soft tissue manipulation fundamentals - leon...

NEUROMUSCULAR TECHNIQUE (NMT)(Chaitow 2003) (with example of NMTtreatment of the mimetic, palatine andtongue muscles: see Box A1.1)

• NMT aims to produce modifications in dys-functional tissue, encouraging a restoration ofnormality, with the primary focus of deactivatingfocal points of reflexogenic activity such asmyofascial trigger points.

• An alternative aim of NMT is to normalizeimbalances in hypertonic and/or fibrotic tissues,either as an end in itself or as a precursor torehabilitation.

• NMT relies on physiological responses involvingneurological mechanoreceptors, Golgi tendonorgans, muscle spindles and other proprio-ceptors, in order to achieve the desiredresponses.

• Insofar as they integrate with NMT, othermeans of influencing such neural reportingstations form a natural set of allied approaches,including positional release (SCS – strain/counterstrain) and muscle energy methods(MET – indeed, many European practitionersspeak of MET as ‘NMT’ (Dvorak & Dvorak1984).

• Traditional massage methods which encouragea reduction in the retention of metabolic wastes,and which enhance circulation to dysfunctional

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Appendix 1

Soft tissue manipulationfundamentals

APPENDIX CONTENTS

Neuromuscular technique (NMT)(Chaitow 2003) 379

Muscle energy technique: summary of variations 388

Positional release techniques (PRT) (includingstrain/counterstrain) 391

Myofascial release (MFR) techniques 396

Conclusion 397

References 397

Appendix 1.qxd 24/03/05 12:52 PM Page 379

tissues, are included in this category of alliedapproaches (Rich 2002).

• NMT can usefully be integrated in treatmentaimed at postural reintegration, tension release,pain relief, improvement of joint mobility, reflexstimulation/modulation or sedation. There aremany variations of the basic technique asdeveloped by Stanley Lief and his cousin BorisChaitow, the choice of which will depend uponparticular presenting factors or personalpreference. Similarities between some aspectsof NMT and other manual systems should be anticipated since techniques have been‘borrowed’ from other systems where appropriate(Chaitow 1992).

• NMT can be applied generally or locally and ina variety of positions (sitting, lying, etc.). Theorder in which body areas are dealt with is notregarded as critical in general treatment but isof some consequence in postural reintegration.

The methods described are in essence those ofStanley Lief and Boris Chaitow, both of whomachieved an unsurpassed degree of skill in theapplication of NMT. Boris Chaitow (personalcommunication, 1983) has written:

The important thing to remember is that thisunique manipulative formula is applicable to anypart of the body for any physical and physio-logical dysfunction and for both articular and softtissue lesions.

To apply NMT successfully it is necessary todevelop the art of palpation and sensitivity offingers by constantly feeling the appropriate areasand assessing any abnormality in tissuestructure for tensions, contractions, adhesions,spasms.

It is important to acquire with practice anappreciation of the ‘feel’ of normal tissue so thatone is better able to recognize abnormal tissue.Once some level of diagnostic sensitivity withfingers has been achieved, subsequent applicationof the technique will be much easier to develop.The whole secret is to be able to recognize the‘abnormalities’ in the feel of tissue structures.Having become accustomed to understanding thetexture and character of ‘normal’ tissue, the pressureapplied by the thumb in general, especially in the

spinal structures, should always be firm, butnever hurtful or bruising. To this end the pressureshould be applied with a ‘variable’ pressure, i.e.with an appreciation of the texture and characterof the tissue structures and according to the feelthat sensitive fingers should have developed. Thelevel of the pressure applied should not beconsistent because the character and texture oftissue is always variable. These variations can bedetected by one’s educated ‘feel’. The pressureshould, therefore, be so applied that the thumb ismoved along its path of direction in a way whichcorresponds to the feel of the tissues.

This variable factor in finger pressureconstitutes probably the most important quality apractitioner of NMT can learn, enabling him tomaintain more effective control of pressure,develop a greater sense of diagnostic feel, and befar less likely to bruise the tissue.

Compare this description involving ‘variable’pressure with that of Pick in Chapter 12, where hedescribes the ‘working level’ used in cranialtherapy – see Figure 12.1.

NMT thumb technique

• Thumb technique as employed in NMT ineither assessment or treatment modes enables awide variety of therapeutic effects to beproduced. The tip of the thumb can delivervarying degrees of pressure via any of fourfacets: the very tip may be employed or themedial or lateral aspect of the tip can be used tomake contact with angled surfaces. For moregeneral (less localized and less specific) contact,of a diagnostic or therapeutic type, the broadsurface of the distal phalange of the thumb isoften used.

• It is usual for a light, non-oily lubricant to beused to facilitate easy, non-dragging, passage ofthe palpating digit.

• For balance and control the hand should bespread, tips of fingers providing a fulcrum or‘bridge’ in which the palm is arched in order toallow free passage of the thumb towards one ofthe fingertips as the thumb moves away fromthe practitioner’s body.

SOFT TISSUE MANIPULATION FUNDAMENTALS380


• During a single stroke, which covers between 2and 3 inches (5–8 cm), the fingertips act as apoint of balance while the chief force isimparted to the thumb tip via controlledapplication through the long axis of theextended arm of body weight. The thumbtherefore never leads the hand but always trailsbehind the stable fingers, the tips of which restjust beyond the end of the stroke.

• Unlike many bodywork/massage strokes, thehand and arm remain still as the thumb,applying variable pressure, moves through itspathway of tissue. The extreme versatility ofthe thumb enables it to modify the direction ofimparted force in accordance with theindications of the tissue being tested/treated.

• As the thumb glides across and through thosetissues it becomes an extension of thepractitioner’s brain. In fact, for the clearestassessment of what is being palpated thepractitioner should have the eyes closed so thatevery minute change in the tissue can be feltand reacted to.

• The thumb and hand seldom impart their ownmuscular force except in dealing with smalllocalized contractures or fibrotic ‘nodules’. Inorder that pressure/force be transmitteddirectly to its target, the weight being impartedshould travel in as straight a line as possible,which is why the arm should seldom be flexedat the elbow or the wrist by more than a fewdegrees.

• The positioning of the practitioner’s body inrelation to the area being treated is also of theutmost importance in order to facilitateeconomy of effort and comfort. The optimumheight vis-à-vis the couch and the mosteffective angle of approach to the body areasbeing addressed must be considered and thedescriptions and illustrations will help to makethis clearer.

• The degree of pressure imparted will dependupon the nature of the tissue being treated,with a great variety of changes in pressurebeing possible during strokes across andthrough the tissues.

• When being treated, the patient should not feelstrong pain but a general degree of discomfortis usually acceptable as the seldom stationarythumb varies its penetration of dysfunctionaltissues.

• A stroke or glide of 2–3 inches (5–8 cm) willusually take 3–5 seconds, seldom more unless aparticularly obstructive indurated area is beingdealt with. If reflex pressure techniques orischemic compression are being employed, amuch longer stay on a point will be needed but in normal diagnostic and therapeutic use the thumb continues to move as it probes,decongests and generally treats the tissues.

• It is not possible to indicate the exact pressuresnecessary in NMT application because of thevery nature of the objective which, in assess-ment mode, attempts precisely to meet andmatch the tissue resistance, to vary the pressureconstantly in response to what is felt. (Comparethis description with that of Pick in Chapter 12,where he describes the ‘working level’ used incranial therapy – see Fig. 12.1.)

In subsequent or synchronous (with assessment)treatment of whatever is uncovered duringevaluation, a greater degree of pressure is usedand this will vary depending upon the objective –whether this is to inhibit, to produce localizedstretching, to decongest and so on. Obviously onareas with relatively thin muscular covering theapplied pressure would be lighter than in tense orthick, well-covered areas such as the buttocks.

