.
Each joint within a chain should be evaluated separately to measure
active or passive range of motion. If the joint has less than a normal range
of motion (hypomobility), stretching can be used to increase range of
motion. Therapies that work well in conjunction with range-of-motion
stretching are trigger point therapy to reduce pain, neuromuscular therapy to
inhibit hypertonic muscles, and connective tissue therapy to break adhesions.
In terms of modalities, heat is often used to reduce pain, decrease spasm, and
increase tissue extensibility.
If a joint has a greater than normal range of motion (hypermobility), any
forms of therapy that increase range of motion, such as stretching or
inhibition techniques, are normally contraindicated. The standard methods
for treating a hypermobile joint are (1) rest and stabilize the joint, (2)
facilitate weak muscles, and (3) strengthen weak muscles with exercise.
Even though insufficient range of motion (hypomobility) is far more
common than excessive range of motion (hypermobility), the two problems
may coexist if two or more joints are part of the same kinematic chain. If
any joints that participate in a basic movement are hypomobile, the body
may try to compensate by forcing the other joints that participate in the same
movement to become hypermobile. Without careful evaluation to separate
one condition from the other, techniques that increase range of motion may
be incorrectly applied to joints that are already hypermobile.
The best way to measure range of motion is by measuring the degrees of
movement produced by any particular joint. When a joint's range of motion
is normal, most muscles should be slightly tense when the joint's ROM is the
greatest and slightly flaccid when the joint's ROM is the least.
Active ROM can be increased by contracting the antagonist and relaxing
the agonist or decreased by contracting the agonist and relaxing the
antagonist. During contraction, muscles can shorten from 20% to 50% of
their normal resting length, and during relaxation, muscles can lengthen
from 120% to 150% of their normal resting length. Opposing muscles must
function normally for the active ROM to be normal.


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Spinal Stretch Reflex

Often thought of as being passive and unchangeable, the spinal stretch
reflexes can apparently be modified in response to trauma or changes in
reflex activity. These modifications are sometimes referred to as memory or
adaptations and may involve changes in the structure or function of spinal
neurons. Not only can neurologic insults affect spinal reflexes, there is also
a chance that spinal reflexes can be modified by static stretching or training.
Besides lengthening connective tissue, static stretching may decrease a
muscle's resistance to passive stretch by desensitizing the stretch reflex. If
trauma increases the excitability of a stretch reflex and causes dysfunction,
static stretching may decrease the excitability and help to restore function.
Like activating the Golgi tendon organs (GTOs) with static stretching,
decreasing the excitability of a spinal stretch reflex causes muscles to relax.
After static stretching lengthens connective tissue and desensitizes the
stretch reflex, stretching exercises can be used to maintain range of motion.
Training that monitors reflex activity and provides feedback is another
way to decrease the magnitude of spinal cord reflexes. Athletes use a
similar type of training to abolish protective autogenic inhibition from the
Golgi tendon organs. In exchange for greater strength, disinhibition of the
GTOs increases the risk of tearing muscles and rupturing tendons.
The time needed to correct abnormal changes in spinal reflex activity
may partially explain why soft-tissue therapy that eliminates trigger points,
hypertonic muscles, or contractures does not always produce immediate,
long-term results. If soft-tissue impairments are being caused, amplified, or
reinforced by abnormal spinal reflexes, therapy will not be effective until
reflex activity generated by the spinal cord is normal. Modifying spinal cord
input normally takes more time than correcting soft-tissue impairments that
are not affected by the central nervous system.

Contraindications to Stretching

severe pain or discomfort
acute tissue damage or hemorrhage
inflammation, infection, or swelling around joints
instability or hypermobility
recent fractures or dislocations
degenerative bone or joint disease


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RELAXATION THERAPY

Relaxation therapy is a combination of techniques and practices that can
help a patient relax. Increasingly, more studies are now showing that
relaxation contributes to health and reduces pain. Of special interest in soft-
tissue therapy is the direct relationship between emotional stress and higher
than normal levels of muscle tension. Abnormal muscle tension has been
shown to increase pain, decrease mobility, and reduce the quality of life.
Homeostasis refers to a state of equilibrium between opposing functions
that must exist within an organism for the body to be healthy. If
homeostasis is lost because one function manages to dominate an opposing
function, the short-term effects may be good or bad, depending on the
reasons for disequilibrium. If an organism is faced with a predator, the
short-term imbalance created by the sympathic functions dominating
parasympathetic functions may be good if the imbalance prepares the
organism to fight or flee (fight-or-flight reaction). While short-term effects
from a loss of homeostasis may be good, the long-term effects may be bad.
To preserve homeostasis, a healthy body tries to maintain a delicate
balance between expending energy (ergotropic functions) and restoring
energy (trophotropic functions). The relationship between ergotropic and
trophotropic functions corresponds to the relationship between the
sympathetic and parasympathetic divisions of the autonomic nervous
system. Both of these functions seem to be controlled by the hypothalamus
and one function counteracts the effects of the other.
Stress appears to shift the balance in favor of ergotropic functions. On
the positive side, this creates an imbalance that allows the body to increase
the expenditure of energy, as indicated by an increase in oxygen (O
2
)
consumption. On the negative side, the shift in favor of ergotropic functions
prevents the body from replacing lost energy. The long-term result of
energy consumption without adequate replacement is partial or complete
dysfunction. Relaxation stimulates trophotropic functions, restores
homeostasis, and helps to prevent dysfunction.
The common forms of dysfunction often associated with long-term
tension include headaches, hypertension without a known cause (essential
hypertension), atherosclerosis, heart attacks, cerebrovascular accidents,
asthma, and chronic musculoskeletal problems. Understanding the nature of
stress should make it easier to understand how physical or emotional tension
contributes to or causes various health problems.


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General Stress

In many respects, stress is the opposite of relaxation. Where relaxation
is characterized by periods of time when the autonomic nervous system,
endocrine system, and muscular system are relatively quiescent, stress is
characterized by an increase in sympathetic nervous system activity and
catecholamine production that increases blood pressure, heart rate, blood
flow to skeletal muscles, and respiratory rates. Catecholamines are
neurohormones produced by the adrenal gland (adrenal medulla) such as
adrenaline (epinephrine) and noradrenaline (norepinephrine). Where stress
represents a general increase in physical and psychological tension,
relaxation represents a decrease in physical and psychological tension.
On the positive side, psychological stress mobilizes the sympathetic
nervous system and prepares the body for vigorous mental or physical
activity. This response is sometimes called a fight-or-flight reaction because
it prepares the body to deal with real or imaginary dangers by standing to
fight or attempting to flee. Nine physiological changes that occur because of
the fight-or-flight reaction include:

increased arterial pressure
increased blood flow to active muscles
decreased blood flow to the gastrointestinal tract
increased rates of cellular metabolism throughout the body
increased blood glucose concentration
increased glycolysis in the liver and muscle
increased rate of blood coagulation
increased muscular strength
increased mental activity

On the negative side, stress can produce negative emotions and appears
to damage a persons health by contributing to heart attacks, strokes, gastric
ulcers, and headaches. Although research is not yet definitive, stress has
recently been linked to atherosclerosis and myocardial ischemia. Stress is
believed to have a psychosomatic effect on essential hypertension, migraine
headaches, asthma, and Raynaud's disease. A contraindication to
cryotherapy, Raynaud's disease causes bilateral cyanosis of the digits due to
arterial or arteriolar constriction.


165
By definition, glucocorticoid is a general classification for adrenal
cortical hormones. When the adrenal cortex overproduces glucocorticoid
because of stress, the long-term effects are increased blood pressure
(hypertension), suppression of the immune system, and damage to muscle
tissue. It is now believed that stress accelerates the aging process, increases
the bodys vulnerability to tumors, and decreases the bodys ability to heal
itself after an injury.
Stress has been implicated as a possible cause for eating or sleeping
disorders, and general stress because of anxiety is known to cause motor
signs such as trembling or twitching. Possibly because of an interaction with
the autonomic nervous system or the endocrine system, stress appears to
increase pain, whereas relaxation seems to decrease pain.

Environment

While most people would agree that some therapeutic environments are
more relaxing than others, the factors that make an environment relaxing are
seldom discussed. The acronym LA CAMRA identifies eight basic ways
to make therapeutic environments more relaxing. In Spanish, the words la
camra mean chamber, hall, or compartment. The letters in the acronym LA
CAMRA stand for:

Lubrication: basic properties.
Activity: mechanical and human.

Color: color and lighting.
Air: temperature and flow.
Music: background music.
Aroma: scent or fragrance.
Rest: mechanical support.
Attitude: professional demeanor.

While most clinicians try to maintain a friendly attitude and most clinics
try to avoid environmental factors that increase the patients anxiety (such as
cold rooms, unpleasant odors, or loud noises), many clinics do not take full
advantage of using environmental factors to reduce stress. More than most
other clinics, cancer, psychiatric, and soft-tissue therapy clinics seem to use
environmental factors for therapeutic purposes.


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Cancer clinics use music to draw the patients attention away from pain
and use various aromas to reduce anxiety. Psychiatric clinics use
comfortable furniture, relaxing colors, and pleasant conversation to reduce
stress during interviews. A large number of soft-tissue therapy clinics use
music, aromas, and color to physically and psychologically relax patients
before, during, and after manipulation. Soft-tissue therapy clinics also use
tables, chairs, and cushions that are specially constructed to make the patient
comfortable during manipulation.

Lubrication

Lubrication is used in soft-tissue therapy to reduce friction between the
patients skin and any surface making contact with the patients skin. In
addition to reducing friction, some lubricants are specially formulated to
produce therapeutic effects such as stimulation, relaxation, or analgesia.
Most patients find a massage more relaxing with lubrication than without
lubrication.
Most of the standard lubricants are oils, creams, or powders derived
from vegetable, mineral, or animal sources. Olive oil and theobroma oil
(cocoa butter) are two of the most common vegetable oils, and baby oil is
one of the most common mineral oils. Lanolin, a purified fatlike substance
from the wool of sheep, is probably the most common animal lubricant.
Of the vegetable oils, olive oil is one of the more expensive and
safflower oil is one of the less expensive. The use of olive oil dates back to
Plato and Socrates, and many people believe that olive oil nourishes the
skin. Olive oil can be mixed with other vegetable oils to reduce the cost or
combined with small amounts of lavender oil to encourage relaxation.
Even though wintergreen oil is used as a counterirritant to reduce pain
and eucalyptus oil is used to improve breathing, oils such as wintergreen and
eucalyptus are more likely to stimulate than sedate. Care should be taken
not to get any lubricant in the eyes, especially an oil containing wintergreen
or eucalyptus.
Even though petrochemical lubricants are normally classified as mineral
derivatives, their original source was animal or vegetable. While many
practitioners prefer vegetable lubricants over mineral lubricants, vegetable
lubricants that are not properly stored may become rancid because of
oxidation or bacterial action.


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Other factors to consider when selecting a lubricant are (1) allergic
reactions, (2) the patients preference, and (3) cleaning. Before using a
lubricant, question the patient about possible allergic reactions and personal
preference. While petrochemical products and talcum powder are more
likely to cause allergic reactions than vegetable products, some patients
prefer the feel of petrochemical products or talcum powder over the
unctuous or greasy feel of vegetable oil. Lubricants that are water-soluble
are easier to clean and less likely to stain clothing than lubricants that are
alcohol-soluble.
Even though most lubricants can be applied at any temperature between
70F and 104F, most patients prefer temperatures that are closer to 104F
than 70F. Even if a patients normal body temperature is 98.6F (core
temperature), lubricants heated to 80F may feel warm if the skin
temperature is below 80F. Skin temperatures are normally higher than
room temperatures but lower than core temperatures.
Practitioners can check the temperature of a lubricant by placing it on
their own hands before using it on the patient. This will also give lubricants
that are too cold a chance to warm and lubricants that are too hot a chance to
cool. Friction can be used to increase the temperature of a lubricant by
rubbing the hands together. Some practitioners use a special heating device
to warm lubricants and keep them at a constant temperature.
Special care should be taken to see that lubricants are not contaminated
by microorganisms or by any type of abrasive material such as sand or dust.
When not in use, lubricants should be tightly sealed to prevent
contamination. If reusable containers are used for dispensing lubricants, the
containers should not come in contact with the patient, and each container
should be sterilized between refills. Possible early warning signs of
contamination include disagreeable odors and changes in color, consistency,
or abrasiveness. If in doubt, clean the container and use new lubricant.

Activity

Activity refers to any mechanical or human activity that is not required as
part of a normal therapeutic environment. Many of these extraneous
activities are distracting and interfere with a patients ability to relax. A
patients irritation is sometimes reflected by rapid eye movements, rapid
breathing, tensing facial muscles, constantly moving body parts, or
repeatedly shifting position.


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Seven potentially distracting activities include:

telephones ringing or water dripping in the background
radios or televisions playing in the background
people having conversations or answering phone calls
sounds produced by dropping or moving equipment
needless questions or distracting conversation
needless or accidental movements that jar the patient
paying attention to matters not related to the patient

Any activity viewed as invading the patients privacy is potentially
distracting. Many patients will find it difficult to relax if their modesty and
right to confidentiality are not protected. A patient should not be exposed to
casual inspection by anyone walking past the treatment area.
Unless more people are needed as part of a treatment protocol, one
person in a treatment room is normally less disturbing for a patient than two
or more people. If more than one person is needed, the patient should be
told the names of everyone present and why they are needed.
Personal body language is a form of activity that can be used to
encourage relaxation. A practitioners body movements should be slow,
deliberate, and correspond with speech patterns. Patients whose body
movements are normally fast, jerky, or haphazard will have a tendency to
slow down and relax if a practitioners body movements are slower and
more relaxed. If a patients body movements are normally slow,
practitioners with rapid body movements may irritate or distract the patient
and make communication more difficult.
If a patient has a tendency to be hyperactive, asking questions and
pausing before and after the answers will encourage the patient to think
more and move less. Another way to decrease physical activity is to have
the patient remain seated while answering questions. If a patients speech
patterns are extremely rapid, partially matching the patients speech patterns
and then slowing down will accomplish two things: (1) help practitioners
gain rapport, and (2) allow practitioners to lead a patient in the direction of
slower speech, deeper breathing, and relaxation.
If certain potentially distracting activities cannot be avoided, discussing
the activities with a patient beforehand may help. Many patients object to
being surprised or alarmed more than they object to the activity itself.
Knowing what to expect beforehand will make it easier for most patients to


169
prepare themselves for possible distractions and make the mental
adjustments needed to control irritation, frustration, or even anger.
If distracting activities occur that were not anticipated, apologize to the
patient and do whatever can be done to avoid further distractions. Be
empathetic and give the patient a chance to express feelings or opinions.
Apologizing for distractions and giving the patient a chance to speak show
respect, sympathy, and concern for the patients welfare.

Color

While the relationship between color and human response is not clearly
understood, certain generalities seem to apply. Red has a tendency to cause
a temporary increase in blood pressure, pulse rate, and respiration, whereas
blue has a tendency to cause a temporary decrease in blood pressure, pulse
rate, and respiration. Red is more likely to cause an increase in muscle tonus
than blue. The response to red is possibly related to the way many people
respond to blood or bleeding wounds. The response to green, in terms of
human physiology, tends to be neutral.
Most people find green and blue more relaxing than red. In terms of
associations, people connect red with anger or danger, green with tranquility
or flora, and blue with sadness or sky. Many people consider red a hot
color, green a neutral color, and blue a cold color. Red is often connected
with fire and blue with ice. Physiologically, hyperthermia (heat) relates to
reddish-colored skin because of hyperemia, and hypothermia (cold) relates
to bluish-colored skin because of cyanosis.
The visible spectrum is that part of electromagnetic radiation that is
discernible to the human eye. The neutral reaction to green can be partially
explained by greens central position in the visible spectrumred, orange,
yellow, green, blue, indigo, and violet. Reactions to yellow and orange are
similar to red, and reactions to indigo and violet are similar to blue.
White, the presence of all colors in the visible spectrum, is associated
with cleanliness, purity, or goodness; while black, the absence of all color, is
associated with dirt, contamination, or evil. Pure white tends to produce a
glare, whereas off-white tends to be neutral. While most people find dim
light more relaxing than bright light, many people fear too much darkness.
While some people claim that incandescent lighting is more relaxing than
fluorescent lighting, that small changes in color are more relaxing than
extreme changes, and that striped patterns are more relaxing than
checkerboard patterns, others have no opinions one way or the other.


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Any claim that one color consistently produces the same responses in
every person is probably false. The way that people respond to a color is a
combination of visual acuity, past experience, mood, and surrounding
circumstances. In terms of relaxation, psychological responses are probably
more significant than physical responses. If enough people believe that red
stimulates and green or blue sedates, belief itself creates its own reality.
Despite the inconstancies, certain guidelines for designing a workable and
relaxing environment seem to apply.

The colors green and blue are more relaxing than red.
Dim lighting is more relaxing than bright lighting.
Incandescent lighting is more relaxing than fluorescent lighting.

To make a blend of colors harmonious and relaxing requires a sense of
color that not everyone has. The safest colors for relaxation are probably
low-intensity hues of blue or green, with a dimmer switch to control
brightness. The intensity or saturation of a color is decreased by adding
gray, and brightness is decreased by adding black.
It seems likely that many people relate low-intensity colors and darkness
with nighttime or sleep. Based on a normal 24-hour circadian cycle, humans
tend to be more active during daylight hours (diurnal) than nighttime hours
(nocturnal). Humans may find blues and greens relaxing because of a
conscious or subconscious connection with relaxing images such as blue
skies, blue-green seascapes, or green landscapes.

Air

Air refers both to air temperature and airflow. The temperature that
most patients find comfortable is somewhere between cool (70 to 80F) and
tepid (80 to 92F). Since many patients are not fully clothed during
treatment, 75F is probably a good starting point for most patients. For most
patients, it is better to err on the side of too warm than too cold. Cool
temperatures have a tendency to increase tonus and make some patients
irritable, while warm temperatures have a tendency to decrease tonus and to
sedate patients.
In the absence of definite signs such as shivering, gooseflesh (cutis
anserina), changes in skin color, or excessive perspiration, feedback from the
patient is the easiest way to determine if the room is too cold or too hot.


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Blankets, and in some cases space heaters, should be available as a short-
term solution for patients who are too cold, and fans can be used as a short-
term solution for patients who are too hot.
Some patients request fans simply for the kinesthetic pleasure of having
air blown over their bodies. Human fascination with the natural movement
of air dates back many centuries. Hippocrates (5th century BC) believed that
wind could be used to indicate the general health of citizens in a town, and
traditional Navajo religion included worship of waterways and winds. The
people who enjoy a definite airflow during therapy are often the same people
who sleep with fans on during cool weather, enjoy standing in the wind, or
enjoy outdoor sports such as sailing or wind-surfing.

