HEMME Approach Concepts and Tehniques

HEMME APPROACH CONCEPTS

AND TECHNIQUES

iINSTRUCTIONS 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 easier to complete the quiz on pages 255–264. As always, there are no trick questions. The answers are clearly stated in the book. Second, the questions are not taken at random; they follow the same sequence as the text. Third, the questions cover the major points. Reading the table of contents, chapter headings, section headings, charts, index, and statements following numbers or bullets (•) will be helpful. Fourth, use the glossary. This course is not easy. Since 16 hours of continuing education credit are given for completing the course, you are not expected to read the manual and complete the quiz in one day. Feel free to use the manual as you take the quiz. It may be helpful to look over the questions before reading the manual. Though 70% or above (two points per question) is a passing grade, this should not be a problem for most people. If needed, retakes will be allowed. Above all else, please follow these three instructions: COMPLETE THE TOP OF THE ANSWER SHEET. ANSWER QUESTIONS 1 THROUGH 50. RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED. When you complete the top of the answer sheet, please print legibly. The spelling of your name for your diploma will be taken from the answer sheet. Please be patient. Quizzes are normally graded the same day they arrive. In addition to a diploma, you will also receive a certificate showing that 16 hours of continuing education credit have been awarded to you for completing this course. Most state boards recommend holding certificates at least four years unless otherwise instructed. Good luck with the quiz, and thank you again for taking the HEMME APPROACH series.

iiHEMME APPROACH CONCEPTS ANSWER SHEET

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iiiHEMME APPROACH CONCEPTS AND TECHNIQUES

EVALUATION FORM

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ivHEMME 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.

vPREFACE

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 manipulation—trigger point therapy, neuromuscular therapy, connective tissue therapy, and range-of-motion stretching—in 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 source—physical medicine, osteopathy, chiropractic, or Swedish massage—the 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

viiACKNOWLEDGMENTS

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.

viiiCONTENTS

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

ixContents 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

xContents 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

xiContents 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

xiiContents 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

xiiiContents 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

xivILLUSTRATIONS 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

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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 person’s 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


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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 person’s 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


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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.


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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, pétrissage, 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.


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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 levers—bones and joints—that 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


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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 muscle’s 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 met—relieve pain, restore normal function, and improve quality of life—the 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


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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 body’s 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.


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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 patient’s range of motion and flexibility, the patient’s 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


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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.


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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)


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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 method—pronounced HEM as in hem and ME as in me—is named after the acronym HEMME that stands for:

HEMMEH HISTORY E EVALUATION M MODALITIES M MANIPULATIONE 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 STEPS1. 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.


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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


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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.


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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)


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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 physician’s 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


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Doctor’s Opinion Questions regarding indications or contraindications should always be resolved by the patient’s 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


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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.


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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 patient’s 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 doctor’s 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


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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 words—AID FIRST—can 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


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Reconstructing an automobile accident may help to explain the acronym AID FIRST. If the front end of a patient’s 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 victim’s vehicle is struck by another vehicle, some of the injuries may relate to secondary forces applied to the victim’s 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


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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.


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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.


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THE ACRONYM PDQ STANDS FOR • Problem • Doctor’s 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 • 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)? 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


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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 patient’s 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.


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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.


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PAIN SCALES

0 1 2 3 4 5 6 7 8 9 10

Numerical Rating Scale

No Pain WorstPossible

Pain

Visual Analog Scale

No Pain WorstPossible

Pain

Graphic Rating Scale

No Pain ModeratePain

MildPain

SeverePain

WorstPossible

Pain


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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).


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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.


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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 bone’s 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


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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 muscle’s 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.


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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.


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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 junction—cause 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. • Trauma causes pain, spasm, edema, and metabolite retention.

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 nociceptor’s 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.


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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,


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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.


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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 (Wolff’s 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.


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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


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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.


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(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


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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 body’s 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.


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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


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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.


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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.


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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 TreatmentInhibition 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.


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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.