• Attention should also be paid to the relativesensitivity of different areas and differentpatients. The thumb should not just mechanicallystroke across or through tissue but shouldbecome an intelligent extension of the practi-tioner’s diagnostic sensitivities so that thecontact feels to the patient as though it issequentially assessing every important nookand cranny of the soft tissues. Pain should betransient and no bruising should result if theabove advice is followed.

• The treating arm and thumb should berelatively straight since a ‘hooked’ thumb, inwhich all the work is done by the distal

Neuromuscular technique (NMT) 381

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phalange, will become extremely tired and willnot achieve the degree of penetration possiblevia a fairly rigid thumb.

NMT finger technique

• In certain localities the thumb’s width preventsthe degree of tissue penetration suitable forsuccessful assessment and/or treatment andthe middle or index finger can usually besuitably employed in such regions.

• The most usual area for use of finger ratherthan thumb contact is in the intercostal mus-culature and in attempting to penetrate beneaththe scapula borders in tense fibrotic conditions.

• The middle or index finger should be slightlyflexed and, depending upon the direction of thestroke and density of the tissues, supported byone of its adjacent members. As the treatingfinger strokes with a firm contact and usually aminimum of lubricant, a tensile strain is createdbetween its tip and the tissue underlying it.This is stretched and lifted by the passage of thefinger which, like the thumb, should continuemoving unless or until dense, indurated tissueprevents its easy passage. These strokes can berepeated once or twice as tissue changesdictate.

• The ideal angle of pressure to the skin surface isbetween 40° and 50°.

• The fingertip should never lead the stroke butshould always follow the wrist, the palmarsurface of which should lead as the hand isdrawn towards the practitioner.

• It is possible to impart a great degree of pull onunderlying tissues and the patient’s reactionsmust be taken into account in deciding on thedegree of force to be used. Transient pain ormild discomfort is to be expected but no morethan that. All sensitive areas are indicative ofsome degree of dysfunction, local or reflex, andare thus important and their presence shouldbe recorded. The patient should be told what toexpect so that a co-operative unworriedattitude evolves.

• Unlike the thumb technique, in which force islargely directed away from the practitioner’sbody, in finger treatment the motive force isusually towards the practitioner. The armposition therefore alters and a degree of flexionis necessary to ensure that the pull or drag ofthe finger across the lightly lubricated tissues issmooth.

• Unlike the thumb, which makes a sweeptowards the fingertips whilst the rest of thehand remains relatively stationary, the wholehand will move as finger pressure is applied.Certainly some variation in the degree of anglebetween fingertip and skin is allowable duringa stroke and some slight variation in the degreeof ‘hooking’ of the finger is sometimes alsonecessary. However, the main motive force isapplied by pulling the slightly flexed middle orindex finger towards the practitioner with thepossibility of some lateral emphasis if needed.The treating finger should always be supportedby one of its neighboring digits.

Application of NMT

• It should be clear to the practitioner thatunderlying tissues being treated should bevisualized and, depending upon the presentingsymptoms and the area involved, any of anumber of procedures may be undertaken asthe contact digit(s) moves from one site toanother. There may be superficial stroking inthe direction of lymphatic flow, direct pressurealong the line of axis of stress fibers, deeperalternating ‘make and break’ stretching andpressure, traction on fascial tissue or sustainedcompression, as in trigger point treatment (seeINIT description later in the chapter, and alsoBox A1.1).

• As variable assessment pressure is beingapplied the practitioner needs to be constantlyaware of diagnostic information being receivedvia the contact digits, as this is what determinesthe variations in pressure, and the direction offorce, to be applied therapeutically.

• Ideally any changes in direction or degree ofapplied pressure should take place without any




The notes that follow have been adapted from Chapter12, Clinical applications of neuromuscular technique(Chaitow & DeLany 2000).

Assessment and treatment of the majority of cranialand facial muscles will be found in Chapter 9. Examplesare given below of neuromuscular treatment of some ofthe muscles of expression, the mimetic muscles andthose associated with the soft palate and tongue.

The muscles of expression (see Fig. 9.17)

Facial expression largely depends on mimetic musclesthat attach skin to skin, skin to underlying fascia or skinto bone.

Mimetic muscles can be divided into four regions thatwork to produce often unconscious muscular movementsthat represent the wide variety of emotions experiencedin life (Gray’s Anatomy 1999, Platzer 1992):

• scalp (epicranial)• eyelids (circumorbital and palpebral)• nasal• mouth (buccolabial).

Those mimetic muscles most involved in head and facialpain are discussed below. Orthodontic and cranialinfluences of the muscles of expression have yet to befully established. Latey (1996) has observed that he hasseldom seen anyone suffering from migraine headacheswho has a normal range of facial expression.

Mimetic muscles of the epicranium

The scalp is composed of five layers. The first three (skin,subcutaneous tissue and epicranius, with its aponeurosis)are considered a single layer since they remainconnected when torn or surgically reflected.

The deeper subaponeurotic areolar tissue allows thescalp to glide on the deepest layer, the pericranium. Theepicranial muscles express surprise, astonishment,attention and fright and are used when glancingupwards. When pulling from below, the frontalis candraw the scalp forward, as in worry, grief or sadness,often in combination with other brow muscles.

NMT of the muscles of the epicranium Thepractitioner sits at the head of the supine patient. Apillow may be placed under the head. Rotation of thehead will be necessary to reach the posterior aspect.

Transverse friction and small, circular massagetechniques may be applied to the entire cranial surfaceto soften the superficial fascia. Tender areas may betreated with combination friction or static pressure.Special attention should be applied to cranial suturelines, where undue tenderness may indicate a need forfurther cranial attention.

Direct manual release of fascial restrictions inoccipitofrontalis is suggested (see Ch. 9 for descriptions).Methods to release such restrictions can include NMT,massage methods, myofascial release and positionalrelease approaches. NMT can be assisted by an isometriccontraction of the muscle. A 7–10 second, strongly heldfrown will reduce hypertonicity and allow easier manualtreatment of the soft tissues.

Mimetic muscles of the circumorbital andpalpebral region

Orbicularis oculi and corrugator supercilii comprise themimetic muscles of the eye region (palpebral fissure).These are important for facial expression and also ocularreflexes. As with all mimetic muscles, they are innervatedby the facial nerve.

Orbicularis oculi is divided into three parts.

• The orbital portion of orbicularis oculi encircles theeye and lies on the body orbit.

• The palpebral portion lies directly on the upper andlower eyelids.

• The short, small fibers of the lacrimal portion crossthe lacrimal sac and attach to lacrimal crest.

Orbicularis oculi is responsible for closing the eyevoluntarily or reflexively, as in blinking. It also aids inreducing the amount of light entering the eye and hence is involved with squinting. Levator palpebraesuperioris antagonizes eye closure by elevating the upper eyelid.

Corrugator supercilii blends with the frontalis muscleand the orbicularis oculi and radiates into the skin of theeyebrows, drawing the brows toward the midline.

These two muscles create vertical furrows betweenthe brows that, over time, can become deeplyentrenched. Orbicularis oculi also produces radiatinglateral lines - ‘crow’s feet’ - and expresses worry orconcern, while corrugator supercilii produces expressionsassociated with thinking hard.

Box A1.1 Soft tissue treatment of mimetic, palatine and tongue muscles

Box continues



NMT for the palpebral region The eye regioncontains delicate tissues and should be treated gently.Care should be exercised to avoid stretching the skin ofthe eye region.

Flat palpation is used to press fingertip portions ofthe orbicularis oculi against the underlying bony orbit.Gentle static pressure or gentle transverse movementmay help assess the underlying muscle.

The corrugator supercilii is easily picked up near themidline between the brows and compressed between thethumb and side of the index finger (see Fig. A1.1). It canalso be rolled gently between the palpating digits. Thiscompression and rolling technique is applied at thumb-width intervals across the width of the brow and mayalso include fibers of the procerus, frontalis andorbicularis oculi, as well as corrugator supercilii.

