Sie sind auf Seite 1von 269

POSITIONAL

RELEASE
ThERAPY
Assessmenr&r;-eannenr
of Musculoskeletal
Dys/unction
POSITIONALRELEASE
TiHER
1- APY Musculoskeletal Dysfunction
Assessment&freatment of

Kerry]' D'Arnbrogio, B.Se., P.T George B. Roth, B.Se., D.C., N.D.


PresIdent, Therapeutic ystems, Inc. Faculty, Department of Post-graduate and
Sarasota, Florida; Continuing Education
Faculty, Dialogues in Contempornry Rehabilitation Canadian Memorial Chiropractic College;
Hartford, Connecricucj Director, Wellness Institute
Faculty, Northeast eminar.; Toronto, Canada;
East Hampstead, New Hampshire; President, Wellness Systems, Inc.
Director of Manual Thernpy, Upledger Insoitu,e Caledon, Canada;
West Palm Beach, Florida Industrial Injury Prevention Consulcant

wid... illustrations by with phocographs by


] eanne Robertson Stuart Hal/Jerin
an d Matthew Wiley

with 256 illustrations


with 342 photographs

T Mosby
SI lOUIS Baltimore Boslon Carlsbad Chicago Naples New York Philadelphia Portland

london Madrid Meltico City Singapore Syrlney Tok.yo Toronto Wiesbaden


.,. A Times Mirror
Company

.f1 \loshy
Vice President and Publisher: Don L1dig
Executive Editor: Martha Sasser
Associate Develo/>mental Editor: Amy Dubm
Develo/nnental Editor: Kellie White
Project Manager: Dana Peick
Project S/>eciaList: Cathenne Albright
Designer: Amy Buxton
Manufacturing Manager: Betty Rlchmoml
COtler Art: Leonardo Da Vinci

Copy right 1997 by Mosby-Year Book, [nco


A Mosby unprmt of Mmby, Inc.

All rights reserved. No part of thi publication may hy reproduced, stored m a retrieval
system, or transmitted, in any form or by my means, electronic, mechanical, photocoPYing,
recordmg, or otherwise, without prior wntten permissH.lIl of the publisher.

Permission to photocopy or reproduce solely for internal or personal use is permitted for lihranes
or other use" regi;tered with the Copyright Clearance Center, provided ,hat the base fee of $4.00
per chapter pIlls $.10 per page" paId directly to the Copyright Clearance Center, 27 Congre"
Street, Salem, MA 01970. This conscm doe not extend to other kind.s of copymg, such as
copymg for general distnbution, for advcrtising or promotional purposes, for creming new
collected works, or for resale.

Printed In the Umted States of America

Comp<)sltion by Accu-Color, Inc.


Pnnting/hinding by Maple V311

Moshy-Vear Book, Inc.


11830 Westlme Industrial Drive
St. LOllIS, MlSsoun 63146

Library of Congress Cataloging.inPublication Data

D'Ambrogio, Kerry J.
Positional release therapy: assesment and rrea[(nenr of
musculoskeletal dysfunction I Kerry J. D'Ambrogll>, George B. Roth ;
with illustrations by Jeanne Rohertson.
p. em.
Includes bibliographIcal references and mdex.
ISBN 0815100965
I. Manipulation (Therapeutics) 2. Soft tissue mJunes.
3. Muscul,,;keletal system-Wounds amlmjunes. I. Roth, George B.
II. TItle
IDNLM: I. Manipulation, Orthopedic-methods. 2. Pain-therapy.
3. Soft TIssue Injuries-therapy. WB 535 D I56p 19971
RZ341.D18 1997
616.7'062----Jc20
DNLM/DLC
for library of Congress 9625538
ClP
98 99 00 01 I 9 8 7 6 5 4 3
About the Authors

KERRY J. D'AMBROGIO, B.Sc., P.T.


Kerry D'Ambrogio, B.Sc., PT., graduated from the University of Toronto, Canada. He has
studied in a great number of manual therapy and exercise cOllrses from around the world in
the Osteopathic, Chiropractic, and Physical Therapy professions' This diverse back.
ground provides Kerry with an integrated approach in the evaluation and treatment of
musculoskeletal dysfunction and rehabilitation. Kerry has been actively involved in
teaching seminars and speaking at research, physical therapy, and athletic therapy ccnven
[ions throughout Canada, the United States, Europe, Australia, and South America. He is
the founder of Therapeutic Systems Incorporated (T.S.I.) and an international seminar
company. He is the Director of the Manual Therapy Curriculum at the Upledger Institute,
and he is also on faculty with Dialogues in Contempcrary Rehabilitation (D.C.R.) and
Northeast seminar group. Kerry has contributed a chapter in a published manual therapy
textbook and has been interviewed on radio [Q educate the public regarding manual
therapy. Kerry currently practices and lives in Bradenton, Florida with his wife Jane and
three children Carli, Cassi, and Blake.

GEORGE B. ROTH, B.Sc., D.C., N .D .


George Roth is a Doctor of Chiropractic and a Naturopathic Physician based in the
Toronto area. He has actively pursued the study of advanced musculoskeletal therapy with
a number of innovators in the field and has contributed to the field through several inno
vation . He has publi hed articles in several journals and is on the faculty in the depart
ment of postgraduate and continuing education at the Canadian Memorial Chiropractic
College. George has taught seminars through the Physical Medicine Research Foundation,
the American Back Society, the University of Western Ontario (Department of Athletic
Therapy). chiropractic. sports medicine. and physical therapy conventions and at
numerous educational and clinical institutions throughout North America. He has been in
practice since 1978 and is the founder of the Wellness Institute. He is also currently
involved as a consultant to industry regarding injury prevention and rehabilitation and in
the development of wellness programs. George lives with his wife and son in the Caledon
countryside. north of Toronto.

v
Dedication

The authors would like to dedicate this book to Dr. Lawrence Jones, D.O., FA.A.O.
(1912-1996) for his pioneering discoveries in the field of musculoskeletal treatment and
his contributions to the service of mankind. Dr. Jones spent over 40 years developing
StrainCounterstrain. During the process he gave his time, energy, and talent so that
future generations of practitioners could enhance the care of their pariencs. His contribu..
tions have gained the respect and admiration of a broad spectrum of health professionals
worldwide. Dr. Jones made it his life's work to share his knowledge for the benefit of
others. We hope that our contribution [Q this continuing work will do his memory justice.

vi
Forewords

The body is a symphony of movement orchestrated by the problem and practitioner B is using method B to treat the
natural oscillations of its component parts. The beat starts same problem as he or she perceives it, and they are both
at the cellular {probably subcellular} level with the oscilla successful in their outcome, then they must both be doing
tions of the individual cells. The organs, the heart, the the same thing to the same thing, no maner what they say
lungs, the brain and spinal fluid, the gut, kidneys, liver, and they are seeing or doing. I suspect that we are all treating
muscles all contribute their rhythm, pitch, and timbre, fir.;t mechanical discords of the musculoskeletal system, inter
to their organ system, and then to the orchestrated body. ferences with the normal oscillations that we, somehow,
When it all functions together, it is a harmonic work of may set right.
great complexity. When one of the players misses a beat it George Roth and Kerry O'Ambrogio have put all these
can produce a discordant mess. The New York Academy of thoughts together in an insightful book. They recognize the
Sciences has held conferences on the nature of biologic oneness of the musculoskeletal system and have built on
rhythms and their dysfunctions and uses the terms dynamic the work of others to devise a treatment method based on
diseases to describe the illnesses caused by these arrythmias. scientific principles of nonlinear dynamic systems. If there
These are disorders of systems that can be described as a is a musculoskeletal dysfunction, we may be able to facili
breakdown of the control or coordinating mechanisms, in tate the normal rhythms of the system by stopping the
which systems that normally oscillate stop oscillating or orchestra, giving it a downbeat, and allowing the natural
begin to oscillate in new and unexpected ways. oscillations, built into the structure, to get things back in
To many of us in the field of musculoskeletal medicine it tune. This is the principle used in defibrillating a dysfunc
has become apparent that what we treat is usually not tional heart by shocking it still, and it seems to be the prin
pathology in the classic Vercovian model, where each dis ciple underlying positional release therapy.
ease has a verifiable tissue injury or biochemical disorder, Positional release therapy is remarkably simple and is
but rather a perturbation of the normal rhythms of the mus guided by the recognized diagnostic duo of somatic dysfunc
culoskeletal system-a dynamic disease. New models that tion (which is characterized as loss of joint play at the joint
can explain both the static and dynamic mechanical fune, level and similar tissue restrictions at each level studied)
tions of the body as an integrated whole are being devel and tender points (which are unrelated to local inflamma
oped. In these models the body is a nonlinear, hierarchical, tion or injury). These appear to be the diagnostic sine qua
structural system with every part functioning indepen# non of dynamic diseases of the musculoskeletal system.
dently and as part of the whole, like instruments in a sym Learning is made easy by this copiously illustrated book that
phony orchestra. How do we fix what is out of tune? is both a "how to" manual and a "why for" text. The mar
Dynamic systems function nonlinearly. Linear processes, riage of the two disciplines, chiropractic and physical
once out of whack, tend to stay out of whack. Nonlinear therapy, makes this a particularly important book. However,
processes tend to be self-correcting. A slight nudge may as pointed out by George and Kerry, this is a book for all
encourage a nonlinear process to correct itself. We take practitioner.; in the field of musculoskeletal medicine.
advantage of this when we jar a dysfunctional television set, Because the technique is so simple, safe, and easy to learn,
scare away a hiccup, or defibrillate a heart. In the muscu it can serve as an introduction to musculoskeletal tech
loskeletal system practitioners may treat similar problems niques for the less skilled and also as a valuable adjunct
with a variety of interventions. Joint manipulation of var technique for the more experienced practitioner. It is a pow
ious ilk, cranial manipulation, acupuncture, massage, exer erful tool that should be included in every clinician's bag.
cise, and so on all seem to work, in the right hands and at
the right time, often for the same problem. John Mennell, Stephen M. Levin, M.D., EA.C.S.
a pioneer in the field of musculoskeletal medicine, said that Director, Potomac Back Center
if practitioner A is using method A to treat a perceived Vienna, Virginia

vii
viii FOREWORDS

Positional release therapy is an extraordinary means of Positional Release Therapy: Assessment arul Treatment of
reducing hypertonicity, both protective muscle spasm and Musculoskelewl Dysfunction is an exceptional textbook that
the spasticity of neurologic manifes[ation. Irs great achieve addresses neuromusculoskeletal dysfunction in an effective
ments are correction of joint hypomobiliry. improvement of and efficient manner. My belief is that their work will
articular balance (which is the normal relationship enhance our goal of improving health care through the use
between twO articular surfaces throughout a full range of of manual therapy.
physiologic motion), elongation of the muscle fiber during My personal thanks are extended to Dr. Lawrence Jones
relaxation, and increase in soft tissue flexibility secondary for his landmark contribution of strain and counterstrain
to reduced excessive sensory input into the central nervous technique. My patients will be forever grateful. And my
system. Pain and disability may be remarkably reduced with congratulations are extended to George Roth and Kerry
this approach. D'Ambrogio for this valuable new book.
Therapists and physicians can use Positional Release
Thera/ry: Assessment arul Treatment of Musculoskelewl Dys Sharon Weiselfish, Ph.D., P.T.
function with almost every patient, in all fields of health Co-partner, Regional Physical Therapy
carc. Orthopedic patients enjoy improved function and West Hartford, Plainville, and South Windsor, Connecticut
decreased pain with increased motion. Chronic pain Copartner, Mobile Therapy Associates
patients experience decreased discomfort, possibly less Glastonbury, Connecticut;
inflammation, and more functional movement. Neurologic Director, Dialogues in Contemporary Research (D.C.R.)
patients, when this approach is slightly adapted to meet Hartford, Connecticut
their unique requirements, attain positive gains in tone
reduction with improved function in all aspects of activities
of daily living. Positional release therapy is a comprehen
sive approach for all persons with stressinduced and dys
functioninduced muscle fiber contraction.
Dr. Lawrence Jones introduced the correction of muscu
10 keletal dysfunction by correlating tender points with
positions of comfort as described in his book Strain arul
Counrersrrain. He based his findings on the theory that the
treatment positions resulted in a reduction of neuronal
activity within the myotatic reflex arc. Kerry D'Ambrogio
and George Roth have extended and organized this
approach and have included several new theories to
account for the clinical manifestations. They have provided
a total body scanning process for increased efficiency in
practice management. Muscle and tissue references are
listed, to provide a clear and pertinent anatomic and kine
siologic basis for treatment. The phomgraphs and illustra
tions are remarkably supportive for the study and practice
of these techniques. Body mechanics, as it relates m the
reduction of strain on the patient and the practitioner, are
addressed in some detail.
Acknowledgments

Many people over the years have helped to develop my Thanks to Jane D'Ambrogio, B.A., B.Ed., Conrad
belief system wid1 regard [Q my healing and treatment Penner, P.T., and Sharon Weiselfish, Ph.D., P.T., for editing
intervention philosophies. It is sometimes difficuh to say chapters and for construccive advice and support.
where specific ideas originated because all these people I would like to thank Dr. George Roth, D.C., for his
shared similar beliefs. I would like to acknowledge this out patience and guidance. I've enjoyed the collaboration,
standing group of professionals for helping me put this book friendship, and learning experiences in the writing of
together. It has been an honor to be associated with those this book.
who are M> dedicated to haTing their knowledge, thoughts. A special thanks to Sharon Weiselfish, Ph.D.,P.T., for
and ideas over the years: her friendship, contributions, incredible insight, and sup
John Barnes, P.T., Jean Pierre Barral, D.O., pOTC. Sharon is an innovative thinker with her finest
Paul Chauffeur, D.O., Doug Freer, P.T., accomplishmel'Hs yet to come.
Dr. Dan Gleason, D.C., Phillip Greenman, D.O., Most of all, I'd like to thank Illy loving wife Jane and Illy
Dr. Vladmir Janda, M.D., P.T., Dr. Lawrence Jones, D.O., family, who have provided me with the love and support
Dr. David Leaf, D.C., Goldie Lewis, PT., needed to write this book. They have comended with more
Frank Lowen, L.M.T., Edward Stiles, D.O., than anyone with regard to time spent and patience
Dr. Fritz Smith, D.O., John Upledger, D.O., required in ''''Titing this lxJok.
and Sharon Weiselfish, Ph.D., P.T.
Thanks again to Doug Freer who originally inspired me. Sincere thanks to all of YOll.
Kerry J. D'Amhrogio

I would like to thank Harold Schwartz, D.O., for helping Working with Kerry has been stimulating, and I feel
to resolve my back pain and for opening me up to a new that, despite occasional challenges, we have become better
way of looking at the body. Dr. Lawrence Jones inspired me (riends and developed a greater respect for each other
through his down[Qearth comlllon sense and his humility, through this collaboration. It can truly be said lhal the
and I hope that he would find this book a worthy testament whole is greater than the sum of each of our parts.
to his goal of bringing these therapies to the world. Last, but not least, I wish to thank my loving wife Deb
Several gifted practitioners, whom I can also call friends, orah and Illy son Joshua for their love and support. The
have been a continuing source of constructive criticism as past 2 years has been a strain on them because of the long
positional release therapy has evolved over the years: Garry hours I spent on this book, often hibernating away well
Lapenskie, P.T., Stephen Levin, M.D., EA.C.S., Iris Wev into the night with my computer to write and edit the
ennan, P.T., Iris Marshall, M.D., Heather Hartsell, Ph.D., text. I cannot begin to express my gratitude for their
P.T., and ecil Eaves, R.M.T., Ph.D. I am specifically patience with their parttime husband and dad during
grateful to Garry Lapenskie, P.T., for his help in editing the rhis time.
manuscript. Stephen Levin, M.D., has been a continuing
source of inspiration and a good friend. George B. RDlh

ix
x ACKNOWlEOOMENTS

Kerry and George would both like to thank the following: put in and an extra thanks to Robin and Mary-Ellen for the
Photographers Stuart Halperin and Matthew Wiley and second photo shoot.
illustrator Jeanne Robertson for their professionalism, Mosby staff Amy Dubin, Kellie White, Catherine
patience, and remarkable talentS. They have created an Albright, and Martha Sasser for their advice, support, and
incredible visual learning experience for the reader. patience with timelines.
Models Mary-Ellen McKenna, N.D., Carol Fisher-Short,
R.M.T., and Robin Whale, D.C., for the long hours they
Preface

liThe magic is not in the medicine but in [he patient's body , in dent that occured during childhood. The condition was
the vis medicacrix naturae, the. recuperative or self,correcnve exacerbated periodically on exertion. After becoming a
energy of nature. \Vha( the treatment does is to stimulate nat, chiropractor, George began seeking more effective and
ural functions ar to remove what hinders them." gentle methods of treatment, which eventually led him to
Miracles, C.S. Lewis, 1940 study with several prominent osteopaths. He read an article
by Jones that described counterstrain and subsequently met
The purpose of this book is to provide the practitioner Dr. Harold Schwartz, D.O. (a student of jones), who was
with a powerful set of tools to precisely and consistently the head of the department of osteopathic medicine at a
resolve difficult cases of soft tissue injury and muscu prominent teaching hospital. At about this time, George
loskeletal dysfunction. This text is an attempt [0 bring this was experiencing an acute episode of his back condition
information co the reader in a format that is concise, that prevented him from sleeping in a recumbent position.
orderly, and user-friendly. We have formulated a system of It had proved resistant to several other modalities over the
assessment and treatment that can be easily learned and previous J months and was relieved by Schwartz in less
readily used to benefit patients. This material is appropriate than 10 minutes.
for physical therapists, chiropractors, osteopaths, medical This experience motivated him to begin a concerted
practitioners, occupational therapists. athletic trainers, and quest to uncover the mysteries of this amazing therapy. He
massage therapists. spent the next 5 years commuting between Toronto and
We acknowledge the pioneers in this field for their con Columbus in order to continue studying with Schwartz and
tributions and view this (ext as a step coward a greater eventually with jones. George then began assisting and
understanding of the complex nature of the human body. coteaching with Jones and developed courses for chiroprac
We 3re hopeful that this work will represent a measure of tors, physical therapists, and other practitioners throughout
progress in the field of musculoskeletal therapy and enhance Canada. He also developed a specialized treatment table
the clinical applicability of these powerful techniques. that was designed to facilitate the application of this form
The basis of the treannen[ program described in this text of therapy.
can be traced to related practices in antiquity. In this cen While playing varsity football at the University of
tury, positional release therapy (PRT) has evolved through Western Ontario, Kerry D' Ambrogio experienced several
the work of various clinicians, but the discovery of the clin recurring injuries to his groin, hip flexors, and right knee.
kal application of these principles is credited primarily to These injuries plagued him during his 3 years at Western
Dr. Lawrence H. Jones, D.O. His dedication to uncovering and limited his activity. As a result, he spent some time in
the basic principles of this form of therapy was a monu the athletic injury clinic and received traditional therapy,
mental achievement. Jones exemplifies the essence of which consisted of cold whirlpools, ultrasound, and
Thomas Edison's definition: "Intelligence is perseverance stretching. While attending therapy Kerry observed other ath
in disguise." He is recognized as one of the great pioneers in letes being treated, and this exposure sparked an interest in
the field of musculoskeletal therapy. physical therapy. He decided to enter into studies at the Uni
Positional release therapy has had a powerful impact on vetsity of Toronto to become a physical therapist. Throughout
both of us in terms of clinical success and patient accep this period he continued to suffer from chronic pai.n.
rance. In addition, our personal experience in dealing with Kerry was first exposed to counterstrain by his professor,
our own painful conditions was instrumental in directing us Doug Freer, and eventually attended a workship with jones.
to the development of this art. At the workship, Kerry discovered several severe tender
In George's case a severe, chronic condition of upper points in his pelvic region and one on his right patellar
back pain developed subsequent to a motor vehicle acci- tendon. Upon treatment, he experienced a dramatic
xi
xii PREFACE

improvement in the function of his pelvis, hip, and right approach. The clinician is also encouraged to perform a
knee. Consequently. he was able to fully resume sports number of reality checks to establish clinical indexes for
activities. This one treatment was able to accomplish morc improved function. These can include standard orthopedic
than the countless previous therapy sessions. This extraoT' and neurologic tests and specialized functional procedures.
dinary response motivated Kerry to pursue the study of (See Chapter 7.)
countersrrain. He eventually assisted with Jones and then The scanning evaluarion (SE), discussed in Chapter 5,
developed his own series of seminars so that he could share and provided in its entirety in the Appendix, is designed to
this technique with other professionals. facilitate the cataloguing of the tender points. The SE pro
Both of us had been exploring soft tissue skills over the vides a system to organize assessment findings and serves as
past several years and found that our paths were inter' a reference that quickly allows the practitioner [Q deter
seeting along synchronous lines as we pursued this knowl mine a prioritized treatment program. This format can save
edge. We both became involved with teaching and writing a great deal of time and provides an efficient method to
manuals for our seminars. When the idea to write a formal track progress of the patient's condition and plan subse
text was presented to George. he contacted Kerry, who, quem treatments.
suprisingly, had been thinking of writing a book as well. Jones coined the terms CDunrfTsrrain aml strain and coun
The collaboration naturally evolved and was seen by both terstrain (the latter being the title of his orginal text). Sev
of us as a unique opportunity co provide a greater degree of eral authors, including Jones, have referred to the general
depth to the material and intergrate the concepts of chiro therapeutic approach as release by positioning and posi
practic, osteopathy, and physical therapy. tional release therapy. We feel that the term positional
We have attempted to provide a theoretical and histor release therapy best describes this form of therapy in its
ical perspective for positional release therapy. This founda broader. generic sense.
tion is intended to support the clinical experience and pro With respect to the terminology used in the treatment
vide a level of confidence in the rationale for these section, we have endeavored to keep this as simple as pos
techniques. An awareness and understanding of the under sible while attempting to maintain a degree of structural
lying principles and context of a therapeutic model can relevance. In certain cases, the terminology as coined by
play an important role in sustaining the perseverance Jones is used; however, every attempt was made to correlate
required to develop the skills necessary for its application. the treatment approach to the anatomic tissues involved.
The reader is provided with criteria for deciding whether In a few instances, a positional reference is used where this
it is appropriate to lItilize PRT as a treatment modality. has been determined to be the most logical format. Abbre
With the numerous emerging therapies available [Q the stu.. viations have been assigned for each treatment; these con
dent of musculoskeletal therapy, we felt that is was neces sist of two to four letters plus numeral designations. For
sary to provide a "road map" in order to plot a course of those trained in the Jones method, a cross-reference with
appropriate treatment. It should be noted that PRT is nor a PRT terminology is provided (see the Appendix). There is
panacea and is best utilized within a complementary range of also a crossreference in the Appendix that correlates mus
therapeutic options as indicated for each individual patient. cles and other tissues with the appropriate PRT treatment.
An outline of genenll treatment principles and rules is This can be used to quickly locate a particular treatment
presented to provide a framework for consistent application according to the involved tissue.
of the procedures. These guidelines have been established Modifications of treatment positions and changes in ter
during the past 30 to 40 years and can serve to increase effi minology are intended to improve the efficiency of treat
ciency and save the therapist from repeating much of the ment and simplify the recording and communication of
trial and error that was involved in the evolution of this clinical findings. These changes should not detract from
PREFACE XIII

pre\'iou discoveries but \\fill hopefully serve to continue the treatment positions, anu written descriptions of the
the development of this art ami science. Evolution is a pro' location of the tender points and the position ofrreatll'lent.
cess of building on previously established foundations. Chapter 7 provides a realistic clinical context to rhe
The descnption of the pomt locations and treatment application of PRT. Strategies to help refine the techniques
procedures represents the core of this text. The underlying and optimize results arc provided, as well as mO<.!tfications
principle In the design of the illustration!'; and photographs for dealing with special clinical challenges. This chapter
has heen to c1e;uly portray the location of the tender addresses the subtleties of the aTl of application of PRT
pOInts, rhe anatomic structures Involved, and the general skills. Potential pItfalls and questions related to clmical
ptlSltion of treatment. The treatment section is divided into issues are also aJdressed.
upper quadrant and lower quadrant sections. Each region of We hope that this text will msplTe the reader to look at
the body (cranium, cervical spine, thoracic spine, upper musculoskeleml disorders in new way. The mhercnt, self#
limb, etc.) b prefaced by an introduction to its clmicai rei, healing potential of the body deserves our respect and sup
evance and general guidelines for the application of PRT. port in the spirit of primwn no nocere (first do no harm). We
Each region is also headed by anatomic illustrations out, believe thm positional release therapy is an approach that
lining the general location of the most common tender embraces this ideal and is truly powerful In its gentleness.
fXllnt:,. Each lender point or group of tender points has a We are hopeful that this wnrk will be of value to you, the
separate page that consists of'1 photograph and illustrmion practitioner. The relief of pain anti the improved function
With the speCific point location, detailed phorographs of of your patients will be the ultimate measure of our success.
Contents

Chapter 1 Origins of Positional Release


Therapy, I

Chapter 2 The Rationale for Positional Release


Therapy, 7

Chapter 3 Therapeutic Decisions, 19

Chapter 4 Clinical P rinciples, 27

Chapter 5 Positional Release Therapy Scanning


Evaluation, 35

Chapter 6 Treatment P rocedures, 39

Chapter 7 The Use of Positional Release


Therapy in Clinical P ractice, 22I

Chapter 8 New Horizons, 227

Appendix, 231

Glossary, 251

xv
POSITIONAL
RELEASE
ThERAPY
Assessmen t&frealmenf
of Musc,.loskeletal D,sfunction
1
Origins of Positional
Release Therapy
Body Positioning 1
Tender Points 2
Indirect Technique 2
History of Counterstrain 4
Recent Advances 5
Summary 5

The purpose of this chapter is to trace the development of


positional release therapy (PRT) and put it into historical
perspective. Positional release therapy is an indirect rech#
niquci it places the body into a position of greatest comfort
and employs tender points to identify and monitor rhe A
lesion. Because PRT appears to be an effective modality, it
must be based on certain general principles that have a
sound physiologic basis. Several of the characteristics of
PRT, which may be shared with other therapeutic models,
can be identified. These include the use of body positioning,
the use of tender points to identify the lesion and to monitor
the therapeutic intervention, and an indirect approach with
re peer to tissue resistance.