Music

While most people agree that music can be relaxing, personal taste
makes it almost impossible to claim that one type of music is more relaxing
than another. Historically, classical music that averages about 60 beats per
minute or less (largo) is usually considered the most relaxing type of music.
It is often suggested that slow music produces a parasympathetic
response (rest) and that fast music produces a sympathetic response (fight or
flight). Overstimulation of the parasympathetic nervous system slows the
heart rate and causes relaxation. Overstimulation of the sympathetic nervous
system accelerates the heart rate and causes anxiety or excitement.
The body has a tendency to synchronize heartbeat with the beat of slow
music. Listening to music with a beat below 60 beats per minute may cause
bradycardia, a slowness of heartbeat characterized by a pulse rate below 60
beats per minute. Deep breathing and meditation may also cause
bradycardia. Other possible effects of slow music, deep breathing, and
meditation are a decrease in respiration and global relaxation or deep sleep.
Just as slow music has a tendency to sedate, fast music has a tendency to
stimulate. Fast rock music is far more likely to increase heart rate and
stimulate physical activity than slow classical music. As a basic guideline,
slow music is recommended for mental activities such as learning or
memorizing and fast music is recommended for physical activities such as
aerobic exercise or dancing.
From all indications, the beat of the music is more important than the
type of music. Since many people do not appreciate classical music and
some may even find it irritating, a possible substitute is any piece of music


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that approximates 60 beats per minute or less. Almost every type of music,
whether jazz, folk, country, western, or rock, has at least some pieces that
many people will find relaxing.
Many clinics use what is commonly called New Age music to induce
relaxation. Much of this music was written specifically for the purpose of
relieving tension. The beat for new age music tends to be slow and
rhythmic, with instruments that are soft, soothing, and pleasing to the ear.
New age music frequently incorporates or reproduces wind, rain, or ocean
sounds as part of the basic composition.
Even if music is not used to induce relaxation, ambient noise should be
avoided. Noise is defined as any unpleasant, irritating, or physiologically
damaging sound. Noises that are loud, unusual, intermittent, or unexpected
tend to be more stressful than noises that are soft, familiar, rhythmic, or
predictable. Chronic noise has been shown to elevate urinary catecholamine
levels and make it difficult for people to perform complex tasks.
While some noises such as scratching chalk on a blackboard or dropping
silverware seem to be intrinsically unpleasant for most people, other noises
such as sounds related to accidents or gunfire seen be unpleasant by
association. Noise has been linked to increases in blood pressure and stress-
related disorders such as gastric ulcers and allergies.

Aroma

The sense of smell is possibly the least understood of all of our senses.
When olfactory cells located in the nasal cavity are activated by chemical
stimuli, the brain receives sensory input that relates to sense of smell. How
the brain reacts to sensory input relating to smell depends on genetic factors,
intensity, and past experience. The two basic physiological responses to
aromas are stimulation and sedation.
Unlike genetic factors, intensity can be varied. While low-intensity
floral fragrances are considered pleasant by most people, high-intensity
floral perfumes give some people headaches. At least one hospital has used
heliotropin, a floral fragrance, to reduce anxiety during magnetic resonance
imaging (MRI) scans. Past experience can influence how people interpret a
smell. A pine fragrance that reminds one person of the great outdoors can
remind someone else of a cleaning product.


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While human olfactory ability may not compare favorably with dogs or
pigs, the human nose can often discriminate between thousands of different
odors. Unlike sensory input that travels to the brain via spinal nerves,
sensory input from olfactory cells travels directly to the brain via the
olfactory nerve (cranial nerve I).
In humans, the significance of our sense of smell is not always clear.
Some odors that humans perceive seemingly relate to food-gathering, sexual
reproduction, or avoidance of toxic materials. While some smells appear to
have no significance at all, other smells evoke definite physical or
psychological responses such as a reflex interruption in breathing because of
smelling ammonia or a strong mood change because of smelling a certain
perfume or cologne.
Another unique property of certain odors is the effect they have on pain.
Some patients report the smell of lavender or vanilla produces a relaxing
effect that eases pain. Of the citrus group, orange has a tendency to sedate,
whereas lemon has a tendency to stimulate. Partially because of distraction,
when certain odors occupy the mind, pain becomes less acute. Aromas that
sedate when used at low intensities may stimulate or cause nausea when
used at high intensities.
The purest natural odors are produced by essential oils. By definition,
essential oils are plant products that give plants their characteristic taste and
odor. Prepared by distillation, percolation, or extraction, essential oils tend
to be oily and quick to evaporate when exposed to air (volatile). Despite the
additional cost, many professionals prefer using genuine essential oils over
incomplete or synthetic substitutes. The essential oils in perfume may be
altered to make them more soluble in alcohol.
The main problem for clinics using aromas for relaxation or pain relief is
being able to clear the air of any residual odor after each patient. Aromas
that some patients find relaxing, other patients find irritating or offensive. In
addition to a good ventilating system that rapidly exchanges air between
patients, using small amounts of essential oil on a cotton swab and then
removing the swab from the room after each patient leaves will help to keep
the air neutral. If essential oils are being used strictly for aroma, there is no
reason for oils to come in contact with a patient.
Essential oils and therapeutic aromas are not recommended for every
patient. Some patientsand many clinicsprefer rooms to be odor-free,
but not scented with any type of fragrance. If essential oils or similar
products are not used, care should be taken to see that all treatment rooms


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are free from unpleasant odors. Carefully selected cleaning products and
deodorants should always be available to control offensive odors. For
patients who respond favorably to therapeutic aromas, essential oils can be
used very effectively in combination with other types of therapy.

Rest

A rest is defined as any device used to support a part of the patients
body, such as a head, arm, or leg. In the past, most soft-tissue therapy
patients were treated on wood or metal tables that supported the entire body.
A few of the early tables had an opening in the top of table for the face (face
hole), but most were solid on top. While most patients considered a table
with a face hole more comfortable than one without, many patients still
complained that face holes are unpleasant to use because of difficulties with
breathing or pressure on the face.
Realizing that tables were not as comfortable as they could be, several
massage-table companies developed a special support for the head called a
face cradle, or face support. Not only did padding contoured to the face or
head increase the patients comfort, but many of these devices were also
adjustable so the patients neck could be flexed or extended to reposition the
head. Flexing or extending the head will sometimes give better access to
neck and shoulder tissues and provide some degree of stretch.
Even though a headrest is fairly common on modern massage tables,
they are less common on tables used for high-velocity spinal adjustments.
Most of these tables are designed for rigid stability more than comfort.
Adjustment tables normally have less padding than massage tables because
padding absorbs part of the kinetic energy that would otherwise be
transmitted to the spine. Since many high-velocity adjustments take less
than 10 minutes to complete, comfort is less of an issue than it would be if
adjustments took 30 or 45 minutes to complete.
In addition to a headrest, some companies offer massage tables with a
rest for the arms and legs. If a single rest is provided for each arm or leg, the
armrest or leg rest on one side of the table can normally be adjusted
differently from the armrest or leg rest on the opposite side of the table.
Beyond comfort, being able to adjust the patients arm or leg position by
using a rest makes it easier to manipulate certain body parts or tissues. By
using mechanical devices to position the body parts being treated,
practitioners are left with both hands free to manipulate tissue.


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After massage tables, massage chairs are probably the next most popular
device for supporting a patients body during treatment. Most massage
chairs have an armrest, chest rest, and leg rest in addition to a headrest. On
most massage chairs, the headrest, armrest, and leg rest are adjustable,
although some chairs use an armrest or leg rest that prevents independent
positioning of each arm or leg. Massage chairs are especially good when
treating head, neck, or shoulder problems.
One of the more recent innovations in soft-tissue therapy is the use of
cushions that are designed to fit the contours of the body. While the main
cushions are being used to support the trunk of the body, one cushion is
normally used as a headrest and a second cushion as foot or leg rest.
Cushions can be used on a table or placed directly on the floor.
Regardless of what type of rest is being used, the device should be
strong enough to support the body parts without risk of collapse and padded
well enough to avoid excessive pressure on the patients body. A rest should
also be durable, pleasant to the touch, and capable of being cleaned
effectively with normal cleaning solutions. Many tables and chairs use
removable padding on headrests, armrests, and leg rests for easy
replacement or washing. Some patients will find it difficult to relax if all
equipment relating to therapy is not visibly hygienic.
Even if a headrest is not self-powered like the ones found on certain
hydraulic or electric tables, the rest should be quick and easy to adjust
without tools. A headrest adjustable with one hand while the patients head
is still on the rest is easier to use than a headrest that requires both hands to
adjust. Some headrests are designed so special cushions can be used to
cover the opening while patients are in a supine or lateral (side) position.

Attitude

The attitude of practitioners and staff contributes as much to the patients
ability to relax as any other environmental factor. While most people would
agree a professional attitude is highly recommended, the characteristics
contributing to a professional attitude are seldom discussed.
Attitude can broadly be defined as a manner of acting or behaving in a
certain way in response to certain people, places, or things. Attitude reflects
your beliefs and state of mind. A professional attitude indicates a
willingness to comply with professional standards. A positive and healthy
attitude toward patients is often called a good bedside manner.


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Three of the basic characteristics for having a positive professional
attitude are defined by the acronym ESP:

Empathy: being sensitive to the feelings of others.
Sincerity: being honest and genuine.
Pragmatism: being practical.

Empathy is having sympathy, sensitivity, and understanding for the
thoughts, feelings, and experiences of other people. Many patients do not
care how much you know until they know how much you care. A statement
such as I know how you feel, Ive felt the same way myself is one way to
express empathy. Sincerity is a quality or state of being honest. If a
practitioner fails to project sincerity, patients often become distrustful and
question the practitioners ability, motivation, and willingness to help.
Pragmatism is a practical approach to solving problems. A patient needs
to believe that health care professionals are looking for practical ways to
solve health care problems. A practical solution should be workable, ethical,
and affordable. Most practical solutions can be tested by measuring the
results. As soft-tissue therapy practitioners become more actively involved
in reading, writing, and research, the number of practical solutions available
for treating soft-tissue impairments will continue to increase.
To express a positive professional attitude, practitioners must be able to
establish rapport with their patients. Rapport in soft-tissue therapy can be
defined as a workable relationship between practitioners and patients
characterized by harmony, understanding, and respect. Even though the
practice of building rapport is more of an art than a science, the following
nine guidelines are very effective when trying to build rapport with patients:

When speaking to a patient, give the patient your full attention.
Communicate in ways the patient understands.
Maintain eye contact, but avoid staring at the patient.
Use gestures and body language to reinforce your words.
Give patients a chance to speak, and listen to what they say.
Never criticize or ridicule a patient for asking foolish questions.
Make the patient feel important.
Encourage happy thoughts and fond memories.
Never argue with a patient.


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Preliminary Relaxation Techniques

In addition to environmental factors, various relaxation techniques can
be used to reduce muscle tension before treatment. The two most common
techniques are autogenic training and progressive relaxation.

Autogenic Training

Autogenic training reduces mental activity and promotes a shift from
sympathetic to parasympathetic activity. The sympathetic nervous system
mediates responses associated with a fight-or-flight reaction such as
increasing heart rate and respiration, whereas the parasympathetic nervous
system mediates responses associated with relaxation, such as decreasing
heart rate, respiration, and muscle tonus.
The two most common phrases used in autogenic training are (1) make
parts of your body feel heavy and relaxed, and (2) make parts of your body
feel warm and relaxed. In recent years, autogenic training has been
supplemented by five classical breathing techniques:

Start with a position that allows easy breathing and comfort.
Shift from chest breathing to abdominal (diaphragmatic) breathing.
Breathe deeply and concentrate on the rise and fall of the diaphragm.
Feel the cool air slowly and smoothly enter and leave the nostrils.
Take about as long to exhale as to inhale.

These techniques can be supplemented by visualizing heat (energy)
traveling from one part of the body to another. A standard circuit might be
from the head to different parts of the body and back to the head or from the
abdominal area to different parts of the body. Visualizing the flow of heat or
energy through the body helps to create a mentally quiet condition. Some
people prefer to visualize colors, concentrate on a single image, or mentally
verbalize words, phrases, or chants.
With training and practice, the mind can learn to become extremely
relaxed and very aware at the same time. The combined state of deep
tranquility and heightened awareness produced by meditation is sometimes
called mindfulness. Higher states of mindfulness are characterized by a loss
of distinction between self and other objects, spontaneous sounds or visions,
and a sense of extreme well-being that resembles euphoria.


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While autogenic training and related techniques are being presented here
as a method for relaxing a patient prior to manipulation, once learned,
patients can practice the same techniques at home to reduce stress. Similar
techniques have been used medically to reduce anxiety, chronic pain, and
drug usage. Autogenic training and related techniques have also been used
to reduce tension headaches, insomnia, and essential hypertension.
Autogenic training will have very little effect on renal hypertension, which
is secondary to renal disease.
With training, some people can develop the ability to relax certain
muscles by giving themselves mental commands. The basic sequence is (1)
a strong desire to relax certain muscles, (2) a strong belief that thoughts have
the power to relax a muscle, and (3) the ability to visualize and feel a muscle
relaxing. One way to visualize and feel a muscle relaxing is to create a
mental image of a muscle becoming warmer and then feel the tension melt
away as the temperature increases. A similar technique can be used to
reduce pain.
Learning to visualize and feel a muscle requires practice. While most
people can taste and smell a lemon, and possibly salivate, simply by thinking
about a lemon, creating a realistic image of a muscle relaxing requires much
more effort. The ability to visualize a muscle can be improved by palpating
the muscle or looking at a picture of the muscle. Some patients visualize the
muscle. The ability to feel a muscle relax can be improved by isometrically
contracting a muscle for about 10 seconds and then noting the changes that
occur as the muscle relaxes.

Progressive Relaxation

Progressive relaxation is a contraction-relaxation technique for reducing
stress by systematically contracting and relaxing muscles. Progressive
relaxation is often done from a supine position with the head, neck, and
trunk straight; the arm and legs slightly abducted from the body; and the
palms facing up (supinated). The normal sequence is (1) try to feel the
tension in muscles, (2) contract muscles for about 10 seconds, and (3) relax
muscles and try to feel the change in tension. The room should be quiet with
subdued lighting, the clothing should be loose, and the eyes closed.
Most patients find it easier to learn progressive relaxation by
systematically contracting and relaxing muscles or muscle groups in the
same order each time. The muscles in the hands can be contracted by


179
making a tight fist, and muscles in the legs should be contracted with the feet
slightly dorsiflexed to avoid cramping. Except for the hands and feet, most
contractions are isometric. Each contraction should be strong enough to
induce moderate tension, but not strong enough to cause shaking, trembling,
or fatigue. The mind should be loosely focused on feeling the muscles
contract and relax. Verbal instructions may be helpful until patients learn to
supervise themselves. A standard sequence might be

contract and relax hand and forearm muscles
contract and relax upper arm muscles
contract and relax shoulder muscles
contract and relax feet and leg muscles
contract and relax thigh muscles
contract and relax hip muscles
contract and relax facial muscles
contract and relax neck muscles
contract and relax chest muscles
contract and relax abdominal muscles

This sequence can be varied or repeated to meet the particular needs of a
patient. While a supine position is recommended, other positions can be
used. With practice, some patients can learn to contract most of the major
muscle groups at one time and then allow the entire body to relax.
Progressive relaxation can be combined with autogenic techniques or
deep breathing. Instead of contracting and relaxing muscles, patients can go
through the same sequence, but think in terms of making muscles feel warm
or heavy. If patients go through the same sequence but use deep breathing
with contraction and relaxation, the breathing sequence is (1) exhale and
contract, (2) inhale and hold the contraction, and (3) exhale and relax.
Exhaling during contraction reduces intrathoracic pressure, and exhaling
during relaxation enhances the patients ability to relax. Many patients will
find breathing easier after contracting and relaxing the abdominal muscles.
In addition to a standard relaxation response that includes a decrease in
heart rate, respiration, and blood pressure, both autogenic training and final
stages of progressive relaxation reduce muscle tension. When autogenic
training and progressive relaxation are combined with classical meditation
techniques such as deep breathing, there may also be a decrease in oxygen
consumption and possibly an increase in alpha brain waves.


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Relaxing Massage

While most practitioners develop their own methods for giving a
relaxing massage, 10 basic elements are common to most methods:

Stay in fairly continuous contact with the patients body.
Give special attention to the back, hands, and feet.
Do not change the patients body position more than needed.
Avoid techniques that cause pain or discomfort.
Use strokes that are smooth, regular, and rhythmic.
Vary strokes enough to avoid monotony.
Use short, rapid, hard or soft strokes to stimulate.
Use long, slow, hard or soft strokes to sedate.
Follow strokes that stimulate with strokes that sedate.
Finish the massage with strokes that sedate.

There are seven factors that may interfere with a patients ability to
enjoy a relaxing massage:

accidentally scratching the patients skin or pulling the patients hair
conversing too much or in ways that interfere with relaxation
dropping the patients head, arm, or leg over the edge of a table
jarring the patients body too many times during the massage
placing the patient in a difficult or uncomfortable position
placing the patient in a position that interferes with breathing
touching in ways that are not professional, deliberate, or caring

Perhaps the most important part of developing a relaxing massage is
listening to the patient. Each patient is unique, and most patients have
personal preferences concerning how a relaxing massage should or should
not be administered. Keeping an accurate written record is the easiest way
to remember these preferences.
One thing that should always be prearranged with a patient is what
procedure will be followed after the massage. While many patients prefer to
sleep after having a relaxing massage, this procedure is seldom feasible.
The next best solution is giving patients at least a few minutes to relax at the
end of the session. For safety reasons after having the massage, patients
should not be allowed to stand up and walk without someone in attendance.


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CHAPTER SUMMARY

THE THREE HEMME LAWS

HEMMEs 1st law: Most conditions treatable by soft-tissue therapy are
HEMMEs 2nd law: Most conditions treatable by soft-tissue therapy can
be identified and treated by using five basic steps: History, Evaluation,
HEMMEs 3rd law: Always be ready, willing and able to disregard any
law, principle, axiom, or belief that proves to be incorrect.

TWENTY-TWO LAWS OR PRINCIPLES OF SOFT-TISSUE THERAPY

All-or-none law
Beevor's axiom
Bells law
Creep
Facilitation-Inhibition
Head's law
Hilton's law
Hookes law
Houghtons law of fatigue
Hysteresis
Inverse square law
Jacksons law
Law of denervation
Law of referred pain
Meltzer's law
Sherrington's law
Stokes law
Stretch reflex
Weigerts law
Thixotropy
Webers law
Wolff's law


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SEVEN CONCEPTS RELATING TO PAIN

Pain will continue if at least one source of pain is active.
Pain may cause spasm and spasm may cause pain.
Pain stimulus applied to skin may cause flexion of a limb.
Pain is often referred from a damaged region to a healthy region.
Pain is often referred to structures that share the same spinal segment.
Pain can result from stretching, compressing, or contracting muscles.
Pain can result when strong tissues try to compensate for weak tissues.

SIX SIGNS OR SYMPTOMS OF TRIGGER POINTS

Points or zones that are tender when pressure is properly applied
Distinct patterns of referred pain or radiated pain
The presence of taut, indurated, or ropy bands within a muscle
Tremors or fasciculations when pressure is properly applied
Jump signs or local twitch responses when pressure is properly applied
Abnormal weakness, shortness, tightness, or spasm within a muscle

THREE WAYS TRIGGER POINT THERAPY REDUCES PAIN

Digital pressure disperses pain-producing chemicals.
Digital pressure stimulates production of endogenous opioids.
Trigger points stimulated by pressure act as counterirritants.