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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.


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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.


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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.


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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


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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).


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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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s elbows. C. Resistance: prevent patient from extending humeri.


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6. Flexion (humerus) A. Patient: humeri flexed to 90 degrees, elbows flexed to 90 degrees. B. Examiner: hands touching superior surfaces of patient’s distal humeri. C. Resistance: prevent patient from flexing humeri.

7. Horizontal Abduction (humerus) (forearms of examiner are parallel)

A. Patient: humeri flexed to 90 degrees, elbows flexed to 90 degrees. B. Examiner: hands touching lateral surfaces of patient’s elbows. C. Resistance: prevent patient from horizontally abducting humeri.

8. Horizontal Adduction (humerus) (forearms of examiner are crossed)

A. Patient: humeri flexed to 90 degrees, elbows flexed to 90 degrees. B. Examiner: hands touching opposite medial surfaces of patient’s 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 patient’s head,

opposite hand touching sternal region of patient’s 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 patient’s 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 patient’s 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.


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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.


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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

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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


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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.


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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 quadrants—left side above the waist, right side above the waist, left side below the waist, and right side below the waist—patients 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.)


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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.


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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 • 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. • Trauma causes pain, spasm, edema, and metabolite retention. 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)


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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.


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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.


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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


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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 Weigert’s 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.


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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.


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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


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factors are overuse, disuse, or improper body use. Once tissues are damaged, pain results and psychological or chemical factors increase or decrease the patient’s 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 factors—such as mechanical, chemical, or electrical agents—that 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.


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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 continues—months or even years—bone 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


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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.


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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 damageacute inflammationpain-producing chemicals

pain or spasmedema or enzymesmetabolite retention

restricted circulationischemia or hypoxiafatigue

restricted motioninactivityfibrosis

adhesions or contracturestrigger pointsatrophy

Soft-Tissue Therapy

Acceptable Recovery

Eliminate or decrease painIncrease range of motionIncrease strength and enduranceImprove 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 32°F to 65°F, 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.


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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 minutes—3 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.


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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 cold—metabolic and circulatory effects—circulatory 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


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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.


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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. • Apply passive range-of-motion stretching to affected body part. • 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


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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 • Raynaud’s 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


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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)


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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.


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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 104°F to 113°F. Blood flow, as indicated by hyperemia, is not significantly increased until tissue temperatures reach 104°F to 113°F, and connective tissue extensibility is not substantially increased until tissue temperatures reach 105°F to 110°F. The upper limit for therapeutic heat is about 113°F, 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 110°F can be more dangerous than immersing a small part of the body in water at 115°F. Although pain and tissue damage normally start at tissue temperatures above 113°F, most patients can tolerate immersing their feet in a hot foot bath that reaches temperatures as high as 115°F. Despite the high local temperatures produced by the heating agent, tissue temperatures (TT) in the feet seldom exceed 113°F 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.


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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 110°F are considered unsafe. For full body immersion in a hot bath, water temperatures should not exceed 100°F. While exposing large portions of the body to temperatures between 100°F and 110°F should not cause superficial tissue damage—the upper limit for tissue damage is 113°F—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 104°F to 113°F 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 (100°F to 104°F) 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


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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 104°F. • 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 adequate—but not excessive—ROM 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.


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When the partial pressure (tension) of oxygen (PO2) 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 PO2 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 light—erythema, pigmentation (tanning), hyperplasia that thickens the stratum corneum (outer layer of epidermis), and production of vitamin D—ultraviolet 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.


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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 165°F 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 130°F. 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 1°C. 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 1°C and releases less heat as the temperature drops 1°C. 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.


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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 Heat1 Muscle spasm 2 Pain 3 Contracture 4 Vascular stasis


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Physical Properties

THERMAL CONDUCTIVITY (k)

air (27°C) ................................................................................ 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 (20°C)............................................................................ 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


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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 temperatures—not surface temperatures—drop below 50°F, 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.


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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.


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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.