, BODY POSITIONING
Body posture and the relative position of body partS has
B
been a subject of intense speculation and research
throughout history. From yoga to the martial arts to rhe
study of body language, the arrangement of the parts of the
human body has been deemed to have a certain mental,
physical, and spiritual significance. Several forms of yoga. a
discipline with over 5000 years of history, include the phys
Fig. I-I Yoga pos(!(res. A, Bow. B, Plough.
ical practice of positioning the body to enhance function
and release tension.1? These positions put certain parts of
the body under stretch while other parts are placed in a therapy. somi. core stabilization, functional technic, and
position of relaxation (Fig. I-I). The benefits of this form of counterstrain (Fig. I Z). These practices share a common#
exercise to relieve musculoskeletal pain are widely ality in that they recognize the relationship of body move#
accepted, and they are used successfully by a substantial ment and posture with the general condition of the body.
number of people.lo,n Modern derivations of this ancient
art may be seen in the practices of Feldenkrais. bioenergetic 'References 1,7.9,10,11,15,17.
2 CHAPTER I Origins of Positional Release Therapy

reflexes that he associated with the functioning of the lym


phatic system (Fig. 1-4). He found that direct treatment of
these reflex tender areas resulted in improved circulation
and lymphatic drainage . Resolution of the underlying con
dition, whether visceral or musculoskeletal, reduced [he
tenderness of these areas. These reflexes have been
described as gangliform contractions within the deep fascia
that are about the size of a pea. More recently, Travell and
Simons33 have systematized the mapping and direct treat
ment of TPs in their two-volume series, M)'ofascial Pain
and Dysfunction. Jonesl reported on his discovery of tender
points associated with musculoskeletal dysfunction as
early as 1964. T he recognition of the tender point, or
trigger point, as an important pathophysiologic indicator
of musculoskeletal dysfunction has also been elaborated
by Rosomoff.2124
Bosey! states that acupuncture points are situated in pal
pable deprcssions--cupules-under which lie fibrous cones
containing neurovascular formations associated with con
centrations of free nerve endings, Golgi endings, and Pacini
corpuscles. Melzack and associates19 contend that there are
no major differences between tender points, trigger points,
acupuncture points, or other reflex tender areas that have
been described by different investigacors. The varying
effects reported with the use of different tender points may
Fig. 1-2 Bioenergefic exercises. (Modified from Lowen A. Lowen L: lie in their relative location with respect to underlying tis
Theway 10 vibrant hhh: a manual o(tHotnergelk exercises. New York, 19704. sues. ChaitOw3 points out that so-called spontaneous sensi
Harper & Row.)
tive points arise as the result of trauma or musculoskeletal
dysfunction. The Chinese refer to these points as Ah Shi
Several authors, both modern and ancient, elaborate on the points in their writings dating back to the Tang dynasty
"energetic" properties of postures and body positions.3 0.31.3 5 (618-907 AD). Chaito\\A insists that these are identical to
Some of these phenomena have been noted regularly by the points used by Jones.
practitioners of PRT as part of the release process, which is In summary, tender points have been recognized for
disclissed in later chapters. The mechanism responsible for thousands of years as having diagnostic and therapeutic sig
these effects is unknown. nificance. Various investigatOrs have rediscovered these
points and have applied a range o( therapeutic interven
tions CO influence them. In general, any therapy that is able
'TENDER POINTS to reduce the tenderness of these tissues appears to have a
Acupuncture points have been used therapeutically for at beneficial effect on the health of the individual. Jonesli was
least 5000 years. TI1CSC points correlate closely with many of the first clinician to associate body position with a reduc
those "discovered" by subsequent investigators (Fig. 1-3).36 tion in sensitivity of these tender points.
References in the western literature to the presence of pal;
pable tender points (TPs) within muscle date back to 1843.
Froriep described his so-called Muskelschwiele, or muscle , INDIRECT TECHNIQUE
callus, which referred to the tender points in muscle that The histOry of therapeutic intervention to affect
were found to be associated with rheumatic conditions. In structures can be broadly divided into direct and indi#
1876 the Swedish investigatOr Helleday described tender reet techniques. Direct techniques involve force being
points and nodules in cases of chronic myositis. In 1904 applied against a resistance barrier, such as stretching, joint
Gowers introduced the term fibrositis to describe the pal mobilization, and muscle energy.S,lO Indirect techniques
pable nodule, which he felt was as ociated with the fibrous employ the application of (orce away from a resistance
elements of the musculoskeletal system. Postmortem studies barrier, that is, in the direction of greatest ease. Indirect
by Schade, which were reported in Germany in 1919, therapies, including PRT, have evolved in various forms
demonstrated thickened nodules in muscle, which served to and share cerrain common characteristics and under
confirm that these histOlogic changes evolved into lesions lying principles.
that were independent of ongoing proximal neurologic In 1943 Sutherland" introduced the concept of manip
excitation.]] In the 1930s Chapman' discovered a system of ulation of cranial StrUCtures. His technique to treat cra-
Origins of Positional Release Theral'Y CflAPTER I 3

//'
( AJ
618
619

K27 ----;---_.
6110
6111
;; '
I
J
J
\
{
61 23 - 6147

6148
61 25
6149

A
' 6150 B

'J

K10 -+---jH
---..
_ 61 53
\ 61 54

6160
W
K3
61 67

fig. I] Acupullcture lJOim5 related [0 A, the kidney meridian; and B, rhe blMder meridian.

nial lesions was to follow the motion of the skull in the Hoover advocated a treatment protocol that was
direction in which it moved most freely. By placing pres respectful of the wisdom of the tissues and the inherent
sure on the bones of the head in the direction of greatest interaction of the neuromuscular, myofascial, and articular
ease, he found that the tissues spontaneously relaxed components. The technique involves movement toward
and allowed (or a normalization of structural alignment least resistance and greatest comfort and relies on the
and function. response of tissues under the palpating hand of the practi#
In the late 19405 Hooverl! introduced functional [echnic. tianer. This dynamic neutral position attempts to reproduce
He found that when a body part or joint was placed in a a balance of tensions, which is ncar the anatomic neutral
position of dynamic recityrocal balance, in which all tensions position for the joint, within its traumatically induced
were equal. the body would spontaneously release the range. A series of tissue changes may occur during the posi#
restrictions associated with the lesion. During that period. tioning that are perceived by the practitioner. The practj#
the prevailing view of musculoskeletal assessment stressed tianer attempts to follow this evolving pattern until the
the position and morphology of body parts. Hoover empha body spontaneously achieves a state of resolution and the
sizcd the impormnce of "listening" [Q the tissues, which treatment is complete.11
refers to the process of carefully observing, through palpa Joncsl5 found that specific positions were able to reduce
tion, the patterns of tension within the tissues and paying the sensitivity of tender points. Once located, the tender
attention [Q their functional characteristics and structure. point is maintained wim the palpating finger at a sub#
He introduced the concept of functional diagnosis, which threshold pressure. The patient is then passively placed in a
takes into account the range of motion and tissuc play position that reduces the tension under the palpating finger
within the structures being assessed. and causes a subjective reduction in tenderness as reported by
4 CHAPTER I Origins of Positional Release Therapy

Fig. 1-4 Chapman s reflexes.


I (Modified from Chaltow L: Sofi tISsue manipulation, Rochener, Vt, 1988. Healing Aru Press.)

the patient.l; This "specific" position is, nevertheless, fine sleep for more than a few minutes was impossible. Jones
tuned throughout the treannent period (90 seconds), mllch in decided that finding a comfortable position that would
the way that Hoover follows the lesion in his technique. allow the patient to sleep would at least provide some tern,
Chaitow' also alludes to the possibility that a therapeutic porary relief and some much,needed rest. After much trial
effect is exerted by maintaining contact with the tender point. and error, they found a comfortable position. jones propped
In 1963 Rumney" described the basis for reestablish the patient in this unusual, looking folded position with sev,
ing normal spinal motion as "inherent corrective forces of eral pillows and left him to rest. Upon his return some time
the body-if the patient is properly positioned, his own later, Jones suggested that the patient memorize the posi,
natural forces may reStore normal motion co an area." Other tion in order to reproduce it when going to bed that night.
clinicians have used an indirect method co treat muscu .The patient was then slowly taken out of the position and
loskeletal dysfunction by having patients actively position instructed to stand up. Much to the amazement of the
themselves through various ranges of morion under the patient and Jones. the patient stood erect and with drasti,
guidance of the practitioner and while being monitored for cally reduced pain. In the words of jones, "the patient was
maximal ease by palpation.BJS delighted and I was dumbfounded!""ll
This discovery emphasized the value of the position of
comfort. Jones found that by maintaining these positions for
, HISTORY Of (OUNTERSTRAIN varying periods of time, lasting improvement would often
In 1954 Lawrence H. Jones, an osteopath with almost 20 be the result. He initially held the position for 20 minutes
years of experience, was called on by a patient who had and gradually found that 90 seconds was the minimal
been suffering with low back pain of 2 months' duration threshold for optimal correction of the lesion.
that had nOt responded to chiropractic care. The patient As jones pursued the possible applications of this new dis
displayed an apparent psoas spasm with resultant antalgic covery, which he referred to as counterstrain, he noted that
posture. Jones was determined that he could succeed where many of the painful conditions that he was able to alleviate
others had failed. However, after several sessions with no were assoc iated with the presence of acutely painful tender
improvement, he was ready to admit defeat in the face of points. The traditional approach to lesions of the spine was to
this resistant case. The patiem was in so much pain that assess and treat on the basis of tender areas in the paraspinal
Origins of Positional Release Therapy CHAPTER I 5

tissues. These points, after positioning of the patient, became specific anatomic structures. IS We have helped simplify the
decidedly reduced in tenderness and remained so even after terminology used to describe lesions and systematized the
the treatment was concluded. Thus an important diagnostic educational program to help make the development of PRT
dimension was added to this fonn of therapy. skills more efficient. In the next chapter we will help to
In many instances of back and neck pain, however, no eStablish a physiologic basis for many of the clinical mani
tender point could be found in the area of the pain within festations of musculoskeletal dysfunction.
the paraspinal tissues. Fate was once again to play a role. A
patient who had been seeing Jones for low back pain was
working in the garden when he was struck in the groin with
, SUMMARY
a rake handle. In pain and fearing that he may have induced Positional release therapy has historical roots in antiquity.
a hernia, he called on Jones. Jones examined the patient The three major characteristics (body positioning, the use
and assured him that no hernia was present. Jones then of tender points, and the indirect nature of the therapy) can
decided that the patient might as well stay and receive a be individually traced to practices established over the past
treatment that was scheduled for later in the week. After 5000 years. Connections can be made with the ancient dis
the patient had been placed in the position for treatment of ciplines of yoga and acupuncture and with the work of
his low back, in which he was supine and flexed maximally investigators over the course of the past twO centuries. The
at the hips, Jones decided to recheck the previously tender correlation of different systems that use tender points sug
area in the groin. To his surprise, the tenderness was gone. gesrs a common mechanism for the development of these
This discovery answered the mystery of the missing tender lesions. Significant contributions to the development of
points, and shortly thereafter Jones was able to uncover an this art and science have been made by Jones121J.16 and
array of anteriorly located tender points that were associ; others. Positional release therapy is being continually
ated with pain throughout the spine.1J He noted that advanced and developed through the contributions of many
approximately 30% to 50% of back pain was associated with clinicians and researchers.
these anterior tender points. With this latter discovery,
much of the guesswork and trial and error in rhe application References
of therapy was eliminated. The use of tender points became I. Brown CW: Change in disc nearmem saves hockey star, Backlmer
a reliable indicator of the type of lesion being encountered, )(Inl.I992.
2. Bosey J: The morphology of acupuncture points. Acupunc Electother
and therapeutic intervention could thus be instituted with Res ),79,1984.
increased confidence and reproducibility. Jones spent the 3. Chaitow L: Sofllimu! manipulation. Rochester, Vl, 1988. Healing
better part of 30 years developing and documenting his dis Arts Press.
4. ChaitOw L: The acupunclUre rreannem of pain, Wellingborough,
coveries, which he first published in 1964.14 He later pro 1976,Thorsons.
duced a bock entitled Strain and Counterstrain.15 5. Chapman F. Owens C: Introduction 10 and endocrine inteT1Jreuwon of
Chapman's reflexes. self-published.
6. O'Ambrogio K: Strain/counterstrain (course syllabus), Palm Beach

, RECENT ADVANCES 7.
Gardens, 1992,Upledger Insmure.
Fcldcnkmis M: Awareness through I7lOt.IeTlltn!: health exercises fCJr pe T
Positional release therapy owes its recent evolution to a sonaigrowlh, New York, 1972, Harper & Row.
8. Greenman PE: Principles of manual m.edicine. Baltimore. 1989.
number of clinicians and researchers. SchwartzI9 adapted Williams & Wilkins.
several techniques to reduce practitioner strain. Shiowitz28 9. HashImoto K: SOlai natural exercise, Oroville, Calif, 1981. George
introduced the use of a facilitating force (compression, tor; Ohsawa Macrobiotic Foundation.
10. Hewitl J: The compiele yoga book , New York, 1977,Random House.
sian, etc.) [Q enhance the effect of the positioning. Ramirez I!. Hoover HV: Funcrionallechnic, AAO Year Book 47.1958.
and othersll discovered a group of tender points on the pos; 12. Jones LH: FOOl nearment without hand tmuma.} Am Osteopath
terior aspect of the sacrum that have significant connec As"" 120481,1913.
13. Jones LH: Missed anterior spinal lesions: a preliminary report. DO
tions [Q the pelvic mechanism. Weiselfish34 outlined the 6075, 1966.
specific application of positional release techniques for use 14. Jones LH: Spontaneous release by positioning. 00 4:109,1964.
with the neurologic patient. She found that the initial 15. Jones LH: Strain and COU1l[CTStrain. Newark, Ohio, 1981. American
Academy of Osteopathy.
phase of release (neuromuscular) required a minimum of 3 16. Jones LH: Str.tin and counterstrain lectures at Jones Institute,
minutes, and she also outlined protocols to locate key areas I99Z-1993.
of involvement with this patient population. She, along 17. Lowen A, Lowen L: The way 10 vibranl health: a manual of bt'orner.
gelic exercises. New York, 1974,Harper & Row.
with one of us (O'Ambrogio), outlined the twO phases of 18. Maigue R: The concept of painlessness and opposite mmion in
release: neuromuscular and myofascial. Brownl developed a spinal manipularions, Am} Phys Med 44:55,1965.
system of exercise for the spine in which a painfree range 19. Melmck R. Stillwell DM. Fex EJ: Tngger points and acupuncture
points for pain: correlations and implications, Pain 3:3,1977.
of motion is maintained. One of us (D'Ambrogio) devel 20. Mitchell FL, Moran PS, Pruzzo HA: An e,-oaluacion and treatment
oped the scanning evaluation procedure to facilitate the effj ml1IlIW of os/eopalhic muscle tnelD procedllres, Valley Park, Mo.
ciency and thoroughness of patient assessment,6 and one of 1979. Mitchell. Moran and Pruzw.
21. Ramirez MA. Haman J. Wonh L: Low back pain: diagnosis by six
us (Roth) has developed improved practitioner body newl' discovered sacml tender points and treatment WIth counter
mechanics to reduce strain and has correlated lesions with strJ.in,} Am Osteopath Assoc 89:7,1989.
6 CHAPTER I Origins of Positional Release Theral'Y

22. Ramnum M: Fundamtnwu of ;ioga, New York. 1972. l"\'uI('J3y. 30. Schwarr: JS HLmum L'TleTSO' .'mcms. New York. 19&), l\muo.
23. R(\S(llUoff Hl: Do hcmlilh.-J UISC;. cause rain! elm} Pam 1:91. 1985. 31. Snuth FF: lnn ">fl: aguLJ.:. W('I1L'Tg)' mot't'1llc'fll tlnJ hlld'Y struclUTe,
..
24. Rus(lmnf( HL. Fihb.Jm DA, Goldberg M, StcdcRosomoff Adanta. 1986. HumallLc.
ICOII finding!> In ratlcntS with chronic Introc.:wble hcniJ!fl rilln of the 31. Sutherland WG: The cranL,ll huwl. } Am OSCt>j)palh AHf)( 2:348,
m ..'Ck amI/or hack. Pam 37:279. 1989. 1944
25. RI)[h GB: CounLm[Tlun: posifional release rhef'aJ1)' htudy U1dc). 31. Tnwcll JG. SLmon!) [X]: MyofrucidJ. t)(lln "oJ J'Y,fUIlCIIOIL rho: m,IW.'T
T(lhlnto. 1992, Wdlnt-" IruILlU(C. -.elf-published, I)oin! manual, f\lhLmore, 1983, WtlIL.lIn& Willom,.
26. Roth CiR: Tuw;!n.!" a umfu -J mndel u( mU!>I.:ull",kderal J';,funC{Jon.
.. H. Weil(i.'ih S; Manual lheratry far !he OTlho/Jidsc and neumk panc11I
Prc..c.:nteJ at Canao.'1n Chlwpmtlc A'<"\(Xliltlon ,1000,,1 ",cetmn. emt,,::mg SCTam and coun!rolTam lechmqLlf. Harrfmd. Conn. 1993,
June. 1995. RegLonal PhYMcal Therapy. 1f.pubIL"hcd.
27. Rumney Ie: Siructumi Jlagno;'l <lnd mampulatlve therapy.) 15. Woodroffc
OSfcnpcuJry 70:21. 1961. 36. WOl,)lerron H, Mclean CJ: Acupuncllm t'nI..>rg:V In h.:>allh and ducase
28. Schlowlt: S: Faelln,lted f"l.'.>ltlonal rcle. j Am O[CoplJ(h Assex: a IW'Ck'Ufal gUide fm a,d,."anceJ snulcrtLS. NurrhamplOmhLrl.'. EnlanJ,
2,141.1990. 1979. ThuN,\Ils.
29. Schwan: HR: The u...e of countersmun In an acutely illm-hmrnal
population.} Am Oleopalh .A.5.mc 86:4B. 19H6.
2
The Rationale for Positional
Release Therapy
Somatic Dysfunction 7 P r opr iocep tor s: Neuromuscular
A New Paradigm 7 Feedback 10
The Tissues 8 ociceptors: Pain Pathways 12
The Significance of the Tender The Facilitated Segment: Neural
Point 9 Crossroads 13
Fascial Dysfunction: Connective
The Role of Positional Release
Tissue Connections 14
Therapy in Somatic Dysfunction 10
Positional Release Therapy Summary 15
Treatment 10