Mimetic muscles of the nasal region

• Procerus arises from the facial aponeurosis over thelower nasal bone and nasal cartilage and attachesinto the skin of the forehead, between the eyebrows.It reduces glare and produces transverse wrinkles atthe bridge of the nose. Expressions associated withprocerus include menacing looks, frowns and deepconcentration.

• Nasalis consists of a transverse (compressor naris)portion, that attaches the maxilla to the bridge of thenose, and an alar (dilator naris) portion, that attachesthe maxilla to the skin on the nasal wing. The

transverse portion compresses the nasal aperturewhile the alar portion widens it, reducing the size ofthe nostril and producing a ‘desiring’ look.

• Depressor septi attaches the mobile portion of thenasal septum to the maxilla above the central incisortooth. It depresses the septum during constriction andmovement of the nostrils.

• Levator labii superioris alaeque nasi attaches the skinof the upper lip and nasal wing to the infraorbitalmargin. When it contracts, it enlarges the nostrils andelevates the nasal wing, producing transverse folds inthe skin on each side of the nose and a look ofdispleasure, such as when sniffing an unpleasant odor.

NMT for nasal region Procerus can be graspedbetween the fingers and thumb at the bridge of the nose.

Flat palpation and light friction may be used alongthe sides of the nose and spreading slightly laterally ontothe cheeks to treat the remaining nasal muscles. The twoindex fingers, very lightly placed, provide precisemyofascial release. The facial tissues are very delicateand anything other than light pressure iscontraindicated.

Mimetic muscles of the buccolabial region

Movements of the lips derive from a complex systemthat postures the lips and controls the shape of theorifice. Gray’s Anatomy (1999) details the followingmuscles of this area.

Box A1.1 Soft tissue treatment of mimetic, palatine and tongue muscles—continued

Figure A1.1 Compression and precisemyofascial release may soften deep verticalfurrows between the brows.



• Elevators, retractors and evertors of the upper lip:levator labii superioris alaeque nasi, levator labiisuperioris, zygomaticus major and minor, levatoranguli oris and risorius

• Depressors, retractors and evertors of the lower lip:depressor labii inferioris, depressor anguli oris andmentalis

• Compound sphincter: orbicularis oris, incisivussuperior and inferior

• Buccinator.

The buccolabial muscles are involved in eating, drinkingand speech, as well as emotional expressions such asreserve, laughing, crying, satisfaction, pleasure, self-confidence, sadness, perseverance, seriousness,doubt, indecision, disdain, irony, etc. (Gray’s Anatomy1999, Platzer 1992).

A number of these muscles converge into themodiolus just lateral to the buccal angle of the mouth.This can be palpated in an intraoral examination and isusually felt as a dense, mobile fibromuscular mass whichmay or may not be tender. This fan-shaped radiation ofmuscular fibers helps integrate facial activities of the lipsand oral fissure, cheeks and jaws, such as chewing,drinking, sucking, swallowing and modulations of variousvocal tones.

NMT for buccolabial region An intraoralexamination including the labial area will address themuscles in this region. The practitioner should wearprotective gloves. Precautions relating to latex allergyshould be adopted (NIOSH 1997).

The gloved index finger is placed inside the mouthand the thumb is placed on the outside (facial) surface.The tissue is compressed between the two digits as theinternal finger is slid against the external thumb whilemanipulating the tissue held between them. The treatingdigits progress at thumb-width intervals around themouth until all the tissues have been examined. Tenderspots or trigger points may be treated with staticpressure (Simons et al 1998).

Musculature of the soft palate

The soft palate is a mobile muscular flap that hangsdown from the hard palate with its posterior border freeand, when elevated, closes the passageway between thenasopharynx and the oropharynx. The uvula hangs fromthe posterior border and, when relaxed, rests on the rootof the tongue. The elevated uvula aids the tensor and

levator veli palatini muscles in sealing off thenasopharynx. Adjacent are the palatine tonsils and thesharp hamulus, around which the tensor veli palatiniturns to radiate horizontally into the palatineaponeurosis (see Fig. A1.2).

The palatine musculature includes levator and tensorveli palatini, palatoglossus, palatopharyngeus andmusculus uvula. Innervation to the soft palatemusculature is controversial (Gray’s Anatomy 1999),possibly including the vagus, trigeminal, mandibular,glossopharyngeal and facial nerves. These muscles areinvolved in swallowing and speech.

Levator veli palatini is a cylindrical muscle whichcourses from the petrous portion of the temporal bone,the carotid sheath and the inferior aspect of thecartilaginous part of the auditory tube to blend into thesoft palate and palatine aponeurosis. This muscle pullsthe soft palate upward and backward. It has little effecton the pharyngotympanic tube (Gray’s Anatomy 1999).

Tensor veli palatini is a thin, triangular muscleattaching to the root of the pterygoid process, the spineof the sphenoid bone and the membranous wall of thepharyngotympanic (auditory) tube. It wraps around thehamulus before attaching to the palatine aponeurosis,which it elevates during swallowing. Its primary role is toopen the entrance to the auditory tube, to equalize airpressure during swallowing (Clemente 1987).

Ear infections in young children and their relationshipwith tensor veli palatini hypertonicity deserve clinicalresearch. Such infections occur most frequently in youngchildren during the chronic sucking stage (thumbs,fingers, pacifiers, toys, nipple of the bottle or breast).

The paired uvulae muscles attach the uvula to thehard palate and soft palate. They radiate into the uvularmucosa, elevating and retracting to seal off thenasopharynx. The uvula may contain trigger points whichinduce hiccups (Simons et al 1998, Travell 1977).

NMT for soft palate The patient tilts the head intoextension and breathes through the mouth slowly orholds the breath to inhibit the gag reflex. A confidentbut not aggressive finger pressure is used to avoid atickling sensation which might cause gagging.

The gloved index finger is placed just lateral to themidline of the hard palate and glides posteriorly on thehard palate until it reaches the soft palate. No pressureshould be placed on the palatine bones or the vomer.

The finger is hooked into a ‘C’ shape as it sinks intothe soft palate posterior to the palatine bone and sweeps


Box continues



out to the lateral one-third of the soft palate. A backand forth medial/lateral movement of the finger, or static pressure, is applied into the lateral third of the soft palate, while pressing through the superficial tissues of the soft palate and onto thepalatini muscles.

Muscles of the tongue (see Fig. A1.2)

Extrinsic tongue muscles arise from outside the tongueto act upon it, while intrinsic muscles arise wholly within

it and have the primary task of changing the shape ofthe main body of the tongue (Leonhardt 1986).

The tongue muscles are innervated by the hypoglossalnerve (cranial nerve XII).

Extrinsic muscles of the tongue include the following.

• Hyoglossus, attaches the side of the tongue to thehyoid bone below, by vertical fibers which serve todepress the tongue.

• Genioglossus, runs from the geniotubercle (cephaladfrom geniohyoid) fanning posteriorly and upwardly to


Pterygoid hamulus

Pterygomandibular raphe

BuccinatorSuperior constrictor

Styloglossus

Stylopharyngeus

Genioglossus

Hyoglossus

Geniohyoid

Thyrohyoid membrane

Cricothyroid

Levator veli palatini

Tensor veli palatini

Rectus capitus lateralis

Superior oblique

Stylohyoid ligament

Transverse process of atlas

Inferior oblique

Vertebral artery

Anterior intertransverse

Transverse process of axis

Middle constrictor

Stylohyoid

Inferior constrictor

Figure A1.2 Muscles of the tongue, soft palate and styloid process (from Gray’s Anatomy 1995, with permission).


sudden release, or application, of force, thatmight potentially irritate the tissues andproduce pain or provoke a defensive response.