SIX TYPES OF TRIGGER POINTS

Active trigger point: symptomatic with characteristic behavior.
Associated trigger point: caused by trigger points in another muscle.
Latent trigger point: symptomatic only when palpated or compressed.
Primary trigger point: caused by mechanical strain in a muscle.
Satellite trigger point: caused by trigger points that share the same zone.
Secondary trigger point: caused by compensating for another muscle.

BASIC GOALS OF NEUROMUSCULAR THERAPY

Inhibition: lengthen hypertonic muscles and strengthen weak muscles.
Facilitation: Shorten stretched muscles and strengthen weak muscles.


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SIX-STEP PROTOCOL FOR NEUROMUSCULAR THERAPY

Evaluate length by range-of-motion testing.
Use inhibition to lengthen restricted tissues.
Evaluate strength by muscle testing.
Use facilitation to strengthen weak muscles.
Evaluate length first and then strength.
If needed, treat again with inhibition or facilitation.

THREE WAYS TO INHIBIT A MUSCLE

Muscle spindle inhibition
Post-isometric relaxation (inhibition)
Reciprocal inhibition

THREE WAYS TO FACILITATE A MUSCLE

Activation of stretch reflex
Muscle spindle facilitation
Repeated contractions

THREE PRINCIPLES OF CONNECTIVE TISSUE THERAPY

Thixotropy
Hysteresis
Creep

THE ACRONYM DAVID STANDS FOR

Duration: holding period.
Angle: direction of pull.
Velocity: rate of loading.
Dosage: repetitions and frequency.


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THREE STANDARD RANGES OF MOTION FOR A JOINT

Active range of motion: up to physiological barrier.
Passive range of motion: up to anatomical barrier.
Anatomical range of motion: beyond anatomical barrier.

CONTRAINDICATIONS TO STRETCHING

Bony obstructions that limit the range of motion
Inflammation, infection, hemorrhage, or swelling around joints
Instability or hypermobility
Recent fractures or dislocations

NINE PHYSIOLOGICAL CHANGES BECAUSE OF FIGHT-OR-FLIGHT

Increased arterial pressure
Increased blood flow to active muscles
Decreased blood flow to the gastrointestinal tract
Increased rates of cellular metabolism throughout the body
Increased blood glucose concentration
Increased glycolysis in the liver and muscle
Increased rate of blood coagulation
Increased muscular strength
Increased mental activity

THE ACRONYM LA CAMRA STANDS FOR

Lubrication: basic properties.
Activity: mechanical and human.
Color: basic color scheme.
Air: temperature and flow.
Music: background music.
Aroma: scent or fragrance.
Rest: mechanical support.
Attitude: professional demeanor.


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THREE GUIDELINES RELATING TO COLOR AND LIGHTING

The colors green and blue are more relaxing than red.
Dim lighting is more relaxing than bright lighting.
Incandescent lighting is more relaxing than fluorescent lighting.

THE ACRONYM ESP STANDS FOR

Empathy: being sensitive to the feelings of others.
Sincerity: being honest and genuine.
Pragmatism: being practical.

NINE GUIDELINES FOR BUILDING RAPPORT WITH PATIENTS

When speaking to a patient, give the patient your full attention.
Communicate in ways the patient understands.
Maintain eye contact, but avoid staring at the patient.
Use gestures and body language to reinforce your words.
Give patients a chance to speak, and listen to what they say.
Never criticize or ridicule a patient for asking foolish questions.
Make the patient feel important.
Encourage happy thoughts and fond memories.
Never argue with a patient.

FIVE CLASSICAL BREATHING TECHNIQUES

Start with a position that allows easy breathing and comfort.
Shift from chest breathing to abdominal (diaphragmatic) breathing.
Breathe deeply and concentrate on the rise and fall of the diaphragm.
Feel the cool air slowly and smoothly enter and leave the nostrils.
Take about as long to exhale as to inhale.

NORMAL SEQUENCE FOR PROGRESSIVE RELAXATION

Try to feel the tension in muscles.
Contract muscles for about 10 seconds.
Relax muscles and try to feel the change in tension.


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TEN ELEMENTS THAT ENCOURAGE RELAXATION

Stay in fairly continuous contact with the patients body.
Give special attention to the back, hands, and feet.
Do not change the patients body position more than needed.
Avoid techniques that cause pain or discomfort.
Use strokes that are smooth, regular, and rhythmic.
Vary strokes enough to avoid monotony.
Use short, rapid, hard or soft strokes to stimulate.
Use long, slow, hard or soft strokes to sedate.
Follow strokes that stimulate with strokes that sedate.
Finish the massage with strokes that sedate.

SEVEN FACTORS THAT INTERFERE WITH RELAXATION

Accidentally scratching the patients skin or pulling the patients hair
Conversing too much or in ways that interfere with relaxation
Dropping the patients head, arm, or leg over the edge of a table
Jarring the patients body too many times during the massage
Placing the patient in a difficult or uncomfortable position
Placing the patient in a position that interferes with breathing
Touching in ways that are not professional, deliberate, or caring


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EXERCISE

According to Tabers Cyclopedic Medical Dictionary (17th ed.),
therapeutic exercise refers to the scientific supervision of exercise for the
purpose of preventing muscular atrophy, restoring joint or muscle function,
increasing muscular strength, or improving cardiovascular fitness. The
scientific supervision of exercise is practiced by many different groups,
including physical therapists, occupational therapists, physical fitness
trainers, personal trainers, athletic trainers, exercise physiologists, physical
education instructors, and coaches.
The relationship between massage and exercise goes back at least as far
as ancient Greece, when Herodicus, one of the teachers of Hippocrates,
made massage and exercise part of medicine. Swedish massage, the most
common form of massage taught in the United States, is a combination of
massage and physical exercise. Tabers Cyclopedic Medical Dictionary
defines Swedish massage as a combination of massage and Swedish
gymnastics, and Swedish gymnastics is a system of active and passive
physical exercise for the various muscles and joints of the body.
The basic principle behind exercise can be described by the acronym
SAID: Specific Adaptation to Imposed Demands. When demands for
strength, endurance, or flexibility are imposed on the body, the body
responds by trying to make specific adaptations. If a demand for strength is
imposed by overloading a muscle, the muscle responds by producing
adaptations that increase strength: greater neurologic efficiency, higher fiber
density, greater mass (hypertrophy), or an increase in the number of
sarcomeres (hyperplasia).
If demands placed on the body are too great, the body may not respond
in a beneficial way and the overload may cause overwork damage. Under
normal circumstances, therapeutic exercises should not cause excessive pain
or fatigue during or after exercise. One sign of fatigue is substitution, where
patients compensate for weakness or pain in one muscle by trying to use
another muscle to produce the same movement. Since two different muscles
seldom produce exactly the same movement, substitution can often be
identified by watching for changes in the way the patient moves.
If a muscle is overloaded beyond its ability to adapt, possible short-term
outcomes include muscle tears, ruptured tendons, or tendons torn loose
(avulsed) from the bone. Long-term outcomes may include overuse injuries,
repetitive-motion injuries, or chronic fatigue.


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Most demands placed on the body should be progressive. If the demand
is for greater range of motion (ROM), a normal sequence is (1) passive
ROM stretching, (2) active-assisted ROM stretching, and (3) active ROM
stretching. The overload and increases in ROM should be progressive,
starting with small gains and working up to larger gains. If the overload is
too high, a common site for injury is the muscle-tendon junction.
Placing progressive demands on the body gives muscle and connective
tissue more time to adapt. Working slowly in the direction of greater range
of motion is less likely to cause tissue tearing and pain than working too
quickly. Even though the concept of no pain, no gain may be true to some
extent when working to increase a patients range of motion, slow and
progressive stretching produces less pain and more gain.
Pain can never be totally avoided during soft-tissue rehabilitation.
Range-of-motion stretching is the most effective way to treat muscle
contractures caused by the shortening of connective tissue such as fascia.
Patients with a limited range of motion who stop short of feeling pain during
stretching exercises are less likely to fully recover than patients who tolerate
or work though at least minimal pain. If a patients limited range of motion
is not challenged on a regular basis, the range of motion will have a
tendency to decrease rather than to increase or to remain the same.
During the early stages of an injury, isometric contractions with active
movement and passive mobilization can be used to offset the effects of
inactivity and deconditioning. Once patients are capable of completing
range-of-motion movements without assistance, the next logical step is
range-of-motion exercise without assistance.
The goals for active range-of-motion exercise are (1) preserve range of
motion, (2) increase strength, (3) increase muscular endurance, and (4)
improve cardiovascular fitness. Patients who exercise on a regular and
progressive basis seem to experience less general pain than patients who
avoid exercise. Even aerobic exercises such as walking or swimming seem
to reduce the amount of pain reported by patients.
While adequate exercise can be beneficial, too much exercise can be
devastating. If demands on the body are too great, tissue will not be able to
adapt quickly enough to escape damage. Working out too much can be just
as damaging to progress as working out too little. If a patient appears to be
working hard, but not making much progress, the solution might be to
decrease, not increase, the intensity, duration, or frequency of exercise.


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The rate of progress during the early stages of recovery should not be
expected to continue throughout the entire process. Most patients make
faster progress during the early stages of rehabilitation than during the latter
stages, and many physical attributes such as strength or endurance can be
redeveloped in less time after an injury than it took to develop the same
attributes before the injury.
Strength, in particular, seems to improve more quickly during the early
stages of recovery than during the latter stages. The reasons for early
improvement include: (1) reduction of pain inhibition, (2) rapid increases in
neurologic efficiency, and (3) greater motivation to exercise at home.
If pain inhibition is the main factor limiting strength, using ice or
neutralizing trigger points produces immediate increases in strength.
Strength is determined by the total number of muscles fibers contracting at
one time. Increasing neurologic efficiency increases strength by: (1)
recruiting more muscle fibers, or (2) increasing the muscle fibers rate of
contraction. Greater motivation to exercise at home makes it more likely
that patients will exercise at recommended levels of frequency, intensity,
and duration.
There are three reasons for slower improvement during the latter stages
of recovery. First, muscular imbalance is more likely to impede progress
than pain, and muscular imbalance takes longer to treat than pain. Second,
strength tends to increase because of increases in muscle mass, and muscle
mass takes longer to increase than neurologic efficiency. Third, many
patients become less motivated during the latter stages of recovery and stop
exercising at home.
Feedback from the patient can be very important when trying to adjust
the intensity, duration, and frequency of exercise. While many patients will
suffer residual pain for one or two days after exercising, this pain should be
moderate and most patients should wait for the pain to disappear before
continuing the same exercises. Continuous pain because of exercise
normally indicates the exercises are too severe.
In terms of rehabilitation, it is always safer to err on the side of too little
exercise than too much exercise. As long as a patient exercises enough to
prevent deconditioning, increasing the difficulty of the program can always
be postponed. Unlike athletes preparing for competition, for most people
recovering from soft-tissue impairments, there are no deadlines for
completing therapy.


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Cardiovascular fitness training has been shown to reduce pain in patients
suffering from fibromyalgia.
Once soft-tissue injuries have healed and range-of-motion for injured
body parts is fully restored and pain-free, the five basic goals for therapeutic
exercise are

maintain range-of-motion and flexibility
improve muscular strength and endurance
improve muscular speed and power
improve mobility and coordination
improve cardiovascular fitness

Even though pain can signal tissue damage, it can also be the cause of
disability after all other causes have been eliminated. When all other
problems except pain have been eliminated, the final goal of therapy
becomes eliminating the pain. Once pain becomes the problem, rather than
a symptom of the problem, removing the pain will often restore normal
function.

Exercise Principles

Even though the particulars of each exercise may vary, the basic
principles that apply to all types of exercise in general remain fairly
constant. Learning exercise principles and how to apply them is usually
more productive than memorizing hundreds of different exercises. By
understanding exercise principles and basic anatomy and physiology, most
practitioners can design their own exercises or modify existing exercises to
meet the special needs of a patient.

EXERCISE PRINCIPLES
(1) The Overload Principle
(2) The Intensity Principle
(3) The Frequency and Duration Principle
(4) The Specificity Principle
(5) The Training Principle


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(1) The Overload Principle

Key concept: The intensity, frequency, or duration of training must be
increased periodically for improvement to continue.

The overload principle refers to exercising at levels of stress that are
greater than normal. When the body is functioning at normal levels of stress,
fitness remains about the same. The body responds to levels of stress above
normal by making biophysical changes called adaptations or training effects
that improve the body's ability to deal with future stress. These changes affect
flexibility, strength, muscular endurance, and cardiovascular fitness.
Overload can be produced by using resistance from gravity, weights,
manual force, or contraction of opposing muscles. Progressive-resistance
exercises are based on the principle that resistance should be increased
incrementally after the body adapts to each new level of stress. Adaptations to
overload will continue until the body reaches its own limit.
Single sessions of an exercise produce temporary changes that are called
responses. These changes become more permanent after repeated bouts of the
same exercise. It is not the exercise itself, but the changes because of exercise
that improve biologic efficiency.
The overload principle can be applied by using both isometric and isotonic
exercises. Isometric contractions do not produce movement because internal
forces are not large enough to overcome external resistance. Muscles
contracting isometrically develop tension without changing length.
Isotonic contractions produce movement because internal forces are large
enough to overcome external resistance. Muscles contracting isotonically
develop tension and become shorter. Isometric contractions improve static
strength such as gripping or holding an object. Isotonic contractions improve
dynamic strength such as pushing or pulling an object.
Although both types of contraction are used in normal living, from a
therapeutic standpoint, isometric contractions generate less friction and are less
likely to aggravate joints and periarticular tissues. Because they are less likely
to cause tissue damage than isotonic exercises that produce movement,
isometric exercises can be used during the early stages of an injury to help the
body maintain strength.
The overload principle can be applied to flexibility training as well as to
strength or endurance training. Flexibility is the ROM available to a joint or
group of joints. The anatomical factors that limit ROM include muscles,


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fascia, tendons, ligaments, joint capsules, fat, skin, and bone. Flexibility is
joint-specific. To increase the flexibility of a joint, overload must be applied
to that specific joint by increasing intensity, frequency, or duration.

(2) The Intensity Principle

Key concept: Increasing intensity is the first way to increase overload.

Where overload measures the amount of energy expended to overcome
resistance, intensity measures the rate of expenditure. Every tissue of the body
has a threshold for improvement. Intensity below this level will not cause
improvement. While high-intensity exercise increases the rate of
improvement, low-intensity exercise decreases the risk of injury. For most
patients recovering from a soft-tissue impairment, low-intensity exercises are
safer and more productive than high-intensity exercise.
In sports training, the best measure of intensity is fatigue. Muscles are
fatigued when they lose their ability to contract and momentarily fail. What
causes fatigue is not always clear. Possible causes are depletion of high-
energy sources such as glycogen, accumulation of metabolites such as lactic
acid, or failure of the body to regulate temperature. Fatigue can result in loss
of coordination, substitution of one muscle for another, and muscle failure.
When exercises are being used during the early stages of rehabilitation,
levels of intensity high enough to cause fatigue are probably not required and
may not be safe. To keep the intensity of an exercise at a safe level, it may be
necessary to assist the patient with active movements (active-assisted
exercise), since muscles afflicted by pain, spasm, or contracture may not be
able to move even their own weight without becoming severely fatigued.

(3) The Frequency and Duration Principle

Key concept: Frequency and duration are the second and third ways to
increase overload.

Increasing frequency or duration are often safer ways of increasing
overload than increasing intensity. When tissues are recovering from an
injury, exercises should be spaced far enough apart to allow sufficient time for
healing. If the overload remains constant, high-intensity exercises are more
likely to cause injuries than high-frequency or long-duration exercises. The


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risk of tissue damage is greater because high-intensity exercises involve larger
amounts of resistance than high-frequency or long-duration exercises. While
increasing intensity will decrease frequency (or duration), increasing the
tension on a muscle increases strength more than increasing repetitions.

(4) The Specificity Principle

Key concept: Specific exercises produce specific biophysical adaptations
that affect specific parts of the body.

Specific exercises produce specific biophysical adaptations. Strength
training increases strength and flexibility training increases flexibility. Each
exercise has its own characteristics in terms of muscles or muscle groups, rates
of energy expenditure, and patterns of movement. These patterns are defined
by changes in force, mass, acceleration, velocity, direction, distance, and time.
Because of specificity, a patient can improve flexibility without improving
strength or improve strength without improving flexibility.
The value of training depends on what type of transfer occurs between
exercise and therapeutic goals. The transfer is positive if the exercise is
beneficial and negative if the exercise is detrimental. Positive transfer is
greatest when the exercise and therapeutic goals are nearly identical. If the
therapeutic goal is increasing abdominal strength, trunk-flexion exercises such
as partial sit-ups would produce a greater positive transfer than trunk-
extension exercises, running, or swimming.
In some cases, one therapeutic goal must be satisfied before another can be
satisfied. In cases of extreme weakness, strength training is the only way to
improve muscular endurance. Without enough strength for a single repetition,
endurance training would be impossible. Where strength is the limiting factor,
strength training is needed to improve muscular endurance.
A similar relationship exists between strength and flexibility. A patient
cannot complete active ROM exercises without enough strength to stretch
opposing muscles and move the body part through at least one complete ROM.
Just as strength may be needed to improve endurance, strength may also be
needed to improve or maintain the patients active range of motion.
Different exercises are needed for each factor that needs to be improved.
A well-rounded training program should include exercises for flexibility,
strength, muscular endurance, and cardiovascular fitness. While most
rehabilitation programs dealing with soft-tissue injuries rely heavily on


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flexibility, strength, and muscular-endurance training, it now appears that
cardiovascular fitness training reduces myofascial pain.
Specific exercises should target specific muscles, muscle groups, joint
angles, and velocities. Increasing the strength or flexibility of one body part
does not increase the strength or flexibility of other body parts. While some
studies suggest that exercising one side of the body may in some ways benefit
the opposite side, equal gains in performance require exercising both sides of
the body. Just as biophysical adaptations are specific for a given exercise, they
are also specific for a given body part or pattern of movements.

(5) The Training Principle

Key concept: Percentages of gains are normally greatest during the early
stages of an exercise program and diminish as the program continues.

The training principle states that patients often make the greatest gains
during the early stages of a new exercise program. The most common reasons
for early improvement are (1) better use of body mechanics and reduction of
counterproductive movements, (2) neural changes that improve neurologic
efficiency, and (3) morphologic changes that alter the mass or chemical
composition of muscles.
After patients become familiar with an exercise program, less fear, greater
relaxation, and more self-confidence may improve performance. If exercise
reduces pain or increases tolerance for pain, performance may improve.
As exercise programs continue, the rate of progress often decreases and
some patients become frustrated, lose interest, and quit training. Explaining
the training principle and the nature of diminishing returns will help patients
understand why training should be continued despite less progress.
Once a patient has completely adjusted to an exercise program, a point
may be reached where increasing overload does not seem to improve
performance. A decrease in response to a constant stimulus such as exercise is
sometimes called accommodation. Because of accommodation, programs
become nonproductive despite increases in frequency, duration, or intensity.
Two possible ways of coping with accommodation are (1) have the patient
take a break from the exercise program for a short period of time, or (2) create
a new exercise program that accomplishes similar goals. Even though creating
a new program may produce a series of rapid gains when the program is first
used, most programs become less productive with time.