This chapter establishes a ra[ional basis of understanding have been supported by the advent of imaging devices such
for [he clinical phenomena associated with positional as the x-ray and its modem derivations (CT scan, MRI).
release therapy (PRT). Somatic dysfunction is discussed in The aim of therapies based on this model is to reshape the
the light of recem discoveries regarding the physiologic stnlC(ure according to an architectural ideal. The assump#
properties of the variolls tissues of (he body. Several models tion is that, by reestablishing the optimal physical relation
of dysfunction are introduced within the context of their ship between body parts, everything will be restored to per#
possible role in explaining the effects of PRT. Certain pre fect working order. The therapeutic intervention is
vailing doctrines may be challenged by the arguments pre designed to remodel the components of the body and to
sented, and we hope (hat the reader will keep an open mind relieve perceived structural stress within the system.
and judge these theories on their rational merit and on the Stretching shortened tissue, vigorously exercising hypo#
basis of how they fit with clinical experience. tonic muscles and surgically refashioning osseous and artic#
ular components of the musculoskeleml system with the
, SOMATIC DYSFUNCTION aim of achieving this architectural ideal have had limited
success. The belief that these procedures should work
A NEW PARADIGM because they are consistent with this model of the body
Prevailing theories regarding the development of muscll encourages persistence, even though the objective results
loskelctal conditions are undergoing intense scrutiny. may contradict the underlying prernise.1718,45 Unfortu
Patients and insurers are demanding effectiveness and reli nately, in many cases, the StruCture resists our efforts. The
ability in therapeutic intervention. If the underlying theory result is often frustration (or the practitioner and torment
regarding the development of somatic dysfunction IS incon for the patient.
sistenr with clinical anu physiologic realities, therapeutic The functional model of the musculoskeletal system
models based on these principles must be questioned. holds that biomechanical discurbances are a manifesta#
The structural model of musculoskeletal dysfunction is tion of the intrinsic properties of the tissues affected.])
associated with gross anatomic and postural deformations The tissue changes may be the result of trauma or inflam#
and degenerative changes (scoliosis, disc degeneration, mation and are seen as a direct expression of fundamental
oSteophytes, etc.). The presence of these physical anomalies processes at the ultrastructural and biochemical levels.
are considered a direct cause of sympcoms. These theories These changes, which are collectively referred to as somatic
7
8 CHAPTER 2 The RatiOlUlIe for Positional Release Therapy

dysfunction, may be expressed as reduced joint play; loss of events may account for the development of myofascial
tissue resilience, rone, or elasticity; temperature and trophic trigger points, protective muscle spasm, reduced range of
changesi and loss of overt range of motion and postural motion, and decreased muscle strength, which consistently
asymmetry. This model views the form of the body as an accompany musculoskeletal injury.
expression of its function. Posture is seen as an outward The effect of trauma to the fascial matrix is also a subject
manifestation of the degree of balance within the tissues, of much speculation. The discoveries of Levin2729 may shed
and greater emphasis is placed on the interaction of all of some light on this complex issue. He and others have
the body parts during physiologic and nonphysiologic demonstrated that the underlying structure of all organic
mmion. This model emphasizes the role of the soft tissues, tissue determines its responses to traumatic forces and may
especially the myofascial elements. account for certain properties that can lead to persisting
A growing body of knowledge supports the premise that dysfunction. 1936.51
a large proportion of musculoskeletal pain and dysfunction PRT, and other functional therapies, do not alleviate or
arises from the myofascial elements as opposed ro neural or attempt to treat any tisslle pathology. The primary role of
articular rissues.J8 Rosomoff and ochers35 have concluded these therapies is to relieve the somatic dysfunction, which,
that over 90% of all back pain may be myofascial in origin. according to Levin,29 is a nonlinear process. A nonlinear
In fact, they contend that one of the mOSt popular theories process is one that exerts an influence over a relatively brief
for [he origin of back pain, that of pressure on a nerve, as in period ohime. These processes tend to be functional rather
disk degeneration or disk protrusion. would result in a so than pathologic and respond rapidly to functional therapy.
called silent nerve. They state that "back pain must be con Functional restoration establishes an environment in which
sidered to be a non,surgical problem, unrelated to neural the linear healing process of the pathologic component of
compression." Pressure on a nerve results in reduced sensa the injury may occur more efficiently.
tion and motor function, not pain. This can easily be Musculoskeletal dysfunction therefore appears to origi
proven by the common experience of placing the arm on nate and be maintained at the molecular and ultrastructural
the back of a chair and noting how the arm "falls asleep." level within the tissues. The intrinsic properties of tissue
During this episode, there is a sensation of numbness and and their inherent pathophysiologic response to trauma
loss of mOtor control-not pain. Ir is only when the pressure seem to be consistent with many of the external manifesta,
is relieved that pain is experienced. along with the gradual tions associated with somatic dysfunction. It is imperative
return of motor function. that we examine our beliefs and hypotheses so that we can
Saal and othersJa have proposed that, when disks are accommodate this developing knowledge base within our
injured or are in the process of degeneration, they release working model of somatic dysfunction. Effective therapy
water and proteoglycans. This material undergoes biochem must be congruent with these principles regarding the
ical transformation through glycosylation and is subsequently response of the body tissues to trauma. We will now
targeted by the immune system as a foreign substance. This examine PRT within the context of its influence on these
results in the initiation of an inflammatory response. As the properties of tissue.
leakage of this Uforeign" protein into the epidural space
continues, there may be a significant rise in the levels of
phopholipase (a component of the arachadonic cascade), THE TISSUES
leading (Q the production of nociceptive chemical mediators The body is composed of several major tissue types. For the
and biochemically induced pain.Ja BrownS notes that disk purposes of this discllssion, with respect to musculoskeletal
herniations may be a "red herring" in many cases of thoracic dysfunction, we will consider three main classes of tissue:
pain and that, barring any significant indications of spinal muscle, fascia, and bone. Even though these tissues are con
cord compression, a conservative approach to relieving the sidered separately and are often discussed in isolation from
myofasdal source of the pain is all that is required. each other in the literature, we should recognize that they
Rosomoff and others)5 point out that, in most cases of are interconnected functionally. The kinetic chain theoryli
musculoskeletal trauma, the accompanying soft tissue injury and the rensegrity model of the body21-29 support the concept
and the resulting release of inflammatory chemical media, that the effects associated with somatic lesions are trans
tors produce the sensation of pain. Myofascial responses to mined throughout the organism. Restriction or dysfunction
injury result from an increased level of proinflammatory in one area or type of tissue can result in reactions and
chemicals present because of the injury or from direct symptoms in other areas of the body. Effective muscu
trauma to the tissues.49 In the latter case it is postulated that loskeletal therapy, including PRT, should address the source
calcium is released from the disrupted muscle, which in tum of the dysfunction, and thus it is essential to have a thor,
combines with adenosine triphosphate to produce sustained ough understanding of the physiology and pathophysiology
contracture) Proprioceptive and neuromuscular responses of the somatic tissues.
are other potentially important mechanisms associated with The muscular system, despite its massive proportions, is
somatic dysfunction. The sudden strain that accompanies maintained in a subtle state of balance and coordination
many injuries engages the mYOtatic reflex arc.n.5) These throughout a wide range of postures and activities. The
The Rarionnle fCYT Posirionni Release Therapy CHAPTER 2 9

muscles are the source and the recipient of the greatest may, theoretically, be applied (Q the osseous component of
amount of neural activity in the body. This includes sensory the dysfunction . IO,'ll
and motor activity, vertical (conscious, cerebral) pathways,
and auronomic activity in relation to the metabolic, vis
ceral, and circulatory demands required during muscular THE SIGNIFICANCE OF THE TENDER POINT
exertion. The muscles, according to Janda, are "at the cross Tender points may arise in any of the somatic tissues:
roads of afferent and efferent stimuli" and arc, in fact, "the muscle, fascia (including ligaments, tendons, articular cap
most exposed part of the motor system."zz Range of motion, sule, synchondroses, and cranial sutures), periosteum, and
segmentally and globally, is largely dependent on the state bone. The tender points in positional release therapy are
of balance ohhe muscles that cross the involved joints, and used primarily as diagnostic indicators of the location of the
restriction of motion may be directly auributed [Q abnor dysfunction. The diagnostic and therapeutic utilization of
maliries in the tone and activity of this system. tender points is central to a wide range of therapies,
The response of muscle to injury is protective muscle including PRT.' An understanding of their pathophysiology
spasm, and this reflex is mediated by local propriocepcors and role in the etiology of somatic dysfunction will help us
and monosynaptic reflexes at the spinal level. The neuro in pursuing our study of PRT.
muscular reflexes involved in this response will be discussed Myofascial pain syndrome (MPS) is defined by Travell
in greater detail later in this chapter in the section on pro and Simons" as follows: "localized musculoskeletal pain
prioceptors. Muscle is interwoven with collagenous and originating from a hyperirritable spot or trigger point (TrP)
elastic fibers and therefore shares certain characteristics within a tallt band of skeletal muscle or muscle fascia." A
with fascial tissue. Fibrous tissue changes within the muscle thorough review of the literature with respect to MP
may thus be a feature of posttraumatic dysfunction. reveals a decided lack of objective criteria for evaluating
The fascial system is a vaSt network of fibrous tissue that and treating this common condition. IS The tender point
contains and supports muscles, viscera, and other tissues (TP) is palpable as a small (0.25 co 1 .0 em) nodule, usually
throughout the body. Injury or inflammation results in located in the subcutaneous, muscular, or fascial tissues,
adhesive fibrogenesis, which may result in the loss of There appears to be a close association between the tender
normal elasticity. According to Barnes! and Becker,] the points used in PRT and by Jones with the Ah Shi points as
collagenous matrix of the fascia is in a state of dynamic described in Chinese writings,S the neurolymphatic points
adaptation to changing conditions, including the effects of as described by Chapman and Owens,9 and the neurovas
strain, trauma, and inflammatory processes. Fascia contains cular points described by Bennett.' (See Chapter I . )
a higher percentage of inelastic collagen fibers than elastin The association o f myofascial trigger points or tender
fibers and thus plays an important role in limiting excessive points with musculoskeletal dysfunction has been estab
motion and conmining inflammation and infection. Alter lished by numerous authors.' Sedentary lifestyles and occu
ations in the electrochemical bonds between collagen fibers pational repetitiveness limit the number of muscles used on
results in the formation of crosslinkages in response to a regular basis. Therefore a relatively small percentage of
chemical irritation related to inflammation, overstretch, or our total muscle mass tends to be ovenvorked, while other
other mechanical influences. As these crosslinkages form, muscles become atrophied and reduced in their ability to
the elasticity of the fascia becomes reduced and the tissue tolerate loads or strain, Postural stress, trauma, articular
alters from a sol to a gel state within the area of involve strain, and other mechanical factors may excessively load
ment. The net effect is the development of an area of myofascial tissues, leading to the biochemical changes
restriction and reduced elasticity, or fascial tension . US involved in the production of TPs. Tender points are most
Neural tension and visceral dysfunction have also been prevalent in mechanically stressed tissues, notably those
cited as separate foci of dysfunction.2,6 These lesions may subject to increased postural demands, such as the upper
represent specific manifestations of fascial tension within trapezius, the levator scapula, the suboccipitals. the psoas,
these tissues. and the quadratus lumborum.l0 On deeper palpation, the
Osseous Structures have long been ignored as active ele intrinsic muscles of the axial skeleton (the multifidus, rota
ments in the pathophysiology of mu culoskeletal dysfunc tOres, levator costorum, scalene, and intercostal muscles)
tion. Recent evidence indicates that bone is much more are also often found to contain active TPs. The "weekend
plastic and responsive than had been previously appreci warrior" often strains the underused muscle groups and
ated. Chauffour" states that fresh long bone has flexibility demands phasic responses from muscles which have adapted
of up co 30 degrees before the induction of fracture. The to a primarily tonic function.
collagenous matrix of bone and the periosteum exhibit inflammarion caused by the initiating injury releases
characteristics similar to fascia elsewhere in the body. In an proinflammatory and vasoconstrictive chemical mediators
injury, bone is no less affected than any other component of such as histamine and prostaglandins. Acute or repetitive
the musculoskeletal system and will display persisting injury
patterns depending on the nature of tile event. Many of 'Refecences 8, 22, 3 1 , 35, 39, 4Z, 45, 48.
the therapeutic modalities used for muscle and fascia 'References 15, ZO, 35, 41, 45, 46, 5457. 58.
10 CHAPTER 2 The Ralionale for PoSItional Release Therapy

trauma may result In the rupturing of the sarcoplasmic to 3 degrees." (See Chapter 4. ) It may be speculated that
reticulum. The ensumg loot! of calcium ions Into rhe toter positionll1g heyond this Ideal range places the antagolllstic
stlrial compartment leads (0 uncontrolled actin anJ myosin muscles or opposing fascial structures under increased
interaction and rhe development of the palpable taut bands suetch, which 111 turn causes a proprioceptive/neural
of muscle associated with myofascial Involvement. The spillover, resulting in reactivation of the facilitated seg#
result of these traumatic events is hypertonicity, inflamma ment. The iueal position is dNermll1cd subjectively by the
[ion, bchemia, anti an increascu concentration of mcrabol patient's perception of tenderness "nd objectively by the
ically active chemical mediators. This vicious cycle, which reduction 111 palpable tone of the tender point. We refer to
will be further perpetuated by repetitive trauma, is thought thIS change as the comfort zone (CZ). This mtrlnsic feed
to be responsible for rhe maimenance of these hypcnrri back system assists In the diagnosis and treatment of mus#
tahle, constricted focal areas of inflammation (TPs) within culoskeletal dysfunction and affords PRT a high level of
the tissues. Z J.4 1,1'1 reliahility within the c1l1lical setting.
Sensitization of nociceptive and mechanoreceptive O'AmbroglO and Welselfish, in their lectures, descnbe
organs within the affected tissues appears to have a role In twO major phases of the release phenomenon: the neuro#
mediating the formation TPs. Group I I I and IV nerve fibers muscular phase, which lasts approxllnateiy 90 econds, and
are sensitive to chemically active compounds such as the myofascial phase, which may last for up ro 20 minutes.
prosraglam.lllls, kinins, hbtamine, and potassium. Micro# WeisclfishSl further Mates that the neuromuscular pha'oC in
scopic examination of muscular TPs reveals the presence of neurologic patients usually lasts for approxllnately 3 mlll#
mast cells (source of histamine) and platelets (source of utes. (See Chapter I .) Clrmcally, several phenomena occur
serotonin). These prolnflammatllry suhstances may con# during the pOSitioning. As one approaches the ez, (he tis#
tribute to the local hypersensluvity that activates the TPs sues 111 the area of the tenuer POInt soften and become less
when mechanical deformation or direct pressure occurs.'o tender. After a period of time, several other observations
The myofascial tis:,ues are, in essence, a continuous net# may he noted. There IS often an II1crease III local tempera
work thar surrounds and penetrates all of the structures and ture. Vibration and pulsation II) the area of the tenuer point
organs of the body without IIlterruption. This can be com# are also common findlllgs as the treatment progresses. The
pared wlrh a piece of woven fabric or a net. Any disruption, breath may he observeJ to alter during the session,
pressure, or kink wlthm this net IS II1stantaneously trans# becomll1g shallow and rapid, followed by several slow, Jeep
mitred to the entire structure and will create a distortion of hreaths. This may occur several times during the treatment.
the previously symmetric architecwre.IU7,}.4 The tender Fascial unwinding may he sensed extendtng from the area of
point may be conceived of as a focus of constriction of the the tender point. The patient often reports several (ransient
myofascial tissues. These nodular focal points of tension symptoms during: the course of the positionmg, includmg
(TPs) within the myofascial continuum may result 111 dis# paresthesia. sensation of heat, fleeting pall1 in other areas
tort ions 111 the biomechanical integrity of thiS matrix. I of the lxxJy, headaches, emotional episodes, and ultimately,
They may also play a role 111 generating Irritable stlilluil, a sense of deep relaxation,
which Illaintain the dysfunction via a facilitated segment The ohserved phenomena associated With somatic dys#
(discussed later). function anJ the therapeutic effect of PRT may be
explained hy several pathophysiological mechanisms: pro

H HE R OLE OF POSITIONAL R ELEASE T HERAPY pnoceptlve systems, nOCiceptive pathways, the facilitated
segment, and fascial dysfunction.
IN S OMATIC D Y S F U NCTION
The role o f PRT in the resolution o f somatic dysfunction i s
assessed within the context o f several o f the current theo#
PROPRIOCEPTORS: NEUROMUSCULAR FEEDBACK
ries of myofascial and neuromuscular pathophysiology. Each In the 1 940s Denslowll and Korr!'U6 began investigating
of these pn.:lCesses may explain a certain aspect of the dys# the role of neuromuscular feedhack sysrem> In the develop
function, and a combination of effects may account for the ment of somatic dysfunction. In functional technic, as
range of manifestations found in clinical practice. uescribed hy HrK.wer, UI range of motion I mOnitored for the
degree of ease or billd. He describes a lesion as having an
exceSSively resistant range of motion 111 one direction and
POSITIONAL RELEASE THERAPY TREATMENT an excessively compliant range in another direction. These
Positional release therapy treatment is accomplisheu by characteristics are nor ascribed to any p<lrticular (issue.
placing the involved tissues in an ideal position of comfort Jones!! is specific in descnbing his technique as the placing:
(POe). The purpose of the POC is to reduce the irmability of the body tn the direction of greatest ease or comfort to
of the tender point and to normalize the tissues associated "arrest tnappropriate proprioceptor activity."
With the uysfunction. Precision is required 111 positioning The proprioceptive organs that monitor the muscu,
the patient becau:)C the range within which the maxi# loskeletal system are locateJ 111 three major areas. The
mal relaxation of tissues occurs is small-usually 2 Ruffini receptors are founu in the jOll1t capsule ilnd report
The Rationale far PoSltioJ1llI Release Therapy CHAPTER 2 II

IntrafuSill
fibers

Extrafusal
muscle fiber

-rh",""""4''--- Encapsulating
connective
tissue

Annulospiral
Flower spray -----J;j':fp'

Fig. 21 Muscle spmdle: and spmal segment.

position, velocity, and direction of motion. This infonna change of length (type la sensory neurons). The veloCIty of
{ion IS trammitted directly to higher centers 111 the cere change of length has great Significance in that it is a predic
bellum and the cerebral cortex and do not seem to have any tive stimulus for potential injury to the muscle and related
JlTect mfluence at the local segmental level. The Goigi tissues. This critical aspect of the sensory function of the
tendon organs arc located ncar the musculotendinous june l11uliCle spindle appears to preJominate III terms of neural
tion and rerond to excessive tension and load on the influence at the spinal level. Thus a force that produces a
muscle. Impulses from these reccproTs exert an inhibitory rapid change III length, such as a sudden stretch on a muscle.
effect at (he spinal level (0 protect the tissues from over will have a more powerful effect in generatmg protective
stretch. The muscle spindles are located between (he reflexes via the monosynaptic connection to the alpha
Il1w;cie fiber.-; of all striated muscle. The mOnitoring system motor neuron. The gamma efferent neurons determine the
nf this complex organelle i uiscu"iseti later.l5.1b.50 length of the intrafusal fibers and establish the threshold for
The muscle ...pindles are perhaps the most sensitive of the stimulation of the sensory neurons. A predetermined resting
proprioceptive organ, to the moment[Qmoment changes tonc, or gamlTlll bias, is maintained to ensure the ability of
III position. load. and VelOCIty of body parts (Fig. 2 1 ). They the somatic muscles to respond to changing demands. TI,e
are connected, threcrly and lIluirecdy, [0 the spinal segment dynamic balance between the muscle spindle and somatic
hy gamma and alpha motor neurons, which supply the muscle as mediated by the gamma system has been referred
intrafusal (mu,cle 'pmdle) fiber; and the extrafusal to as a high#gain servomechanism.2s,l6 This system main
{somatic mU5Cle} fiher, respectively. Two types of receptors tains ideal tone amI preparedness of the muscle and may also
Within d1C mule spindle gcnerate afferent impulses. The be a mechanism for the development and perpetuation of
fIouer spray enJmgs locateJ near the enJs of the spinJles are the response to myofascial inJUry.
stimulateJ by the Jegree of stretch on the intrafusal fibers According to Jones." the muscle spindle apparatus plays
(type 1 \ sensory neurons). The annulospiral endings. a predominant role in the development of somatic dysfunc#
IOGHed around the central nuclear bag of the inrrafusal tion. In his book. Jones describes the effect of a strain on a
fihers, repOft not only degree of ..,trctch, but also the rate of pair of antagonistic muscles (A amI B) on a joint. Figure 2#2,
12 CHAPTER 2 The Rationale far Positional Release ThfTaJry

B A

I I I I I I I I II I I I II

B I I II I I
Neutral Strain Dysfunction

which is divided into three sectiOns, illustrates this theory. sion on the affected tissues and minimizes the stimulation of
Section I represents a joint at rest with approximately an the affected proprir)Ceptors. By some mechanism, as yet nor
equal state of tone within both muscles. as displayed in the understood, maintaming the POC for a minimum period of
electromyogram (EMG) schematic. Section 2 shows a con approximately 90 seconds appears to neutralize this otherl
dition of joint stram. Muscle A is overstretched. causing an wise nonaaapting reflex arc, which is responSible for the
increased rate of neural impulses to be generated withan the continuing hypertonicity. This theory, however, fails to
gamma system. Muscle B is in a hypershorrened state, explain some of the other observed effects associated wid,
resulting in a decreased rate of impulses. The sudden stretch somatic dysfunction.
that occurs in muscle A results in a myotatic reflex con
traction and a rapid rebound from the initial direction of
strain. This produces a sudden stretching of the hypershort
NOCICEPTORS: PAIN PATHWAYS
ened muscle B. The annulospiral endings. which respond Tissue injury is accompanied by the release of i.lf3chadonic
mainly to the rate of change of length. would theoretically acid. ThIS mmates the so-called arachadonic cascade and
be hyperstimulated as muscle B is suddenly stretched. results in the production of prostaglandin, thromooxanc,
resulting in me generation of a massive neural discharge in monohydroxy fatty acids, and leukotrienes. which promotcs
relation co this muscle. Section 3 represents the joint subse# the progression of the inflammatory response and the devel#
quent [Q the mjury. It is unable [0 rerum CO neutral because opment of hyperalgesia. This in tum results in vasodilation,
of the hypershortened state of muscle B.22 Thus muscle B the aUf3ction oflcukocytcs, the release of complcment acti#
may become a primary source of the persisting dysfunction. vacors, and the release of pam;prcx.iucmg neuropepridcs
This explanation may account for one aspect of the dys such as histamine, serotonin, and bradykinln.1411.9.51
function. and in theory it is at this level that PRT may exert Van Buskirk" makes a compelling argument for the role
a major influence during the initial 90lsecond interval of the small myelinated (type III) and unmyelinated (type
(approximately 3 minutes for the neurologic patient). IV) peripheral neurons, which constitute the nociceptive
The POCo by movmg away from the restriction barrier and system and which resrond directly to the chemtcal medta
in the direction of greatest ease, essentially reduces the ten# tors associated with tissue trauma and hypoxia. TI)ese free
The Rationale far Positional Release Therapy CHAPTER 2 I3

Cerebral centers

Central descending
pathways to alpha and
Skin

Triceps
(inhibited)

Phrenic
nerve Biceps

liver. gallbladder,
and diaphragm
Su prasp inatus

Fig. 2-3 Faciliuued segment componen" (C5-7).