• Lief’s basic spinal treatment followed a setpattern, part of which is set out in Figures 9.10

and 9.11 (p. 267). The fact that the same patternis recommended to be followed at eachtreatment does not mean that the treatment isnecessarily the same – far from it. The patternprovides a framework, a useful starting and


attach to the hyoid bone, blending with the middlepharyngeal constrictor, attaching to the hyoglossalmembrane and the whole length of the ventralsurface of the tongue, from root to apex,intermingling with the intrinsic lingual muscles. Itpulls the tongue forward to protrude its tip from themouth.

• Styloglossus, anchors the tongue to the styloidprocess, near its tip, and to the styloid end of thestylomandibular ligament. Its fibers divide into alongitudinal portion, which merges with the inferiorlongitudinal muscle, and an oblique portion, whichoverlaps and crosses hyoglossus to decussate with it.It draws the tongue posteriorly and upwardly.

• Chondroglossus, ascends from the hyoid bone tomerge with the intrinsic musculature between thehyoglossus and genioglossus, assisting the hyoglossusin depressing the tongue.

• Palatoglossus, extends from the soft palate to the sideof the tongue and the dorsal surface and merges withthe transverse lingual muscle. It elevates the root ofthe tongue while approximating the palatoglossalarch, so closing the oral cavity from the oropharynx.

Intrinsic muscles of the tongue include the following.

• Superior longitudinal, bilaterally extends fromsubmucous tissue near the epiglottis, and from themedian lingual septum, to the lingual margins andapex of the tongue. It shortens the tongue and turnsthe tip and sides upward to make the dorsumconcave.

• Inferior longitudinal, extends from the lingual rootand the hyoid bone to the tip of the tongue, blendingwith styloglossus. It shortens the tongue and turnsthe tip and sides downward to make the dorsumconvex.

• Transverse lingual, extends from the median fibrousseptum to the submucous fibrous tissue at thetongue’s lingual margin. It narrows and elongates thetongue.

• Vertical lingual extends from the dorsal to the ventralaspects in the borders of the anterior tongue. Itmakes the tongue flatter and wider.

The tongue muscles can act alone or in pairs, and inendless combination. They provide the tongue withprecise movements and tremendous mobility, whichimpacts not only the acts of chewing and swallowing butalso speech.

Myofascial tissues are known to produce triggerpoints and trigger points are known to produce patternsof referral as well as to encourage dysfunction of co-ordinated movement of the muscles in which they arehoused (Simons et al 1998). The tongue muscles mightalso contain trigger points that produce pain insurrounding tissues, as well as being involved indysfunctional responses which interfere with swallowingor normal speech patterns. The tongue should beexamined and, if necessary, treated in these conditions aswell as in those involving voice dysfunction, elevatedhyoid bone or sore throat.

NMT for muscles of the tongue The tonguemuscles are most easily addressed by reaching across thebody to the opposite side of the tongue. Thepractitioner’s gloved index finger is placed on the lateralsurface, as far posteriorly as possible. The finger curlsinto a ‘C’ shape as it is slid forward the full length of thetongue. The curling action of the finger sinks it into theside of the tongue and penetrates the musculature moreeffectively than attempting to slide a straight finger.

The gliding, curling movement is repeated a numberof times. The finger is moved caudally at fingertip widthsand the process repeated as far caudally as possible.Special attention should be given to the most caudal,most posterolateral aspect of the tongue, where the longgliding strokes, previously applied, may become shorterand more precisely applied or static pressure may be used.

The tongue may also be gently tractioned forward andthe muscles stretched by grasping it firmly through aclean cloth. This stretch can be held for 30–60 secondsand the direction of tension changed by pulling thetongue to one side or the other.



ending point, but the degree of pressure (andtime) applied to the various areas of dysfunc-tion revealed varies, based always on whatinformation the palpating contacts are pickingup and the objectives required by the situation.This is what makes each treatment different,despite a similar grid being used to comb thetissues in each case.

• The areas of dysfunction should be recorded ona case card together with all relevant informationincluding diagnostic findings relating tomyofascial tissue changes, trigger points andreference zones, areas of sensitivity, restrictedmotion and so on.

What is working when the thumb applies NMT?

Consider which parts of the practitioner’s body/arm/hand will be involved with the variousaspects of the glide/stroke as delivered by thethumb (finger strokes involve completely differentmechanics).

• The transverse movement of the thumb is ahand or forearm effort.

• The relative straightness or rigidity of the lasttwo thumb segments is also a local muscularresponsibility.

• The vast majority of the energy imparted via the thumb results from transmission ofbody weight through the straight arm into thethumb.

• Any increase in pressure can be speedilyachieved by simple weight transfer, from backtowards front foot, together with a slight ‘lean’onto the thumb from the shoulders.

• A lessening of imparted pressure is achieved byreversing this body movement.

(See Chapter 9, Lief’s NMT application to thecranial base area, p. 316, for a detailed descriptionof individual strokes by the thumb through thesetissues. See Figure 9.59A–E.)

MUSCLE ENERGY TECHNIQUE: SUMMARYOF VARIATIONS

(DiGiovanna 1991, Greenman 1989, Janda 1989,Lewit 1986, Liebenson 1990, Mitchell 1967, Travell& Simons 1992)

1. Isometric contraction – using reciprocalinhibition (RI)

Indications— Relaxing muscular spasm or contraction— Mobilizing restricted joints— Preparing joint for manipulation.

Contraction starting point For acute muscle orany joint problem, commence just short of, or at,the ‘easy’ restriction barrier.

Modus operandi An isometric contraction isintroduced involving the antagonists to affectedmuscle(s), so obliging shortened muscles to relaxvia reciprocal inhibition. The patient is attemptingto push through the barrier of restriction againstthe practitioner’s precisely matched counterforce.

Forces The practitioner’s and patient’s forces arematched. Initial effort involves approximately20% of the patient’s strength with an increase tono more than 30–40% on subsequent contractions.Increasing the duration of the contraction (up to 15 seconds) may be more effective than anyincrease in force.

Duration of contraction Initially 7–10 seconds,increasing to up to 15 seconds in subsequentcontractions, if greater effect required.

Action following contraction Area (muscle/joint) is taken to its new restriction barrier withoutstretch after ensuring complete relaxation. Performmovement to new barrier on an exhalation.

Repetitions Repeat two to three times or until nofurther gain in range of motion is possible. Nostretching is introduced where tissues are acutelysensitive or have been recently traumatized (3 weeks or so).



2. Isometric contraction – using postisometric(PIR) relaxation (without stretching)

Note: This approach is ideal for acute settings,involving recent trauma or severe pain.

Indications— Relaxing muscular spasm or contraction— Mobilizing restricted joints— Preparing joint for manipulation.

Contraction starting point At or just short ofresistance barrier.

Modus operandi The affected muscles (agonists)are used in the isometric contraction, therefore theshortened muscles subsequently relax via post-isometric relaxation. The practitioner is attemptingto push through the barrier of restriction againstthe patient’s precisely matched countereffort.

Forces The practitioner’s and patient’s forces arematched. Initial effort involves approximately15–20% of the patient’s strength, increasing to nomore than 30–40% on subsequent contractions.Increase of the duration of the contraction (up to15 seconds) may be more effective than anyincrease in force.


Action following contraction Area (muscle/joint)is taken to its new restriction barrier withoutstretch after ensuring that the patient hascompletely relaxed. Perform movement to newbarrier on an exhalation.

Repetitions Repeat three to five times or until nofurther gain in range of motion is possible. Holdstretches for not less than 30 seconds.

3. Isometric contraction – using postisometricrelaxation (with stretching, also known aspostfacilitation stretching)

Note: This approach is ideal for chronic settings.