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Muscle Soreness

The basic theories that explain muscle soreness after exercise are very
similar to the basic theories that explain soft-tissue pain in general.
Understanding muscle soreness can lead to a better understanding of
musculoskeletal pain as related to soft-tissue impairments.
Muscle soreness may increase with the intensity of exercise. Exercises
that produce a training effect are more likely to cause muscle soreness than
exercises for maintenance. Overwork damage is considered a form of trauma
more than muscle soreness. Exercise that allows disuse atrophy will probably
not cause muscle soreness.
The two types of muscle soreness commonly recognized are (1) acute
muscle soreness, and (2) delayed-onset muscle soreness. Acute muscle
soreness occurs during or immediately following exercise, whereas delayed-
onset muscle soreness usually occurs within 24 to 72 hours after exercise.
Acute muscle pain is probably caused by a decrease in blood flow that
occurs when muscles repeatedly contract and hydrostatic pressure increases.
Compromising blood flow during intense exercise may cause ischemic
damage and metabolite retention. The metabolic waste products commonly
thought to accumulate and cause acute muscle soreness are lactic acid and
potassium. Acute soreness often occurs in conjunction with burning pain,
fatigue, or muscle failure. Shortly after exercise is over and muscles relax,
blood flow returns to normal and pain-producing metabolites are removed.
While lactic acid probably contributes to acute muscle soreness, the belief
that lactic acid is the major cause of either acute or delayed muscle soreness
appears to be incorrect for three reasons. First, lactic acid does not remain in
the body long enough to cause delayed muscle soreness, and recent magnetic-
resonance spectroscopy studies have shown that acute soreness disappears
before lactic acid dissipates. Second, when concentric and eccentric
contractions elevate lactic acid to about the same level during a single bout of
exercise, eccentric contractions produce more delayed muscle soreness than
concentric contractions. Third, people with McArdles disease experience
muscle soreness both during and after exercise even though their bodies are
unable to produce lactic acid. McArdles disease is hereditary and is caused
by the absence of phosphorylase, an enzyme required for breaking down
glycogen into lactic acid.
The release of pain-producing chemicals after ischemia may explain acute
muscle soreness better than lactic acid accumulation. When tissues are


196
damaged by ischemia, chemical agents such as histamine, serotonin, and
bradykinin sensitize nerve receptors and mediate pain. Prostaglandins are
probably not involved since nonsteroidal anti-inflammatory drugs (NSAID)
that inhibit prostaglandin production such as aspirin and ibuprofen have little
or no effect on acute muscle soreness.
Three basic theories have been suggested to explain delayed muscle
soreness: (1) the muscle spasm theory, (2) the osmotic pressure theory, and
(3) the tissue damage theory. What all of these theories acknowledge is that
isometric contractions or concentric isotonic contractions are less likely to
cause muscle soreness than eccentric isotonic contractions.
During isometric contractions, muscles contract, the distance between
origin and insertion remains the same, and no movement occurs. During
concentric isotonic contractions, muscles contract, the distance between origin
and insertion decreases, and movement occurs. Isometric contractions slightly
produce more delayed muscle soreness than isotonic concentric contractions.
During eccentric isotonic contraction, muscles contract but the distance
between origin and insertion increases. Because of a counterforce, even
though muscles are contracting, their length becomes longer instead of shorter.
Eccentric isotonic contractions are called negative contractions or lengthening
contractions. At the same velocity, the maximum tension produced by
eccentric contractions is greater than that produced by isometric or concentric
contractions.
If the trunk of the body flexes forward from a standing position, trunk
extensor muscles contract eccentrically to prevent the trunk from falling
forward under the influence of gravity. When the trunk returns to a standing
position, trunk extensors contract concentrically to raise the trunk.
Based on the principle that eccentric contractions cause more muscle
soreness than concentric contractions, lowering a heavy object to the floor is
more likely to cause delayed muscle soreness than lifting a heavy object from
the floor. While this observation may not apply to all cases of common low-
back pain, it does draw attention to the possibility that lowering a heavy object
might be just as capable of triggering an episode of low-back pain as lifting a
heavy object.
While the exact cause of muscle soreness remains unknown, the probable
causes seem to involve spasm, osmotic pressure, and tissue damage. It also
appears that even if one theory is more significant than the others, all three
play at least partial roles in causing delayed muscle soreness. Of all three
theories, the most useful theory is probably the tissue damage theory.


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Muscle Spasm Theory

This theory proposes that muscle soreness is caused by muscle spasm.
This theory is partially supported by electromyographic (EMG) studies that
show a direct correlation between electrical activity, spasm, and muscle
soreness. When painful muscles are treated by range-of-motion stretching,
electrical activity, spasm, and muscle soreness decrease. The recommended
sequence for using range-of-motion (ROM) stretching to decrease muscle
soreness is (1) two minutes of static stretching, (2) one minute of rest, and (3)
two more minutes of static stretching.
The spasm related to muscle soreness is possibly caused by ischemic tissue
damage. As the blood flow to a muscle decreases during strenuous activity, a
corresponding decrease in oxygen (hypoxia) causes pathologic tissue death
(ischemic necrosis) and reflex spasm. This can also be the start of a spasm
painspasm cycle:

spasm causes ischemic damage and pain
ischemic damage and pain cause spasm

Osmotic Pressure Theory

The osmotic-pressure theory states that an increase in osmotic pressure
because of metabolite accumulation causes delayed muscle soreness. Since
metabolite accumulation is 5 to 7 times greater during concentric contractions
than during eccentric contraction, this theory would appear to be flawed if
contractions are the only factors that contribute to metabolite accumulation.
The osmotic pressure theory becomes more plausible if tissue damage is
considered as another possible reason for metabolite accumulation. The
inflammatory stage that follows tissue damage is characterized by increases in
metabolite retention, osmotic pressure, and local edema. Since muscles
affected by delayed muscle soreness often feel slightly swollen, increases in
hydrostatic pressure may precede pain.

Tissue Damage Theory

The tissue damage theory purports that minute tears or ruptures of muscle
tissue or connective tissue cause delayed muscle soreness. This theory is
supported by two observations: (1) eccentric contractions are more likely to


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cause muscle soreness than concentric contractions, and (2) eccentric
contractions place a greater strain on muscle tissue and connective tissue than
concentric contractions.
If tissue damage contributes to muscle soreness, the next step is
differentiating between muscle-tissue damage and connective-tissue damage.
This difference can be determined by measuring myoglobinuria and urinary
levels of hydroxyproline. Unlike creatine kinase, an enzyme that catalyzes the
reaction that forms adenosine-triphosphate (ATP) from adenosine diphosphate
(ADP) and is sometimes used as an enzyme marker to indicate general tissue
damage, myoglobin and hydroxyproline can be used to distinguish between
muscle-tissue damage and connective-tissue damage.
Myoglobin is an oxygen-binding pigment that stores oxygen and gives
muscles a red color. Myoglobinuria occurs when muscular exertion, ischemic
damage, or trauma cause the release of myoglobin into urine. Hydroxyproline
is an amino acid found in connective tissue. Hydroxyproline levels increase
when connective tissues break down because of an imbalance of collagen
metabolism or because of trauma.
When myoglobinuria was measured after exercise, subjects with muscle
soreness had about the same levels of myoglobin in their urine as subjects
without muscle soreness. This indicates a lack of causal relationship between
muscle soreness and damage to muscle tissue.
By contrast, when hydroxyproline levels in urine where measured after
exercise, subjects with muscle soreness showed higher levels of
hydroxyproline than subjects without muscle soreness. This implicates
damage to connective tissue, such as fascia or tendons, as a possible cause of
muscle soreness. The pain that follows connective-tissue damage is probably
caused by four basic factors related to inflammation:

pain-producing chemicals
local edema
reflex spasm
local ischemia

Since delayed muscle soreness is normally caused by microtrauma as
opposed to macrotrauma, inflammation tends to be self-limiting, with or
without treatment. Most cases of delayed muscle soreness peak within 48
hours and are fully resolved within 4 to 5 days. Delayed-onset muscle
soreness seldom causes self-perpetuating pain cycles. Because of a possible


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relationship with inflammation and prostaglandin synthesis, delayed muscle
soreness is more responsive to aspirin than acute muscle soreness.
If connective-tissue damage is one of the main causes for delayed muscle
soreness, this could explain why the frequency of muscle soreness decreases as
the body becomes accustomed to an exercise. When starting a new exercise,
connective-tissue length may not be sufficient to accommodate the stretching
needed to complete an exercise.
As a result of insufficient length, a certain number of connective tissue
fibers are probably torn or ruptured. As the exercise is repeated over a period
of time, connective-tissue fibers probably lengthen and make it less likely that
stretching will cause connective-tissue damage or muscle soreness. There is
also a possibility that exercising a muscle increases the length of the muscle by
adding sarcomeres in series.
Three ways to reduce delayed soreness after exercise are (1) warm-up and
stretch muscles before starting a strenuous exercise, (2) avoid ballistic
movements if a joints active ROM is restricted or much smaller than the
passive ROM, and (3) work up progressively from low levels of intensity or
duration to high levels of intensity or duration. Besides failing to warm-up
correctly, using ballistic movements, and starting with too much overload,
exercising while fatigued is another way to invite connective-tissue damage
and delayed muscle soreness.

Implications

As a consequence of these theories, at least three possibilities can be
implied concerning soft-tissue manipulation. First, delayed muscle soreness
relating to soft-tissue manipulation is possibly caused by damage to connective
tissue such as tendons or fascia. Since the stretching or tearing of fascia often
produces a burning sensation, delayed muscle soreness following stretching
that causes a burning sensation is possible proof that connective-tissue damage
is causing delayed muscle soreness.
Second, to avoid delayed soreness, do not stretch muscles that are
contracting eccentrically. During eccentric contractions, the distance between
a muscles origin and insertion are increasing despite various degrees of
efforts by the muscle to contract and shorten. If a patient contracts a muscle to
produce resistance, do not apply a counterforce sufficient to overcome or
break the patients contraction. Eccentric contractions are sometimes called
isolytic contractions.


200
The main justification for using counterforce to overcome a patients
contraction is a need to break down fibrous connective tissue. Even with slow
and steady force, the risk of tissue damage is greater than it would be if the
same muscle was stretched while relaxed.
Because of delayed soreness and the risk of tissue damage, breaking a
patients contraction simply to lengthen a muscle is not recommended.
Stretching a muscle during contraction is more likely to rupture a tendon than
stretching the same muscle while relaxed. Only in rare cases, such as breaking
down a highly resistant contracture, should breaking a patients contraction be
used to break down fibrous connective tissue.
Third, gentle range-of-motion stretching after a treatment may reduce
delayed soreness. The sequence for stretching after soft-tissue manipulation
would be the same as the sequence for stretching after exercise: (1) two
minutes of single-repetition static stretching, (2) one minute of rest, and (3)
two more minutes of single-repetition static stretching. Light massage can be
applied during the rest period to stimulate circulation. The stretching sequence
should be repeated about three times per day. Stretching is most effective
when delayed soreness is caused by spasm or osmotic pressure.
Muscle soreness caused by connective-tissue damage is less likely to be
affected by range-of-motion stretching than muscle soreness caused by spasm
or osmotic pressure. Once connective tissues have been torn or ruptured, pain
will continue at least as long as inflammation continues, and possibly longer if
trigger points, adhesions, or contractures develop.
Fourth, if range-of-motion stretching causes delayed soreness 24 to 72
hours after a treatment, the main cause for soreness is probably connective-
tissue damage. As repeated bouts of stretching encourage connective tissues
to lengthen, the intensity of delayed soreness should decrease. Since
adaptations to stretching are specific to the tissues being stretched, soreness
may reappear if new stretches are used that affect different tissues.
Since delayed muscle soreness seems to occur most when large overloads
are placed on individual muscles, delayed soreness from range-of-motion
stretching can be reduced by gradually increasing the amount of stretch with
each treatment. Another way to reduce delayed soreness from stretching is to
use therapeutic heat before stretching to increase tissue extensibility. Daily
doses of vitamin C (100 mg) and E (800 IU) may help to prevent muscle
soreness. If severe delayed soreness continues after two or three identical
treatments, the pain may be caused by infection, repetitive strain, or joint
disease as opposed to uncomplicated connective-tissue trauma.


201
Deconditioning

Deconditioning occurs rapidly when a person stops exercising. Without
muscle contractions, strength may decrease 5% per day. Significant losses
occur after two weeks and many of the training adaptations gained through
exercise are completely lost after two months. Just as an organism or tissue
adapts to stress by making changes in structure or function that allow it to
tolerate greater stress, the same organism or tissue will adapt to the absence of
stress by reversing the training effects. Once a muscle is deconditioned,
reconditioning may take two or three times longer than deconditioning.
In the short term, deconditioning reduces flexibility, strength, muscular
endurance, and cardiovascular fitness. In the long term, deconditioning affects
the integrity of ligaments, tendons, and bones.
Decreased muscle strength is one of the first signs of deconditioning. The
adaptations that decondition a muscle are almost the opposite of adaptations
that condition a muscle. Most decreases in strength are caused by:

a decrease in neurologic efficiency
a decrease in fiber density
a decrease in muscle mass (atrophy)
a decrease in the number of sarcomeres

The decreases in neurologic efficiency characteristic of deconditioning are
caused by: (1) a decrease in the number of motor units firing at one time, (2) a
decrease in the rate of firing, and (3) a decrease in the efficiency of recruitment
patterns. A decrease in fiber density may occur even if the number of actin
and myosin filaments remains the same.
The decrease in muscle mass (atrophy) is the opposite of an increase in
muscle mass (hypertrophy). A myofibril is one of the fine longitudinal fibrils
that occur within a muscle fiber. Atrophy results from a decrease in the
number of myofibrils within a given muscle fiber.
A decrease in sarcomeres is one reason muscles decrease in length during
periods of inactivity. Sarcomeres are lost mostly at the end of muscle fibers.
Another reason is connective tissue shortening during periods of inactivity or
immobility (myogenic contracture). While lack of regular stretching may
cause contractures; hemorrhage, inflammation, or ischemia may alter the
microenvironment of a muscle and hasten the development of contractures.
Connective-tissue shortening often occurs before a decrease in sarcomeres.


202
Both strengthening exercises and passive range-of-motion stretching will
increase the length of a muscle fiber by adding sarcomeres in series. Passive
range-of-motion stretching will also increase the length of connective tissues
that surround or support muscle fibers and separate or enclose muscles or
muscle groups (fascia).
Despite years of recommending bed rest as a cure for common low-back
pain, most doctors now realize that bed rest deconditions the body and reduces
mobility even faster than a lack of exercise. To use bed rest beyond the acute
stage of an injury is more likely to cause harm than good.

Motivation

Even with strong evidence that a lack of exercise can lead to permanent
disability, some patients will resist exercise and refuse to participate in their
own cure. Even if practitioners explain the benefits of exercise and the
consequences of inactivity, nothing can make patients exercise but their own
will. For most patients, the best approach is to help them find a method of
exercise that is both enjoyable and beneficial. For those patients who strongly
oppose exercise, almost any form of exercise is better than no exercise at all.
In addition to health benefits and reduction of pain, regular exercise promotes
general relaxation and a sense of well-being.

Eight guidelines for motivating patients to exercise:

Clearly explain the reasons and goals for an exercise program.
Help patients understand the exercise principles and safety measures.
Introduce an exercise program slowly enough for the patient to adjust.
Encourage patients to set aside specific times for exercise.
Set realistic and measurable short-term and long-term goals.
Provide patients with methods and timetables for measuring progress.
Make patients responsible for their own health.
Encourage patients to seek immediate professional help if problems arise.

Even if therapy is properly administered and the patient is fully
cooperative, some people will never be able to live and work as normally as
they did before an injury or impairment. These patients can best be helped
by helping them live in the best way possible. For patients who cannot be
cured, symptomatic relief is better than no relief at all.


203
Prevention

While most practitioners agree that prevention is the best form of
treatment, the basic factors that contribute to injuries are seldom discussed.
The following list of danger signs summarizes the seven basic factors that
contribute to most soft-tissue injuries that result from strenuous activity.

Seven danger signs that increase the risk of injury:

extremely limited active or passive ranges of motion
large discrepancies between active and passive ranges of motion
weakness caused by deconditioning, soft-tissue impairments, or fatigue
hypermobility that causes instability
lack or coordination or timing
activities involving repetitive or high-impact movements
activities involving ballistic or high-velocity movements

If ballistic movements cannot be avoided, the following five guidelines
may help to reduce the risk of injury:

Use warm-up exercises to elevate tissue temperatures.
Use static stretching first to increase range-of-motion.
Progressively increase the velocity and magnitude of movements.
Stop if severe pain, abnormal sensations, swelling, or weakness occurs.
Stop at the first sign of fatigue, incoordination, or dysfunction.

If injuries do occur because of exercise, trying to work through the pain
is not always the best solution. Some injuries require rest and stabilization
before tissues can tolerate additional stress without further damage. If there
are no soft-tissue impairments causing pain, limited range-of-motion, or
weakness, the five steps between injury and a full recovery are represented
by the acronym TIRED as in "Tired of being injured."

Trauma: acute or sudden injuries and chronic or cumulative injuries.
Inflammation: vascular, hemostatic, cellular, and immune responses.
Repair: collagenization, contraction, remodeling, and maturation.
Exercise: activities to stretch and strengthen injured tissue.
Diligence: carefully avoiding activities that may cause further injuries.


204
Even though low back pain and neck and shoulder pain are among the
most common problems treated by soft-tissue therapy, these types of pain
can often be prevented by following basic guidelines.

Five basic guidelines to prevent common low back pain include:

Do stretching and strengthening exercises at least twice a week.
Do not allow soft tissue impairments to go untreated.
Avoid any activities that are known to cause low back pain.
Develop good health habits such as adequate rest and proper nutrition.
Use extreme care when lifting or setting objects in place.

The seven basic guidelines for lifting or setting objects in place include:

Think before you lift.
If the weight exceeds your capacity to lift, get help.
Squat down, use the legs, and keep your head up when lifting an object.
Keep feet apart and objects being lifted or set in place close to body.
Do not lift or set objects in place while trunk is rotated.
Do not make rapid movements when lifting or setting objects in place.
When moving an object sideways, rotate the body by moving the feet.

Seven basic guidelines to prevent neck and should pain include:

Discontinue activities that cause pain or fatigue.
Avoid conditions that cause fatigue because of overuse or repetition.
Warm-up before vigorous neck or shoulder movements.
Face objects and stand close before moving or lifting the object.
Avoid working with the arms while stooped over.
Avoid working with the arms above the shoulders.
Do neck and shoulder exercises to improve strength and flexibility.

While soft-tissue therapy provides the tools for correcting many of the
factors that contribute to injuries such as pain or limited range of motion, the
final keys to preventing an injury are good judgment and common sense:
avoid activities that increase the risk of injury and pursue activities that
decrease the risk of injury. Without good judgment and common sense, just
knowing how to prevent injuries will not make a difference.