nerve endings are distributed throughout all of the connec


tive tissues of the body with the exception of the Stroma of THE fACILITATED SEGMENT: NEURAL CROSSROADS
the brain. These receptors are stimulated by neuropeprides In 1 947, Denslow and Korr" introduced the concept of the
produced by noxious influences, including trauma, chemical facilitated segment and described it as follows:
irritation, metabolic or visceral disturbance, or pathology. A lesion represents a facilitated segment of the spinal cord, main
Impulses generated in these neurons spread centrally and rained in that stare by impulses of endogenous origin entering the cor
also peripherally along the numerous branches of each responding dorsal root. All structures receiving efferent nerve fibers
neuron. At the terminus of the axons, peptide neurotrans; from that segment are, therefore, potentially exposed to excessive
excitation or inhibition.
mirrers such as substance P are released. The response of the
musculoskeletal system to these painful stimuli may thus play The central nervous system (CNS) is continuously sub
a central role in the development of somatic dysfunction. ject to afferent impulses arising from countless reporting
According to Van Buskirk48 and Schmidt,40 nociceptors stations (receptors) throughout the body. Within any given
are known to produce muscle guarding reactions and the segment of the spinal cord, there are a fixed number of sen
autonomic changes associated with somatic dysfunction. sory and motor neurons. Much like the relay centers in a
Because proprioceptors are not present in all of the tissues telephone exchange, there are limits to the number of
that may be connected with somatic dysfunction (bone, vis "calls" that can be handled. If the number or amplitude of
cera ). the role of nociceptors should be considered as poten impulses from the proprioceptors, nociceptors, and higher
tial agents in the perpetuation of the irritable reflexes asso centers channeled to a particular segment exceeds the
dated with these conditions. capacity of the nonnal routing pathway, the electrochem..
The action of PRT on the nociceptive system may be ical discharges may begin to affect collateral pathways. This
exerted through the relaxation of the surrounding tissues spillover effect may be exerted ipsilaterally, contralaterally,
and the resulting improvement in vascular and interstitial or vertically. Impulses may arise from any tissue (fascia,
circulation. This may have an indirect effect on removing muscle, articular capsule, meninges, viscera, skin, cerebral
the chemical mediators of inflammation. The subsequent cognitive or emotional centers, etc.). When these impulses
resolution of the guarding reflexes in the myofascial struc extend beyond their nonnal sensorimotor pathways, the
tures may also contribute to a reduction in the release of CNS begins to misinterpret the information because of the
further nociceptive substances. Postional release therapy effect of an overflow of neurotransmitter substance within
may also act on this traumatic cycle by helping to resolve the involved segment. For example, afferent impulses
"facilitated segments" within the central nervous system. intended to register as pain in the gallbladder manifest as
14 CHAPTER 2 The Rationale for Positional Release Therapy

shoulder pain. The phrenic nerve and portions of the to exert an influence in reducing the threshold within the
brachial plexus share common spinal origins. This may also FS and may thus open a window of opportunity for the CNS
be the basis of so-called referred pain ." to normalize the level of neural activity,4S
The resulting overload at the CNS level is referred to as
a facilitated segment (FS) (Fig. 2-3). Chronic irritation can
involve the sympathetic/autonomic pathways and lead [0
FASCIAL DYSFUNCTION: CONNECTIVE TISSUE CONNECTIONS
trophic and metabolic changes. which may be the basis for In the late 1 970s, Stephen Levin, an orthopedic surgeon,
some of the local tissue changes associated with muscu conceived of a model for the structure of organic tissue that
loskelctal dysfunction. The neuromuscular reflex arc is at could account for many physical and clinical characteris
the crossroads for several sources of noxious stimuli, including tics. Through a process of systematic evaluation of the basic
trauma, viscerosomatic reflexes. and emotional distress. as physical properties of tissue, he arrived at the conclusion
well as the vast proprioceptive system reporting from stri .. that all organic tissue must be composed of a type of truss
ated muscle throughout the body. According to Upledger,47 (triangular form) and that the essential building block of all
the facilitated segment is exemplified by the following: tis ue must be the tension icosohedron.17.19 This model, also
I . HypersemititJiry. Minimal impulses may produce exces referred to as the <emegriry model anJ the myofascial skeletol
sive responses or sensations because of a reduced truss, has gradually emerged as a viable explanation for the
threshold (or stimulation and depolarization at the nature of organic tissue. Recendy, this model has been con
level of the FS. firmed by electron-microscopic methods and through phys
2. Overflow. Impulses may become nonspecific and spill ical stress extrapolation experiments.19,S1 This model
over to adjacent pathways. Collateral nerve cells, lat accounts for the concept of the kinecic chain , which recog
eral tracts, and vertical tracts may be stimulated and nizes that lesions transmit tensions throughout the body
produce symptoms of a widely divergent nature. and that symptoms can be traced back to their source and
Referred pain may be produced. treated indirectly by aligning fascial lines of force in rela
3. Autonomic dystro/lhy. The sympathetic ganglia become tion to the primary focus of restriction { Fig. 2-4). ")4
excessively activated, leading to reduced healing and The implications of Levin's model, from a clinical per
repair of target cells, reduced immune function, spective, are that all tissues share cerrain fundamental char
impaired circulation, accelerared aging, and deteriora actcristics. Indeed, this model confirms that all tisslles are
rion of peripheral tissues. Digestive and cardiovascular alike at the molecular and ultrastructural level. The tension
disturbances and visceral parenchymal dystrophy may icosohedron helps clarify the properties of the tissues and
also develop over time. may be predictive of the effects of any therapeutic system.
Because of the excessive discharge arising from a variety The tensegrity model delineates the following properties of
of recepmrs, the facilitated segment may eventually become somatic tissue: the forces maintaining the structure of the
a selfperpetuating source of irritation in its own right. An body are tension and compression and have no bending
injury, for example, of the biceps produces an increase in momentS (such as in the hinge mechanism ascribed to
high-frequency discharge ( i ncreased neural impulses), joints); the structural integrity of the body is gravity inde
which is transmitted by way of the type la and II neurons, pendent and is stable with flexible joints; the tissues of the
to the spinal segment at the level of CS. If the discharge is body have a nonlinear stress/strain response to external
excessive,. other muscles connected to this segment forces; and the body is a functional lInit, in that forces
(supraspinatus, teres minor, levator scapula, pectoralis applied to it at one point are transmitted uniformly and
minor, etc.) may receive a certain amount of spillover dis instantaneously throughout the entire organism.
charge. This results in an increase in the gamma gain to This model implies that a perceived condition in one
these muscles. Thus several muscles supplied by the same area of the body may have its origin in another area and
segment may have a generally increased setting of their that therapeutic action at the source of the dysfunction will
gamma bias (background tone fed to the muscle spindle have an immediate, corrective effect on all secondary areas,
apparatus), which leads to increased hypertonicity and sus including the site of symptom manifestation. It also may
ceptibility to strain. Other tissues (skin receptors, viscera, account for some of the physiologic effects that produce the
and cerebral emotional centers) may also feed into this loop release phenomenon. I
either as primary sources of highfrequency discharge or sec Because of this interconnectedness of the entire fascial
ondary to the neuromuscularly induced hyperirritability.50 system, restriction in one area may result in a reduced range
Positional release therapy appears to have a damping of morion in a distal stnlcture.J10,14 The area of perception
influence on the general level of excitability within the of pain by the patient, especially in chronic cases, may often
facilitated segment. Weiselfish5l has found that this charac be remore from the area of the most sensitive tender points.
teristic of PRT is unique in its effectiveness and has utilized Because the tender points represent areas of relative fixa
this feature to successfully treat severe neurologic patients tion, these areas are, in essence, splinted, and this results in
even though the source of the primary dysfunction arose lines of tension that extend to peripheral structures. As we
from the supraspinal level. Postional release therapy appears move peripherally from the primary foclls of restriction, the
The Rauonnle frYr POSlClonnl Release Therapy CHAPTER 2 15

reduce the exceSSive tissue ph.1Y and range of motion. Ther#


apies such as fusion or prolotherapy create relative fixation
of tI"ues.1l The reduced mechanical strain and the cnnse
quent diminishment in the release of nociceptive mediators
result In reduced pain. These approaches may, however, also
produce secondary lesions and an increase in aherrant
biomechanics.
It is hypothesized that PRT, hy reducing the tension on
the myofascial system, also engages the fascial componems of
the dysfunction. TIle reduction in tension on the collagenow,
crOS!).llnkages appears [Q induce a dic;engagemenr of (he elec
trochemical bonds and a conversion back to the sol state.
This fascial component of release during the roc appears to
require a maintenance of the positionmg for several mmures.
The 90 seconJ mterval espouoed by Jones theoretically
addresses only the neuromuscular aspect of thc dysfunction.
Some of the effects of the POC may be (brecdy
attrihutable to the changes in the condition of the fascial
matnx Itself. Othcrs may be due to aumnomic and electro
chemical associations betwecn the myofascial structures
and othcr systems."! The resulting reduction in tension at
the level of the pnmary lesion would, III accordance With
the tensegnty m<.xlel, create an equilibration of tension
throughout the orgaOism. The previous discrepancy between
hypomobile and hyperrnobde arcas woulJ be resolveJ, anJ
there would be a reduction in the abnormal hlOmechanical
stresses associated with the stimulation of pain receprors.
Positional release therapy thus appears to be capable of
initiating a release of tension patterns both at the neufU#
muscular level and at the f'lscial levcl. The determining fac#
tors are the preCision and skill exercised by the practitioner
In maintaining thc ideal position and the length of time
requireJ for the completion of the release prt'lCCSS.

, SUMMARY
New paradigms are emerging that are morc coru,I':otcnt with
clinical observation in the field of musculoskeletal dysfunc#
[Ion. Current m(K.lels recognizc the Intrinsic properties of
the tissues and how these arc affectcd at thc ultrastructural
Fig. 2-4 Represenuuion of fascial [erui(m pauems . Icvcl. Somatic dysfunction may manifest within <-lny of the
tissues of the body. Each of these tissues expresses trauma
[cnl'gnty HuCtlirC of the tisslies transmits these forces, and dysfunction In unique ways and is interconnected With
without any Imi of intensity, to an area of the body which ,)11 of the tissues of the body a part of a kinctic challl. Thus
interfaces with external mechanical influences. trauma to one part of the body may result III pe"l>ting dys'
TI'lC hoJy anempts to create a full range of gross motion function in any other pan.
by compenS3nng for arca of relative fixation. This results The render poilU is a clinically recognized exprcs.o;ion
in excessive morton in regions of the hoJy that extend from of somatic dysfunction and is used in PRT a a diagnn'tlc
the focus of dysfunction. Excessl\'c force, Jue to strain or indicator.
repetitive motion against thc restriction barrier, may cause Several pathophysiologic mechanisms may he respon
local mflammation amI pam. The mcreaseu mechanical sible for the development of the c1mical manifesrations
deformation anJ strccch wlthu) these tissues may result in associated with somatic dysfunction. N curomuscular
the release of pain-producing chemical mediacors. Thus responses, mediated by monosynaptic reflexes and musculo
pam may be exprc!lScJ within WiSUCS, which are, III fact, tendinous proprioceprors, can alter the length/tenSion rela#
secondary areas of Involvemem. The goal of treatment of tionship of the muscular component of the dysfunction.
these hypermobile tissues (joints, ligaments, etc.) is [0 Tissue injury results in the release of proinflammltory
16 CHAPTER 2 The Rationale far Posirional Release Therapy

chemical mediators. which in tum stimulate the pain recep 16. Hey LR. Helcwa A: Myofascial pain syndrome: a critical
tors within the involved tissues. This further promotes the review of the literature, J Can Phys Assoc 46:28, 1994.
1 7. Hey LR. Helewa A: TIle effects o( stretch and spray on
development and maintenance of protective muscle spasm
women with myofascial pain syndrome: a pilot scudy, Phys
and may result in a persisting dysfunction, which can iorher Can, 44:4, 1 992 (abstract).
become a focal point for reinjury and continuing pain. This lB. Hoover HV: Functional technic, MO Year Book 47, 1958
cycle of events feeds inm the neurologic phenomenon 19. Imgber DE, Jamieson J: Cells as rensegrity stnlCtures: archi
referred to as the facilitated segment. Other, nonsomatic tectuml regulation o( histodifferentiation by physical forcel:
transduced over basement membrane. In Andersonn LL,
stimuli may also interact with this pathway and lead to a
Gahm CT. Kblom PE, editors: Gene expression during
self#perpcruaring cycle of irritability. Fascial structures nannal and malignanc difierenciation, New York, 198;, Aca
respond to trauma and the ensuing inflammatory process demic Press.
through the production of adhesive cross-fibers and fascial 20. Jaeger B, Reeves JL: Quantification o( changes in myofas
tension, which may impair mobility throughout rhe cial lrigger point sensitivity with the pressure algometer fol
lowing passive metch, !'ain 27(2):203, 1986.
organism. The tensegrity model of organic tissue has given
21. Janda V: Muscle and joint correlations. Proceedings. IV
new insight into the nature of tissue interactions and a FINN, Prague, 1974, Rehabilitation Suppl 10- 1 1 , 1 54
greater understanding of the pathophysiology of somatic 1 58, 1975.
dysfunction. 22. Jones LH: Srrain and COIHucTSlrain, Newark, Ohio, 1 98 1 ,
Positional release therapy theoretically addresses neuro American Academy o( Osteopathy.
23. KalyanRaman UP and mhers: Muscle pathology in pri
muscular hyperirritability and muscular hypertonicity as
mary fibromyalgia syndrome: a light microscopic, histo
mediated by the proprioceptive system. It also appears to chemical and ultrastructural scudy, } Rheuma[01 2 :80B, 1984
reduce tissue tension, allowing for the resolution of the 24. Kanab R, Schaible HG. Schmidt RF: AC[iv3tion of fine
inflammatory response and the release of the electrochem anicular afferent units by bradykinin, Brain Res 327:8 1 ,
ical bonds associated with fascial restriction. Any tissue may 1985.
25. Korr 1M: Propriocepmrs and the behaviour of lesioned scg
be implicated in the pathophysiology of somatic dysfunc
ments, Osreopath Ann 2: 1 2, 1974.
tion. The clinician should be guided by tissue response 26. Korr 1M: Proprioceptors and somatic dysfuncrion,} Am
rather than by symptoms in the search for the underlying Osreopa,h A.!soc 74:638, 1975.
cause and treatment of the dysfunction. 27. Levin SM: The icosohedron as the threeimensional finitl
element in biomechanical supporr. Proceedings of the
References Society o( General Systems Research on Mental Images.
Values and Reality, Philadelphirt, Society of General Sys
1. Barnes J : Myofascial release: the search far excellence, 1990, tems Research, May 1986.
self.published. 28. Levin, SM: The space truss as a mooel for cervical spine
2. Barral JP: Visceral manilm/acion , Scanle, 1988, Eastland mechanics-a systems science concept. In Paterson JK,
Press. Burn L, editors: BClCk pain: an international review, Boston,
3. Becker RF: The meaning of fascia.and fascial continuity, 1990, Kluwer Academic.
Osreopa,hic Ann, 1975:3546. 29. Levin SM: The importance of soft tissue for structural sup
4. Bennett R: In Chapman's Reflexes. Martin R. editor: port of the lxxIy, Spine: Stale of lhe an reviews. 9(2):357,
Dynamics of correccion of abnannal function, Sierre Madre, 1995.
alif, 1977, selfpublished. 30. Lowe JC: Treatment-resistant myofascial pain syndrome. Ir
5. Brown CW: Change in disc treatment saves hockey star. Hammer WI, editor: Functional sofr tissue examinaLion and
Back I.e, 7 ( 1 2 ) : 1 , 1992. treatment by manual methods, Gaithersburg, Md, 1991.
6. Buder DS: Mobilisation of rhe nervous system, Melbourne. Aspen.
1 99 1 , Churchill Livingstone. 31. Melzack R . tillwell OM, Fex EJ: Trigger points and
7. Caillet R: Sol' ,issue pain and disabiUry, Philadelphia, acupuncture points for pain: correlations and implications.
1 980, Davis. Pain 3:3, 1977.
8. Chaitow L: The aeulJuncture treatment of pain, We\lingbor 32. Mense S: Nervous outflow (rom skeleral muscle following
ough, 1976, Thorsons. chemical noxious stimlJlation , ) PhysioI 267:75, 1977.
9. Chapman F, Owens C: InCTocillCtion to and endocrine inlerpre 33. Paris SV: Manual therJpy: treat function not pain. In
tation of chapman's reflexes, selfpublished. Michel TH, editor: Pain, New York, 1985, Churchill
10. Chauffour P: Uen mechanique (mechanical link), Paris, Livingstone.
1 986, Maloine. 34. Rolf I: Rolfing, [he imegration of human scrucwre, New York,
11. Chauffour P: Lecrures (mechanical link}, Palm Beach, FL, 1977, Harper & Row.
1 994, 1995. 35. Rosomoff HL and others: Physical findings in patients with
1 2. Denslow JS, Korr 1M, Krems AB: Quanitative sHldies of chronic intractable benign pain of the neck and/or back,
chronic facilitation in human mo[Oneuron pool. Am J Pain 37:279, 1989.
Phy.ioI 1 50:229, 1947. 36. Roth GB: Towards a unified model of musculoskeletal dys
1 3. Dorman TA, editor: Prolotherapy in the lumbar spine and function. Presented at Canadian Chiropractic Association
pelvis, Spine: "are o[ ,he AT! Review. 9(2), May 1995. 1nnual mccting. June 1995.
14. Gray G: Functional kinetic chain rehabilitation: overuse 37. Ruch TC: Pathophysiology of pain. In Ruch T, Patron HD
and inflammatory conditions and their management, Sports editors: Physiology and biophysics: the brain and neural fWlc
Medicine Updare, 1993. ,ion, ed 2, Philadelphia, 1979, Saunde".
I S. Henriksson KG: Microscopic and biochemical changes in 38. Saal JS and olhers: Biochemical evidence of inflammation iI
fobromyalgia, Proc I " 1m Symp MP May 1 989 (abstract). discogenic lumbar radiculopathy: analysis of phospholipase
The Rationale far Positional Release Therapy CIiAPTER 2 17

Al ac t i v i ty 10 human hcrniareJ Ji<,e, In ProceeJLng of rhe 50. Wall PD: PhyslololCal mechanisms mvolved In the pro
Imcrnatinn<1i Soclcty for Study of the Lumhar Spine, duction and relief of pam. In Bonica J, Procacci P, Pagm
Kyoto, J apan, 1989. CA. editors: Recent admnces in pam pcuhophysiologrcal and
39. Sarno JE, Mmd VI'", hack [XUll , New York, 1982, Berkley. clonical aspects, SpnngflclJ, III, 1974, Charb C TI,0m<l>.
40. SchmlJ, RF, KnlHkl KD, Schomberg ED, Dcr Eonfu" Kleon 51. Wang N . Butler JP, Imgber DE: Mechanotransduction
Kahhriger Muskelaffcrenten fluf den Mukeltonus. In Bauer across the cell surface and through the cytOskeleton, SCience
HJ anJ ", her" Therapoe der S"'IIk, 1 98 1 , Veri,lg fur .nge 260, 1 1 24, 1993.
wilnJte WI:>.!!Cn::.chafren. Munchen. 52. Weinstein IN: A natomy and neurophYSiologic mecho.lOl!)ms
41. ScuJd!. RA, Ewart NK, Trahel L The (reJrtnem of of spinal pam. In Frymoyer JW, editor: The adult sl>me: prin,
myo(iThClal trigger points with hellUmneon and gallium. ciples and practice, New York, 1 99 1 , Raven Prcs.
arsenide laser: a blmJcd, crossover trial, Pam 5(suppl):768, 53. Welsclf"h 5, Manual rherapy for the ormol><d;c and ne"",
1990 (a\Y.,tmct). logic patient emphasiting sn-run and counterstram rc!chmque ,
42. Smith FF: Inner hridges: a guide w ('nerg)' mOl'emenl and body Hartford, Conn. 1993, Reg ional Physica l Therapy,
srructllTt.'. Adant!,.. 1986, Hunl<m ics New Age. self-pub l IShed.
43. SmoklerdJ: Myofas.c.:ial (rigger '"""li nts. In Hammer W I , 54. Wolfe F: The clinical synJrome of fibro'>ltis, Am J Med
edi tor: FUllc[icnuzl sofr [!Slue exammarion and trearmem by 8U, 1 986.
manum mecJlOd.s, Gau hershurg, Md, 1991. Aspen. 55. Wolfe F: FibroSitis, flbromyalgla and mll"Culoskeleral dis
44 Snow CJ and others: RanJomlzed controlled c1mical trial ease: the currenr status of the fibro:,tt1s syndrome, Arch Ph)s
of srrcrch and l'ipray for relief of back and nec k myofasc lal Med Rehab 69'\27, 1 988.
paon, Physiorher Can 44,8, 1992 (abstrdct). 56. Wolfe F and others: The fibromyalgm and myofascial paUl
45. T",vei l JG, S,mon; D() MyofascIlII pam and dysjomcllon, the syndromes: a preliminary study of tender POUlt'> and tngger
mgger I)Omr manual , Baltllnorc. 1983, Wdham & Wilkms. POUlrs in persons wilh fibromyalgia, myofascial p. u n syn,
46. Travcll JG, Rimier SH: The myofasc ial genc:,is of pam , d rome and 110 d isease, ) Rheuma,oI 1 9(6),944, 1 992.
POSlgrad Med I I A25, 1952. 57. Wolfe F and others: Cnteria for fibromyalgl<l , Anhnus
47. Upledger JE, The facoi l tatcJ segment, Massage Ther), Rheum 32,547, 1989.
Summer 1 989. 58. Yunus MB and others: Pathological changes III muscle III
48 Van Bukirk RL: NociceptIVe reflexes and [he somatic dys rrimary fibromyalgia syndrome, Am J Med 81 :.38, 1986.
function, a model , ) Am Osteopath Assoc 9,792, 1 990.
49. Vane JR: Pam of mflamm:mon: an introduction. In Bonica
J, Lmdhlom U, 19J::o A, cdu()fs: Admnces in pain research
and dlL>ratry, vol 5, New York, 1 983. Raven Press.
3
Therapeutic Decisions
What Is Positional Release Conditions of the Spine. Rihs.
Therapy? 20 Pelvis. and Sacrum 22
Conditions of the Upper Quadrant 22
The Effects of Positional
Conditions of the Lower Quadrant 23
Release Therapy 20
Motor Vehicle Accident Cases 23
Contraindications to the Use Geriatric Patients 23
of Positional Release Therapy 20 Pediatric Patients 23
Which Conditions Respond Best Sporrs Injuries 23
to PoSItional Release Therapy? 21 Respiratory Patients 24
Amputees 24
When Is It Appropriate to Use
Neurologic Patients 24
Positional Release Therapy? 21
Summary 24
Who Can Benefit from
Positional Release Therapy? 22

The activities of daily living, work, and recreation provide It IS evident that our lives provide Inany opportunities
many orpof[unitie for protective muscle spasm to flCcur. for soft tissue mjury to occur. The human hody h"'1s an
Protective muscle spam or guardmg {muscle hypertonicity incredible ability to adapt to several minor stresses, hut as
that (lecun; as the result of an injury, slich as a strain; in soon as the number increases above a certain range, which
response (0 ahnormal biomechanics; or as a reaction to may be Jifferent for each tndividual, the body ha, less room
emocional stress or a pmhologic process, such as inflamma to adapt. Finally, it reaches a point where it cannot i.lJlPt
tion) may c)(:
. cur any further. Once the physiologic adaptive range has been
through repetitive smaller movementS, or 1 5 ,
.. consequence exceeded, there is a greater susceptibility to injury,s For
of bruising, straining. or tcaring,l Events that can result in example, a person may bend over to pick up something, an
muscle guarJmg mclude falls. catching oneself while failing, action the person has performed repeatedly without lIly
improper lifting, motor vehicle accidencs, throwing injuries, problem. Today, however, the person's back "goe, out." The
and unexpected sudden movemencs. Most people experi; injury is usually not caused by that particular movement but
ence severnl injuries over a lifetime. The injuries may be the accumulated stresses to the body over a lifetime. This
cumulative, especially if nO properly neated. For example, was the "straw that broke the camel's back."
most infanrs fall severnl times while learning how to walk. Over the years the body may develop certain areas of
Children fall off tricycles, sliJes, and swings and usually muscle guarding, joint hypomohility and fascial tension.
experience some TOugh;and;wmble play. As they grow older ThIS affece, functional mohility and flexibility and can leaJ
they participate in a variety of sports and other rigorous to faulty posture. When this dysfunctional body is put into
activitie:;. Adolescents and aJults enter the workforce, and motion, such as in recreational or work;relateJ actiVities, or
their employment may require awkward positions that is subject to an accident, [he preexisting uysfunction influ;
Involve lifting. Add to these common experiences any ences the resulting condition of the body. For example, five
numher of severe injuries, stich as falls and motor vehicle people involved in [he same car accident Inay suffer com;
accidents, and one can easily understand the presence of pletely different mjuries. One may get low back pam, one
the numerous lesions that are observed clinically. may experience shoulder pam, another may get cervical and

19
20 CHAPTER 3 Therapeuric Decisions

temporomandibular JOint (TMj) pam. The fourth person may This appears to ease the tension around the jOint,
feel pain in all these areas and the fifth person may not expe which allows it to move morc freely. Therefore proper
rience any pain or dysfunction. The extent of the current biomechal1lcal movement is restored to the jomt.
injury relates to the condition of the tissues at the time of the 4. Increased circulation and reduced swelling. As the
accident and the dysfunctions that were previously present. musculoskeletal structures are relaxed using PRT, pres
The aim of positional release therapy (PRT) is to identify sure appears to be relieved on imcrvenmg structures
areas of dysfunction and nonnalie the somatic tissues to such as blood and lymph vessels. The result may be
improve the general condition and adability of the body. increased circulation, which m tum aids m the
healing of damaged tissue. The Improved lymphatic
drainage assists in the reabsorption of tissue fluids. thus
'WHAT Is POSITIONAL RE lEASE THERAPY? reducing the swelling associated with inflammation.
Positional release therapy is a method of total body evalua 5. Decreased pain. The pam of Jomt dysfunction is posi
tion and treatment using tender points (TPs) and a position [Jon oriented. from sc\'ere pain In one position to
of comfort (POe) to resolve the associated dysfunction. almost complete comfort in the opposite position. The
PRT is an indirect (the body part moves away from the resis patient has pain, which may be associated with muscle
tance barrier, I.C., the direction of greatest ease) and passive guarding. fascial tension, and restriction of joint move..
(the therapist performs all the movements without help ment. Positional release therapy appears to alleviate
from the patient) method of treatment. All three planes of muscle spasm anu restore proper rainfree movement
movement are used co attain the position of greatest com and tissue fleXibility. The patient may have some
fort. Once the most severe tender poims are found, they are remaining discomfort because of residual mf1amma
palpated as a guide to help find the POc. The POC pro tion, but the sharp pain is often slgI"Iificantly reduced.
duces optimal relaxation of the involved tissues. 6. Increased strength. By normalIZing the proprrocep
One theory holds that while in the position of comfort, tive and neural balance withm muscle tissue and
there is a reduction and arrest of inappropriate propriocep' removing inhibition caused by pam, PRT can help
rive activity.6 As a result of treatment using PRT, there is a restore normal tone and function of the involved mus
decrease In mUM:le tenion. fascial tension, and joint hypo; c1es. Thus PRT may optimIZe the blomechanical effi
mohility. These changes in (urn result m a Significant increase ciency of muscle and Improve the responsiveness to
in functional range of 1110[ion and a decrease in pain. prescribed conditioning exercises.