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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 (104°F) followed by 1 minute of cold (55°F). 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.


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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


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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 113°F will cause tissue damage and pain. If a patient’s skin is extremely sensitive to painful stimuli (hyperalgesic), the threshold for pain may be lower than 113°F. 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.


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Temperatures

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

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 113°F, a thermometer is a safer—and more reliable—method 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


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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.


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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. • Apply passive range-of-motion stretching to affected body part. 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. • Apply passive range-of-motion stretching to affected body part. • 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 104°F. • 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. Pflüger's Laws of Unilaterality, Symmetry, Intensity, and Radiation are classical examples. Written in 1853 by the German physiologist Edward Pflüger, these laws were widely accepted for more than 50 years. Pflüger 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 points—pain increases with increases in pressure until numbness occurs—other situations involving painful stimulation produce continuous pain instead of numbness. Stedman’s Medical Dictionary (26th ed.) shows the Arndt-Schultz Law as obsolete.

The Three HEMME Laws

The HEMME APPROACH is based on three fundamental laws:

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

HEMME’s 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.

HEMME’s 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. Bell’s 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. Hooke’s 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. Houghton’s 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. Jackson’s 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. Weber’s 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. Weigert’s 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 muscle’s 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 pain—a dull constant aching pain or a sharp, stabbing, shooting pain—and 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 muscle’s 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 contract–relax–passive 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 contract–relax–passive stretch, the patient should be encouraged to actively stretch the target muscle. The sequence would then become contract–relax–passive stretch–active 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 proprioceptor’s 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 (Beevor’s 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 muscle’s 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 Thixotropy2 Hysteresis3 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 manipulation—compression, tension, or shear—is 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 pull–and–release or push–and–release. 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 patient’s 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 patient’s 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 Wolff’s 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 patient’s 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 practitioner’s 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 muscle’s 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 patient’s 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. Intensity: magnitude of force. 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 Dosage—five 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 patient’s 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 Hooke’s 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 patient’s 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-up–and 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 patient’s 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 patient’s 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 stretching—using one or more body parts to stretch another body part—is easier to use in water than passive or active-assisted stretching. Swimming is also considered an excellent exercise for improving or maintaining a patient’s 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 joint’s 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 joint’s 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 bone–to–bone contact felt during complete elbow extension or soft as in the muscle–to–muscle 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 position—neither stretching nor contracting—is called a neutral point. When a body part’s 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 muscle’s 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.


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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 (O2) 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 person’s 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.


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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 body’s vulnerability to tumors, and decreases the body’s 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 CAMÁRA identifies eight basic ways to make therapeutic environments more relaxing. In Spanish, the words la camára mean chamber, hall, or compartment. The letters in the acronym LA CAMÁRA 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 patient’s 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 patient’s 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 patient’s skin and any surface making contact with the patient’s 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 patient’s 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 70°F and 104°F, most patients prefer temperatures that are closer to 104°F than 70°F. Even if a patient’s normal body temperature is 98.6°F (core temperature), lubricants heated to 80°F may feel warm if the skin temperature is below 80°F. 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 patient’s ability to relax. A patient’s 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 patient’s 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 practitioner’s 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 practitioner’s body movements are slower and more relaxed. If a patient’s 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 patient’s speech patterns are extremely rapid, partially matching the patient’s 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


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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 patient’s 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 green’s central position in the visible spectrum—red, 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 80°F) and tepid (80° to 92°F). Since many patients are not fully clothed during treatment, 75°F 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 patients—and many clinics—prefer 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 patient’s 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 patient’s comfort, but many of these devices were also adjustable so the patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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, I’ve 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 practitioner’s 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


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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 patient’s 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 patient’s body. • Give special attention to the back, hands, and feet. • Do not change the patient’s 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 patient’s ability to enjoy a relaxing massage: • accidentally scratching the patient’s skin or pulling the patient’s hair • conversing too much or in ways that interfere with relaxation • dropping the patient’s head, arm, or leg over the edge of a table • jarring the patient’s 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 • HEMME’s 1st law: Most conditions treatable by soft-tissue therapy are

characterized by pain, limited range of motion, or weakness. • HEMME’s 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.