205
CHAPTER SUMMARY

FIVE BASIC GOALS OF THERAPEUTIC EXERCISE

Maintain range-of-motion and flexibility
Improve muscular strength and endurance
Improve muscular speed and power
Improve mobility and coordination
Improve cardiovascular fitness

FIVE PRINCIPLES OF EXERCISE

Overload principle
Intensity principle
Frequency and duration principle
Specificity principle
Training principle

FOUR FACTORS RELATED TO DECONDITIONING

A decrease in neurologic efficiency
A decrease in fiber density
A decrease in muscle mass (atrophy)
A decrease in the number of sarcomeres

EIGHT GUIDELINES FOR MOTIVATING PATIENTS TO EXERCISE

Clearly explain the reasons and goals for an exercise program.
Help patients understand the exercise principles and safety measures.
Introduce an exercise program slowly enough for the patient to adjust.
Encourage patients to set aside specific times for exercise.
Set realistic and measurable short-term and long-term goals.
Provide patients with methods and timetables for measuring progress.
Make patients responsible for their own health.
Encourage patients to seek immediate professional help if problems arise.


206
SEVEN DANGER SIGNS THAT INCREASE THE RISK OF INJURY

Extremely limited active or passive ranges of motion
Large discrepancies between active and passive ranges of motion
Weakness caused by deconditioning, soft-tissue impairments, or fatigue
Hypermobility that causes instability
Lack or coordination or timing
Activities involving repetitive or high-impact movements
Activities involving ballistic or high-velocity movements

FIVE GUIDELINES TO REDUCE BALLISTIC MOVEMENT INJURIES

Use warm-up exercises to elevate tissue temperatures.
Use static stretching first to increase range-of-motion.
Progressively increase the velocity and magnitude of movements.
Stop if severe pain, abnormal sensations, swelling, or weakness occurs.
Stop at the first sign of fatigue, incoordination, or dysfunction.

THE ACRONYM TIRED STANDS FOR

Trauma: acute or sudden injuries and chronic or cumulative injuries.
Inflammation: vascular, hemostatic, cellular, and immune responses.
Repair: collagenization, contraction, remodeling, and maturation.
Exercise: activities to stretch and strengthen injured tissue.
Diligence: avoiding activities that may cause further injuries.

FIVE GUIDELINES TO PREVENT COMMON LOW BACK PAIN

Do stretching and strengthening exercises at least twice a week.
Do not allow soft tissue impairments to go untreated.
Avoid any activities that are known to cause low back pain.
Develop good health habits such as adequate rest and proper nutrition.
Use extreme care when lifting or setting objects in place.


207
SEVEN GUIDELINES FOR LIFTING OR PLACING OBJECTS

Think before you lift.
If the weight exceeds your capacity to lift, get help.
Squat down, use the legs, and keep your head up when lifting an object.
Keep feet apart and objects being lifted or set in place close to body.
Do not lift or set objects in place while trunk is rotated.
Do not make rapid movements when lifting or setting objects in place.
When moving an object sideways, rotate the body by moving the feet.

SEVEN GUIDELINES TO PREVENT NECK AND SHOULD PAIN

Discontinue activities that cause pain or fatigue.
Avoid conditions that cause fatigue because of overuse or repetition.
Warm-up before vigorous neck or shoulder movements.
Face objects and stand close before moving or lifting the object.
Avoid working with the arms while stooped over.
Avoid working with the arms above the shoulders.
Do neck and shoulder exercises to improve strength and flexibility.


208
CONCLUSION

The HEMME APPROACH is easy to learn and simple to use. After
HISTORY and EVALUATION are used to identify or appraise the problem,
MODALITIES, MANIPULATION, and EXERCISE are used to solve the problem.
Even though medical histories are normally more subjective than physical
evaluations, even physical evaluations involve some degree of subjectivity.
The link between problem and solution is a step called alternatives.
Once the problem is identified, practitioners must formulate a plan that
selects the best alternatives for solving the problem. A basic list of possible
alternatives includes

MODALITIES:
cryotherapy
thermotherapy
vibration

MANIPULATION:
trigger point therapy
neuromuscular therapy
connective tissue therapy
range-of-motion stretching

EXERCISE:
strengthening exercise
stretching exercises
muscular endurance exercises
cardiovascular fitness exercises

After selecting alternatives and implementing a treatment plan, feedback
from the patient is used to determine if the plan is producing positive or
negative results. If the results are positive, the plan is continued, if the
results are negative, the plan is changed. The three main areas monitored by
feedback are (1) pain, (2) range of motion, and (3) weakness.
If the plan is not working, practitioners have the option of changing the
plan at any time by redefining the problem or using different methods of
treatments. The option of using outside information from other health care
professions or reference materials is always available.


209
When therapy is finally terminated, the two basic outcomes are (1)
objective satisfied, and (2) objectives not satisfied. While in some cases the
outcomes will be easy to classify based on obvious success or failure, in
many cases success or failure will be a matter of degree. Even if the patients
regain normal function, the quality of life may not be the same because of
residual pain, stiffness, or general discomfort.
There is also a difference between short-term outcomes and long-term
outcomes. Even though practitioners may have a great impact on short-term
outcomes, long-terms outcomes often depend on the patient's willingness to
follow recommended exercise programs and comply with injury-prevention
guidelines. Once formal therapy is discontinued, patients must either take
responsibility for their own health or risk the consequences.

Sample HEMME APPROACH Application

The following example shows how the HEMME APPROACH can be used
to identify and treat common soft-tissue impairments. This procedure is
based on information presented in previous chapters and follows the basic
HEMME acronym:

HISTORY
EVALUATION
MODALITIES
MANIPULATION
EXERCISE

General Background

The patient stated she injured her right arm by falling off a horse and
landing on her right arm. After 8 weeks, her arm continues to be stiff,
painful, and weak. She has difficulty straightening her right arm, using her
right arm to lift objects above eye level, and sleeping at night.
The general practitioner who saw her shortly after the injury stated there
were no signs of bone fracture, joint damage, or subcutaneous bleeding. The
doctor suggested an arm sling and prescribed medication for pain and
inflammation. Since the injury was expected to heal without further
treatment, no additional treatments were recommended or scheduled.


210
HISTORY

Using the acronym PDQ:

Problem: What is the nature of the problem?

How did the injury occur (mechanism of injury)?
When did the injury occur (time, day, and date)?
Type of onset: insidious or traumatic.
Stage of wound healing: acute, subacute, or chronic.
What is the extent of disability (physical or psychological)?

If there is disability because of pain, limited ROM, or weakness:

Pain


Limited ROM

Does it hurt when you try to straighten your arm?
Do you feel tension when you try to straighten your arm?
Is your range of motion always limited to the same degree?

Weakness

Do you feel weakness and pain together?
Do you feel weakness and tingling together?
Is the weakness constant?

Doctor's care: Are you under a doctor's care?

Did you see a doctor (what type of doctor)?
Are you under a doctor's care (how many doctors)?
Are you taking any medication (what type of medication)?


211
Quality: If treated before, what was the quality of past treatment?

Have you had a similar injury?
How was the injury treated?
Was the treatment effective?

EVALUATION

Observation:

Does the injured body part appear to be normal (structure)?
Does the injured body perform properly (function)?
Does the patient's behavior indicate the body part is injured?

Palpation:

Is the body part atrophied, moist, swollen, hot or cold?
Is the body part hypertonic (spasm) or hypotonic (flaccid).
Does movement produce snapping, clicking, or crepitus?

Muscle Testing:

Is active range-of-motion testing normal?
Is passive range-of-motion testing normal?
Is resisted range-of-motion testing normal?

Can any particular syndrome be identified?

Does the condition resemble fibromyalgia syndrome (FMS)?
Does the condition resemble myofascial pain syndrome (MPS)?
Does the condition have characteristics of both FMS and MPS?

MODALITIES

Is heat needed relieve pain or spasm or increase tissue extensibility?
Is cold needed to relieve pain or spasm or produce analgesia?
Can vibration be used to inhibit or facilitate muscles or relieve pain?


212
MANIPULATION

Trigger point therapy:

Is trigger point therapy needed to relieve pain or pain inhibition?
Is trigger point therapy needed to reduce spasm?
Will deep sliding pressure be more effective than digital pressure?

Neuromuscular therapy:

Is neuromuscular therapy needed to inhibit hypertonic muscles?
Is neuromuscular therapy needed to facilitate weak muscles?
Which method of inhibition or facilitation will be most effective?

Connective tissue therapy:

Is connective tissue therapy needed to break adhesions?
Is connective tissue therapy needed to lengthen scar tissue?
Will trigger point therapy be more effective than cross-fiber friction?

Range-of-motion stretching:

Is ROM stretching needed to lengthen contractures?
Is ROM stretching needed to improve flexibility?
Should ROM stretching be used after other forms of manipulation?

Relaxation therapy:

Is relaxation therapy needed to decrease hypertonia?
Is relaxation therapy needed to produce psychological relaxation?
Is relaxation therapy needed to prepare the patient for manipulation?

EXERCISE

Is exercise needed to improve range-of-motion?
Is exercise needed to improve strength?
Is exercise needed to improve muscular or cardiovascular endurance?


213
HEMME APPROACH Charts and Forms

Answering the above questions should make it clear how the HEMME
APPROACH can be used to appraise and treat injuries. The outline
emphasizes major points under each of the five basic categories: History,
Evaluation, Modalities, Manipulation, and Exercise.
The answers to the questions listed under HISTORY and EVALUATION
should make it easier to answer most of the questions listed under
MODALITIES, MANIPULATION, and EXERCISE. For help answering questions
such as "Which technique is more effective?" or "When should a given
technique be used?" review the chapter titled MANIPULATION.
Rather than follow a simple directive such as plan your work and work
your plan, soft-tissue therapy often requires that you plan your work, work
your plan, and change your plan to make it work. In addition to knowledge,
physical skills, logic, intuition, and perseverance, it requires a tremendous
amount of adaptability to become a competent soft-tissue therapist.
To make record keeping easier, practitioners can use the

HEMME APPROACH Evaluation Chart
HEMME APPROACH Appraisal and Treatment Form

The HEMME APPROACH Evaluation Chart uses a series of abbreviations
and symbols as a short-cut method for recording information. Additional
abbreviations, symbols, or words can always be added if needed.
Abbreviations and symbols can be used in combination with each other.
If the symbol is used to mark a joint, the symbols + or can be added to the
symbol to indicate the ROM is greater or less than normal.

+ indicates ROM is greater than normal (hypermobile)
indicates ROM is less than normal (hypomobile)

Adding the abbreviation for spasm (SP) or contracture (CA) to the
symbol for limited ROM () indicates that the ROM is limited by spasm or
contracture. The slash symbol ( / ) is used as a connector.

SP/CA indicates ROM is limited by spasm and contracture
SP indicates ROM is limited by spasm
CA indicates ROM is limited by contracture


214
HEMME APPROACH EVALUATION CHART

TR trigger point SP spasm TW isotonic weakness
+ / plus and minus
TE tender point CA contracture MW isometric weakness / point or area
GP general pain AD adhesions GW general weakness
ROM
SW swelling ST stiffness NU numbness pointer
PATIENT DOB SS#
PRACTITIONER DATE TIME


215
HEMME APPROACH APPRAISAL AND TREATMENT FORM
HISTORY

EVALUATION

MODALITIES

MANIPULATION

EXERCISE

COMMENTS

PATIENT DOB SS#
PRACTITIONER DATE TIME


216
Ten basic guidelines for using the HEMME APPROACH Evaluation Chart:

Use pointer () when space is not adequate to mark directly on a figure.
The pointer symbol () can be used without an arrow at the end.
The point symbol () can be increased or decreased in size for visibility.
The area sign () can be a square or rectangle of any size.
Isotonic weakness refers to weakness when moving an object.
Isometric weakness refers to weakness when holding an object.
General pain or weakness affects entire body parts.
If needed, add words or phrases to clarify the chart.
Complete a new chart with each treatment.
Red or blue pens can be used to make markings more visible.

Sample Evaluation Chart

1 TR/SP/GW
2 CR
3 GP/GW

Interpretation:

1 TR/SP/GW indicates trigger points, spasm, and general weakness.
2 CR indicates crepitus and limited range of motion (elbow joint)
3 GP/GW indicates general pain and general weakness in the area defined
by the rectangle.

Once the process of filling out charts and forms has been mastered, it
should be possible to recite the important details of a case without any
reliance on memory. The charts and forms should speak for themselves.
Like most other valuable skills, accurate record keeping requires (1) correct
and frequent practice, (2) perseverance, and (3) a strong desire to improve.


217
Final Considerations

Despite heroic efforts and full cooperation from the patient, some cases
do not respond well to therapy. Rather than abandon all hope, consider the
following observations as seven possible ways to overcome difficult cases.

1 Make certain wound healing has progressed far enough for soft-tissue
therapy to be effective. The basic sequence for treating a soft-tissue
impairment is (1) rest, stabilization, and possibly cryotherapy during the
acute stage of injury, (2) mobilization and isometric contractions during
the early subacute stage, and (3) modalities, manipulation, and exercise
after the early subacute stage.

2 Repeat the history and evaluation steps to make certain the tissues being
treated are (1) the cause for the problem being treated, and (2) the only
cause for the problem being treated.

3 Follow the sequence of (1) lengthen with passive ROM stretching, and
(2) strengthen with active movement. Single-repetition static stretching
combined with active movement will help to reset proprioceptors,
dampen spinal reflexes, and counteract the effects of habitual disuse.

4 Remember that strength is not the same as resistance to active or passive
stretch. Strength measures a muscle's ability to contract and exert force.
Even though a muscle is short and difficult to stretch, it may also be
weak. Treat for both, shortness first and weakness second.

5 To avoid continuing ineffective treatments, follow the acronym EMT
Evaluate, Manipulate, and Test the results. If retesting reveals positive
results, continue with the same treatment. If retesting reveals no results
or negative results, change techniques.

6 If a patient is having repeated bouts of the same problem, check for
trigger points, a limited range of motion, or weakness that may have
gone unnoticed or untreated before the patient was discharged.

7 If soft-tissue therapy fails to produce positive results, never hesitate to
refer the patient to another health care professional.


218
SELECTED BIBLIOGRAPHY

Alter, Michael J. 2004. Science of stretching. 3d ed. Champaign, Illinois:
Human Kinetics Books.

Anderson, Bob. 1980. Stretching. Bolinas, California: Shelter Publications,
Inc.

Anderson, James E. 1983. Grant's atlas of anatomy. 8th ed. Baltimore:
Williams & Wilkins.

Andrews, James R., and Kevin E. Wilk, ed. 1994. The athlete's shoulder.
New York: Churchill Livingstone.

Appenzeller, Otto and Ruth Atkinson. 1983. Sports medicine. 2d ed.
Baltimore: Urban & Schwarzenberg.

Arnheim, Daniel D. 1985. Modern principles of athletic training. 6th ed. St.
Louis: Times Mirror/Mosby College Publishing.

Arnold, Lee E. 1978. Chiropractic procedural examination. Seminole,
Florida: Seminole Printing, Inc.

Backhouse, Kenneth M., and Ralph T. Hutchings. 1986. Color atlas of
surface anatomy. Baltimore: Williams & Wilkins.

Basmajian, John V., and Carlo J. Deluca. 1985. Muscles alive. 5th ed.
Baltimore: Williams & Wilkins.

Basmajian, John V., and Rich Nyberg, eds. 1993. Rational manual therapies.

Basmajian, John V., ed. 1985. Manipulation, traction and massage.

Bates, Barbara. 1983. A guide to physical evaluation. 3d ed. Philadelphia:
J.B. Lippincott Company.


219
Bennett, Claude J. and Fred Plum, eds. 1996 Cecil textbook of medicine.
20th ed. Philadelphia: W.B. Saunders.

Berne, Robert M., and Matthew N. Levy. 1988. Physiology. 2d ed. St.
Louis: The C.V. Mosby Company.

Bogduk, Nikolai and Lance T. Twomey. 1991. Clinical anatomy of the
lumbar spine. 2nd ed. Melbourne: Churchill Livingstone.

Bohm, Max and Charles F. Painter. 1929. Massage. Philadelphia: W.B.
Saunders.

Bourdillon, J.F., and E.A. Day. 1987. Spinal manipulation. 4th ed. Norwalk,
Connecticut: Heinemann Medical Books.

Boyling, Jeffery D. and Nigel Palastanga, eds. 1994. Grieves modern
manual therapy of the vertebral column. 2d ed. Edinburgh: Churchill
Livingstone.

Boyling, Jeffery D. and Nigel Palastanga, eds. 1994. Grieves modern
manual therapy of the vertebral column. 2d ed. Edinburgh: Churchill
Livingstone.

Braddom, Randall L. 1996. Physical medicine & rehabilitation.
Philadelphia: W.B. Saunders.

Bueche, Frederick. 1981. Technical physics. New York: Harper & Row,
Publishers.

Butler, David S., Mark A. Jones. and Richard Gore. 1991. Mobilization of
the nervous system. Edinburgh: Churchill Livingstone.

Cailliet, Rene. 1991. Neck and arm pain. 3d ed. Philadelphia: F.A. Davis
Company.

Cailliet, Rene. 1991. Shoulder pain. 3d ed. Philadelphia: F.A. Davis
Company.


220
Cailliet, Rene. 1993. Pain: mechanisms and management. Philadelphia: F.A.
Davis Company.

Cailliet, Rene. 1996. Soft tissue pain and disability. 3d ed. Philadelphia:
F.A. Davis Company.

Cantu, Robert I., and Alan J. Grodin. 1992. Myofascial manipulation theory
and clinical application. Gaithersburg, Maryland: Aspen Publishers, Inc.

Carlson, Neil R. 1992. Foundations of psychological physiology Boston:
Allyn and Bacon.

Chaitow, Leon. 1987. Soft-tissue manipulation. Wellingborough, Great
Britain: Thorsons Publishing Group.

Chusid, J.G. 1982. Correlative neuroanatomy & functional neurology. 18th
ed. Los Altos, California: Lange Medical Publications.

Cipriano, Joseph J. 1985. Photographic manual of regional orthopaedic tests.

Corrigan, Brian and G.D. Maitland. 1983. Practical orthopaedic medicine.
London: Butterworths.

Currier, Dean P., and Roger M. Nelson, eds. 1992. Dynamics of human
biological tissue. Philadelphia: F.A. Davis Company.

Dalessio, Donald J. and Stephen D. Silberstein. 1993. Wolff's headache and
other head pain. 6th ed. New York: Oxford University Press.

Daniels, Lucille and Catherine Worthingham. 1995. Therapeutic exercise.
6th ed. Philadelphia: W.B. Saunders.

Davidson, Paul. 1989. Chronic muscle pain syndrome. New York: Villard
Books.

DeGowin, Elner L., and Richard L. DeGowin. 1976. Bedside diagnostic
examination. New York: Macmillan Publishing Co., Inc.


221
DeLisa, Joel A. and Bruce M. Gans, eds. 1998. Rehabilitation medicine. 3d
ed. Philadelphia: J.B. Lippincott.

deVries, Herbert A. and Terry J. Housh. 1996. Physiology of exercise. 5th
ed. Dubuque, Iowa: WCB Brown and Benchmark Publishers.

DiGiovanna, Eileen L., and Stanley Schiowitz, eds. 1991. An osteopathic
approach to diagnosis and treatment. Philadelphia: J.B. Lippincott Company.

Donatelli, Robert, and Michael J. Wooden, eds. 1994. Orthopaedic physical
therapy. 2d ed. New York: Churchill Livingstone.

Dorlands illustrated medical dictionary. 28th ed. Philadelphia: W.B.
Saunders Company.