n HE E F FE CTS OF POSITIONAL RElE ASE THE RAP Y , CONTRAIN DICATIONS TO THE USE
The following are six treatment outcomes using PRT:
OF POSITIONAL RE LEASE THE RAPY
1. Normalization of muscle hypertonicity, Clinically it If the therapist is following the PRT general rules and prin
has been found that the first, or neuromuscular, phase ciples as srated in Chapter 4. there are only a few con
of the PRT treatment lasts approximately 90 seconds rraindications to be aware of. stich as maltgnancy. aneurysm,
for general orthopedic patients' and J minutes for and acute rheumatoid arthritis. The following are regional
neurologic patients.11 Positional release therapy contraindlcations to the use of PRT:
appears [0 affect inappropriate proprioceptive activity Open wounds
during thiS phase, thus helping to normalIZe tone and Sutures
set the normal length,rension relationship in the Healing fractures
muscle. This results in (he elongation of the involved Hematoma
muscle fibers [Q their normal sr3rc.6.1 J Hypersensitivity of the skin
2. Normalization of fascial tension. It is hypothesized Systemic or localized mfection
by D'Ambroglo' and Weiselfish 12.11 that the second, The patient should always complete a thorough history
or fascial, phase of the PRT treatment begins after 90 and evaluation before beginning treatment. A complete
seconds for general onhopedic patiencs and after 3 diagnostic workup may also be necessary. Although a cer
minutes for neurologic patients. Durmg this phase, PRT tain PRT technique may not be recommended for one area
apparently begins to engage the fascial tension patterns of the body because of one of the aforementioned con
as:,()c13teU with trauma, inflammation, and adhesive tramdications. it may be safe to use on other regions.
pathology.2.7111is process may Involve an "unwinding" Always proceed with caution, taking Into account the emo
action in the myofascial tissue. I I A significant release tional state of the patient. Allow the patient to make
response may be palpated during this phase. informed decisions.2
J. Reduction of joint hypomobility. When the muscles When placing the patient into the position of comfort,
crossing jOints become hypertonic or tight, the result it is imperative that the tissues he allowed to relax. There
is joint hypomobility (i.e., joint stiffness). By using should be no palpable tendemess or pam, and the patient
PRT, the affected muscles and fascial tissues relax. should never be forced mto a position. It must be a com
Therapeutic Decisions CHAPTER 3 21

fortable process with the patient 10 a completely relaxed , WHE N Is IT ApPROPRIATE TO U SE POSITIONAl
position. Although It IS emphaSIZed that the patient should
experience no pain while being placed in rhe POC, pain or
RE lEASE T HE RAm
paresthesia may develop during the treatment. This is There are four phases of treaunent, which comprise struc
normal and usually lasts I to 2 minutes. It is part of the tural and functional rehabilitation.
release process, 10.1 I Phase 1. This phase deals with treating patients 10 the
Problems tend to arise when the therapist tries to force a acute phase of the injury. Positlonal rele.,e therapy is the
patient IOta a POC. If the patient is in immediate discorn, treatment of choice in this phase and can be useJ imme
fort on being placed in the position, this may indicate rhe diately after Injury because of ItS gentleness. Positional
presence of a conflicting lesion. In this case the therapist release therapy helps reset the inappropriate propriocep
should search for another significant tender point or use tive actiVity and decreases the amount of muscle spasm,
another modaltry. joint hypomobtlity, and fascial tension. It can create a
Special care must be taken when working on the neck better environment for healing to take place emu help
with regard to the vertebral artery.- When extending the decrease the sharp pam and swelling that may develop.
patient's head and neck over the end of the table, it is essen Positional release therapy can be extremely effective in
tial to go down the kinetic chain extremely gently, keeping rhis phase of recovery and may significantly reduce
the suboccipital region in flexion and axial extension. The downtime for athletes and help promote a rapid return to
patient's eyes must be kept open, and the therapist should preinjury status. Once in the clinic, rhe therapisr can
monitor for signs of vertebral artery compression (such as also integrate other modalities, such as icc, microcurrcnt,
nystagmus)- It is recommended that the therapISt keep pulsed ultrasound, and taping, and use of assisrive
calking to the patient or questionmg the patient regarding devices such as canes, crutches, and splints.
dizzmess. It is important to use sound judgment and [0 Phase II. This phase deals with treating structural dys
ensure that the patient is always taken into a position of function with lx>th acute and chronic parients. With
ease. The therapISt should feel the tissues becoming relaxed. chronic patients, there are w;ually several aretlS of long
As long as these gUideltnes are followed, the nsk of harm to standing dysfunction. Positional release therapy by Itself or
the patient will be mmimized. in conjunction With other manual therapies can he used [0
reduce spasm, jOint hypomobility, and fascial rension. This

, WHICH CONDITIONS RESPOND BEST can result In improved postural alignment anu an Increase
in functional mobility and flexibIlity In the spine, nbs,
TO POSITIONAL RElEASE THE RAPY? pelvis, and penpheral jomts. There is usually a decrease 10

As mentIOned earlier, PRT treats protective muscle spasm, pain. This enables the patient to move much more easily
fascial tension, and JOtnt hypomobility, which are usually the and comfortably. At this point, mobility and Strength
result of a physical tnJury. Therefore any patient who has a ening exercises can be adJed to further facilitatc changc
distmct, phYSical mechanism of tnJury wtll respond favorably and to progress the patient to the next phase. This phase
to PRT. These mclude injuries resultmg from falls; improper prepares the patient's boJy for movement.
lifting; throwing; motor vehicle accidents; sudden, unex Phase Ill. Phase III deals with the restoration of hmc
peeted movements; and sports. The degree to which the tionaI movement. Once the pauent has overcome (he
patient responds depends on the degree of dysfunction that acute and srnlctural phase, he should be moving more
preceded the acute IIlJury. easily with less dIscomfort and be ready to progress to a
Those patients whose pain commenced Insidiously with more dynamic movement program. This Includes cardio
no obvious immediate mechanism of mjury but who have a vascular fitness (aerobics), strengthening (weIght lifting),
hIStory of trauma also tend to respond well to PRT. In these and a continuation of flexibility and mobility exercises
Ca5C>, the pain may be the result of surpassing a physiologic from phase II. The patient at this stage should not be ex
adaptive range. So-called repemlve strain injunes (RSls) may penencing any sharp pain, although Jull pam may occur
result from excessIve challenge to the acccumulated muscular with the healing process. The patient's range of motion
guarding, fascial tension, anti/or Jomt restrictions. Treatment should be relatlvely pain free. The focus of therapy is on
directed to these background dysfunctions may allow for res improving functional movement, strengthening muscles
olution of these rypes of conditions. Those patients who have for structural support, and improving cardiovascular fitness.
had acute or chroniC pam that arose insidiously with no clear Phase IV. Phase IV deals WIth nonnalozatlon of lIfe activ
mechanism of injury or history of trauma tend not to respond Ities. It takes mto consideration the patient's lifestyle and
as well. Their dysfunctIons tend to be related to stress, visceral goals. Is the patient able to continue with hiS work, actIv
dysfunction, pathology (e.g., infections, tumours), or surgical ities of daily living, and sports or recreational activities?
Intervention. Initial evaluation of the patient and subjective Does he need retraining, lifesryle modification, or addI
findtng> should help identify these red flags. An appropriate tional therapy? Appropriate refe<rals to other profeSSIonals
referral for further Investigation may be necessary to ascertain or functIonal capacity evaluation shaulll be consiuereu to
underlying conditions. facilitate thIS final transitional phase.
22 CHAPTER 3 Therapeutic Decisions

All four phases are important, and sometimes patients


must progress through all phases. However, each patient
CONDITIONS OF THE SPINE, RIBS, PELVIS, AND SACRUM
muSt be evaluated as an mdividual. For example. a patient Patients with a herniated disk, facet Impmgement, stenosis,
may need only the wellness program because she is uccon# fusion, spondylolisthesis, degenerative disk disease,
ditioned. Another patient might require only some mantlal arthTltis, scoliosis, fracture, postsurgical lammectomy, post
therapy. Prohlcms can arise, for example. when a patient surgical diskectomy, HarTington rods, sacroiliac pain, lum
who has low back pam is treated only as an acute patient in bos",cral pam, lumbar strain, myofascial pain, or coccydynia
phase I. The patient may be treated with ultrasound, icc, or have all benefitted from PRT alone or in conjunction
electrical sumularion for 3 months, and rhen when therc is with other moJalities. Positional release therapy is not c()n
no improvement, she is thrown inm a work#haruening pro# trallldicated in patients with osteoporosis, as trcatmcm IS
gram or functional capacity evaluation. She will likely fail completely nontraumatic. As srated previollsly we feel that
miserably because she is nO[ conditioned and no one has PRT does not repair these ratholgic or surgical conditions.
worked on the dysfunction in her !)opine or peripheral joint. Positional Release Therapy treats the dysfunction hy
In some clinics, patient') are put into a wellness program decreasing muscle hypertolllcity, reduclllg fascial tension,
Immediately, withollt any manual therapy being done. anJ restoring jomt mobility. As a result, the patient will
Patients must he prepared for exercises. Do they have some begin to move more easily and with less pam. In cases of
ptnal Impairment! hi there some muscle guarding, fascial severe restnctum of motion, It is possible to apply PRT only
tension, or Joint restriction which might impede them from within this limited available range. The positioning will
exercising properly! Other clinics may treat a paticnt with gradually approach the optimal POe; however, this may
only manual therapy and without including any exercise. require several successive treatments. With the IIlcorpora
Consequently, it is a passive process, and the patient has no tion of mobility, flexibility, strengthening, and cardiovas
responSIbilitIes. ThIS approach may also (ail with many cular exercises, the patient should respond well.
patients because their dysfunction might be directly caused OrthopedIC surgery dlles not "ddress the underlymg dys
hy a sedentary lI(estyle, which has not been addressed. function. There may be a postsurgical reuuction III s)lmp
To achieve succe, It is essential that all patients be toms; however, thi:; is not always the case, and relief is often
evaluated (() determine their !o.pecific requirement<;. Some of only short duration.] In thee cases it is appropriate to
patients may require acute attention, such as icing or other trear the dysfunctions uSlIlg comervative manual methods
modalities. Onc patient may reqUIre minimal handson and other modaltties to normake the tissues and restore
treatment, whereas another may need extensive handson optimal biomechanics.
therapy to alleviate restricted jOlllts, fascial restrictions, or It is our opinion that in many cases ;]ttributeu to Ji5k
protective muscle spasm. After treatment the patient pachology, arthritis, or stenOSIS, the symptoms may, III fact,
should progress IIlto a wellness program where his muscles !)e caused by soft tissue uysfunction. What appears as a
arc being worked appropriately, and the therapist should pathology on an xray may be the end result of abnormal
encourage hlln to exercise on hiS own. Finally, whether the biomechanics, which is the result of the dysfunction."
pfltient can return to his previous employment must be con Unfortunately, soft tissue or articular dysfunction cannot be
siucred. Each paticnt must be individually evaluated <.lnd a visuali.:ed using currell( IInaging technology, and thus the
unique and !)pectalized plan followeJ. patient's symptoms are oftcn atrthutcd to abnormalities
associated with an osseous Image. Conservative functional

, WHO CAN BENE F IT F ROM therapies, such as PRT, should be considered before surgIcal
options are lIlitiateJ.
POSITI ONAL RE lEASE T HE RAPY1
A wide assortment of patients, from IIlfants to geriatric
patients, can henefit from PRT. The human frame may he
CONDITIONS OF THE UPPER QUADRANT
viewed as an evolutionary compromise. The bipedal posture Patients who have been diagnosed wi(h burSitis, rotator cuff
and the WIde range of motion afforded the upper IlInbs have tendinitis, impingement syndrome, thoracic outlet syn
allowed humans to dominate their environmem. n,ese drome, acromioclavicular sprain, stcrOllClavicular sprain,
adaptations, however, have not been without a cot. A rostfracture conditions, frozen shoulder, tennis elbow, and
higher center o( gravity and reduced stability in the upper golfer's elbow have benefited from PRT.
quadrant cause humans to be more vulnerable to transla TIle shoulder IS an inhcrently unstahle JOint and relies
[ional forces anu resulram musculoskeletal injuries. Posi heaVily on the muscles that cro it for support. Careful
tlonal release therapy, because of its efficiency and gentle examination of all of these tissues should be carried our
ness, is appropriate for a wide range of injuries to which when locally assessmg this jomt. T he upper limb IS directly
humans are subject. Imked to the cervicorhoracic spine and rib cage III relmion
Treatment IS always directed to the mdlvldual and the to nerve supply, circulatory supply, and muscular and fascial
indlviuufll's unique set of dysfunctions as opposeu to a uiag extenSions. It has been founu clinically that dlrJers of the
noscu condirion or group of symptoms. shoulder, elhow, wrist, and hand may often arise from
Thera/Jeuric Decisions CHAPTER 3 23

primary dyfunc[lons of the axial skeleron. Commonly, sig, injuries. Most elderly patients feel that the pain in their hip
nificant tender poinrs are present in the cervical spine, tho or knee is due to arthritis or is a factor of age. They do nOt
racic spine, or rib cage, that, when treated according to the believe that much can be done for them. When confronted
general niles, help resolve many of the conditions that with this argument, the therapist may wish to say to the
cause primary symptoms in the upper limb. patient, "Your right and left knees are the same age, so why
did only one knee develop the arthritis?" This type of rea
soning may encourage them to reconsider their limiting
CONDITIONS OF THE LOWER QUADRANT belief and thus allow them to cooperate more fully with the
Patiems with hip bursitis, tendinitis, rotal hip replacemem, treaunent program.
arthritis, jumper's knee, rotal knee replacement, patellar Usually, when elderly patients are exposed to PRT, they
tendinitis, chondromalacia, menisclls tears, ligament sprain, quickly accept it because it is gentle and effective. Positional
capsu\itis, and plamar fasciitis have all responded success release therapy may be able to release several chronic dys
fully to PRT. Positional release therapy addresses the flmc functions that have been preventing the patient from
tional component as opposed to the pathology. In cases of achicving a normal functional range of motion. These
total hip and knee replacements, the tissues will still be able patienrs are often surprised and excited with the results. They
to guide the therapist. Sometimes the therapist may feel find themselves moving more easily with less discomfort and
that the hips arc being placed in a compromising position, pcrfonning movements that they have not done in years and
but ifrhe tension in the tissues is relaxing, the tenderness is assumed they had lost forever. These may include tying shoes,
disappearing, and the patient states that it feels good, she looking both ways whcn driving, riding a bike, walking,
should continue with the treatment. Therefore it is impor swimming, and other activities of daily living. Osteoporosis is
tant for the therapist to continually monitor for changes. a consideration with this patient population. PRT may be the
Muscle guarding, strains, and sprains are common in the treatment of choice in these cases and it is a gentle technique
lower quadram. Positional release therapy can be effective which the elderly generally tolerate very well.
at treating injuries involving the hip, knee, ankle, and foot
and can help the patient progress to a weightbearing and
walking stage quickly. PE DIATRIC PATIENTS
Infants and young children with torticollis, brachial plexus
injuries (Erb's or mixed palsy), and colicky babies have been
MOTOR VEHICLE ACCIDENT CASES treated successfully with PRT. Sometimes it may be difficult
Patients who have been involved in a mOtor vehicle acci to communicate effectively with this patient population,
dent respond well to PRT, as in other cases where there is and there is a need to rely on observation and palpation
a clear mechanism of Injury that is traumatic in nature. If skills. For example, in the case of an infant with a right
the accident is severe and there are many conflicting sided torticollis (i.e., right side bent and left TOtated cervical
tender points, a severe tender point in another area, as spine), evaluation of the movement restrictions may reveal
determined by the scanning evaluation (SE) (see Chapter reduced left lateral flexion and right rotation. One may also
5), may neeJ to be treated initially. Otherwise craniosacral palpate hypertonicity in the sternocleidomastoid (SCM)
therapy, myofascial release, or other modalities may be used muscle on the right side. Treatment is a Simple matter of
as initial interventions. Once the conflicting protective reproducing the action of the SCM muscle. The child's
muscle spasm has diminished, PRT in the local area may be neck is treated by placing the child into flexion, right lat
instituted. If thc injury is minor to moderatc and it is pos eral flexion, and left rotation. The therapist feels for soft
sible to localize a distinct tender point and find a POC, the ening of the involved SCM muscle as a guide. Clinically,
results with PRT will be good. Positional release therapy this technique is much more effective than stretching the
alone has helped with cervical sprains and strains, muscle. The child will likely be more cooperative because
headaches, tinnitus, dizziness, and TMJ dysfunctions. the treatment is more comfortable than stretching.
Therefore, depending on the severity of the accident and Infants and very young children are best treated close (Q
which systems have been affected in the patient's body, an their nap time or after feeding. The assessment may be per,
integration of the various manual therapies is usually effec fanned during the initial visit without treatment, in order
tive. Early post#injury intervention has been clinically to gain the child's confidence. This also provides an oppor
found to reduce the incidence of secondary compensations tunity to make the treatment session as short and efficient
and conflicting tender points. This can simplify treatmenr as possible and to arrange it at an optimal time within the
and speed recovery. child's schedule.

GE RIATRIC PATIE NTS SPORTS INJURIES


Arthritic conditions may develop in one hip or knee Patients with sports injuries respond extremely well to PRT.
because of biomechanical imbalances arising from previous As mentioned previollsly, PRT works best when there is a
24 CHAPTER 3 Therapeutic Decisions

c1earcut mechanism of injury that is traumatic in nature. release when treating individuals with hypertonicity sec
With the exception of the weekend athlete, this population ondary to both upper and lower motor neuron lesions. T hese
is in good shape and responds quickly to PRT. The younger patients include those With traumatic bram injury, cerebral
athletes who have fewer accumulated dysfunctions respond vascular accident, multiple sclerosis, cerebral palsy, and
espeCially well. Weekend athletes wHi also respond, but If spinal cord injuries. Patients with hypotonia or atonia (i.e.,
they have an accumulation of dysfunctions. they may not flaccid ann and leg tone) are not appropriate for treatment
respond as quickly. using PRT. This is a regional consideration only;
For the most parr, rhe treatments for this population an individual may have flaccid patterns m one area of the
arc straightforwarJ. Common injuries such as sprained body and a spastic pattern in another region. The hypertonic
ankles, hamstring or calf strains, knee ligament sprains, or spastic region would be amenable to treatment using PRT.
pelvic or sacroiliac strains. and rotator cuff and elbow Positional release therapy may be used to normalize tone
injuries can be treared effectively using PRT in conjunction in order to assist with tfimk elongation, improve pelvic
with rangcofmotion exercises, strengthening exercises, positioning, and increase mobility and functional movel
and other modalities. ment. Posttonal release therapy helps create an improved
neuromusculoskeletal environment that allows for optimal
implementation of a neurodevelopmental program.
RESPIRATORY PATIENTS It may be difficult to communicate With this patient por
Patients who have dIfficulty breathing can benefit from PRT. ulation. Therefore it is essential to be aware of postural dys
Many respiratory patients are taught breathing exercises for function and movement restriction patterns and be able to
energy conservation and to Improve their respiratory poten palpate changes in tone of the affected muscles. As an
tial. These are functional 10 nature. However, restricted rib, example, a neurologic patient has increased flexor tone in
splOe, pelVis, and hypertonic muscles may prevent these the hIps. Palpation of the involved muscles and an evalua
patients from achieving full funwonal benefit. They can only tion of the range of motion confinns this finding. This
achieve a certain potential with these breathing exercises. patient will tolerate flexion and external rotation of the
Therefore by treating the restrictions in the spine, pelvis, ribs, hips but may not tolerate extension. Treatment uSing PRT
and hypertonic muscles (I.e., diaphragm, psoas, quadratus would involve hip flexion and external rotation. The therl
lumborum, and Intercostal muscles) the patient may be able apist would follow the ease of movement of the tissues and
[Q expand the rib cage more fully and with greater ease and palpate the hip flexors to be guided Into the POCo
may be able to perfonn breathing exercises to a greater poten Remember that neurologic patients require an initial posi
tial and with more comfort. It is important to understand that tioning of a minimum of 3 minutes for the neuromuscular
PRT does not treat the respIratory dISease but rather Improves release. A fascial release will occur after rhis.
breathing mechaniCS, whIch may support the healing process, For additional information regarding the treatment of
and makes the patient feel more comfortable. the neurologic patient, refer to the Ii&t of common tender
points for the neurologic patient and WClSelfish's postural
pathokinesiologic model In the Appendix.
AMPUTEES
Some amputees with a history of trauma (e.g., car accident}
benefit from PRT. When the pelvis, sacrum, spine, and non
affected leg are treated, this may result in bener alignment PoSItional release therapy has been found clinically to work
and comfort when sitting in a wheelchair. When the best where there has been a clear mechanism of mjury,
patient has pain or exceSSive pressure on the stump, theral either acute or chronic in nature. Therefore history of
rists often assume that the prosthetic device needs trauma is Important in the patient's initial evaluation. Posi
adjusting. The practitioner should fil'>t evaluate for dys tiona1 release therapy has been found to benefit a WIde
functions In the patient's pelvis, sacrum, spine, and other assortment of patients. Positional release therapy is pri
sites and provide appropriate treatment. Often, this is marily used III the first two phases of rehabilitation, the
enough to realign the patient's body, decrease the pain, and acute and Structural phases. It mu't be understood that PRT
reJuce the excessive pressure or discomfon that the patient does not change pathologic or surgical conditions. The
is experienCing. If pain or discomfort prevents these therapist is not treating a "diagnosis." He is treating a
patients from exercising or walking, PRT can be used in human being WIth dysfunctions. The alln of PRT is to
conjunction With other techniques such as mat exerCises, remove restrictive barriers of movement m the body. This LS
and galt and balance training. accomplished by decreasing protective muscle spasm, fascial
tension, joint hypomobtlity, pain, and swelling and
increasing circulation and strength. As a result the patient
NEUROLOGIC PATIENTS begins to move more easily, with less pain and discomfort.
POSItional release therapy has been used successfully along he can then be progressed to phases III and IV, the well.
with craniosacral therapy, muscle energy, and myofascial ness and work reconditioning phases of rehabilitation.
Therapeutic Decisions CHAPTER 3 zs

References of Genern! Systems Research on Mcmal lmacs, Valves and


Reality, Philadelphia, Society o(Gcneral System.') RCSI..>arch, May
I. Anderson DL: Muscle pain relief in 90 seconds: {he fold and hold 1986.
method, Minnearoli. 1995, Chronimed. 8. Rosomoff HL and others: Physical findings In p3Ucnts with
2. Barnes J: Myofrucial release: the search JOT excellence, 1990, chronic Intractable benign pain of the nl.'1:k and/or hack. Pam,
self-published. 370279,1989.
l Brown CYI/: The narural hltor'i of thorncic uisc degeneration, 9. Saunders HO; Eva/Italian, {rcatment and prevention of musculoslwlawl
S()ine, (suppl) June 1992. disorders, Mmneapolis, 1989, Viki ng Press.
4. O'Ambrogio K: StTain/colinrermam (course syllabus), Palm Beach 10. Smith FF: Inll>f bridge.s-a guUk 10 energy mOt-'t!meflf and body
Gardens. 1992, UpleJger In!olitutc. mucwre, Atlanta. 1986. Humanics New Age.