Indications Stretching restricted, fibrotic, con-tracted, soft tissues (fascia, muscle).

Contraction starting point Short of resistancebarrier, in mid-range.

Modus operandi Affected muscles (agonists) areused in the isometric contraction, therefore theshortened muscles subsequently relax via post-isometric relaxation (PIR), allowing an easier stretchto be performed. The practitioner is attempting topush through the barrier of restriction against thepatient’s precisely matched countereffort.

Forces The practitioner’s and patient’s forces arematched. Initial effort involves approximately30% of the patient’s strength; an increase to nomore than 40–50% on subsequent contractions is appropriate. Increase of the duration of thecontraction – up to 15 seconds – may be moreeffective than any increase in force.


Action following contraction Rest period of 5–10 seconds to ensure complete relaxation beforestretch is useful. On an exhalation, the area(muscle) is taken to its new restriction barrier anda small degree beyond, painlessly, and held in thisposition for at least 10 seconds. The patientshould, if possible, help to move to and throughthe barrier, effectively further inhibiting thestructure being stretched and retarding thelikelihood of a myotatic stretch reflex occurring.

Repetitions Repeat three to five times or until nofurther gain in range of motion is possible. Holdstretches for not less than 30 seconds.

4. Isotonic concentric contraction

Indications Toning weakened musculature.

Contraction starting point In a mid-range easyposition.

Modus operandi The contracting muscle isallowed to do so, with some (constant) resistancefrom the practitioner.

Forces The patient’s effort overcomes that of thepractitioner, since the patient’s force is greaterthan practitioner resistance. The patient usesmaximal effort available but force is built slowlynot via sudden effort. The practitioner maintains aconstant degree of resistance.

Muscle energy technique: summary of variations 389


Duration 3–4 seconds.

Repetitions Repeat five to seven times or more ifappropriate.

5. Rapid isotonic eccentric contraction (isolytic)

Indications Stretching tight fibrotic musculature.

Contraction starting point A little short ofrestriction barrier.

Modus operandi The muscle to be stretched iscontracted and is prevented from doing so bysuperior practitioner effort, so that the contractionis overcome and reversed and the contractingmuscle is stretched. Origin and insertion do notapproximate. Muscle is stretched to, or as close aspossible to, full physiological resting length.

Forces The practitioner’s force is greater than thepatient’s. Less than maximal patient’s force isemployed at first. Subsequent contractions buildtowards this, if discomfort is not excessive.

Duration of contraction 2–4 seconds.

Repetitions Repeat two to three times ifdiscomfort is not excessive.

Avoid using isolytic contractions on head/neckmuscles or at all if patient is frail, very painsensitive or osteoporotic. Isolytic contractions ofthis sort (rapid isotonic eccentric stretch) createmicrotrauma and will result in soreness forseveral days.

6. Slow eccentric isotonic contraction (SEIC)

Indications Toning inhibited antagonists whilepreparing agonists for subsequent stretching

Contraction starting point At restriction barrier.

Modus operandi The muscle to be stretched at the end of the procedure is taken to itscomfortable end of range and actively held thereby the patient’s effort. The practitioner usessuperior effort to slowly overcome this attempt toremain at the barrier and returns the structure

(e.g. arm, leg, etc.) to its neutral position. Thiseffectively tones the muscles that are being slowlystretched, while inhibiting their short/tightantagonists. The short/tight structures can thenbe stretched as in the example of RI and PIR givenabove (methods 2 and 3).

Forces The practitioner’s force is greater than thepatient’s. Less than maximal patient’s force isemployed at first. Subsequent contractions buildtowards this, if discomfort is not excessive, and ifthe practitioner can overcome the resistance in acontrolled manner (i.e. no jerking or undue efforton either part).

Duration of contraction 5–10 seconds.

Repetitions Repeat two to three times for bestresults. Hold stretches for not less than 30 seconds.

7. Isokinetic (combined isotonic and isometriccontractions)

Indications— Toning weakened musculature— Building strength in all muscles involved in

particular joint function— Training and balancing effect on muscle fibers.

Starting point of contraction Easy mid-rangeposition.

Modus operandi The patient resists withmoderate and variable effort at first, progressingto maximal effort subsequently, as the practitionerputs joint rapidly through as full a range ofmovements as possible. This approach differsfrom a simple isotonic exercise as whole ranges ofmotion rather than single motions are involvedand because resistance varies, progressivelyincreasing as the procedure progresses.

Forces The practitioner’s force overcomes thepatient’s effort to prevent movement. First move-ments (taking an ankle, say, into all its directionsof motion) involve moderate force, progressing tofull force subsequently. An alternative is to havethe practitioner (or machine) resist the patient’seffort to make all the movements.

Duration of contraction Up to 4 seconds.

Repetitions Repeat two to four times.


! CAUTION


Important notes on assessments and use of MET

1. When the term ‘restriction barrier’ is used inrelation to soft tissue structures it is meant toindicate the first signs of resistance (aspalpated by sense of ‘bind’ or sense of effortrequired to move the area or by visual or otherpalpable evidence), not the greatest possiblerange of movement available.

2. The shorthand reference of ‘acute’ and ‘chronic’is commonly used to alert the reader to thevariations in methodology which these variantscall for, especially in terms of the startingposition for contractions (acute – and all MET joint treatment – starts at the barrier,chronic short of the barrier) and the need to take the area to (acute) or through (chronic) the resistance barrier subsequent tothe contraction.

3. Assistance from the patient is valuable asmovement is made to or through a barrier,providing the patient can be educated to gentleco-operation and not to use excessive effort.

4. In most MET treatment guidelines the methoddescribed involves isometric contraction of the agonist(s), the muscle(s) which requirestretching. There also exists the possibility ofusing the antagonists to achieve reciprocalinhibition (RI) before initiating stretch ormovement to a new barrier, an approachsuggested if there is pain on use of agonist or ifprior trauma to the agonist has occurred.

5. There should be no pain experienced duringapplication of MET although mild discomfort(stretching) is acceptable.

6. The methods recommended provide a soundbasis for the application of MET to specificmuscles and areas. By developing the skillswith which to apply the methods, as described,a repertoire of techniques can be acquiredoffering a wide base of choices appropriate innumerous clinical settings.

7. Breathing co-operation can and should be usedas part of the methodology of MET. Basically, ifappropriate (the patient is co-operative andcapable of following instructions), the patient

should inhale as they slowly build up anisometric contraction, hold the breath for the7–10 second contraction and release the breathon slowly ceasing the contraction; they shouldbe asked to inhale and exhale fully once more following cessation of all effort as theyare instructed to ‘let go completely’. Dur-ing this last exhalation the new barrier isengaged or the barrier is passed as the muscleis stretched. A note to ‘use appropriate breath-ing’, or some variation on it, will be found in the text describing various METapplications.

8. Various eye movements are sometimesadvocated during contractions and stretches.

9. There are times when ‘co-contraction’ is useful,involving contraction of both the agonist andthe antagonist. Studies have shown that thisapproach is particularly useful in treatment ofthe hamstrings, when both these and thequadriceps are isometrically contracted priorto stretch (Moore et al 1980).

POSITIONAL RELEASE TECHNIQUES (PRT)(INCLUDING STRAIN/COUNTERSTRAIN)(Chaitow 2002)

There are many different methods involving thepositioning of an area, or the whole body, in sucha way as to evoke a physiological response whichhelps to resolve musculoskeletal dysfunction. Themeans whereby the beneficial changes occur seemto involve a combination of neurological andcirculatory changes which occur when a distressedarea is placed in its most comfortable, its most‘easy’, most pain-free position. The impetus towardsthe use of this most basic of treatment methods ina coherent rather than a hit-and-miss manner liesin the work of Laurence Jones, who developed anapproach to somatic dysfunction which he termed‘strain and counterstrain’ (SCS) (Jones 1981).Walther (1988) describes the moment of discoveryin these words.