Downer, Ann H. 1978. Physical therapy procedures. Springfield, Illinois:
Charles C. Thomas, Publisher.

Downey, John A., Stanley J. Myers, Erwin G. Gonzalez, and James S.
Lieberman, eds. 1994. The physiological basis of rehabilitation medicine. 2d
ed. Boston: Butterworth-Heinemann.

Downie, Patricia A., ed. 1986. Cash's textbook of neurology for
physiotherapists. Philadelphia: J.B. Lippincott Company.

Downing, Carter Harrison. 1923. Principles and practice of osteopathy.
Kansas City, Missouri: Williams Publishing Co.

Dvorak, J., V. Dvorak, and W. Schneider, eds. 1985. Manual medicine 1984.
Berlin: Springer-Verlag.

Ebner, Maria. 1985. Connective tissue manipulations. Malabar, Florida:
Robert E. Krieger Publishing Co., Inc.

Evjenth, Olaf and Jern Hamberg. 1984. Muscle stretching in manual therapy.
Vol. 1, The extremities. Sweden: Scand Book.


222
Evjenth, Olaf and Jern Hamberg. 1984. Muscle stretching in manual therapy.
Vol. 2, The spinal column and the temporomandibular joint. Sweden: Scand
Book.

Fields, Howard L. 1987. Pain. New York: McGraw-Hill Company.

Finnerty, Gertrude Brentano and Theodore Corbitt. 1960. Hydrotherapy.
New York: Frederick Ungar Publishing Co.

Foreman, Stephen M., and Arthur C. Croft. 1988. Whiplash injuries.

Fox, Edward L., Richard W. Bowers, and Merle L. Foss. 1988. The
physiological basis of physical education and athletics. Philadelphia:
Saunders College Publishing.

Friction, R. James, and Ronald Bubner. 1995. Orofacial pain and
temporomandibular disorders. New York: Raven Press.

Friedman, H. Harold, ed. 1983. Problem-oriented medical diagnosis. 3d ed.
Boston: Little, Brown and Company.

Fritz, Sandy. 1995. Mosbys fundamentals of therapeutic massage. St. Louis:
Mosby Lifeline.

Fryette, Harrison H. 1954. Principle of osteopathic technic. Colorado
Springs, Colorado: American Academy of Osteopathy.

Glasgow, E.F., L.T. Twomey, E.R. Scull, and A.M. Kleynhans, eds. 1985.
Aspects of manipulative therapy. 2d ed. Melbourne: Churchill Livingstone.

Goldberger, Leo, and Shlomo Breznitz, eds. 1993. Handbook of stress. 2d
ed. New York: The Free Press.

Golden, Abner. 1983. Pathology. Baltimore: Williams & Wilkins.


223
Goleman, Daniel and Joel Gurin, eds. 1993. Mind body medicine. New
York: Consumer Report Books.

Grant, Ruth, ed. 1994. Physical therapy of the cervical and thoracic spine. 2d
ed. New York: Churchill Livingstone.

Greenman, Philip. 1996. Principles of manual medicine. 2d ed. Baltimore,
Maryland: Williams & Wilkins.

Grieve, Gregory P. 1981. Common vertebral joint problems. Edinburgh:
Churchill Livingstone.

Grieve, Gregory P. 1984. Mobilization of the spine. 4th ed. Edinburgh:

Griffin, James, Terence C. Karselis, and Dean P. Currier. 1982. Physical
agents for physical therapists. 2d ed. Springfield, Illinois: Charles C.
Thomas, Publisher.

Gustafson, Daniel R. 1980. Physics: health and the human body. Belmont,
California: Wadsworth, Inc.

Guyton, Arthur C. 1992. Human physiology and mechanisms of disease. 5th
ed. Philadelphia: W.B. Saunders Company.

Guyton, Arthur C. and John E. Hall. 1996. Textbook of medical physiology.
9th ed. Philadelphia: W.B. Saunders Company.

Haldeman, Scott. 1992. Principles and practice of chiropractic. 2d ed. New
York: Appleton-Century-Crofts.

Hamil, Joseph and Kathleen M. Knutzen. 1995. Biomechanical basis of
human movement. Baltimore: Williams & Wilkins.

Hamilton, Eva May Nunnelley, Eleanor Noss Whitney, and Frances
Sienkiewicz Sizer. 1985. Nutrition: concepts and controversies. 3d ed. St.
Paul: West Publishing Company.


224
Hammer, Warren I. 1999. Functional soft tissue examination and treatment
by manual methods. 2nd ed. Gaithersburg, Maryland: Aspen Publication.

Hasson, Scott M. 1994. Clinical exercise physiology. St. Louis: Mosby.

Hayes, Karen W. 1993. Manual for physical agents. 4th ed. Norwalk,
Connecticut: Appleton & Lange.

Hecox, Bernadette, Tsega Andemicael Mehreteab, and Joseph Weisberg.
1994. Physical agents. Norwalk, Connecticut: Appleton & Lange.

Hoag, Marshall J., ed. 1969. Osteopathic medicine. New York: McGraw-
Hill Book Company, Inc.

Hollinshead, W. Henry and Cornelius Rosse. 1985. Textbook of anatomy.
4th ed. Philadelphia: Harper & Row, Publishers.

Hoppenfeld, Stanley. 1976. Physical examination of the spine and
extremities. Norwalk, Connecticut: Appleton-Century-Crofts.

Hoppenfeld, Stanley. 1977. Orthopaedic neurology. Philadelphia: J.B.
Lippincott Company.

Janse, Joseph, R.H. Houser, and B.F. Wells. 1947. Chiropractic principles
and technique. Chicago: National College of Chiropractic.

Jaskoviak, Paul A., and R. C. Schafer. 1986. Applied physiology. Arlington,
Arlington: The American Chiropractic Association.

Jayson, Malcolm I., ed. 1992. The lumbar spine and back pain. 4th ed.
Edinburgh: Churchill Livingstone.

Jones, Lawrence H. 1981. Strain and counterstrain. Colorado Springs,
Colorado: The American Academy of Osteopathy.

Kandel, Eric R., and James H. Schwartz. 1985. Principles of neural science.
2d ed. New York: Elsevier.


225
Kandel, Eric R., James H. Schwartz, and Thomas M. Jessell, eds. 1995.
Essentials of neural science and behavior. Norwalk, Connecticut: Appleton
& Lange.

Kaplan, Paul E., and Ellen D. Tanner. 1989. Musculoskeletal pain and
disability. Norwalk, Connecticut: Appleton & Lange.

Kendall, Florence Peterson, Elizabeth Kendall McCreary, and Patricia Geise
Provance. 1993. Muscles testing and function. 4th ed. Baltimore: Williams
& Wilkins.

Kessler, Randolph and Darlene Hertling. 1996. Management of common
musculoskeletal disorders. 3d ed. Philadelphia: Harper & Row, Publishers.

Kimberly, Paul E., ed. 1980. Outline of osteopathic manipulative
procedures. 3d ed. Kirksville, Missouri: Kirksville College of Osteopathic
Medicine.

King, Mark, Larry Novik, and Charles Citrenbaum. 1983. Irresistible
communication. Philadelphia: W.B. Saunders.

Kirkaldy-Willis, William H., and Charles V. Burton, eds. 1992. Managing
low back pain. New York: Churchill Livingstone.

Kisner, Carolyn and Lynn Allen Colby. 1996. Therapeutic exercise. 3d ed.
Philadelphia: F.A. Davis Company.

Knight, Kenneth L. 1995. Cryotherapy in sport injury management.
Champaign, Illinois: Human Kinetics.

Korr, Irvin M., ed. 1978. The neurobiologic mechanisms in manipulative
therapy. New York: Plenum Press.

Kottke, Frederic J., and Justus F. Lehmann. 1990. Krusen's handbook of
physical medicine and rehabilitation. 3d ed. Philadelphia: W.B. Saunders
Company.


226
Kreighbaum, Ellen and Katharine M. Barthels. 1985. Biomechanics.
Minneapolis, Minnesota: Burgess Publishing Company.

Krejci, Vladimir and Peter Koch. 1979. Muscle and tendon injuries in
athletes. Translated by David Le Vay. Stuttgart: Georg Thieme Publishers.

Kruprian, Werner. 1995. Physical therapy for sports. 2d ed. Translated by
Todd Kontje and Lynn Braunsdorf. Philadelphia: W.B. Saunders Company.

Kulund, Daniel. 1982. The injured athlete. Philadelphia: J.B. Lippincott
Company.

Lachmann, Sylvia and John R. Jenner. 1994. Soft tissue injuries in sports.
London: Blackwell Scientific Publications.

Lamb, David R. 1984. Physiology of exercise. 2d ed. New York: Macmillan
Publishing Company.

Langilotti, Frank T. 1985. Adjunctive therapy. Glen Head, New York: New
York Chiropractic College.

Laurens, Henry. 1933. The physiological effects of radiant energy. New
York: The Chemical Catalog Company, Inc.

Leach, Robert A. 1986. The chiropractic theories. 2d ed. Baltimore:
Williams & Wilkins.

Lehmkuhl, L. Don and Laura K. Smith. 1983. Brunnstrom's clinical
kinesiology. 4th ed. Philadelphia: F.A. David Company.

Lewit, Karel. 1985. Manipulative therapy in rehabilitation of the motor
system. London: Butterworths.

Licht, Sidney, ed. 1965. Therapeutic heat and cold. 2d ed. Baltimore:
Waverly Press, Incorporated.


227
Liebenson, Craig, ed. 1996. Rehabilitation of the spine. Baltimore: Williams
& Wilkins.

Luttgens, Kathryn and Katharine F. Wells. 1982. Kinesiology. 7th ed.
Philadelphia: Saunders College Publishing.

Magee, David J. 1987. Orthopedic physical assessment. Philadelphia: W.B.
Saunders Company.

Magoun, Harold I., ed. 1978. Practical osteopathic procedures. Kirksville,
Missouri: The Journal Printing Company.

Maigne, Robert. 1996. Diagnosis and treatment of pain of a vertebral origin.

Manheim, Carol J., and Diane K. Lavett. 1989. The myofascial release
manual. Thorofare, New Jersey: Slack Incorporated.

Mannheimer, Jeffrey S. 1984. Clinical transcutaneous electrical nerve
stimulation. Philadelphia: F.A. Davis Company.

Mayer, Tom G., and Robert J. Gatchel. 1988. Functional restoration for
spinal disorders: The sports medicine approach. Philadelphia: Lea &
Febiger.

Mazzarelli, Joseph P., ed. 1983. Chiropractic interprofessional research.
Torino, Italy: Edizioni Minerva Medica.

McArdle, William D., Frank I. Katch, and Victor L. Katch. 1994. Essentials
of exercise physiology. Philadelphia: Lea & Febiger.

McArdle, William D., Frank I. Katch, and Victor L. Katch. 1996. Exercise
physiology. 4th ed. Philadelphia: Lea & Febiger.

McCulloch, Joseph M., Luther C. Kloth, and Jeffrey A. Feedar. 1995.
Wound healing: alternatives in management. Philadelphia: F.A. Davis
Company.


228
McLatchie, Greg R. 1986. Essentials of sports medicine. Edinburgh:

McRae, Ronald. 1983. Clinical orthopaedic examination. 2d ed. Edinburgh:

Melzack, Ronald and Pat D. Wall, ed. 1984. Textbook of pain. Edinburgh:

Melzack, Ronald and Patrick D. Wall. 1988. The challenge of pain. 2d ed.
Great Britain: Penguin Books.

Mennell, John McM. 1960. Back pain. Boston: Little, Brown and Company.

Mennell, John McM. 1964. Joint pain. Boston: Little, Brown and Company.

Michlovitz, Susan L. 1996. Thermal agents in rehabilitation. 3d ed.

Miller-Keane encyclopedia & dictionary of medicine, nursing, & allied
health. 5th ed. Philadelphia: W.B. Saunders Company.

Moor, Fred B., Stella C. Peterson, Ethel M. Manwell, Mary C. Noble, and
Gertrude Muench. 1964. Manual of hydrotherapy and massage. Mountain
View, California: Pacific Press publishing Association.

Mosbys medical, nursing, & allied health dictionary. 4th ed. The C.V.
Mosby Company.

Murray, Chas H. 1912. Practice of osteopathy. 3d ed. Elgin, Illinois: The
Murray Publishers.

Nestle, Marion. 1985. Nutrition in clinical practice. Greenbrae, California:
Jones Medical Publications.

Nestle, Marion. 1985. Nutrition in clinical practice. Greenbrae, California:
Jones Medical Publications.


229
Neumann, Heinz-Dieter. 1989. Introduction to manual medicine. Translated
and edited by Wolfgang G. Gilliar. Berlin: Springer-Verlag.

Nicholas, N. S. 1974. Atlas of osteopathic technique. 2d ed. Philadelphia:
Philadelphia College of Osteopathic Medicine.

Noback, Charles R., and Robert J. Demarest. 1981. The human nervous
system. Guatemala: McGraw-Hill Book Company.

Norkin, Cynthia C., and D. Joyce White. 1985. Measurement of joint
motion: a guide to goniometry. Philadelphia: F.A. Davis Company.

Norkin, Cynthia C., and Pamela K. Levangie. 1983. Joint structure &
function. Philadelphia: F.A. Davis Company.

Okamoto, Gary A., ed. 1984. Physical medicine and rehabilitation.
Philadelphia: W.B. Saunders Company.

Palmer, D.D. 1910. The science, art and philosophy of chiropractic.
Portland, Oregon: Portland Printing House.

Payne, Rosemary A. 1995. Relaxation techniques. Edinburgh: Churchill
Livingstone.

Peterson, Barbara, ed. 1979. The collected papers of Irvin M. Korr. Colorado
Springs, Colorado: American Academy of Osteopathy.

Peterson, Barbara, ed. 1983. Postural balance and imbalance. Newark, Ohio:
American Academy of Osteopathy.

Porterfield, James A., and Carl DeRosa. 1991. Mechanical low back pain.

Porterfield, James A., and Carl DeRosa. 1995. Mechanical neck pain.

Price, Shirley, and Len Price. 1995. Aromatherapy of health professionals.


230
Prior, John A., and Jack S. Silberstein. 1977. Physical diagnosis. 5th ed.
Saint Louis: The C.V. Mosby Company.

Prudden, Bonnie. 1980. Pain erasure. New York: Ballantine Books.

Prudden, Bonnie. 1984. Myotherapy. New York: The Dial Press.

Rachlin, Edward S. 1994. Myofascial pain and fibromyalgia. St. Louis:
Mosby.

Rasch, Philip J., and Roger K. Burke. 1978. Kinesiology and applied
anatomy. 6th ed. Philadelphia: Lea & Febiger.

Reinert, Otto. 1983. Fundamentals of chiropractic techniques and practice
procedures. Chesterfield, Missouri: Marian Press, Inc.

Rolf, Ida P. 1978. Rolfing: The integration of human structures. New York:
Harper & Row, Publishers.

Rothenberg, Beth and Oscar Rothenberg. 1995. Touch training for strength.
Champaign, Illinois: Human Kinetics Books.

Roy, Steven and Richard Irvin. 1983. Sports medicine. Englewood Cliffs:
Prentice-Hall, Inc.

Saunders, H. Duane. 1985. Evaluation, treatment and prevention of
musculoskeletal disorders. Minneapolis: Viking Press, Inc.

Schafer, R.C. 1980. Chiropractic physical and spinal diagnosis. Oklahoma
City, Oklahoma: Associated Chiropractic Academic Press.

Schafer, R.C. 1982. Chiropractic management of sports and recreational
injuries. Baltimore: Williams & Wilkins.

Schafer, R.C. 1987. Clinical biomechanics. 2d ed. Baltimore: Williams &
Wilkins.


231
Schmidt, Robert F., ed. 1981. Fundamentals of sensory physiology. 2d ed.
New York: Springer-Verlag.

Schmidt, Robert F., ed. 1985. Fundamentals of neurophysiology. 3d ed. New
York: Springer-Verlag.

Schooley, Thomas F. 1987. Osteopathic principles and practice. Newark,
Ohio: American Academy of Osteopathy.

Sheon, Robert P., Roland W. Moskowitz, and Victor M. Goldberg. 1996.
Soft tissue rheumatic pain. 3d ed. Philadelphia: Lea & Febiger.

Shriber, William J. 1975. A manual of electrotherapy. 4th ed. Philadelphia:
Lea & Febiger.

Shumway-Cook, Anne and Marjorie H. Wollacott. 1995. Motor control
theory and practical applications. Baltimore: Williams & Wilkins.

Smith, Emil L., Robert L. Hill, I. Robert Lehman, Robert J. Leflowitz, Philip
Handler, and Abraham White. 1983. Principles of biochemistry: Mammalian
Biochemistry. 7th ed. New York: McGraw-Hill Book Company.

Smith, Nathan J., and Carl L. Stanitski. 1987. Sports medicine. Philadelphia:
W.B. Saunders Company.

Slveborn, Sven-A. 1985. The book about stretching. Tokyo: Japan
Publications.

Souza, Thomas A., ed. 1994. Sports injuries of the shoulder. New York:

Starkey, Chad. 1993. Therapeutic modalities for athletic trainers.

Stedmans medical dictionary, 26th ed. Baltimore: Williams & Wilkins.


232
Still, Andrew T. 1899. Philosophy of osteopathy. Kirksville, Missouri: A.T.
Still.

Stillwell, Keith G., ed. 1983. Therapeutic electricity and ultraviolet
radiation. Baltimore: Williams & Wilkins.

Stoddard, Alan. 1969. Manual of osteopathic practice. New York: Harper &
Row, Publisher, Inc.

Stoddard, Alan. 1980. Manual of osteopathic technique. London:
Hutchinson Publishing Group.

Strang, Virgil V. 1984. Essential principles of chiropractic. Davenport:
Palmer College of Chiropractic.

Tabers cyclopedic medical dictionary. 17th ed. Philadelphia: F.A. Davis
Company.

Thompson, Clem W. 1985. Manual of structural kinesiology. 10th ed. St.
Louis: Times Mirror/Mosby College Publishing.

Tollison, C. David, ed. 1994. Handbook of pain management. 2d ed.

Torg, Joseph, Joseph J. Vegso, and Elizabeth Torg. 1987. Rehabilitation of
athletic injuries: An atlas of therapeutic exercise. Chicago: Year Book
Medical Publishers, Inc.

Travell, Janet G., David G. Simmons. 1999. Myofascial pain and dysfunc-
tion. Vol 1, Upper half of body. 2d ed. Baltimore: Williams & Wilkins.

Travell, Janet G., and David G. Simmons. 1992. Myofascial pain and
dysfunction. Vol. 2, The lower extremities. Baltimore: Williams & Wilkins.

Twomey, Lance T., and James R. Taylor. 1994. Physical therapy of the low
back. 2d ed. New York: Churchill Livingstone.


233
Tyldesley, Barbara and June I. Grieve. 1989. Muscles, nerves and
movement. Oxford, London: Blackwell Scientific Publications.

Umphred, Darcy Ann, ed. 1995. Neurological rehabilitation. 3d ed. St.
Louis: The C.V. Mosby Company.

Valnet, Jean. 1982. The practice of aromatherapy. New York: Destiny
Books.