5. Gelb H: Killing pam WIthoUt presrnpuon, New York. 1980, 11. UpleJgcr JE: CrlllniosacraI lherapy, Seattle, 1983,tli1nd Pr......
Harper & Row. 12. Weisclfish S: Manual therapy far the arcJwpedic and flt?urofogic patient
6. Jones LH: Strain and COltntmrrain, Newark. Ohio, 1981, American emphasjmg main and cOImlmrrain techniqcle. Harrfon.l. Conn, 1993,
Academy of o..rcopadl)" Regional Physical Thcmpy, self-published.
7. levin SM: TIle !cosohedron llS the thrcc-dimcnsion;li finile 13. Weis elfish S; Personal communication, 1995.
clemcOi in hiomechanical support. Proceedings of the St.)Cicty
4
C linical Principles
What Is the Clinical Significance General Principles of Treatment 29
of the Tender Point ? 28
What Is the Comfort Zone? 29
Where Are the Tender Points? 28
Achieving the Optimal Position
How Hard Should Tender of Comfort 30
Points Be Palpated during the
How Long Is the Position of
Assessment ? 28
Comfort Maintained ? 30
How Is the Severity of Tenderness
The Immediate Posttreatment
Graded? 28
Response 31
What Happens If the Patient Is
Frequency, Duration, and
Unable to Communicate? 28
Scheduling of Treatment 31
Preparing a Positional Release
Summary 32
Therapy Treatment Plan 29

This chapter outlines the clinical significance of the tender For example, in Fig. 4, I a patient develops symptoms in
point (TP), identifies where to find TPs, and explains how his right knee as a result of running. The patient has a
ro grade the severity of their tenderness. It explains how to hypomobile right 5,1 joint that is causing excessive prona,
prioritize these tcnder points in order [Q prepare a treatment tion in the right foot and ankle. If there is prolonged
plan and explains the general rules and principles to follow pronation during toe off this will result in internal rotation
when performing positional release therapy ( PRT). The fre of the tibia and external rotation of the femur, causing a
quency, duration, and scheduling of trearmenrs are dis# torque through the knee Over time this can lead to the
cussed. It is important to understand the general principles development of symptoms in the right knee. If one were
so that the treatment sessions will be as efficient as possible. to treat only the symptoms the problem would persist.
Before beginning treatment, it is important to undcf# Trearing globally first (Le., the hypmobile right 5-1 joint)
stand the difference between global and local treatment. The would reduce the torque on the knee and reduce the
scanning evaluation (SE) will reveal the most clinically sig chance of reoccurrence. After trearing the global dysfunc,
nificant lesions. There may be several significant lesions as tion, the therapist may elect to treat the knee locally
the result of successive injuries, creating a layering effect of for symptomatic relief.
the dysfunction pattem. This pattem of interrelated lesions
is referred to as the global dysfunction.
Given the presence of several possible significant lesions
I AGGRAVATING FACTORS I

""r""
within the global dysfunction, the practitioner must never,
theless find a place to begin therapy. By comparing these
lesions in a sequential manner, the practitioner will be able
to determme the one or two dominant lesions, each of
which is represented by a dominant tender point (DTP).
ICAusel . " I
The primary aim of therapy is to treat the global dysfunc
(e.g.. S-I hypomobility) (e.g.. Knee pain and swelling)
tion via the DTPs because this pattern represents the source
of the patient's symptoms. Fig. 41 Global tlerSlloS local treatment.

27
28 CHArTER 4 Clinical Priniciples

, WHAT Is THE CLIN ICAL SIGNIF ICANCE OF THE - Extremely sensitive

TENDER POINT? e Very sensitive


-

A lender point may be defined as a remiC, tender, edema


- Moderately sensitive
tOllS region that is located Jeep in muscles, tendons, "ga
mCll[S, fasc ia, or bone. I t can measure I elll acro&> or less, o - No tenderness
With the most acute pOint being about 3 !TIm in diameter.
Fig. 4-2 System used [0 grade the el't"TU:'l of lender POUlts.
Tension IS abo felt In the tissues surrounding the [cnJer#
ness. The tenLier poil)[ is usually four times as sensitive as
normal tissue. S As mentioned III Chapters I and 2, the
tender pOints associated with PRT share common charac#
tcrhrics and locations with trigger poinrs,R neurolympharic , H ow Is THE SEVE RITY OF TENDERNESS
POIlHS, J neurovascular pOints, U and acupuncture (Ah Shi
POints) Most people feel that the tenJer point itself IS the
G RADED?
dysfunction. l lowever, it is only an outward manifestation When evaluating the body fot tender pomb, a grtluing
of the reaction of the tisslies (() an underlying lesion. :'::Iystem is necessary In order to measure the seventy of each
Patient!) orten find it IIHeresnng to learn that there I::' ten point, In thb text, four clrcle with various amounts of
ucrne:,::, In i.l body region thac is nO( obviously paln(ul for shading as shown 111 Fig. 42 are u"ied to graue the seventy
them. They often have no palpable renJernes!'! in rhe area of the tender points.
of pam. When palpating a patient who hl.ls an extremely sensl
[lve tender POll1t, there IS l Visual Jump sign, and the
patient will express extreme senulvity to touch. ThiS point
, WHERE ARE THE TENDER POINTS? is labeled extremely seruirit'e, and 111 the SE the entire circle
Tender poims are found throughout the body, anteriorly, is shaJed (e). If the point is very tenJer hut there IS no Jump
posteriorly, meJlally, and laterally. A diagram of these SIgn, the point is IabeleJ very serulli.'e and only the top half
tender points i!'i ::,hown in the Appendix. As illustrated, of the clTcle is fdled in (e). The pattent srates that the pOint
thc:,c lcnucr point!'i arc founu on muscle origin!'! or in5cr is very tenuer but does not flinch or jump away when TP
tions, within the muscle belly, over the ligaments, tendons, is wuched.
fascia, and bone. If the patient notices some tenderness of the point
but there is no jump sign, it is labeled moderme anu

, H ow H ARD SHOULD TENDER POINTS B E only the bonom half of [he mcle IS (tIleJ In ( ). If there
IS no tenderness at all, the mcle " left hlank ( 0 ). The
PALPATED DURING T H E ASSESSME NT? Scannll1g Evaluation Rccordmg Sheer I hown m
When documentlllg the tender points, the tissue should the AppenJix.
not be pressed so hard that tenderness on all the POllltS IS
elicited. Likewise, If the touch IS toO light tender points
' W HAT HAPPENS IF THE PATIENT Is U NABLE
may he misseJ. There is no suhstitute for clinical experi
ence and objective trial and error. We recommend that the
TO COMMUNICATE?
practitioner find one tender point on the patient and then The mabillty to directly communicate the severity of ten
uetermine how hnle pressure is required ro elicit the Jllmp derness is a (acOr With certam neurologic patients and
siKn. A Jump sign is characterized by certain responses, infmus, among others. Occasionally a Jump sign mtly he
such lS a sudden Jerking motion, grabblllg of the therapist\ detected with palpation. If nm, other cues must be used.
hanu, a facial grimace, or the expression of a vocal exple Posture, range of motion, and tenSIOn In the muscle must he
tive. Through practice, the precise degree of pressure will evaluMed and used as " gUIde. Wel'ellish has developeJ a
be learned. The depth of the ti"ue bemg palpated must chart ro evaluate movement anu poturtll restriclions assn
also he considercJ. Deeper tissue requires more pressure ciateu with tender point!'! to as.''i[st thempists treating these
than "iuperficial tissue, but It must be done gently and with types of pattent>. (Sec p. 243 III the AppenJIX for an
finesse. It IS Important to he firm when palpating, but example of the postural pmhokineslologic l11odel'CI for
tIue mut he entered gently, and only necessary pre:,sure determination of treatment.) For example, If a patient has a
mur he used to palpate through the layers of tissue. The TIght protracted shoulJer, she Intght be able to horizontally
patient being evaluated should be taken into account. adduct WIth ease hut finJ Jifficulty with horizontal abduc
Bahle" chddren, athletes, anJ elJerly patients may tion. TenSion may abo be founu on palpation o( the right
respond differently to touch. Patients' belief systems, how pectoralis minor. In (hi:, Situation, hypertonicity of the right
much pam they are m, <lIld how frail their bodies are can pectoralis minor woulJ be Indicatcu hased on observation of
all be (actors in dcterminmg the amount of pressure that the patient's posture, evaluation of movement restrtctions,
may be lIsed to palpate. and palp:nion of tension within the muscle belly Itself.
Clinical Principles CHAPTER 4 29

Some neurologIc patients who have significant hIp flexor


tone are able to flex their hips with ease but find great
, GENERAL PRINCIPLES OF TREATMENT
dIfficulty extending their hips. Common points for Jones's general treatment procedure was basically to folu the
these patients would be the iliacus point or the medIal body part over the tender point to shorten and relax the
hamstring pOInt. This technique may be used duoughour affected muscles and other soft tissues. This has been found
the boJy. to be a useful guide in many cases. However. there arc lJome
Weiselfish, who speciailzes 10 the treatment of neuro exceptions. and these are identified in Chapter 6. Following
logIC patients. has compiled a lISt of common PRT points are four basic rules developed by Jones that should be
for neurologIc pattents for both the upper and lower quad observed when attempting to treat a tender poinr.
rants. These are found on p. 242 10 the Appendix. 1 . Anterior tender points are usually treated in fleXIOn.
For example. see the treatment position for IL on
, PREPARING A POSITIONAL RElEASE THERAPY p. 1 5 1 of Chapter 6.
2. Posterior tender points are treated in extension. For
TREATMENT PLAN example. see the treatmem position for PL3 on p. 1 62
Before prepanng a treatment plan, the body must be of Chapter 6.
scanned for tender pomts. The Appendix contains an 3. If a tender point is on or near the midline, it is treated
example of the Scanning Evaluation and Tender Point with more pure flexion for anterior points and with
Body Chart. Once all these points have been recorded. the more pure extension for posterior points. For example,
general rules ant! principles are used to prioritize the TPs see treatment position AT I AT6 on p. 86 (Chapter
and to ulttmately determme the DTP. which WIll be treated 6) and the treatment position of UPL5 on p. 164 of
first. These general rules and pTlnciples were developed by Chapter 6.
Dr. Jones from over 40 years of c1mlcal experience. By fol 4. If the tender point IS lateral to the midline. It is [Tea ted
lowing these guidelines. treatments will be much more with the addition of side bending, rotation. or both.
effectIve and effiCIent. The anterior/flexion or posterior/extension rule mUSt
The most 1I11pormnt rule IS to treat the most severe tender also be followed. For example. see the treatment posi
POint first The secont! most important rule is treat proximal tion AR3- 1 0 on p. 93 of Chapter 6.5
w diswl ' The second rule is required If there are equally sen
sitive tender pomts proximally and distally. For example. if
there is a tender pomt In the neck and the shoulder. and , WHAT Is THE COMFORT ZONE?
they are equally sensitive, the neck is treated first. If it is A key concept to understand i s that PRT i s a n indirect
found that the shoulder is more sensitive, the proximal/distal technique. meaning the body is taken imo a poSItion of ease
rule IS superceded by the first rule. which is to treat the most away from the resistance barrier. For example, if the patient
severe tender rOlOt first. has hypertonicity of the long head of the biceps. the patient
A third type of situation can arise. If there are several will fee l tension in that muscle if the elbow is extended.
areas of extremely sensitive tender POints, treat the area The patient will find it more comfortable to flex the elbow,
with the greatest number of TP's first. If several equally causing shortening of the biceps. whereas extension would
sensitive tender points are found in a row (for example. on challenge the resistance in the affected muscle. Therefore
the anterior aspect of the sternum. i.e., if the anterior first in PRT the painful and restricted position IS avoioed, and
to anterior seventh points are all equally tender), the one the goal is to find a position of ease. The optimal poSition
in the Imddle is [Tea ted first. This wtll be the pOint that is of ease is the comfort zone (CZ). Figure 4-3 illustrates the
monltoreu for this group of tender pOints. If there are only relationship of the CZ to the positIon of the boJy and the
two points. side by side. and they are equally tender. they method used to find tho comfort zone for the long head of
can be monitored together. The key is to pick onc point in the biceps. The vertical axis represents the severity of tcn
the mIddle to represent the rest of the group. and III gen derness and palpable tissue tension or tone for the long
eral " WIll be found that they wtli all shut off with the head of the bIceps tender POint. The scale ranges from 0 to
same treatmenr position:t.5 Based on this hierarchy, the 1 0, with 0 representing complete comfort with no tenuer
therapISt should be able to identify one or more DTPs. ness and minllnal tissue tension and 1 0 representing
whIch will be the focus of treatment. extreme tenderness and maximal palpable tissue tension.
The horizontal axis represents the range of motion of the
General Rules for PrepaTlng a PRT Treatment Plan: elbow from 0' to I SO' of elbow flexion. It IS apparent that
I . Treat the most severe render point first. large movements from 0 to 1 10 of flexion produce little
2. Treat the more proximal or meuml tender points before change in the tenderness level. However. with movement
those that are more uistal or lateral. from 1 1 50 to 1 20, which is only a 50 range. there is a dra
3. Treat the area of greatest accumulation of tender points first. matic change in the tem.lcrncssjtcnsion level. A position is
4. When tender pomts are in a row, (reat the one near the then reacheJ at which there is no renucrness and the tissues
Imddle of the row first. are completely relaxed; this is the comfort zone. Moving to
30 CIIAPTER 4 Clmical Priniclples

Extreme 1 0 maintain contact with the tender point being treated. Con
Tenderness tact is maintained by keeping a gentle touch on the tender
POint, no! by applying adJitlOnal pre""ure.' A. the comfort
zone is approached, increased pressure must be applieu peri
odically to rhe tender poilU to monitor Irs progress. How
ever, as soon as the comfort zone is reached, cunmct should
Severity of he mamtamed but no additional pressure applieu. It is the
Tenderness 5
position 111 which the patient has been placed that is the
(0- 1 0 scale)
treatment, not the pressure on the tender point, which IS
primarily a monitor to help locate this position of ca')C.
(Chaitow2 contends that even light pressure on the tender
point may exert a therapeuttc effect.) While the patient b
in the POC, prcsure may he added intermittently to con
firm that rhe ideal pOSition IS being properly maintained.
No Tenderness 0 An important point to note IS that as the patient is being
o 45 1 200 1 50
placeJ IOtO the POe he sholllJ he pain free. If any palO "
Extension Flexion experienced while the patient is being JX1sItioned, it is not
Elbow ROM the correct position for him. For example, although an
anterior tender point may Improve by flexing the patient, a
Fig. 4-3 ComfoTl one of lhe long head of the biceps. (M",b/I,'J from posterior tender point may be stressed, which is morc sig
)m,,,' LH StrtUll t1nJ (fmnt<-"f'StTllIn, N.:u<ll'k. Oluu, 19S1 Am.'ric"n
A(tklmi'l.1j <.>sI.... '{Itlln:t,) nificant, thus reqUIring primary treatment. A thorough
evaluation before treatment wdl reJuce the hkchhooJ of
this occurring. Discomfort or other sen:;attons ariSing after
the left of the CZ on the diagram, into extension, will the POC has been achieveJ (generally after 30 to 60 sec
induce increased tenderness and tension in the tissues. With onds) are usually a parr of the normal release process and
movement further to the right of the comfort zone, into tend to subside after another I to 3 minutes. It has been
flexion, an Increase In tenderness and tension in the tissues found that having the patient take a deep breath in anu out
will agam he encoumcreJ. In the latter case, the response of releases tension in the affecteu tissues. The use of either trac
the (i!)Sues may he the result of engaging the antagonist (for tion or compression In small amounts may also help with the
example, the triceps), placing It IOto relative stretch and complete resolution of the tender JX1int. Once the j:X)sltton
thus creatlllg an IIlcrease in proprioceptive stimulation that is close to the comfort mne, It is important to make the
woulJ then fcoJ back to the agonist (hicep.) ' movements as small as IXlsslble to fine-tunc rhc posi{Jolllng.

' ACHIEVING THE O PTIMAL POSITION OF COMFORT , H ow LONG Is THE POSITION OF


Achieving the optimal POC IS rhe ultimate goal of trear
COMFORT MAINTAINED?
mcn[ anJ the one that requires the greatest uegrce of e1in, Once the patient IS i n a poSition of comfort, the difficult
ical finesse. ThiS will uctermmc rhe ultimate success of the phase of the treatment is over. Now It is a walttng game.
therapeutic intervention. The comfort zone is specific and According to Jones, 90 seconds is sufficient for release of
is uifferent for each of the treatment I)sitions. As the pTac, tension In the muscle tissue, and this has been backed up by
ririoncr treat.s [he panel)( amJ 3ncmprs co inJ rhe comfon 30 years of chmcal experience.' According to Weiselfish
zone, the lISC of fine movements will he necessary as the CZ and D'Ambrogio, there are two phases to the release of the
is approached, In order [0 avoid missing the small range of tender points. The first phase is a length-tension changc 111

motion In which It appear.;. The signals that tn<.i1carc that the muscle tissue Itlf, which takes approxl1ll<1tely 90 sec
the optimal CZ has been attamed mcluue a dramatic onds for routine orthopedic paticnts. Weiselfih has found
reuucrinn in tenucrncss anu a Significant, palpable soft, that the change in the length-tenSion relationship with the
cnmg of the tissues in the area of the tender point. A posi, muscle Will take approximately J minutes with neurologic
tion will be reached at which there is no tenderness and patients '" Whde in the POC the patient may be surprISed
the tissue IS completely softened around the palpating that the point is no longer tenJer anJ will frequently a.k If
finger. The response of the tender point can vary from the therapist is still on the same I'omt. The seconJ phase of
patient to patient. Some patients have easily ueteeted treatmcnt is a fascial release component and may take any
comfort zones; in others the response will be mOfe difficult where from 5 to 20 minutes to resolve. Times vary from
to (l')cermin. When tT)"lI1g to shut off a tender point, the patient to patient depending on the dysfunction.
key is perseverance. Therefore in answering the lIlitial question, "How long
It IS Impormnt to remember that it IS essential, while do we hold a patient III the position of comforc?" the answer
moving the patient's htxJy Into the treatment pOSition, [0 " "The patient's hoJy will tell you." This approach to [X>si-
CliniC1l1 Principles ClIAPTER 4 31

tiona I release was referred to by such pioneers as Hoover as I t is extremely important to explain to all patients that
early as the 1 940,. (See Chapter I . ) While the patient is in there may be some increased soreness. It may be explained
the comfort zone, the tissues are being palpated for a release as a natural part of the body's healing process and the soft
phenomenon.7.? The release phenomenon, which can be felt tissue reorganization taking place. If the patient is not
by both the patient and the therapist, signifies a normaliza warned of the possibility of soreness, confidence in the ther
tion of the tissues. The therapist monitors for relaxation apist may be diminished.
and softening in the tissues. pulsation. vibration, heat, and
changes in perspiration. Changes in breathing rhythm,
, F REQUENCY, D U RATION, AND SCHEDULING
heart rate, and eye motor activit), may also be detected.
These responses occur during the treatment, and once these
Of TREATMENT
changes cease the treatment is over and the patient often It i s important t o b e thorough o n the initial evaluation
experiences a deep sense of relaxation. The therapist can because this will save much time and frustration later on. If
help the patient feel these sensations by identifying them as the patient has several areas of dysfunction, that is, has had
they occur. The patient may also experience some achiness, surgeries, fractures, mOtor vehicle accidents, or pain that is
pain, or paresthesia. Reassure the patient that these sensa chronic in nature, an evaluation without treatment is rec
{ions are transitory, tending to dissipate within a minute or ommended during the first visit. This is both to save time
two, and are usually followed by a further release of tension. and to minimize sensory overload because the examination
Each patient will be different, and the patient's body will itself may temporarily activate several of the dysfunctions.
dictate how long the patient needs to be in the JX,lsition of After an evaluation, a treatment plan is prepared for future
comfort. While the patient is in the POC, it is up [Q the sessions. If the patient does not possess multiple dysfunc
practitioner to monitor for the release phenomenon. If tions (for example, if the injury is acute or involves a spe
there is pain while getting into the position of comfort, that cific mechanism of injury), treatment may begin immedi
is a contraindication for that position. atcly after evaluation. It is recommended that a thorough
PRT scanning evaluation of the patient's body be performed
on the initial visit.
HHE IMMEDIATE POSTTREATME NT RESPONSE Remember, tender points represent dysfunctions in the
It is important [Q mention that once the point has been patient's body, and the aim is to treat dysfunction. Pain is
fully released the body must return to a neutral position the end result of dysfunction. If only the painful areas are
slowly especially for the first 1 5' of motion. It is hypothe examined, the treatment will not be as effe ctive or efficient.
sized that the ballistic proprioceptors will be reengaged by The goal is not to treat all the patient's tender points bur to
returning [Q neutral too quickly. This may result in the use the general rules and principles to help find the most
reestablishment of the protective muscle spasm. After dominant point in the patient's body, treat it, and then
returning to neutral, the tender point must be rechecked. move on to the next most dominant point.
DUring this entire process, the therapist's finger should Positional release therapy treatment differs from that
remain over the tender point. This point should be either described by Jones and other practitioners. With conven
fully eliminated or at least 70% improved.' There should tional counterstrain and other forms of positional release, a
also be immediate changes in the patient's pain level, patient with shoulder pain is treated using the same general
posture, muscle tension, joint mobility, and biomechan rules and principles. Therapy is mainly localized to that
ical movement. After treating this point, the other signif upper quadrant, and six to eight points might be treated for
icant points noted in the screening evaluation should be a total of 90 seconds each. With global PRT sessions, only
rechecked. Some of the other points will be found to one to three points are usually treated. The goal is to spend
have been completely released or significantly reduced more time on evaluation and less time on treatment. If the
in severity. Then, using the general rules and principles, most dominant point of the body is located and treated, a
the practitioner should decide which is the next most majority of the other tender points (which may be adapta
severe point to be treated, and then the whole process tions to the dominant lesion) will often be eliminated. The
is repeated. dominant point may be located anywhere in the body, often
After the treatment, the patient will feel a sense of relax remote from the area of symptoms. To achieve maximal
at ion in that area. She will often find that she is able to benefit, both a muscular release and a fascial release should
move more easily and with less discomfort. be obtained. This can take from 5 to 1 0 minutes and occa
In the next 24 to 48 hours, clinical experience has sionally up to 20 minutes in the position of comfort. Each
demonstrated that approximately 40% of patients feel some patient is different, and the release phenomenon mUSt be
increased soreness. This soreness may be found not only in felt. By persisting until a complete release is achieved, much
the region treated but also in areas remote from the treat time and needless treatment will be saved because many of
ment area. For example, if the sacmm was treated, the the secondary tender points will be eliminated. The patient
patient might experience some pain in his neck or shoulder may not come in for another manual therapy session for
for the next few days. another week or longer. During that time. the patient may
32 CIIAPTER 4 Clinical Prinicip/e,

be seen twO to three times per week for local PRT sessions, continues to monitor the tender POInt the entire
which are held for 90 seconds, exercise therapy, the appli time. It should be monitored for a decrease In tension
cation of modalities, correctIOn of body mechanics, and tenderness. ThIS feedback IS necessary III orJer to
ergonomic education, and orher forms of supportive care. assist in the fine tunmg required to locate the precise
n,. goal with PRT is to help decrease pain, muscular hyper comfort zone.
tolllciry, fascial tension, and jomt hypomobility and to 4. Maintain contact on the tender point while in the
encourage the parienr to take an active role in recovery. position of comfort. The tender point should be
Clinically it has been found that it is better to perform monitored thmughout the treatment. Attention
manual therapy once a week and use the other Jays for exer should be given to the changes takmg place In the
cise, moJaliries, and education, This allows the patient's area of the TP, such as pulsation, heat release, vibra
body to adapt to the changes made during the manual tion, unwinding, and the release m rhe patient's body
therapy session. It has been found c1mically that approxi that indicates when treatment is lwer. Once the treat
mately 40% of patient, wlil experience a degree of soreness ment is over, contact should be maintained [0 be cer
for a few days following the treatment. For thiS reason, tam that the same spot that was evaluateJ before
modality and movement therapies may he beneficial during treatment is being reevaluated. When patient!) notice
the remainder of the week follOWing mitial treatment. (This that the point IS no longer tender, they will often ak,
usually only occurs after the first onc or two visits.) When "Are you sure you are on the same poind"
the patient returns for the next manual therapy session In 5. Hold the position of comfort until a complete
one week to ten days, a re-evaluation should be performed release is felt. The position of comfort is held as long
USing the general rules anu principles to find the next most as necessary to obtain a complete release in the body
dominant lesion and treat it if necessary. ( i .e., a sense of relaxation in the muscle, a decrease in
In the Scanning Evaluation Recordmg Sheet (see the heat emitted, an elimination of achiness, cessa
p. 232) there are five circles, which represent five treatment tion of pulsation, vihratlon, or unwinding taking
days. Thee five circles represent each of the manual place in the tissue, and a relaxation ofthc hreathing).
therapy days. If PRT has not made any significant changes If the patient is removed from the position of comfort
in three to five visits, there may be another system involved too S<.)()n, the results will be more short term and the
or It Inay he a red flag for a fracture, dislocation, tom tissue, tender POint may reappear and reqUire further treat
infection, malignancy, or emotional stress. The patient mcnt. It is llTIportant to remember that when treating
should then be reexamined. It is important to understand globally, the POe i, usually held longer (e.g., 5 10
that PRT is not a panacea. min) and will have a more profound effect on the
body. Local treatments are u,ually helJ for approxI
mately 90 seconds.
SUMMARY 6. Return to neutral slowl y It is Important to memion
.