Jones’s initial observation of the efficacy ofcounterstrain was with a patient who wasunresponsive to treatment. The patient had beenunable to sleep because of pain. Jones attempted

Positional release techniques (PRT) (including strain/counterstrain) 391


to find a comfortable position for the patient to aidhim in sleeping. After twenty minutes of trialand error, a position was finally achieved in whichthe patient’s pain was relieved. Leaving thepatient in this position for a short time, Jones wasastonished when the patient came out of theposition and was able to stand comfortably erect.The relief of pain was lasting and the patientmade an uneventful recovery.

The position of ‘ease’ which Jones found for thispatient was an exaggeration of the position inwhich spasm was holding him, which providedJones with an insight into the mechanisms involved.Since Jones first made his valuable observationthat a position which exaggerated a patient’sdistortion could allow a release of spasm andhypertonicity, many variations on this basic themehave emerged, some building logically on thatfirst insight with others moving in new directions.

Common basis

The commonality of all of these approaches is thatthey move the patient or the affected tissues awayfrom any resistance barriers and towardspositions of comfort. The shorthand terms usedfor these two extremes are ‘bind’ and ‘ease’, termswhich anyone who has handled the human bodywill recognize as being extremely apt.

The need for the many variations to be under-stood should be obvious. Different clinical settingsrequire that a variety of therapeutic approaches beavailable. Jones’s approach requires verbal feed-back from the patient as to the degree of discomfortin a ‘tender’ point being used as a monitor by thepractitioner who is palpating/compressing it, asan attempt is made to find a position of ease.

One can imagine a situation in which the use ofJones’s ‘tender points as a monitor’ methodwould be inappropriate (loss of the ability tocommunicate verbally or someone too young toreport levels of discomfort). In such cases there isa need for a method that allows achievement ofthe same ends, without verbal communication.This is possible using either ‘functional’ approachesor ‘facilitated positional release’ methods, involvingfinding a position of maximum ease by means ofpalpation alone, assessing for a state of ‘ease’ inthe tissues.

As we examine a number of the variations onthe theme of PRT, release by placing the patient, orarea, into ‘ease’, the variety of clinical andtherapeutic potentials for the use of this approachwill become clearer.

It is important to note that if positional releasemethods are being applied to chronically fibrosedtissues, a reduction in hypertonicity may result,but a reduction in fibrosis is not possible. Painrelief or improved mobility might therefore beonly temporary in such cases.

1. Exaggeration of distortion (an element of SCSmethodology) Consider the example of anindividual bent forward in psoas spasm/’lumbago’. The patient is in considerablediscomfort or pain, posturally distorted intoflexion together with rotation and sidebending.

Any attempt to straighten towards a morephysiologically normal posture would be metby increased pain. Engaging the barrier ofresistance would therefore not be an ideal firstoption.

However, moving the area away from therestriction barrier would not usually be aproblem for such an individual. The positionrequired to find ‘ease’ for someone in this statenormally involves painlessly increasing thedegree of distortion displayed, placing theperson (in the case of the example given) intosome variation based on forward bending,until pain is found to reduce or resolve. After60–90 seconds in this position of ease, a slowreturn to neutral would be carried out andcommonly, in practice, the patient will besomewhat, or completely, relieved of pain andspasm.

2. Replication of position of strain (an elementof SCS methodology) Take the example ofsomeone who is bending to lift a load when anemergency stabilization is required and strainresults (the person slips or the load shifts,perhaps). The patient could be locked into thesame position of ‘lumbago-like’ distortion as inexample 1, above.

If, as SCS suggests, the position of easeequals the position of strain, then the patientneeds to be taken back into flexion, in slowmotion, until tenderness vanishes from the



monitored tender point and/or a sense of‘ease’ is perceived in the previously hyper-tonic, shortened tissues. Adding small ‘fine-tuning’ positioning to the initial position ofease, achieved by flexion, usually results in a maximum reduction in pain. This positionis held for 60–90 seconds before a slow returnto neutral is allowed, at which time, as inexample 1, a partial or total resolution ofhypertonicity, spasm and pain should beexperienced. The position in which the strain took place is likely to be similar to the position of exaggeration of distortion, as inexample 1.

These two elements of SCS are of limitedclinical value and are described as examplesonly, since it is not every patient who can describe precisely in which way theirsymptoms developed. Nor is obvious spasm,such as torticollis or acute anteflexion spasm(‘lumbago’), the norm. Ways other than‘exaggeration of distortion’ or ‘replication ofposition of strain’ are therefore needed in orderto be able to identify probable positions of ease.

3. Using Jones’s tender points as monitors(D’Ambrogio & Roth 1997, Jones 1981) Overmany years of clinical experience Jonescompiled lists of specific tender point areas,relating to every imaginable strain, of most ofthe joints and muscles of the body. These arehis ‘proven’ (by clinical experience) points.Tender points are usually found in tissueswhich were in a shortened state at the time ofstrain, rather than those which were stretched.Tender points, other than those identified byJones and his colleagues, are periodicallyreported on in the osteopathic literature – forexample, sacral foramen points relating tosacroiliac strains (Ramirez et al 1989).

Jones and his followers provided strictguidelines for achieving ease in any tenderpoints which are being palpated. The positionof ease usually involving a ‘folding’ orcrowding of the tissues in which the tenderpoint lies. This method involves maintainingpressure on the monitored tender point, orperiodically probing it, as a position isachieved in which:

• there is no additional pain in whatever areais symptomatic

• pain in the monitored point has reduced byat least 75%.

The position of ease is held for an appropriatelength of time (90 seconds according to Jones;however, there are variations suggested for thelength of time required in the position of ease,as will be explained).

In the example of the person with acute lowback pain who is locked in flexion, the tenderpoint will be located on the anterior surface ofthe abdomen, in the muscle structures whichwere shortened at the time of strain (when thepatient was in flexion). The position thatremoves tenderness from this point will usuallyrequire flexion and probably some fine-tuninginvolving rotation and/or sidebending.

If there is a problem with Jones’s formulaicapproach it is that, while he is frequentlycorrect as to the position of ease recommendedfor particular points, the mechanics of theparticular strain with which the practitioner isconfronted may not coincide with Jones’sguidelines. Any practitioner who relies solelyon Jones’s ‘menus’, or formulae, could find itdifficult to handle a situation in which theprescription failed to produce the desiredresults. Reliance on Jones’s menu of points andpositions can therefore lead to the practitionerbecoming dependent on them and it issuggested that development of palpationskills, and other variations of Jones’s originalobservations, offers a more rounded approachfor dealing with strain and pain.

Fortunately Goodheart (and others) hasoffered less rigid frameworks for usingpositional release.

4. Goodheart’s approach (Goodheart 1984, Walther1988) George Goodheart (the developer of‘applied kinesiology’ – see Chapter 5) hasdescribed an almost universally applicableformula which relies more on the individualfeatures displayed by the patient and less onrigid formulae, as used in Jones’s approach.

Goodheart suggests that a suitable tenderpoint be sought in the tissues opposite those‘working’ (active) when pain or restriction is



noted. If pain/restriction is reported/apparenton any given movement, muscles antagonisticto those operating at the time pain is noted willbe those housing the tender point(s). Thus, forexample, pain (wherever it is felt) whichoccurs when the neck is being turned to the leftwill indicate a tender point located in themuscles that turn the head to the right.

In examples 1 and 2, of a person locked inforward bending with acute pain and spasm, ifGoodheart’s approach is applied, pain andrestriction would be experienced as the personstraightened up (moved into extension) fromtheir position of enforced flexion.