• HEMME’s 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 • Bell’s law • Creep • Facilitation-Inhibition • Head's law • Hilton's law • Hooke’s law • Houghton’s law of fatigue • Hysteresis • Inverse square law • Jackson’s law • Law of denervation • Law of referred pain • Meltzer's law • Sherrington's law • Stokes’ law • Stretch reflex • Weigert’s law • Thixotropy • Weber’s 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. • Intensity: magnitude of force. • 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 CAMÁRA 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 patient’s body. • Give special attention to the back, hands, and feet. • Do not change the patient’s 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 patient’s skin or pulling the patient’s hair • Conversing too much or in ways that interfere with relaxation • Dropping the patient’s head, arm, or leg over the edge of a table • Jarring the patient’s 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 Taber’s 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. Taber’s 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 patient’s 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 patient’s 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 fiber’s 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 patient’s 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 McArdle’s disease experience muscle soreness both during and after exercise even though their bodies are unable to produce lactic acid. McArdle’s 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


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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–pain–spasm 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 joint’s 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 muscle’s 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 patient’s contraction. Eccentric contractions are sometimes called isolytic contractions.


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The main justification for using counterforce to overcome a patient’s 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 patient’s 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 patient’s 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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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

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)?

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)?


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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?


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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?


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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


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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


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HEMME APPROACH APPRAISAL AND TREATMENT FORM HISTORY EVALUATION MODALITIES MANIPULATION EXERCISE

COMMENTS PATIENT DOB SS# PRACTITIONER DATE TIME


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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.


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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.


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GLOSSARY absolute zero Theoretically the lowest possible temperature because all molecular movement has stopped (-460°F or -273.2°C). 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 person’s 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.


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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.


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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.


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bath immersion of the body or any of its parts in water—liquid or vapor—for therapeutic purposes. Beevor's axiom: The brain knows nothing of individual muscles, but thinks only in terms of movement. Bell’s 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 1°C. 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.


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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.


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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.


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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.


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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.


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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.


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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 32°F to a liquid at 32°F. heat of vaporization The heat needed to change water from a liquid at 212°F to a gas (vapor) at 212°F. heliotherapy Exposure to sunlight for therapeutic purposes. HEMME Acronym for history, evaluation, modalities, manipulation, and exercise. HEMME’s 1st law Most conditions treatable by soft-tissue therapy are characterized by pain, limited range of motion, or weakness. HEMME’s 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. HEMME’s 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.


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homeostasis A state of equilibrium in the body controlled by positive and negative feedback. Hooke’s 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. Houghton’s 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 forms—liquid, solid, or vapor—for 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.


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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 98.6°F 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.


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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.


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Jackson’s 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.


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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.


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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.


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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.


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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.


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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.


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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.


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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 1°C (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.


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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.


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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 10°C rise in temperature. vasoconstriction Decrease in the caliber of a blood vessel.


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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. Weber’s 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. Weigert’s 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.


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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)


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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


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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


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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


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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


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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. 96°F-100°F b. 100°F-104°F c. 104°F-105°F d. 105°F-110°F 29. Tissue damage and pain normally start when tissue temperatures reach: a. 100°F b. 104°F c. 113°F d. 126°F 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 98°F. 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.


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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. Weber’s law c. Weigert’s 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


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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


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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


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46. The fourth A in the acronym LA CAMÁRA 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 "–Õ" indicate the ROM is: a. normal b. less than normal c. greater than normal d. unknown


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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 Bell’s 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


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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 Hooke’s law 111 hot-to-cold stretch 99-100 Houghton’s 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 Jackson’s law 112 LA CAMÁRA 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


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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 Weber’s law 113 Weigert’s law 113 Wolff's law 113

HEMME Approach Concepts and Tehniques

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