There arc nine Important points to remember when per that once a tender point has been treated ucces.!)fully,
formmg PRT: the patient's body muM be returned 1O neutral slowly.
I . Scan the body, grade the severity of the tender The first 1 5 is the most important range. If the
points, and record the findings. patient is taken out of the comfort :onc roo quickly,
2. Follow the general rules. It " Important that the the ballistic propnoceptors may then be reengaged
therapist treat the most severe tender pOInt first and the protective muscle spasm can return. These
regardless of where the pain IS. Remember that the tissues are often connected to a faci htated segment,
tender pomt represents the patienc's dysfunction. The which renders them more vulnerahle to reinjury and
aim is to treat that dysfunction. Pain is a result of dys to the reestablishment of mflammation and spasm.
function. Once the tender pomt is treated and move (See Chapter 2.)
ment " re>tored, the pam will eventually subside. The 7. Recheck the tender point and use other reality
second most Ilnportant rule is to treat proximal to checks after treatment. After succesfully treating a
distal. If there are two equal tender points, treat prox; tender point, it IS unportant for the thcrapiM and the
Imally before distally. This often e1unmates most of patient to note what change.!) have taken place. The
the distal tender points. With several areas of extreme patient may he eXCited that there is a significant
sensitivity, treat the area with the greatest number of reduction III tenderness. However, this by itself may
TP's first. Lastly treat the tender point in the middle not be enough. It is important to have several reality
of a row of equally tender pomts. By following these checks. A reality check is finding a pOSItiOn, move
simple niles, the efficiency and effectiveness of treat ment, or specific jOll"lt, fascial, or muscle evaluation
ment will be enhanced. that IS objective, can be measured, and WIll reproduce
3 . Monitor the tender point while finding the position the patient's pain or complalllt. For example, a low
of comfort. It is important that while placing the back patient might have limitation III extension and
patient into the poSition of comfort, the therapist left side hending In the quarter range, which might
Clinical Principles CHAPTER 4 33

increase the pain to 9 out of 10. A knee patient may 9. Treat only once per week, and allow the body to
have limitation in knee flexion to approximately 30 adapt to the treatment. Use PRT to remove barriers
with pain at 8 out of 10. A shoulder patient may have to movement, which w i l l allow the patient to
limitations of abduction to 60 and external rotation progress with activities of daily living and a func
(Q 30 with 9 out of 1 0 pain rating on bmh at the end tiona I rehabilitation program.
of rhe available range. Afrer treating with PRT, it is
important (Q recheck these movements (Q see if the References
patient is functionally moving better with less dis I. Bennett R: In Chapman's Reflexes. In Martin R, ediror: Dynamics
comfort. If these changes are not demonstrable, the of c:oTTccLion of abnormal function, Sierre Madre,Calif, 1977, self
published.
treatment may nO( have addressed a primary lesion.
2. Chaitow L: The acupuncwre eTeatmenr of pain . Wellingborollh,
These tests are an important source of feedback and 1976. Thorsons.
can help the practitioner determine the future direc J. Chapman F. Owens C: fnLf'OducLion to and endocnne mrerprewuon of
Chapman's reflexes. selfpubltshcd.
tion of the tre3nnent program. They are also useful in
4. O'Ambroglo K: S(T(un/counrersLTam (course syllabus), Palm Beach
encouraging the patient and engaging her coopera Gardens, 1992, Upledger Institute.
tion in the recovery process. 5. Jones LH: SeTaln and coumt!wrain, Newark. Ohio, 1981, American
Academy of Osreopathy.
8. Warn the patient of possible reactions and to avoid
6. O'Connor J. Bevsky 0: AcupuncLure: a com/1l'ehensit1e rext. Seattle,
strenuous activity after treatment. The patient who 1988, Easdand Press.
is forewarned of the possible reactions to treatment 7. Smith FF: fnner bridges-a guide to energy move-men! and bod] struc
fIIre, A tlanta , 1986, Humanics New Age.
will not only cooperate with the therapy program, but
8. Travell JG, Simons lXi: M]ofascial pain and d]sfunction: w. trigger
will also gain an appreciation for the power of this /X>IIlL manual, Baltimore. 1983, Williams & Wilkms.
apparently simple and painless technique. The avoid 9. Upledger JE: CT"allio.sacrai Ute:ralry , Seattle, 1983, Easlianu Press.
10. Weiselftsh 5: Manual therapy for Uu.> orLhopedic and JU!ltroLugic patient
ance of Strenuous activity for 24 (Q 48 hours after
emphasivng SeTaln and cOllllterseTain rechniqlU? Hartford, Conn, 1993.
treatment will help ensure a more efficient recovery Regional Physical Therapy, selfpublished.
and reduce unnecessary discomfort. Failure to warn
the patient may result in a loss of confidence in and
cooperation with the rehabilitation program.
5
Positional Release Therapy
Scanning Evaluation
Purpose of the Scanning
Evaluation 35

How to Prepare a Treatment Plan 37


Case Study I 37
Case Study 2 38

Summary 38

The Scanning Evaluation (SE) outlined in this chapter tender point (DTP), and the treatment plan can then
was designed by one of us (D'Ambrogio). The SE record be implemented.
ing sheet and tender point body chartS in the Appendix The SE should be considered an assessment tool [0 work
are very simple co use and are crossrefcrenced with in conjunction with the normal battery of orthopedic and
Chapter 6, the treatment section of this book. These ncurologic rests (range of motion, strength testing. nerve
can be photocopied and used to assist in the evaluation conduction, pain questionnaires, etc.). Because this book
of patients. deals mainly with positional release therapy (PRT), these
other evaluation methods will not be reviewed. They are
already adequately covered in sevcral other books.
WURPOIE OF THE SCANNING EVALUATION If time is taken [0 understand and implement the SE and
The purpose of the SE is to evaluate the entire body for PRT techniques, treatments will be much morc effective
tender points (TPs) and to prioritize rhem according to and efficient. Several patients may have the same com
their severity. In this context the TPs represent muscu plaint (e.g., knee pain, shoulder pain, or low back pain) but
loskelctal dysfunction. As in most other techniques, treat the source of the condition, as revealed by the SE, may be
ment is the easy part. The difficult question is, "Where different for each. No twO patients are the same, no matter
does one begin treating?" The SE, if used properly, will pro how similar their presentations may be. The PRT scanning
vide a clear, visual representation of the location of the evaluation will precisely reveal the source of rhe dysfunc
dysfunctions that are contributing to the sympmffiS. I n tion through to DTP. By identifying the location of the key
Chapter 4, the term render point was defined, and a n expla dysfunctions (which may have different locations than the
nation was given of where and how [0 find these points. perceived pain) and treating restrictive muscular and fascial
The prioritization of the TPs using the general rules and barriers, the pain will begin to subside. As we continue to
principlcs was also discussed. By recording the severity of use the SE, we may begin [0 reexamine our thoughts about
rhe tender points in the SE, the practitioner will have crc the body, where pain originates, and how dysfunction and
ated an organized chart of the most significant tender pain interact. Let us now look at the SE recording sheet in
points, which can then be specifically categorized detail. If you turn to the Appendix you will see a full view
according to their clinical significance. This information of the SE. You can refer back to the SE as we break it down
will allow the practitioner [0 dctermine the dominant into its components and explain step by step the nuts and

35
36 HAPTER 5 Positional Release Therapy Scanning E.aluation

bolts of how to record tender points, prioritize your findings If an extremely sensitive tender point is found equally on
using the general rules, and prepare a treatment plan. both points, fill in the circle and do not put any lines under
neath (e). If an extremely sensitive tender point is found
Positional Release Therapy Scanning Evaluation
on both sides, but the right side appears more tender, draw
Pauem's Name _______ Practitioner _____
slashing lines to the left and the right and place a crossing
Da!es ' _ 2_3_4_5 _ line through the one on the right. If the point is extremely

o Extremely senSitive 0 very 0 moderate 0 no tenderness


sensitive on the right but only moderately or very sensitive
\ nghr I left + most sensuive 0 rrcatmem on the left, it is recorded in the same manner.

At the [OP of the scanning evaluation, fill in the patient's


and practitioner's name. We have included five treatment
dates. These five treatment dates correspond [0 the five cir When a point is treated during a session, place a small dot
cles that you see beside each of the number> and abbrevia over the filled-in circle (,o). It is important to identify which
tions of the treatment names. For example, no.40 in Chapter point was treated so that the effects of those treatments can
6, Section IV, Anterior Thoracic Spine, looks like this: be observed during reevaluation of the patient at subse,
quent sessions. Finding and treating the most severe tender
40. AT I 00000 point often results in the elimination of many of the sec
ondary tender points. which may have been adapting around
The five circles are used to help us evaluate the extent the primary dysfunction. This procedure is what affords
of the dysfunction for each area of [he body. The circles PRT such a high degree of efficiency and effectiveness.
should be filled in with a pen or pencil appropriately There are approximately 2 1 0 points, and each point has
as follows: a number, an abbreviation, and five circles to the right.
During the initial evaluation, palpate the patient's body for
e.Exuemely sensitive e Vcry QModernte O-No tenderness tender points and record them on the recording sheet. Use
the key given at the beginning of this section to grade the
The key is lIsed to record the severity of the tender tender poims. On the initial evaluation, fill in only the first
points. If a point is palpated and there is an observable circle of each number. If there is no tenderness, leave the
jump sign (wherein the patient responds with a jerking point blank (0). In the example below, it is found that no.
motion, pulling away from the contact, with facial grimace 40, ATI, is the most severe tender point. the recording
or vocal expletive), label that point exrremely sensitive and would appear as follows:
fill in the whole circle (e). If the patient feels that the
point is very tender but does not have the jump sign, the IV. Anterior Thoracic Spine [po 85]
point is .ery ,ender and the top part of the circle is filled in
( e ) . If the patient has no jump sign and feels only a mod 40. AT! eoooo iJ. AT; ecoco 46. AT)00000 SO. ATtOOOOOO

erate amount of tenderness, the point is moderately semi, 41. AT2 QOOOO H. ATS00000 47. AT8 QOOOO SI ATiI 00000

li.e and the bottom part of the circle is filled in ("). If the 4l. ATJ eooco 45. AT600000 48. AT9 52. ATI200000

patient experiences no tenderness whatsoever, the point is


left blank (0). Once the therapist has identified the DTP from the
After recording the severity of the tender point by filling SE using the general rules and principles, [he position of
in the circle, its location is noted. If, for example, a central treatment should be looked up in Chapter 6. The exact
point is found on the superior aspect of the manubrium and page reference is provided in the SE recording sheet in
it is extremely tender, the circle for no. 40, ATI, is marked brackets to the right of the section heading that is cross ref
as follows: e. However, if a tender point is found on either erenced with Chapter 6. In this example the DTP is no. 40
side of the body (for example, no. 170, MK), the following ATI. If you look to [he right of [he heading IV Anterior
keys are used to label it properly: Thoracic Spine you will see the page reference (p. 85). If
YOll tum to p. 85 you will see an illustration of all the ante,
\ Right / Left + Most sensitive 0 Treated rior thoracic tender point . If you rum the page over and
look up No. 40, which is found on p. 86, you will see:
For example: - A sketch of the involved anatomy with the TP super-
imposed on it
1 70. MK, This means that the extremely sensitive - A photograph of the location of the TP
tender point is found on the medial - A description of how to find the location of the TP
aspect of the lef[ knee. - A photo of how to perform the treatment
1 70. MK, This means that the extremely sensitive - A description of how to position the patient in the
tender point is found on the medial treatment
aspect of the right knee.
PositiolUll Release Therafry Scanning Evaluation CHAPTER 5 37

As you can see the SE is very user friendly and will assist AT4 and ATIO were moderately sensitive. AT7 was treated
you in the planning and implementation of YOUT treatments. during the first visit. As a result of the treatment, we 3re left
Therefore onc can quickly appreciate the simplicity of with AT! extremely sensitive and AT7 and AT12 very sen
the scanning evaluation. First u e the Tender Point Body sitive. AT I was treated during the second visit, and, as a
Chart showing all of the tender points as a guide. Then result, all the points were resolved.
record the tender points on the SE recording sheet, using There are a total of five circles, representing five treat
the keys given on p. 232 to grade the severity. Then use the ment days. Normally this is sufficient to eliminate all of the
general rules and principles from (Chapter 4) to prioritize tender points. The scanning evaluation will also help iden#
the tender points. Once the tender points that require treat tify any red flags. For example, if a tender point persists in
ment have been located, refer to the page number for the being extremely sensitive after each visit and PRT does not
corresponding treatment section (Chapter 6). In the treat# seem to be shutting off that point, there may be another
ment section, you will find a sketch of that particular part of point in the body which is also extremely sensitive that
the body, with the dysfunction indicated by name, a descrip must be treated before this. There may also be a pathologic
tion of the location of the tender point, and the position of condition or visceral disorder causing this dysfunction. This
treatmenc. Any necessary clinical nQ[es are also included. A is explained in greater detail in Chapter 7, which will iden
photograph demonstrating the most common position of tify different treatment strategies.
treatment is also provided to help visualize the correct pro If the time is taken to do a full evaluation of the patient
cedure. Therefore the scanning evaluation, when combined on the first visit, a clear picture will form showing the loc<l#
with the treatment section of the text, provides a user tions of all the dysfunctions. Then, by using the general
friendly road map to an effective treatment program. rules and prioritizing the tender points. a treatment plan
may be formulated. It is worth repeating that it is very
important to treat (he most severe tender point first no matter
How TO PREPARE A TREATMENT P LAN where the pain seems to be because a tender point repre
Follow these steps t o prepare a treatment plan: sents the dysfunction. The objective is to treat dysfunctions
I. Scan the body for TP using the TP body chart as a guide, rather than symptoms. By using the scanning evaluation to
and record your findings appropriately on the SE re assist in pinpointing dysfunctions, the number of dysfllnc
cording sheet using the key provided. tions will be reduced significantly, proper functional move
2. On the first visit, record the date and fill in only the first ment will be restored, and eventually the pain will subside.
circle for each point that is tender. The other four circles Following are two case studies to illustrate how to use the
are used on subsequent visits. scanning evaluation.
3. Determine the DTP using the following four general rules
and principles:
a. Treat the most severe tender point first. CaseSwyl ________________________

b. Treat the more proximal or medial tender points Patient: Male in his early rhircies.
before those that are more distal or lateral. Diagnosis: Medial collateral ligament strain. second degree,
c. Treat the area of the greatest accumulation of tender right knee.

points first. Mechanism of injury: Patient states that four days prior he
jumped off a 5 fc. high wall, experiencing a valgus stress to his
d. When tender points are in a row, treat the one
right knee before landing on his back. Patient experienced
nearest the middle of the row first.
immediate pain and swelling [Q his right knee.
4. Once the DTP has been found look up the position of
Weight-bearing status: Patient was weight bearing as tol
treatment in Chapter 6 from the page reference provided erated with crutches and was wearing a knee immobilizer on
in the SE recording sheet. his right knee.
5. On the subsequent visit repeat steps I to 4 and use the Range of motion: Knee extension _8, knee flexion 25-.
second circle to record the findings. This is continued Pain: Patient was in constanr pain that varied in intensity. He
until all five circles have been used up or patient's symp would always feel a baseline of soreness and stiffness at approx
toms have subsided. imately 5/10 on the pain scale. TIlis pain could increase [Q
For example: 10/10 if he was on his feet for a prolonged time, which meant
more than one half hour, or if he made a quick rotational
movement or tried [0 move his knee beyond its available range.
IV. Anterior Thoracic [po 85)
Palpation: Patiem was tender in the medial aspect of the
knee with some warmth and swelling evident. On specific posi
40. AT! 000 43. AT4 46. AT? eeooo 49. AT!O QOOOO
tional release PRT evaluation, his most dominant tender point
41. An eoooo 44. AT5 00000 47. AT8 0 50. ATII 00000
was found to be in the paraspinal muscles at L3 posteriorly
4z.AT3eoooo 45.AT600000 48.AT900000 51.ATlz.eooo (PL3). Even [hough there was some soreness and palpable ten#
demess in and around the knee, there was no comparison to

On the first visit ATI, AT2, AT7, and AT I 2 were all the observable jump sign he had on palpation of [he paraspinal
extremely sensitive; AT3 and ATB were very sensitive; and muscles at L3 posteriorly.
38 CHAPTER 5 Positional Release TheraJry Scanning EvalWltion

Treatment: The PU tender point was treated on one occa;


sian, in a position of comfort lasting approximately 7 minutes.
, SUMMARY
As a result, the patient was able [0 increase his knee extension These case studies show how two different people can have
(rom ;8 (0 4 and his knee flexion from 2So [Q 125-, and he similar problems with range of motion, swelling, and pain in
was able to bear much morc weight on his right knee with less the knee. The source of their problem was two different
discomfort. The knee immobilizer was not used after the first
regions. In the first case, it was coming from the low back;
visit, The patient returned for one more visit that week and
in the second case, it was coming from the pelvic region. A
two visits the next week, then was discharged after a towl of
patient with knee pain may have the dominant point in the
four visits. One visit was used for positional release thcrapy and
knee. In many cases, however, the dysfunction is completely
three visits for exercise prescription,.)[ which time an exercise
program to work on the mobility, flexibility, and strength of his removed from the area of pain. These cases reinforce the
knee. pelvis, and low back was srancd. This patient was off his importance of a thorough evaluation of the patient to
cnltches after the first visit and regained functional range of detect the location of the dysfunction instead of lIsing pain
motion by his second visit. as a guide. Remember that positional release therapy is only
one mode of treatment. To improve the efif ciency
This case study clearly indicates that if we had proceeded ment, incorporation of other treatment modalitie is
directly to the area of the patienes pain, his right knee, we required. Various modalities are necessary to assist in the
would have found some tenderness to treat. However, the treatment of inflammation, atrophied muscles, and pain
severity of tenderness at the knee was minor compared with management. Other manual therapies may be needed to
the tenderness that the patient had in his low back. By fol evaluate and treat articular or fascial tension. Finally, an
lowing the general rules and principles and by treating the exercise program should be instituted to improve strength,
most dominant tender point, the effectiveness and effj mobility, flexibility, cardiovascular fitness, and functional
ciency of treatment was improved. The patient did have a movement. The integration of the different modalities is
low back problem as a result of the fall, and this dysfunction discussed in more detail in Chapter> 3 and 7.
was affecting the muscles of his right lower extremity. This
can be explained from the facilitated segment model dis
cussed in Chapter 2.
Case Swdy 2 _____________

Patient: Female in her early rhirries.


Diagnosis: Medial collateral ligament strain, second degree,
left knee.
Mechanism of injury: One wcek prior, patient fell and
twisted her knee whilc skiing.
Weight-bearing status: Weight bearing as rolerarcd with
crutches and knee immobilizer.
Range of motion: Extcnsion I 0$, knec flexion 30.