This action (straightening up) would usuallycause pain in the back but, irrespective ofwhere the pain is noted, a tender point wouldbe sought (and subsequently treated by beingtaken to a state of ease as in the Strain/counterstrain described above) in the musclesantagonistic to those working when pain wasexperienced – i.e. it would lie in the flexormuscles (possibly psoas) in this example.

Note It is important to emphasize this factor,that tender points which are intended to be usedas ‘monitors’ during the positioning phase are notsought in the muscles antagonistic to those wherepain is noted, but in the muscles that antagonizethose which are actively moving the patient, orarea, when pain or restriction is noted.

5. Functional technique (Bowles 1981, Hoover1969) Osteopathic functional technique relieson a reduction in palpated tone in stressed(hypertonic/spasm) tissues as the body (or part)is being positioned, or fine-tuned, in relation toall available directions of movement, in a givenregion. One hand palpates the affected tissues(molded to them, without invasive pressure).This is described as the ‘listening’ hand, sinceit assesses changes in tone as the practitioner’sother hand guides the patient, or part, througha sequence of positions which are aimed atenhancing ‘ease’ and reducing ‘bind’.

A sequence is carried out involving differentdirections of movement (e.g. flexion/extension,rotation right and left, sidebending right andleft, etc.) with each movement starting at thepoint of maximum ease, as revealed by the

previous evaluation, or combined point of easefollowing a number of previous evaluations. Inthis way one position of ease is ‘stacked’ onanother, until all movements have beenassessed for ease.

Were the same fictional patient with the lowback problem, as previously discussed, beingtreated using functional technique, the tensetissues in the low back would be the ones beingpalpated. Following a sequence involvingflexion/extension, sidebending and rotating ineach direction, translation right and left, trans-lation anterior and posterior and compression/distraction – so involving all availabledirections of movement of the area – a positionof maximum ease would be achieved afterwhich (if the position were held for 30–90seconds) a release of hypertonicity and reductionin pain should result.

The precise sequence in which the variousdirections of movement are evaluated seems tobe irrelevant, as long as all possibilities areincluded.

Theoretically (and often in practice) theposition of palpated maximum ease (reducedtone) in the distressed tissues should cor-respond with the position which would havebeen found were pain being used as a guide, asin either Jones’s or Goodheart’s approach, orusing the more basic ‘exaggeration of distortion’or ‘replication of position of strain’ formulae.

6. Any painful point as a starting place for SCS(McPartland & Zigler 1993) All areas whichpalpate as painful are responding to, or areassociated with, some degree of imbalance,dysfunction, sensitization or reflexive activity,which may involve acute or chronic strain.Jones identified the probable positions oftender points relating to particular strainpositions. It makes just as much sense to workthe other way around, by identifying the strainpattern associated with any identified painpoint. It is useful to consider that any painfulpoint/area located during soft tissue evalu-ation can be treated by positional release,whether the strain that produced the dysfunc-tion is known or not and whether the problemis acute or chronic.



This approach, of being able to treat anypainful tissue using positional release, is validwhether the pain is being monitored via verbalfeedback from the patient (using reducinglevels of pain in the palpated point as a guide)or a functional approach is adopted, assessingfor maximal reduction in tone in the tissues.The recommended time for holding theposition of maximum ease is 60–90 seconds.

Experience, and simple logic, suggest that the response to positional release of achronically fibrosed area will be less dramaticthan from tissues held in simple spasm orhypertonicity. Nevertheless, even in chronicsettings, a degree of ‘release’ can be anticipated,allowing for easier access to the deeperfibrosis.

7. Integrated neuromuscular inhibition technique(INIT) (Chaitow 1994) INIT involves usingthe position of ease as part of a sequence whichcommences with the location of a tender/pain/trigger point, followed by application ofischemic compression (optional – avoided ifpain is too intense or the patient too sensitive)followed by the introduction of positionalrelease. After an appropriate length of time,during which the tissues are held in ‘ease’, thepatient introduces an isometric contractioninto the affected tissues for 7–10 seconds, afterwhich these are stretched to attempt to restorenormal resting length to the tissues.

Method A trigger point should initially betreated by direct inhibitory (‘ischemic’) pressure(sustained or intermittent) until a change inperceived pain is reported.

Pressure is continued as the tissues in which thetrigger point lies are positioned in such a way asto reduce the pain (entirely or at least by approxi-mately 70%). When this has been achieved themost (dis)stressed fibers surrounding the triggerpoint will have been placed into a position of ease.

Following a period of 20–30 seconds of thisposition of ease and inhibitory pressure (constantor intermittent), the patient should be asked tointroduce an isometric contraction into thesetissues and to hold this for 7–10 seconds,involving the precise fibers which had beenrepositioned to obtain the positional release.

The effect of this would be to produce(following the contraction) a reduction in tone inthese tissues. The hypertonic or fibrotic tissuesshould then be gently stretched, as in any muscleenergy procedure, so that the specifically targetedfibers are lengthened.

SCS rules of treatment

The following ‘rules’ are based on clinicalexperience and should be borne in mind whenusing positional release methods (SCS, etc.) intreating pain and dysfunction, especially wherethe patient is fatigued, sensitive and/or distressed(McPartland & Zigler 1993).

• Never treat more than five ‘tender’ points atany one session and treat fewer than this insensitive individuals.

• Forewarn patients that, just as in any otherform of bodywork which produces alteredfunction, a period of physiological adaptationis inevitable and that there will therefore be a‘reaction’ on the day(s) following even thisextremely light form of treatment. Soreness andstiffness are therefore to be anticipated.

• If there are multiple tender points – as isinevitable in fibromyalgia – select those mostproximal and most medial for primary attention;that is, those closest to the head and the centerof the body rather than distal and lateral painpoints.

• Of these tender points, select those that aremost painful for initial attention/treatment.

• If self-treatment of painful and restricted areasis advised – and it should be if at all possible –apprise the patient of these rules (i.e. only a fewpain points on any day to be given attention, toexpect a ‘reaction’, to select the most painfulpoints and those closest to the head and thecenter of the body).

The guidelines which should therefore beremembered and applied are:

• locate and palpate the appropriate tender pointor area of hypertonicity

• use minimal force



• use minimal monitoring pressure• achieve maximum ease/comfort/relaxation of

tissues• produce no additional pain anywhere else.

These elements need to be kept in mind as pos-itional release/SCS methods are learned and aremajor points of emphasis in programs which teachit (Jones 1981). The general guidelines which Jonesgives for relief of the dysfunction with which suchtender points are related involve directing themovement of these tissues towards ease, whichcommonly involves the following elements.

• For tender points on the anterior surface of thebody, flexion, sidebending and rotation shouldbe towards the palpated point, followed byfine-tuning to reduce sensitivity by at least 70%.

• For tender points on the posterior surface of thebody, extension, sidebending and rotation shouldbe away from the palpated point, followed byfine-tuning to reduce sensitivity by 70%.

• The closer the tender point is to the midline, theless sidebending and rotation should berequired and the further from the midline, themore sidebending and rotation should berequired, in order to effect ease and comfort inthe tender point (without any additional painor discomfort being produced anywhere else).

• Sidebending when trying to find a position ofease often needs to be away from the side of thepalpated pain point, especially in relation totender points found on the posterior aspect ofthe body.

PRT: the cranial dimension

• The treatment of tender points on the craniumhas been described in Chapter 10.

• Many cranial methods involve functional tech-nique concepts (e.g. exaggeration of distortion).

• All PRT methods can be safely used on softtissues attaching to the cranium, even in acutesettings.

• Upledger’s release of ‘energy cysts’, as describedin Chapter 10 (p. 326), incorporates positionalrelease methods.

• Apparently ‘direct’ approaches such as the V-spread (see Exercise 7.6, Ch. 7) might actuallyinvolve PRT mechanisms, by virtue of aslackening of internal fascial structures (e.g.tentorium cerebelli, falx cerebri) via thesustained light pressure involved.