Voss, Dorothy E., Marjorie K. Ionta, and Beverly J. Myers. 1985.
Proprioceptive neuromuscular facilitation. 3d ed. Philadelphia: Harper &
Rowe.

Wall, Patrick D., and Ronald Melzack, eds. 1999. Textbook of pain. 4th ed.

Walther, David S. 1981. Applied kinesiology. Vol. 1, Basic procedures and
muscle testing. Pueblo, Colorado: Systems DC.

Walther, David S. 1983. Applied kinesiology. Vol. 2, Head, neck, and jaw
pain and dysfunctionthe stomatognathic system. Pueblo, Colorado:
Systems DC.

Ward, Robert C., ed. 1997. Foundations for osteopathic medicine.

Wells, Peter E., Victoria Frampton, and David Bowsher. 1988. Pain
management in physical therapy. Norwalk, Connecticut: Appleton &
Langue.

Werner, Ruth, 1998. A Massage therapists guide to pathology. Baltimore,
Maryland: Williams and Wilkins.

White, Augustus A., Monohar M. Panjabi. 1990. Clinical biomechanics of
the spine. 2d ed. Philadelphia: J.B. Lippincott.

Zatsiorsky, Vladimir M. 1995. Science and practice of strength training.
Champaign, Illinois: Human Kinetics.


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GLOSSARY

absolute zero Theoretically the lowest possible temperature because all
molecular movement has stopped (-460F or -273.2C).

accommodation A property some nerves possess that allows them to lower
their threshold of excitation as the strength of stimulus increases.

Achilles tendon reflex An ankle jerk caused by the involuntary contraction
of the calf muscles when the Achilles tendon is sharply struck.

acrocyanosis A circulatory disorder in which the fingers and hands, and
less commonly the toes and feet, are persistently cold and blue (cyanotic).

action Anatomical movements produced by the normal contraction of a
muscle.

active exercise The force needed to move a body part is provided entirely by
the voluntary contraction of muscles that normally control the body part.

active movement Movement of a body part caused entirely by a persons
own effort without assistance or resistance from external forces.

active trigger point Hyperirritable spots or zones that actively produce pain
and may cause autonomic responses.

acute Short duration, not chronic, rapid onset, severe.

acute inflammation Inflammation with rapid onset and clear termination
characterized by pain, swelling, redness, heat, and loss of function.

adhesion A tissue structure holding parts together that are normally
separated.

afferent nerve A sensory nerve conveying impulses from the periphery to
the central nervous system.


235
agonist Muscle or muscle group primarily responsible for performing some
movement (prime mover).

algesic Painful or causing pain.

algesiogenic Pain-producing, algogenic.

algogenic Pain-producing, algesiogenic.

algometer An instrument for measuring the degree of sensitivity to pain.

algometry The process of measuring pain.

All-or-none law The weakest stimulus capable of producing a response
causes skeletal muscle fibers to contract maximally.

allodynia Pain or distress resulting from non-noxious stimulus.

anabolism The constructive phase of metabolism.

analgesia A decrease or absence of sensibility to pain.

anesthesia Partial or complete loss of feeling, with or without loss of
consciousness.

ankylosis Fixation of a joint.

anoxia Without oxygen.

antagonist Muscle or muscle group that opposes the movement of the
agonist and produces the opposite movement.

antidromic Propagation of an impulse along an axon in a direction opposite
to the normal direction.

antipyretic An agent that reduces fever.


236
aponeurosis A flat fibrous sheet of connective tissue that attaches muscles
to bone.

approximate To bring close together.

apraxia Loss of ability to perform purposeful movement in the absence of
paralysis.

arachidonic acid A fatty acid and biological precursor for prostaglandins.

asthenia Loss of strength or energy.

ataxia Loss of motor coordination.

athetosis Snakelike movements.

atonia Lack of tension or tone, flaccid.

atrophy Decrease in size of an organ or tissue.

auscultation Listening for sounds made by various body structures.

axonotmesis The interruption of the axons of a nerve followed by complete
degeneration distal to the injury without the nerve being severed.

bacteriostatic Inhibiting or retarding growth or reproduction of bacteria.

ballistics A study of motion and trajectory.

balneotherapy Partial or complete immersion of the body in mineral water
as a form of therapy.

baroreceptor A sensory nerve ending that is sensitive to stretching that
results from pressure.

barrier An obstruction that tends to restrict free movement.


237
bath immersion of the body or any of its parts in waterliquid or vapor
for therapeutic purposes.

Beevor's axiom: The brain knows nothing of individual muscles, but thinks
only in terms of movement.

Bells law: Anterior spinal nerve roots are efferent (motor) nerves and
posterior spinal nerve roots are afferent (sensory) nerves.

blanch To become pale, white, or lose color.

blepharitis Inflammation of the eyelids characterized by swelling, redness
and dried mucus.

calorie The amount of heat energy needed to raise the temperature of one
gram of water 1C.

capsulitis Inflammation of a capsule.

catabolism Destructive phase of metabolism.

caudad In direction toward the feet, tail, or distal end, opposite of cephalad.

causalgia Burning pain.

cavitation Formation of a cavity or microscopic bubbles.

cephalad In direction toward the head, opposite of caudad.

chemotaxis The movement of leukocytes to an area of inflammation in
response to chemicals.

chronic Long duration, normally more than six months.


238
chronic inflammation A persistent inflammation appearing quickly or
slowly with a vague termination and characterized more by pain, loss of
function, and new connective tissue formation than by swelling, redness, or
heat.

claudication Lameness resulting from inadequate circulation.

clonus Uncontrolled spasmodic muscle jerking.

coagulation A clotting process that transforms blood from a liquid to a
solid.

cocontraction A muscular state in which opposing muscles around a joint
contract simultaneously to provide stability.

cold compress A cloth dipped in cold or ice water, wrung out, and applied
to the body as a form of cryotherapy.

cold mitten friction Cold water and friction applied to the body with a terry
cloth towel or friction mitts as a form of stimulation.

collagen A white fibrous protein found in connective tissue.

concentric contraction A muscle shortens during contraction.

conduction Transfer of heat between two objects in contact with each other.

conjunctivitis Inflammation of the conjunctiva characterized by red eyes, a
thick discharge, and sticky eyelids in the morning.

consensual A reflex action in which stimulation on one side of the body
causes a circulatory, muscular, or glandular response on the opposite side of
the body. A consensual reaction to light occurs when light directed at one
eye causes the opposite pupil to contract (consensual light reflex).

contractility Having the ability to contract or shorten in response to
stimulus.


239
contraction Increased tension caused by physiologic shortening of a
muscle.

contracture The pathologic shortening of a muscle due to fibrosis or
muscle fiber defects that increase resistance to active or passive stretch.

contralateral Affecting or pertaining to the opposite side of the body.

convection Transfer of heat in liquids or gases by movement of heated
currents.

convergence The moving of two or more forces toward the same point.

conversion 1. Transformation of electrical or mechanical energy into heat.
2. Changing emotions, such as hysteria, into physical manifestations.

cosine law The intensity of radiation is highest when rays from a source
strike the patient at an angle of 90 degrees.

counterirritation Superficial irritation that relieves another irritation or
deep pain.

cramp Strong and painful spasm.

creep Deformation of viscoelastic materials when exposed to a slow,
constant, low-level force for long periods of time.

crepitus The sound of bone rubbing against bone.

cryoglobulinemia The presence of abnormal plasma protein (cryoglobulin)
in the blood plasma.

cryotherapy Therapeutic application of cold.

cyanosis Bluish or gray discoloration of skin that results from reduced
hemoglobin in blood or excessive venous blood.


240
decubitus ulcers A chronic ulcer caused by the pressure of body weight
when patients are confined to bed or otherwise immobilized (bedsore).

derivation The drawing of blood or body fluids away from congested parts
of the body to other parts of the body.

diapedesis The passage of blood or blood cells through the intact walls of
blood vessels.

diaphoresis Profuse sweating or perspiration.

diathermy Use of high-frequency currents to heat deep tissue.

disease A morbid or pathologic condition that deviates from normal
function where the agent, signs, and symptoms are identifiable.

disinhibition Removal or inhibition of an inhibition.

distraction Extension of a limb to separate joint surfaces.

divergence The moving of two or more forces away from a common center.

dysesthesia Unpleasant sensations produced by ordinary stimulus.

dystrophy Progressive abnormal changes that result from defective
nutrition of a tissue or organ.

eccentric contraction A muscle lengthens during contraction.

efferent nerve A motor nerve conveying impulses from the central nervous
system to the periphery.

elastin A yellow elastic fibrous mucoprotein found in connective tissue.

EMG Acronym for electromyogram, the graphic record of muscle
contraction that results from electrical stimulation.


241
encephalitis Inflammation of brain.

endogenous Produced or developed from within the organism.

enthesitis Traumatic disease occurring at the insertion of muscles where
repeated stress causes inflammation and possibly fibrosis or calcification.

entrapment syndrome Entrapment of a nerve by hard or soft tissue.

ergotropic Mechanisms of the nervous system that expend energy, opposite
of trophotropic.

erythema Inflammatory redness of skin that results from dilatation and
congestion of superficial capillaries.

etiology Scientific study involving the causes of disease.

exacerbation Aggravating symptoms or increasing the severity of a disease.

exostosis Bony growth arising from surface of bone.

extensibility The ability to lengthen.

exteroceptor A sense organ receiving stimuli from outside the body.

extracellular Outside the cell.

extravasation Fluids escaping from vessels into surrounding tissue.

fascia A fibrous, connective-tissue membrane covering, supporting, and
separating a muscle.

facilitation Encourages or hastens a process, the opposite of inhibition.

fasciculation Spontaneous contraction or twitch of a group of muscle
fibers.


242
fascitis Inflammation of any fascia.

fibrinolytic Dissolution or splitting up of fibrin.

fibroblast A cell that produces connective tissue.

fibroma A fibrous, connective-tissue tumor.

fibroplasia Development of fibrous tissue during wound healing.

fibrosis Abnormal formation of fibrous tissue as part of a reparative or
reactive process.

fibrositis Inflammation of fibrous tissue.

flaccid Soft, relaxed, flabby, or without muscular tone.

flush Sudden or transient redness of skin.

FMS Acronym for fibromyalgia syndrome.

fomentation A warm and moist cloth applied to the surface of the body.

force That which changes or tends to change a body's motion or shape.

gamma motor neuron An efferent nerve cell that innervates the ends of
intrafusal muscle fibers.

ganglion Benign cystic tumors developing on a tendon or aponeurosis.

gangrene Necrosis (tissue death) due to a loss or decrease of blood supply
or bacterial invasion.

goniometry The measurement of joint angles and range of motion.

GTO Acronym for Golgi tendon organ.


243
guarding Involuntary muscle contractions that limit range of motion to
avoid pain.

handedness Preferential use of right or left hand when performing
voluntary motor acts.

Head's law If painful stimulus is applied to areas of low sensibility in close
central connection with areas of high sensibility, pain may be felt where
sensibility is high.

heat of fusion The heat needed to change water from a solid at 32F to a
liquid at 32F.

heat of vaporization The heat needed to change water from a liquid at
212F to a gas (vapor) at 212F.

heliotherapy Exposure to sunlight for therapeutic purposes.

HEMME Acronym for history, evaluation, modalities, manipulation, and
exercise.

HEMMEs 1st law Most conditions treatable by soft-tissue therapy are

HEMMEs 2nd law Most conditions treatable by soft-tissue therapy can be
identified and treated by using five basic steps: History, Evaluation,

HEMMEs 3rd law Always be ready, willing, and able to disregard any law,
principle, axiom, or belief that proves to be incorrect.

hertz (Hz) A unit for measuring frequency equal to 1 cycle per second. One
million hertz (Hz) equal one megahertz (MHz).

Hilton's law: The nerve trunk that supplies a joint also supplies the muscles
that move the joint and the skin that covers the insertions of the muscles that
move the joint.


244
homeostasis A state of equilibrium in the body controlled by positive and
negative feedback.

Hookes law: The stress applied to stretch or compress a body is
proportional to the strain or changes in length thus produced, provided that
the elastic limit of the body has not been exceeded.

Houghtons law of fatigue: When muscles or muscle groups are kept in
constant action until fatigue sets in, the total amount of work done is the
same, regardless of rate.

humidity Moisture, dampness, or water vapor in the atmosphere.

hydrolytic Causes hydrolysis: chemical decomposition of a substance into
simpler compounds by splitting bonds and adding the elements of water.

hydrostatic pressure The pressure exerted by fluids.

hydrotherapy The use of water in any of its three formsliquid, solid, or
vaporfor therapeutic purposes.

hypalgesia Decreased sensitivity to pain, opposite of hyperalgesia.

hyper- Prefix meaning more than, excessive, above.

hyperalgesia Increased sensitivity to pain, opposite of hypalgesia.

hyperemia Increased quantity of blood in body part shown by redness of
skin.

hyperesthesia Increased sensitivity to touch or pain.

hyperhidrosis Excessive or profuse sweating.

hyperirritable Increased response to stimulus.

hyperkeratosis Overgrowth of the horny layer of the epidermis.


245
hypermobility Excessive mobility of any joint.

hypersensitivity Abnormal sensitivity to stimulation by a foreign agent
with exaggerated responses.

hyperthermia Abnormally high fever induced therapeutically.

hypertonia Excessive tone of skeletal muscles that increases resistance to
passive stretch.

hypertonic A state of greater than normal tension in muscles.

hypertrophic scar An elevated scar resembling a keloid scar but not
spreading in surrounding tissues.

hypertrophy Increase in size of organ or tissue.

hypo- A prefix meaning less than, deficient, beneath.

hypoesthesia Decreased sensitivity to touch or pain.

hypokinetic Decreased motor function.

hypomobility Decreased mobility of a joint or range of motion.

hypothermia A body temperature significantly below 98.6F because of
prolonged exposure to cold.

hypotonia Diminished tone in skeletal muscles and decreased resistance to
passive stretch.

hypotonic A state of less-than-normal tension in muscles.

hypoxia Inadequate or decreased concentration of oxygen.

hysteresis Energy loss in viscoelastic materials subjected to stress or to
cycles of loading and unloading.


246
hysteria A neurotic condition presenting somatic symptoms in the absence
of organic disease.

iatrogenic An adverse state or condition induced by treatment.

idiopathic A disease of spontaneous origin with unknown cause.

impulse 1. Sudden pushing or rapid loading. 2. A change in momentum
calculated by multiplying magnitude of force by time of application.

incontinent Inability to prevent discharge of urine or feces.

induration Hardening of soft tissue caused by extravasation of fluids.

inflammation A localized protective response to tissue damage or irritation
that is characterized by pain, swelling, redness, heat, and loss of function.

inhibition Restrains or represses a process, the opposite of facilitation.

innocuous Harmless or benign.

insidious A disease that appears slowly and progresses with few or no
symptoms indicating the illness.

inspection Examination by the eye.

Inverse square law The intensity of radiation (heat) is inversely
proportional to the square of the distance between the point of the source and
the irradiated surface.

ipsilateral Affecting same side or on same side of the body.

ischemia Insufficient or decreased blood supply to a tissue or organ due to
constriction, obstruction, or pressure (ischemic pressure).

isometric contraction Contraction of a muscle with no change in length.

isotonic contraction Contraction of a muscle with a decrease in length.


247
Jacksons law The nerve functions that evolve last are the first to be lost
when the brain is damaged by disease.

joint mice Bits of bone or cartilage that are present in joint space.

jump sign A general, involuntary response caused by withdrawal from pain
when pressure is applied to a trigger point.

keloid scar A raised, red, smooth scar that is often painful.

kinetics A study of forces acting on a system.

kyphosis Backward convexity, prominence, or hump on the spine caused by
flexion.

latent trigger point Trigger points that lie dormant except when palpated.

Law of denervation When a structure is denervated, sensitivity to certain
chemical agents is increased (denervation supersensitivity).

Law of referred pain Referred pain arises only from irritation of (visceral)
afferent nerves that are sensitive to the same stimuli that produce pain when
applied to surface (cutaneous) afferent nerves.

lesion Pathologically altered tissue, injury, or wound.

ligament A band of fibrous connective tissue connecting the articular ends
of bones.

loading To increase the mass or weight supported by an object or organism.

lordosis Forward convexity in the curvature of the lumbar or cervical spine
as viewed from the side.

lyse Break up or disintegrate.


248
lysosome A membranous organelle found in many cells that contains a
hydrolytic enzyme capable of digesting foreign material such as bacteria.

malingering Pretending to be ill.

manipulation Therapeutic use of hands with or without impulse.

matrix The intercellular substance of a tissue.

mechanism of injury The forces that caused the injury.

mechanoreceptor A receptor that responds to mechanical pressure or
distortion.

Meltzer's law (Contrary Innervation) All living functions are continually
controlled by two opposing forces.

meralgia A pain in the thigh.

metabolite Any product of metabolism.

metastasis Spread of malignant cells.

mobilization Making a joint movable.

modality A therapeutic or physical agent such as thermotherapy (heat),
cryotherapy (cold), hydrotherapy (water), or vibration.

monocytes A relatively large mononuclear leukocyte (white blood cell).

mottled A blotchy discoloration of skin often caused by heat.

MPS Acronym for myofascial pain syndrome.

MRI Acronym for magnetic resonance imaging.

muscle atrophy A decrease in the size of a muscle.


249
muscle hypertrophy An increase in the size of a muscle because of
activity.

myalgia Muscular pain.

myofascial Involving muscles and fascia.

myofascial release An osteopathic technique that follows the principle of
creep.

myofibroblasts A cell seemingly responsible for contracture of wounds.

myofibrosis Replacement of muscle tissue by fibrous connective tissue.

myositis Inflammation of a voluntary muscle.

myotenositis Inflammation of a muscle and its tendon.

necrosis Death of a tissue.

necrotic inflammation Acute inflammation with fairly rapid necrosis.

neoplasm A new and abnormal formation of tissue with uncontrolled and
progressive cell growth, which may be malignant or benign.

nerve conduction velocity The speed at which a peripheral nerve impulse
travels the length of a nerve.

neuralgia Pain along the course of a nerve.

neuritis Inflammation of a nerve.

neuropraxia Loss of conduction in a nerve because of local pressure or
ischemia.

nociceptor A nerve for receiving and transmitting injurious or painful
stimuli.


250
NSAID Acronym for nonsteroidal anti-inflammatory drug.

nystagmus Involuntary, rapid, and rhythmic oscillations of the eyeballs,
either horizontal, vertical, rotary, or mixed.

opioid An opiate-like synthetic or naturally occurring narcotic not derived
from opium.

osteoarthritis Chronic disease involving degeneration of joints.

osteoblast A cell that produces bone.

oxidative killing Aerobic destruction of a substance or bacteria acted upon
by an enzyme, with production of energy and water.

pacinian corpuscle Encapsulated sensory nerve endings that are sensitive
to deep or heavy pressure and vibration.

palliative Relieving severity, intensity, or symptoms, but not a cure.

pallor Lack of color or paleness of skin.

palpation Examining the body by application of hands or fingers to the
surface of the body.

paralysis Loss or impairment of voluntary muscle function.

paresis Incomplete loss of voluntary muscle function.

paresthesia Abnormal sensation of burning, tickling, or tingling sometimes
referred to as a feeling of pins and needles.

passive movement Movement of a body part that is caused entirely by
external forces such as those provided by a therapist or machine.

patellar reflex A leg jerk caused by the involuntary contraction of the
quadriceps muscle when the patellar tendon is sharply struck.