MYOFASCIAL RELEASE (MFR)TECHNIQUES (Barnes 1996, Shea 1993)

John Barnes writes: ‘Studies suggest that fascia, anembryological tissue, reorganizes along the linesof tension imposed on the body, adding support tomisalignment and contracting to protect tissuesfrom further trauma’ (Twomey & Taylor 1982).Having evaluated where a restriction area exists,MFR technique calls for a sustained pressure (gentleusually) that engages the elastic component of theelastico-collagenous complex, stretching this untilit ceases releasing. This barrier is held until releaserecommences as a result of what is known as the‘viscous flow phenomenon’ in which a slowlyapplied load (pressure) causes the viscous mediumto flow to a greater extent than would be allowedby rapidly applied pressure. As fascial tissuesdistort in response to pressure, the process isknown by the short-hand term ‘creep’. Hysteresisis the process of heat and energy loss by thetissues as they deform (Dorlands medical directory1985).

Mark Barnes (1997) describes the simplest MFRtreatment process as follows.

Myofascial release is a hands-on soft tissuetechnique that facilitates a stretch into therestricted fascia. A sustained pressure is appliedinto the tissue barrier; after 90 to 120 seconds thetissue will undergo histological length changesallowing the first release to be felt. The therapistfollows the release into a new tissue barrier andholds. After a few releases the tissues will becomesofter and more pliable.

Shea (1993) explains this phenomenon.

The components of connective tissue (fascia) arelong thin flexible filaments of collagen surroundedby ground substance. The ground substance iscomposed of 30%–40% glycoaminoglycans(GAG) and 60%–70% water. Together GAG and



water form a gel … which functions as alubricant as well as to maintain space (criticalfiber distance) between collagen fibers. Anydehydration of the ground substance will decreasethe free gliding of the collagen fibers. Applyingpressure to any crystalline lattice increases itselectrical potential, attracting water molecules,thus hydrating the area. This is the piezoelectriceffect of manual connective tissue therapy.

By applying direct pressure of the appropriatedegree, at the correct angle (angle and force needto be suitable for the particular release required), aslow lengthening of restricted tissue occurs.

A number of different approaches are used inachieving this (note that it bears a strongresemblance, in parts, to the methodology of Lief’sNMT as described above).

• A pressure is applied to restricted myofasciausing a ‘curved’ contact and direction ofpressure in an attempt to glide, or slide, againstthe restriction barrier.

• The patient may be asked to assist by means ofbreathing tactics or moving the area in a way which enhances the release, based onpractitioner instructions.

• As softening occurs the direction of pressure isreassessed and gradually applied to movetowards a new restriction barrier.

• In using patient assistance single directions andsmall, slowly applied degrees of effort arecalled for initially until you are sure of what itis you want of the patient.

MFR technique is used to improve movementpotentials, reduce restrictions, release spasm, easepain and to restore normal function to previouslydysfunctional tissues.

CONCLUSION

The range of soft tissue methods available to treatsoft tissue dysfunction associated with thecranium is no less varied than for other parts ofthe body. This chapter has attempted to provide abasic introduction to some of the most widelyused methods and their rationale. There are othersoft tissue approaches, as well as numerous othervariations deriving from NMT, MET, PRT andMFR, that have not been described. What is of themost importance is that skills be acquired that lieoutside basic cranial manipulation methodology,to enable the practitioner to encourage normaliz-ation of the soft tissues that attach to the cranium,as part of an integrated and comprehensiveapproach to treatment.

References 397

REFERENCES

Barnes J 1996 Myofascial release in treatment of thoracicoutlet syndrome. Journal of Bodywork and MovementTherapies 1(1): 53–57

Bowles C 1981 Functional technique – a modern perspective.Journal of the American Osteopathic Association 80(3):326–331

Chaitow L 1992 Soft tissue manipulation. Healing ArtsPress, Vermont

Chaitow L 1994 Integrated neuromuscular inhibitiontechnique. British Journal of Osteopathy 13: 17–20

Chaitow L 2002 Positional release techniques, 2nd edn.Churchill Livingstone, Edinburgh

Chaitow L 2003 Modern neuromuscular techniques, 2ndedn. Churchill Livingstone, Edinburgh

Chaitow L, DeLany J 2000 Clinical applications of neuro-muscular technique. Churchill Livingstone, Edinburgh

Clemente C 1987 Anatomy: a regional atlas of the humanbody, 3rd edn. Urban and Schwarzenberg, Baltimore, MD

D’Ambrogio K, Roth G 1997 Positional release therapy.Mosby, St Louis, MO

DiGiovanna E 1991 Osteopathic diagnosis and treatment.Lippincott, Philadelphia, PA

Dorlands medical directory 1985, 26th edn. WB Saunders,Philadelphia, PA

Dvorak J, Dvorak V 1984 Manual medicine: diagnostics.Georg Thieme Verlag, New York

Goodheart G 1984 Applied kinesiology. Workshopprocedure manual, 21st edn. Privately published, Detroit, IL

Gray’s Anatomy 1995, 38th edn. Churchill Livingstone,Edinburgh

Greenman P 1989 Principles of manual medicine. Williamsand Wilkins, Baltimore, MD

Hoover H 1969 Collected papers. Academy of AppliedOsteopathy Year Book, Colorado Springs

Janda V 1989 Muscle function testing. Butterworths, London


Jones L 1981 Strain and counterstrain. Academy of AppliedOsteopathy, Colorado Springs

Latey P 1996 Feelings, muscles and movement. Journal ofBodywork and Movement Therapies 1(1): 44–52

Leonhardt H 1986 Color atlas and textbook of humananatomy: vol. 2, internal organs, 3rd edn. Georg Thieme,Stuttgart

Lewit K 1986 Muscular patterns in thoraco-lumbar lesions.Manual Medicine 2: 105

Liebenson C 1990 Active muscular relaxation techniques,parts 1 and 2. Journal of Manipulative and PhysiologicalTherapeutics 12(6): 446–451 and 13(1): 2–6

McPartland JM, Zigler M 1993 Strain-counterstrain coursesyllabus, 2nd edn. St Lawrence Institute of HigherLearning, East Lansing

Mitchell F Snr 1967 Motion discordance. Yearbook of theAcademy of Applied Osteopathy 15, Carmel, CA

Moore M et al 1980 Electromyographic investigation manualof muscle stretching techniques. Medicine and Science inSports and Exercise 12: 322–329

NIOSH (National Institute for Occupational Safety andHealth) 1997 Preventing allergic reactions to naturalrubber latex [in USA call 800-365-4674]

Platzer W 1992 Color atlas/text of human anatomy: vol. 1,locomotor system, 4th edn. Georg Thieme, Stuttgart

Ramirez M, Hamen J, Worth L 1989 Low back pain –diagnosis by six newly discovered sacral tender pointsand treatment with counterstrain technique. Journal ofthe American Osteopathic Association 89(7): 905–913

Rich G 2002 Massage therapy: the evidence for practice.Mosby, Edinburgh

Shea M 1993 Myofascial release – a manual for the spineand extremities. Shea Educational Group, Juno Beach, FL

Simons D, Travell J, Simons L 1998 Myofascial pain anddysfunction: the trigger point manual, vol. 1, 2nd edn.Williams and Wilkins, Baltimore, MD

Travell J 1977 A trigger point for hiccup. Journal of theAmerican Osteopathic Association 77: 308–312

Travell J, Simons D 1992 Myofascial pain and dysfunction,vol. 2. Williams and Wilkins, Baltimore, MD

Twomey L, Taylor J 1982 Flexion, creep, dysfunction andhysteresis in the lumbar vertebral column. Spine 7(2):116–122

Walther D 1988 Applied kinesiology synopsis. Systems DC,Pueblo, CO



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