251
pathogenesis The pathologic mechanism that results in development of a
disease, illness, or morbid process.

pathology Condition or manifestation produced by disease.

percussion Tapping sharply on the body to determine position, size, and
consistency of underlying structures.

periosteum A fibrous connective tissue membrane that covers bone.

phagocytosis The process of ingestion and digestion of solid substances by
phagocytic cells.

physiatrist A doctor specializing in physical medicine.

piezoelectricity Electric currents generated by pressure upon certain
crystals such as quartz or calcite (bone).

pilomotor Pertaining to the arrector muscles that cause hairs to move or
stand erect (goose flesh).

plyometrics Exercises that use a stretch-contract sequence of movement to
increase explosive power.

PNF Acronym for proprioceptive neuromuscular facilitation.

prone Lying horizontal with face down, opposite of supine.

proprioceptor A receptor within the body that responds to pressure,
position, or stretch.

proteoglycans The extracellular matrix of connective tissue composed of
glycosaminoglycans (GAG) bound to protein chains.

psychogenic Created by the mind.

pyogenic Related to pus formation.


252
pyrogen A substance that produces or causes a rise in fever.

radiation The transfer of heat from objects by electromagnetic rays that can
travel through a vacuum.

radiculitis Inflammation of a spinal nerve root, especially the portion of the
root that lies between the spinal cord and spinal canal, accompanied by pain
and increased sensitivity to touch.

range of motion The maximal span of a joint as measured by angular
displacement between two adjacent segments.

Raynaud's disease A peripheral vascular disorder characterized by
abnormal vasoconstriction of the extremities when exposed to cold.

reaction Response to brief hot or cold (heat sedates and cold stimulates).

rebound tenderness Pain or discomfort when pressure is released.

recruitment Activating additional motor units to produce greater activity as
the intensity of stimulus remains constant and the duration of stimulus
increases.

reflex An involuntary response to stimulus.

reflexogenic Producing, increasing, or causing a reflex action.

relative humidity The ratio between the amount of water vapor present and
the amount possible for the temperature (complete saturation is 100%).

remodeling The process of reshaping of an injured area during wound
healing.

rheumatoid arthritis A form of arthritis involving inflammation of joints,
stiffness, and swelling.

RICE Acronym for rest, ice, compression, and elevation.


253
ROM Acronym for range of motion.

SAID Acronym for specific adaptations to imposed demands.

salicylate Any salt of salicylic acid used in drugs such as aspirin to reduce
pain and temperature.

satellite trigger point A trigger point activated by another trigger point in
the same reference zone.

sciatica Severe pain along the sciatic nerve.

scoliosis A lateral curvature of the spine normally consisting of a primary
curve and a secondary compensatory curve.

secondary trigger points Trigger points that develop in a synergist or
antagonist because of overload.

self-limiting A condition that runs a definite course and then stops without
treatment.

sentient Capable of feeling sensation.

serous inflammation Inflammation in which the exudate is predominantly
a serum.

servomechanism A control mechanism that operates by positive or
negative feedback.

Sherrington's laws 1. Every posterior spinal root nerve supplies one
particular region on the skin, though fibers from segments above and below
can invade this region. 2. Reciprocal Inhibition: when the agonist receives
an impulse to contract, the antagonist relaxes. 3. Irradiation: nerve impulses
spread from a common center and disperse beyond the normal path of
conduction. Dispersion tends to increase as the intensity of stimulus
becomes greater.

shivering Involuntary trembling from cold or fear.


254
sign Objective evidence of an illness.

soft-tissue impairment A soft-tissue lesion, defect, or dysfunction that
causes pain, limited range of motion, or weakness.

soft-tissue therapy Manipulation of superficial or soft tissue for therapeutic
purposes, with or without modalities, exercise, or mechanical devices.

somatic dysfunction Altered or impaired function related to components of
the body and treatable by manipulation.

spasm Involuntary contraction of a muscle beyond physiologic needs.

spastic Characterized by spasms or spasticity.

specific heat The amount of heat required to raise the temperature of 1
gram of any substance 1C (water is 1.0, ice is 0.50, and steam is 0.48).

splinting Rigidity or fixation of a body part because of reflex spasm.

spondylosis Vertebral ankylosis that may involve osteoarthritis.

sprain Trauma to a joint causing injury to ligaments.

stasis Stagnation of blood or other body fluids.

stenosis Constriction or narrowing of a passage.

Stokes law A muscle situated above an inflamed mucus or serous
membrane is often affected by paralysis.

strain Trauma to a muscle or musculotendinous unit.

strength The ability of a muscle to contract and exert muscular force.

stress The results produced when a structure is acted upon by force.


255
stretch reflex A muscle contracts in response to passive longitudinal
stretch. (also called myotatic reflex or Liddell-Sherrington reflex)

subluxation A partial or incomplete dislocation.

substitution The function of one muscle being replaced by the function of
another muscle or a muscle group that has a similar function or action.

superoxides A highly reactive form of oxygen that attacks biologic targets.

supine Lying horizontal with face up, opposite of prone.

symptom Subjective evidence of an illness.

syncope A transient loss of consciousness caused by inadequate blood flow
to the brain (fainting).

syndrome A group of signs and symptoms characterizing a disease.

synergist A muscle functioning in cooperation with another muscle.

temperature A relative measure of hotness or coldness resulting from the
average kinetic energy of any substance.

tendon A fibrous connective tissue attaching muscles to bones.

tendonitis Inflammation of a tendon.

tensile strength The maximum longitudinal (tensile) stress a material can
endure without elongation.

thermal conductivity The rate of heat passage through a material.

thermography The process of taking a thermograph with an infrared
camera to show distribution of the body's surface temperature.

thermostat An automatic device for regulating temperature.


256
thermotherapy Therapeutic application of heat.

thixotropy A property of certain gels that liquefy when agitated and
become semisolid again when left standing.

TMP Acronym for temporomandibular pain syndrome.

tonus A partial, steady contraction of skeletal muscle that causes firmness,
aids in the maintenance of posture, and helps blood return to the heart.

torque A turning caused by rotary force acting about a pivot point.

traction Process of pulling apart.

trigger point A tender point or spot on the body that produces sudden pain
when stimulated by pressure or compression.

trigger zone A tender zone or area on the body that produces sudden pain
when stimulated by pressure or compression.

trophic Relating to interruption of a nerve supply and nutrition.

trophotropic Mechanisms of the nervous system that restore energy,
opposite of ergotropic.

tumor A swelling or enlargement, one of the four cardinal signs of
inflammation.

twitch response Transient contraction of a muscle fiber group when
pressure is applied to a trigger point.

urticaria Eruption of skin characterized by severe itching.

van't Hoff's law The rate of chemical reactions increases twofold or more
for each 10C rise in temperature.

vasoconstriction Decrease in the caliber of a blood vessel.


257
vasodilation Increase in the caliber of a blood vessel.

vertigo Sensation of whirling or rotating in space or being surrounded by
objects that are whirling or rotating in space.

vesiculation Blistering.

viscoelastic A viscous material that is also elastic (e.g., connective tissue).

viscosity Resistance to flow or shear caused by stickiness or cohesion.

Webers law The increase in cutaneous stimulus necessary to produce the
smallest perceptible increase in sensation bears a constant ratio to the
strength of the stimulus already acting.

Weigerts law The loss or destruction of living tissue is apt to be followed
by overproduction of such tissue during the process of wound healing.

Wolff's law Bone and collagen fibers develop a structure most suited to
resist the forces acting upon them.


258
HEMME APPROACH QUIZ

1. A soft-tissue lesion, defect, or dysfunction that causes pain, limited
range of motion, or weakness is called a:

a. somatic dysfunction
b. subluxation
c. soft-tissue impairment
d. spondylosis

2. Manipulation of superficial or soft tissue for therapeutic purposes, with
or without modalities, exercise, or mechanical devices is called:

a. osteopathy
b. soft-tissue therapy
c. chiropractic
d. podiatry

3. Which type of manipulation is not used in HEMME APPROACH?

a. trigger point therapy
b. neuromuscular therapy
c. range-of-motion stretching
d. spinal manipulation therapy

4. Which sequence defines the HEMME APPROACH?

a. history, evaluation, modalities, manipulation, energy
b. history, evaluation, modalities, medication, exercise
c. history, evaluation, music, manipulation, energy
d. history, evaluation, modalities, manipulation, exercise

5. Which condition contraindicates soft-tissue therapy?

a. hypertonia
b. hot, painful, or swollen joints
c. myofascial pain syndrome (MPS)
d. fibromyalgia syndrome (FMS)


259
6. Which acronym is used for taking a medical history?

a. EMT
b. ASP
c. PDQ
d. GTO

7. The first I in the acronym AID FIRST stands for:

a. intensity
b. impulse
c. impairment
d. insidious

8. Damage to the sarcoplasmic reticulum surrounding a muscle fiber and
release of calcium ions (Ca
++
) may cause:

a. hypotonia
b. hypertonia
c. hypermobility
d. hyperthermia

9. Which statement is not true concerning pain cycles?

a. The mechanisms that cause pain cycles are easy to locate.
b. Pain can migrate from one area to another.
c. Muscle imbalance perpetuates pain cycles.
d. Reflex activity perpetuates pain cycles.

10. If the force for movement is provided by the patient without assistance
or resistance from the examiner, which range of motion is being tested?

a. active range of motion
b. passive range of motion
c. active-assisted range of motion
d. resisted range of motion


260
11. Muscle weakness can be caused by:

a. inhibition
b. pain
c. spasm
d. all of the above

12. Which muscle testing grade is the highest?

a. trace
b. fair
c. good
d. normal

13. Which type of positioning is not used in muscle testing?

a. positioning to create active insufficiency
b. positioning to reinforce fixator muscles
c. positioning to avoid substitution
d. positioning to reduce somatic dysfunction

14. Which procedure increases the risk of tissue damage during resisted
range-of-motion muscle testing?

a. Apply resistance slowly and progressively.
b. Do not apply excessive force.
c. Break the patient's contraction by using appropriate force.
d. Remove resistance slowly and progressively.

15. The HEMME APPROACH Quick Test is used for testing:

a. individual muscles
b. stretch reflexes
c. basic movements
d. aerobic fitness


261
16. By definition, which points cause fibromyalgia syndrome (FMS)?

a. trigger points that refer pain
b. trigger points that do not refer pain
c. tender points that refer pain
d. tender points that do not refer pain

17. By definition, which syndrome is most likely to cause widespread pain?

a. myofascial pain syndrome
b. fibromyalgia syndrome
c. carotid sinus syndrome
d. temporomandibular pain syndrome

18. The five classic signs of inflammation are:

a. pain, swelling, redness, heat, anxiety
b. pain, swelling, hemorrhage, heat, anxiety
c. pain, swelling, redness, heat, loss of function
d. pain, sweating, redness, heat, loss of function

19. During wound healing, cryotherapy:

a. reduces pain, controls edema, and increases local metabolism
b. reduces pain or spasm and increases local blood flow
c. kills bacteria and increases local blood flow
d. reduces pain, controls edema, and reduces local metabolism

20. During wound healing, thermotherapy:

a. reduces pain, controls edema, and increases local metabolism
b. reduces pain or spasm and increases local blood flow
c. kills bacteria and increases local blood flow
d. reduces pain, controls edema, and reduces local metabolism


262
21. The last stage of inflammation is:

a. increased blood flow to the inflamed area
b. edema caused by plasma leaking from capillaries
c. infiltration of the injury by leukocytes (neutrophils or monocytes)
d. proliferation of connective tissue and wound healing

22. Which type of inflammation is characterized by pain, proliferation of
connective tissue, and loss of function?

a. acute inflammation
b. serous inflammation
c. necrotic inflammation
d. chronic inflammation

23. Secondary damage is caused by:

a. phagocytosis and lysosomal enzyme damage
b. ischemic or hypoxic damage
c. hydrostatic pressure damage
d. all of the above

24. The first step in the Advanced Rehabilitation Model is:

a. soft-tissue therapy
b. mobilization
c. cryotherapy
d. original injury

25. If a body part takes about 20 minutes to cool, rewarming takes about:

a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 40 minutes


263
26. In the ice-pressure method for treating trigger points:

a. the last step is passive range-of-motion stretching
b. the last step is active range-of-motion stretching
c. the second step is moderate pressure with ice until numbness occurs
d. moist heat is applied after passive range-of-motion stretching

27. Which condition contraindicates the used of cold?

a. trauma
b. spasms
c. edema
d. rashes

28. Connective tissue extensibility does not substantially increase until
tissue temperatures reach:

a. 96F-100F
b. 100F-104F
c. 104F-105F
d. 105F-110F

29. Tissue damage and pain normally start when tissue temperatures reach:

a. 100F
b. 104F
c. 113F
d. 126F

30. To achieve the greatest amount of permanent increase in tissue length
possible with the least amount of force or tissue damage:

a. Heat tissues to a therapeutic temperature of at least 98F.
b. Quickly stretch tissues with enough force to overcome elasticity.
c. Hold tissues in a fully stretched position until cooling is complete.
d. Use ballistic stretching after tissues are cooled for about 20 minutes.


264
31. Which condition contraindicates the use of heat?

a. pain
b. spasm
c. edema
d. vascular stasis

32. Which law states that most conditions treatable by soft-tissue therapy
are characterized by pain, limited range of motion, or weakness?

a. HEMME's 1st law
b. Head's law
c. Hilton's law
d. Hooke's law

33. Which law states that bone and collagen fibers develop a structure most
suited to resist the forces acting upon them?

a. HEMME's 2nd law
b. Webers law
c. Weigerts law
d. Wolff's law

34. Which concept is not correct concerning pain?

a. Pain will continue if at least one source of pain is active.
b. Pain stimulus applied to skin may cause flexion of a limb.
c. Pain may cause spasm and spasm may cause pain.
d. Pain is never referred from a damaged region to a healthy region.

35. Myofascial trigger points may be indicated by:

a. distinct patterns of referred pain or radiated pain
b. the presence of taut, indurated, or ropy bands within a muscle
c. tremors or fasciculations when pressure is properly applied
d. all of the above


265
36. Which trigger point is asymptomatic unless palpated or compressed?

a. active trigger point
b. latent trigger point
c. primary trigger point
d. secondary trigger point

37. Deep sliding pressure (DSP) is used to treat:

a. individual trigger points or tender points
b. taut, indurated zones or bands within a muscle
c. contractures
d. keloid scars

38. The key to understanding neuromuscular therapy is realizing that
muscles contract or relax because of:

a. trigger points and tender points
b. contractures
c. inhibition and facilitation
d. collagen fibers

39. Neuromuscular therapy may not be effective if:

a. the injury being treated is still acute or poorly healed
b. acute inflammation or infection are present
c. trigger points are reversing the effects of neuromuscular therapy
d. all of the above

40. Inhibition and facilitation can both be used to:

a. lengthen hypertonic muscles
b. shorten stretched muscles
c. strengthen weak muscles
d. neutralize trigger points


266
41. What is the underlying principle that applies to almost any form of soft-
tissue therapy?

a. strengthen first, lengthen second
b. strengthening exercises are more important than stretching exercises
c. lengthen first, strengthen second
d. modalities can be used to lengthen tissues without stretching

42. Which form of manipulation is used to reset proprioceptors?

a. range-of-motion stretching
b. connective tissue therapy
c. neuromuscular therapy
d. trigger point therapy

43. The first D in the acronym DAVID stands for:

a. duration
b. dosage
c. disinhibition
d. divergence

44. Single-repetition stretching is based on:

a. thixotropy
b. hysteresis
c. creep
d. plyometrics

45. Which range of motion has both elastic and plastic regions?

a. active ROM
b. physiologic ROM
c. passive ROM
d. anatomical ROM


267
46. The fourth A in the acronym LA CAMRA stands for:

a. attitude
b. aroma
c. air
d. activity

47. The three ways to increase overload are:

a. increase specificity, frequency, and duration
b. increase specificity, intensity, and duration
c. increase intensity, frequency, and duration
d. increase specificity, intensity, and frequency

48. Which type of contraction is most likely to cause muscle soreness?

a. isometric
b. isotonic
c. eccentric
d. concentric

49. The D in the acronym TIRED stands for:

a. disease
b. distraction
c. dystrophy
d. diligence

50. The symbols " " indicate the ROM is:

a. normal
b. less than normal
c. greater than normal
d. unknown


268
INDEX

activation of stretch reflex 136
active insufficiency 46-47
activity 167-169
adhesions 140
Advanced Rehabilitation Model 73
AID FIRST 20
air 170-171
All-or-none law 111
aroma 172-174
attitude 175-176
autogenic training 177
ballistic stretching 154
Beevor's axiom 111
Bells law 111
chronic inflammation 69-70
color 169-170
connective tissue therapy 138-144
contracture 32
contraindications, 16
creep 140
cross-fiber friction 142-144
cross-over stretch 153
cryotherapy 75-83
DAVID 147-148
deconditioning 201-202
deep sliding pressure (DSP) 125
DSP (deep sliding pressure) 125
exercise principles 190-194
facilitation-inhibition 111
fascial stretching 151-152
fibromyalgia syndrome (FMS) 53-58
FMS (fibromyalgia syndrome) 53-58
force-couple stretch 153-154
frequency and duration principle 192-193
functional techniques 157-159
Head's law 111


269
HEMME APPROACH 11-55
HEMME APPROACH Appraisal and Treatment Form 215
HEMME APPROACH Evaluation Chart 214
HEMME APPROACH Quick Test 49-52
HEMME laws 110
HEMMEGON 14
Hilton's law 111
Hookes law 111
hot-to-cold stretch 99-100
Houghtons law of fatigue 111
hypertonia 30-32
hysteresis 139
ice-massage method 81
ice-pressure method 81-82
indirect techniques 157-159
inflammation 63, 67-68
intensity principle 192
Inverse square law 112
isolytic stretching 156
Jacksons law 112
LA CAMRA 165
Law of denervation 112
Law of referred pain 112
lubrication 166-167
Meltzer's law 112
multiple-repetition stretching 149
muscle imbalance 114-115
muscle soreness 195-200
muscle spindle facilitation 136
muscle testing 41-48
music 171-172
myoglobinemia 127
neuromuscular therapy 128-137
neutral positioning 159-160
overload principle 191-192
pain cycles 33-40
pain scales 27
PDQ 19


270
post-isometric relaxation 134
posture 116-117
prevention 203-204
progressive relaxation 178
proprioceptive inhibition 133
q.i.d. 20
range-of-motion stretching 145-162
reciprocal inhibition 135
rehabilitation 72-74
relaxation therapy 163-180
relaxing massage 180
repeated contractions 136
rest 174-175
secondary damage 70-71
Sherrington's laws 112
single-repetition stretching 149
skin pulling 141-142
skin rolling 141
soft-tissue impairment 2
soft-tissue therapy 4
spasm 30
specificity principle 193-194
Stokes' law 112
Stretch reflex 112
thermotherapy 84-94
thixotropy 139
TIRED 203
training principle 194
trigger point therapy 118-127
vibration 103
Webers law 113
Weigerts law 113
Wolff's law 113

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