Pain evaluation: Patient is in consmnt pain that varies in


intensity. Most of the time she feels a lot of soreness and s[iff
ncss, approximately 5/10. It can get as high as 10/10 with
sudden movemcnt and movement beyond her available range.
Palpation: Swelling, heat, and rendemess noted on the
medial aspect of the knec. On specific PRT evaluation, the
dominalu point was found to be the gluteus minimlls, which is
1 cm lateral to d,C anterior inferior iliac spine. This point lics
at the origin of thc rectus femoris Illuscle.
Treatment: The gluteus minimus tender point was treated
for approximately 6 minures. As a result, knec extension was
incrcilsed from 10- to 4 and knee flexion from 30- to 128-.
This patient was able to get functional range of morion within
the next 3 days and was able to tolerate full weight bearing
without crutches or the knee immobilizer. Her therapy lasted
anorher 3 weeks because she had some ligamentous damage,
which gradually healed.
6
Treatment Procedures
I. UPPER QUADRANT II. LOWER QUADRANT
Cranium 43 Lumbar Spine, Pelvis, and Hip 143
Anterior Lumbar Spine 144
Cervical Spine 64
Anterior Pelvis and Hip 150
Anterior Cervical Spine 65
Posterior Lumbar Spine 159
Anterior Medial Cervical 74
Posterior Pelvis and Hip 166
Lateral First Cervical 75
Posterior Sacrum 174
Posterior Cervical Spine 77
Lower Limb 181
Thoracic Spine and Rib Cage 84
Knee 182
Anterior Thoracic pine 85
Ankle 193
Anterior and Medial Ribs 90
Foot 204
Posterior Thoracic Spine 95
Posterior Ribs 100

Upper Limb 104


Shoulder 105
Elbow 126
Wrist and Hand /33
Thumb /38
Fingers 139

This chapter is divkled into twO sections. Section I covers of the body arc headed by a drawing of the pertinent
the positional release thcrapy (PRT) assessment and treat anatomy of the area showing the common tender points
ment program for the upper half of the body: the cranium, associated with that area. These subsections include the
the cervical spine, the thoracic spine and rib cage, and the anterior cervical spine, the posterior cervical spine, the
upper limb. Section II deals with the same topics for the anterior thoracic spine, the knee, the shoulder, and so on.
11Imblr spine, pelvis, hip, sacrum, and lower limb. A scan# Each treatment is associated with one or morc tender
ning evaluation (SE) for the entire body can be found in points and is displayed on a single page. The treatment
the Appendix. The SE may be used once the student has name is given with the appropriate abbreviation and the
mastered PRT for the whole body. In this chapter, separate area of anatomy considered as being treated by that position
SEs are provided for sections I and II, to allow the begin of comfort (POe). This page includes a smaller drawing
ning student to be able to concentrate on one section at a indicating the location of the specific tenuer points under
time or SO a local treatment may be perfonned, (or example. consideration. A photograph or photographs demonstrate
for an acute injury. the commonly used techniques, and the text describes the
Each major region of the body is introduced by a discus techniques in detail, with variations that may be used in
sion of some of the clinical and functional considerations special circumstances or as preference dictates.
for the area of the body in queStion. This includes a per Note that tender points not directly over the tissue of
spective on pertinent functional anatomy, typical clinical involvement, which may be considered reflex points
manifes[ations. and special treatment considerations. because they may be somewhat distant from the area of dys
Within each section the reader will find that separate areas function, are designated with an asterisk (*).
39
40 CHAPTER 6 Trearmenl Procedures

In the AppendIx. the reader will find an anatomic cross Once attempted, the user may then wish to adapt the tech.
reference that can help detennine which treatment may be nique to the needs of the individual if It is found that the
most pertinent to a given area of the body. There is also a prescribed method is less than satisfactory. The scanning
cross reference of PRT termmology wIth that given by Jones evaluation will help the practitioner prioritizc the (feat
No text can hope to replace educational workshops. We ment program.1 We suggest that the practitioner use the fol
encourage you [0 pursue the further development of your lowing protocol for the most efficient use of thIS text:
skills and to experiment with the technique and modify it l. Scan the paticm's body for tendcr points and record
(() the needs of the presenting condition and to the greatest them appropriately on the scanning evaluation.
advantage of your patient. 2. Determme the most dominant tender pomt (DTP)
using the general rules and prinCiples.
3. Look up the appropriate treatment for the DTP. The
, DIAGNOSIS AND TREATMENT PROTOCOLS page reference is provided m the scanning evaluation.
The diagnosis of soft tissue involvement IS based on sev# 4. Treat accordmg to the deSCription provided 10 the
eral objective and subjective criteria. A careful hiStory, treatment section in Chapter 6.
Including a clarification of any trauma or repetitive strain Treatment consists of precise positionmg of the body
ac[tvincs, is essential. It is important to differenriare 1"101"1# part or joint in order to maximally relax the involved tis
musculoskeletal factors, such as viscerosomatic reflexes, sues. The descriptions of the poSitions of comfort are pre
malignancy, infectious processes, and psychologic involve sented in their gross form. The ideal position is achieved
ment. Postural and structural asymmetry are significant through the use of micromovemenrs, or finetuning.8 This
mdicators of mvoluntary antalgic stratcgies (0 reduce irri typically reduces the subjective tenderness and objective
tability of involved tissues. In general, an individual will finnness of the associated tender point. Careful attention to
adopt a posture that mmimizes tension or loading of hyper the subtle changes occuring in the area of the tender point
tonic or Inflamed tissue."/) Range-of-mollon (ROM) assess is necessary m order to obtam thc opomal release. Once
ment wtll heIr confirm and localIZe the Involvement of this Ideal position IS achieved. It IS held for a period of no
flexors, extensors, roratofS, latcral flexors, or related liga. less than 90 seconds. During the pOSItioning. whIch may
ments and fascia.lo Local tissue changes (tension, tex(Ure, last for 5 minutes or more, further softening, relaxation, pul.
temperature, tenderness) and reduced joim play are also sation, vibration, or unwinding of the tissues is often noted.
nared because these may indicate underlYing dysfunction. I\ The position 109 is followed by a passive return of the
The tender point is a discrete. localized. hyperirritable region body part or jOlllt to an anatomically neutral poSition.
associated wnh thc dysfunction and is used as a monimr Reevaluation may then be carried out to confirm the em
durmg (fearment.ZI cacy of the therapeutic intervention. This approach will
It is recommended that the user follow the outlined suffice for the majority of cases and will provide valuable
(featment positions as closely as poSSible because they have experience m the development of the kills necessary to
been carefully assessed over many years and have been refine this art.
determmed to be efficacious in a large percentage of cases.
I UPPER QUADRANT
PRT Upper Quadrant Evaluation
Patient's name Practitioner

Dates 2 J 4 5

; Extremely sensitive e Very sensitive


" - Moderately sensitive o - No tenderness

\ - Right / - Left + ; Most sensitive 0; Treatment


I. Cranium (pages 43-63)

I. OM 00000 6. DG 00000 II. NAS 00000 16. AT 00000


2. 0CC 00000 7. MPT 00000 12. SO 00000 17. PT 00000
3. PSB 00000 B. LPT 00000 13. FR 00000 lB. TPA 00000
4. LAM 00000 9. MAS 00000 14. SAG 00000 19. TPP 00000
5. SH 00000 10. MAX 00000 IS. LSB 00000 00000

II. Anterior. Medial. Lateral Cervical Spine (pages 65-76)

20. ACI 00000 23. AC4 00000 26. AC7 00000 29. LCI 00000
21. AC2 00000 24. AC5 00000 27. ACB 00000 30. LC -
00000
22. AC3 00000 25. AC6 00000 2B. AMC 00000 30. LC -
00000

111. Posterior Cervical Spine (pages 77-83)

31. PCI-F 00000 34. PC3 00000 37. PC6 00000 00000
32. PCI-E 00000 35. PC4 00000 3B. PC7 00000 00000
33. PC2 00000 36. PC5 00000 39. PCB 00000 00000

IV. AnteriorThoracic Spine (pages 85-89)

40. AT l 00000 43. AT4 00000 46. AT7 00000 49. ATlO 00000
41. ATZ 00000 44. AT5 00000 47. ATB 00000 50. AT lI 00000
42. AT3 00000 45. AT6 00000 4B. AT9 00000 51. AT l2 00000

V. Anterior Ribs. Medial Ribs (pages 90-94)

52. ARI 00000 57. AR6 00000 62. MR3 00000 67. MRB 00000
53. AR2 00000 5B. AR7 00000 63. MR4 00000 6B. MR 9 00000
54. AR3 00000 59. ARB 00000 64. MR5 00000 69. MRIO 00000
55. AR4 00000 60. AR9 00000 65. MR6 00000 00000
56. AR5 00000 61. ARlO 00000 66. MR7 00000 00000

VI. PostenorThoracic Spine (pages 95-99)

70. PTI 00000 73. PT4 00000 76. PT7 00000 79. PT lO 00000
71. PT2 00000 74. PT5 00000 77. PTB 00000 BO. PTlI 00000
72. PT3 00000 75. PT6 00000 7B. PT9 00000 B1. PT l2 00000

41
Vll. Posterior Ribs (pages 100103)

82. PRI 00000 85. PR4 00000 88. PR7 00000 91. PRIO 00000
83. PR2 00000 86. PR5 00000 89. PR8 00000 92. PRII 00000
84. PR3 00000 87. PR6 00000 90. PR9 00000 93. PRI2 00000

Vlli. Shoulder (pages 105125)


94. TRA 00000 99. SUB 00000 104. PMI 00000 109. ISS 00000
95. SC L 00000 100. SER 00000 105. LD 00000 110. ISM 00000
96. AAC 00000 101. MHU 00000 106. PAC 00000 Ill. lSI 00000
97. SSL 00000 102. BSH 00000 107. SSM 00000 112. TMA 00000
98. BLH 00000 103. PMA 00000 108. MSC 00000 113. TMI 00000

IX. Elbow (pages 126132)


114. LEP 00000 116. RHS 00000 118. MCD 00000 120. M O L 00000
liS. MEP 00000 117. RHP 00000 119. LCD 00000 121. LOL 00000

x. Wrist & Hand (pages 133137)


122. CFT 00000 124. PWR 00000 126. CMI 00000 128. D I N 00000
123. CET 00000 125. DWR 00000 127. PIN 00000 129. IP 00000

42
C RANIUM

, CRANIAL DVSFUNGION Cramal dysfunction may manifest as headache, earache,


It is not within the scope of this text to delineate an exhaus# tinnitus, vertigo, recurring sinusitis, lachrymal dysfunction,
[lve treatise on the complex functional anammy of the era, dental symptoms, dysphasia, temporomandibular jOint
mum. TI1.C reader houkl refer to the resources listed in the (TMJ) dysfunction, seizure activity, and certain neurologic
Appendix (0 obtain training In thi important and clini# and cognitive conditions.22
cally relevant region. It is recommended that an anatomy With any cranial treatment, it is recommended that
text and the drawings at the beginning of this section be certain precautions be taken. Symptoms and signs of space
reviewed In order (0 familiarize oneself with the basic occupying lesions and acute head trauma are clear con
anaromlC relationships. traindications. A history of seizures or previous cerebrovas
For many practitioners. cranial lesions may present ehal, cular accident should be approached With caution; If In
lenges 111 terms of diagnosis and treatment. Mobility and doubt, a colleague with more experience In cranial therapy
motihty (self,actuared movement) within the cranium has should be consulted.
now been well established, although it is not fully accepted n,e PRT approach to cranial therapy is preCISe and
10 all circles. Sutherland," Upledger," and others have effective and can have an important role along with other
useJ various mcrhoJs of diagnosis and [rcarmenr [Q nor' techniques in the armementarium for addressing the
malize the function of this important area of the body. Cra cranial region.
nial function may have il significant bearing on the circula
tion of the cerehrospinal fluid (CSF) to the central nervous
syrem and thu:, on the functioning of the entire nervous HREATMENT
system.!l Dysfunctions caused by injuries, including birth Commonly used methods of cranial manipulation involve
trauma and persisting lesions resulting from childhooJ direct force against the movement barrier. Positiomll release
inJUries, <lre nm uncommon. MoLlem methods of birthing therapy uses primarily indirect movement. Tender points
may h.we a slgnlfic,uH effect on the prevalence of lateral are usually located in the vicinity of the cranial suture, With
strain lesions of the sphenoid and compression lesions of certam exceptions. The amount of force is in the range o( 1
the temporoparietal suture. to 2 kg (2 to SIb).

4^
eRANIU M Tender Points __________

FR

LAM
SO
PSB
NAS
OCC
MAX
OM

MAS

MPT

Anterior View Posterior View

TPA
---.----

PT
....f-I
. c++-'- LSB

TPP -\----"l
E)"t-----.,.,-SAG

Lateral View Superior View

44
Treannem Procedures CHAPTER 6 45

1 . Occipitomastoid ( OM ) Tentorium Cerebelli

Sagittal --r-------<;
suture
Parietal bone

OCCipital
bone
LAM
PSB Lambdoidal --\r--''''
ace suture 1'''irl-- OM
OM

Mandible

, Location of This tender point is located on the oCcipitomastoid suture just medial and superior
Tender Point to the mastoid process. Pressure is applied anterosuperiorly.

Position of Patient lies supine. The therapist sits at the head of the table and grasps the cranium
Treatment laterally with both palms. Pressure is applied medially. and counterrotation of both
(Unilaleral temporal bones is produced around a transverse axis. The direction of the rotary
tenderness) force is determined by the comfort of the patient or by the response of the tender
point (which may be difficult to palpate). (See photo above left.)

Position of The patient lies supine. The therapist sits at the head of the table. The therapist
Treatment grasps the occipital bone and applies an anterior and caudal pressure and with the
(Bilateral other hand applies pressure posteriorly and caudally. The occipital hand exerts a
tenderness) greater force. (See photo above right.)
46 CHAPTER 6 Treacmem Procedures

CRANIUM

2. Occipital ( OCC)

Sagittal --r------<;
suture
Parietal bone

Occipital
bone
LA M
PSB Lambdoidal
suture ----'<'r
oee
OM

Mandible

l Location of This tender point is located medial to the lambdoid suture approximately 3 cm (1.2
Tender Point in.) lateral to the posterior occipital protuberance just cephalad to the OM tender
point. Pressure is applied anteriorly.

l Position of The patient is supine. The therapist is at the head of the table and grasps both mas
Treatment toid processes with the heel and fingertips of the same hand or with the heels of
both hands. Gentle pressure is applied medially. (See photo above left.)
Alternatively. the palpating hand is placed under the occiput. the other hand is placed
on the anterior aspect of the frontal bone. and an anterior-posterior (AP) pressure
is applied. (See photo above right.)
Treaunent Procedures CIIAPTER 6 47

3 . Posterior Sphenobasilar ( PSB) Sphenobasilar Rotation

Sagictal
suture
Parietal bone

PSB

OCcipital
LAM bone
PSB Lambdoidal
OCC suture
OM
L
Mandible

Location of This tender point is located just medial to the lambdoid suture approximately 3 cm
Tender Point ( 1 .2 in.) superior to and 3 cm (1.2 in.) lateral and slightly superior to the posterior
occipital protuberance. Pressure is applied anteriorly.

l Position of
Treatment
The patient is supine. The therapist sits at the head of the table and grasps the
cranium with one hand on the frontal bone and one hand on the occipital bone.
Pressure is exerted in a counterrotary direction around the AP axis. The direction
of the rotation is determined by the comfort of the patient or by the response of
the tender point (which may be difficult to palpate during the treatment).
48 CHAPTER 6 Treatment Procedures

CRANIUM

4. Lambda ( LAM) Occipital Rotation

Sagittal
suture
Parietal bone

LAM

Occipital
LAM bone
PSB Lambdoidal
OCC suture
OM

l Location of This tender point is located medial to the lambdoid suture approximately 2 cm (0.8
Tender Point in.) inferior to the lambda. Pressure is applied anteriorly.

Position of The patient is supine. The therapist applies anterior pressure to the occipital bone, at
Treatment the level of the tender point, on the opposite side.
Treatmenl Procedures CHAPTER 6 49

5 . Stylohyoid (SH)

TPA
Temporalis

FR
LSB
Lateral
PT pterygoid
TPP AT
Styloid
SH
process
MAS Mastoid Masseter
process

- - - - DG Digastric
(anterior belly)
-

- MPT bone

Location of This tender point is located on the styloid process just anterior and medial to the
Tender Point mastoid process (pressure is medial).

Position of The patient is supine. The therapist flexes the upper cervical spine, opens the
Treatment patient's mouth, and pushes the mandible toward the tender point side.
Alternatively, the hyoid bone is pushed from the opposite side toward the tender
point side (not shown).
50 CHAPTER 6 Treatmenr Procedures

CRANIUM

6. Digastric ( DG)
Sphenoid

process--'V-""':'/1'I
Zygomatic Lateral pterygoid

process f----f- Medial


Digastric -->.,; pterygoid
(posterior belly)

S<ylohyoid

Digastric
Hyoid bone (anterior belly)

Location of This tender point is located in the anterior belly of the digastric muscle just medial
Tender Point to the inferior ramus of the mandible and anterior to the angle of the mandible.
Pressure is applied in a cephalad direction.

Position of The treatment is that for stylohyoid (SH).


i Treatment Alternatively, the hyoid bone is pushed from the opposite side toward the tender
point side (not shown).
Treatment Procedures CHAPTER 6 5I

7. Medial Pterygoid (MPT)


Sphenoid
TPA

PT
TPP

MastOid;;-::X&'
proc:ess V,II----f- Medial
_---.l0___- MAS Digastric: - pterygoid
LC (posterior belly)

MPT
Stylohyoid
- - MPT

Digastric:
Hyoid bone (anterior belly)

location of This tender point is located on the medial surface of the ascending ramus of the
Tender Point mandible, just superior to the mandibular angle. Pressure is applied laterally.

Position of The patient is supine with the therapist at the head of the table. The therapist
Treatment pushes the mandible away from the tender point side while applying a stabilizing
force on the contralateral side of the frontal bone.

Note: This point is found inferior and medial to AC I .


52 CHAPTER 6 Treatment Procedures

CRANIUM

8. Lateral Pterygoid ( LPT)


Sphenoid
TPA
ZygomatiC
PT
TPP :-,.-_-AT '
- - - - LPT
SH - - - LPT ii:Medial
OM -- process , pterygoid
.....
--'i'-- MAS Digastric -
LC (posterior belly)
....
. - - - - DG
- - MPT Stylohyoid
Hyoid bone
l location of I . Intraorally, medial to the coronoid process of the mandible in the posterior and
Tender Point superior aspect of the cheek pouch on the lateral aspect of the lateral pterygoid
plate. Use a gloved finger. Pressure is applied posteriorly.
2. Extraorally, with the mouth slightly open, just anterior to the articular process of
the mandible and inferior to the zygomatic arch.

Position of The patient lies supine. The patient's jaw is opened slightly and the head is supported
l Treatment and placed in a position moderate flexion, rotation, and side bending away from the
tender point side.

Note: This position is similar to the treatment for AC3.


Treatment Procedures CHAPTER 6 53

9. Masseter (MAS) Masseter, Temporalis

TPA
Temporalis

TPP PT lateral
AT pterygoId
SH Styloid
OM process
MAS
Mastoid Masseter
process
Digastric
- - MPT (anterior belly)

Location of This tender point is located on the anterior border of the masseter muscle over the
Tender Point anterior edge of ascending ramus of the mandible. Pressure is applied posteriorly.

Position of The patient is supine. The therapist braces the patient's head against the therapist's
Treatment chest. The jaw is pushed toward the side of the tender point, and closure pressure is
applied on the mandible toward the tender point side while applying a counterforce
on the ipsilateral aspect of the frontal bone toward the opposite side.
54 CHArTER 6 Treatment Procedures

CRANIUM

1 0. Maxilla (MAX)
Frontal bone

Parietal bone
FR
bone -.u-\-;;!)1i
Temporal
.:T-H+ Sphenoid bone
NAS ===---
SO Nasal bone
Zygomatic bone
MAX ...... . 'w-r-N'Y'{Y1.,;::;'t- Maxilla
MAS

l Location of This tender point is located in the region of the infraorbital foramen. Pressure is
Tender Point applied posteriorly.

Position of The patient is supine. The therapist interlaces his or her fingers and compresses
Treatment medially with the heels of both hands on the zygomatic portion of the maxillary
bones.
Treatment Procedures CIIAPTER 6 55

1 1 . Nasal (NAS) Internasal Suture

Frontal bone

Parietal bone
Temporal---,-
bone ","u
Nasal bone -I:!--'G,.. Ih.t::t-t-;f-'- Sphenoid bone
Zygomatic bone
NAS

Location of This tender point is located on the anterolateral aspect of the nose. Pressure is
Tender Point applied posteromedially.

l Position of
Treatment
The patient is supine. The therapist pushes medially on the portion of the nose con
tralateral to the tender point.
56 CHAPTER 6 Treatment Procedures

CRANIUM

1 2. Supraorbital ( SO) Frontonasal J oint

Frontal bone

Parietal bone
_-i\CT SO
Temporal
bone
Nasal bone -lrQ"i IhMf' Sphenoid bone
Zygomatic bone
,""""'NV\IV\;:;:;Ifflt-- Maxil a

l Location of This tender point is located in the region of the supraorbital foramen. Pressure is
Tender Point applied posteriorly.

Position of The patient is supine. The therapist places his or her forearm on the patient's fore
Treatment head and pulls in a cephalad direction while pinching the nasal bones with the fingers
of the other hand and pulling in a caudad direction.
Treatment Procedures CHAPTER 6 57

1 3 . Frontal (FR)
Parietal bone __---,-
- _
FR
TPA
Temporal bone Sphenoid bone
.!<t'k.':-" Nasal bone
PT
:...:..-_- AT OCcipital bone ;:';-'7F--= Maxi
t1
Zygomatic bone
la
- - - LPT

_-ir--- MAS
IIIiIIJIooi - - - - DG Mandible
-, MPT

Location of This tender point is located above the lateral portion of the orbit on the frontal
Tender Point bone. Pressure is applied medially.

l Position of
Treatment
The patient is supine. The therapist pushes the top of the frontal bone caudally (see
photo above left) or compresses the frontal bone bilaterally (see photo above right).
58 CHAPTER 6 Treatment Procedures

CRANIUM

1 4. Sagittal Suture ( SAG) Falx Cerebri

Frontal bone

SAG
Sagittai -+ --1-3
-If-
___

suture Parietal
bone

OCCipital bone

Location of This tender point is located on the superior aspect of the head just lateral to and
Tender Point along either side of the sagittal suture. Pressure is applied caudally.

l
Position of The patient is supine. The therapist pushes caudally on the parietal bone just lateral
Treatment to the sagittal suture on the opposite side of the tender point.
Treatment Procedures CHAPTER 6 59

1 5 . Lateral Sphenobasilar ( LSB) Sphenobasilar Lateral Strain

TPA Parietal bone


< Frontal bone
Temporal bone '--,
Sphenoid bone
<: Nasal bone
PT
AT LSB

Occipital bone Zygomatic bone


Maxilla
MAS

- MPT

Location of This tender point is located on the lateral aspect of the greater wing of the sphenoid
Tender Point in a depression behind the lateral ridge of the orbit. Pressure is applied medially.

Position of The patient is supine. The therapist applies a lateral pressure on the opposite greater
Treatment wing of the sphenoid toward the tender point side. A counterpressure is used on
the frontal bone and the zygoma of the involved side using the fingers and heel of
the hand.
60 CHAPTER 6 Treatmenl Procedures

CRANIUM

1 6. Anterior Temporalis ( AT )

Parietal bone _--.


-__
TPA
Frontal bone
Temporal bone Sphenoid bone
....,'"
... '
><' Nasal bone
__ PT
=-_- AT

OCCipital bone :;;;o-;f'-1i:.: Maxi


r1
Zygomatic bone
la
_----,IF-- MAS
AT

1 Location of This tender point is located in the anterior fibers of the temporalis muscle approxi
Tender Point mately 2 em (0.8 in.) posterior and lateral to the orbit of the eye and superior to
the zygomatic arch. Pressure is applied medially.

l
Position of The patient is supine. The therapist is on the side of the tender point and grasps the
Treatment frontal bone with one hand and applies a force around an AP axis toward the tender
point. The heel of the other hand is placed under the zygomatic bone. and pressure
is exerted in a cephalad direction.
Treatment Procedures CHAPTER 6 61

1 7. Posterior Temporalis (PT)

Parietal bone
TPA ,
, Frontal bone
...,
Temporal bone Sphenoid bone
-, -<{:':V Nasal bone
PT
AT
Occipital bone
,
1 ;-::.-:rL Zygomatic bone
-? Maxilla
MAS
Mastoid process PT

Mandible
- MPT

l Location of This tender point is located in the posterior fibers of the temporalis muscle approxi
Tender Point mately 3 cm ( 1 .2 in.) anterior to the external auditory meatus superior to the zygo
matic arch. Pressure is applied medially.

Position of The patient is supine. The therapist is on the side of the tender point. grasps the
Treatment parietal bone with one hand. and applies a force to rotate the skull around an AP
axis toward the tender point. The heel of the other hand is placed under the zygo
matic bone. and pressure is applied in a cephalad direction.

Note: AT and PT are treated using a similar technique.


62 CHAPTER 6 Treatmem Procedures

CRANIUM

1 8. Temporoparietal ( Anterior) (TPA)

Parietal bone
Frontal bone
Temporal bone Sphenoid bone

OCCipital bone ;:;;;-.:/'-1s: Zygomatic bone


(i Maxil a
__.::---- MAS
.!':: - - - DG
-

1 location of This tender point is located cephalad to the ear, on or just above the temporopari
Tender Point etal suture. Pressure is applied medially.

Position of The patient lies on the unaffected side with a small roll under the opposite zygo
Treatment matic area. The therapist sits near the head of the patient, grasps the parietal bone
(Unilateral with the fingers, and pulls the parietal bone cephalad and medially away from the
tenderness) tender point side. Alternatively, the therapist may stand and apply the force with the
heel of the hand. Counterpressure is applied with the other hand in a medial direc
tion on the mastoid process on the same side as the tender paint.

1
Position of The patient is supine with the therapist seated at the head of the table. The therapist
Treatment grasps the patient's cranium on both sides, just cephalad to the temporoparietal
(Bilateral suture on the parietal bones. A medial pressure is applied bilaterally (see bottom
tenderness) right photo on p. 57).
Treaonem PmcedHre. CIIAPTER 6 63

1 9. Temporoparietal ( Posterior) (TPP)


Parietal bone ;
TPA < Frontal bone
Temporal bone Sphenoid bone
Nasal bone
PT TPP
AT OCCipital bone Zygomatic bone
Maxil a
SH
MAS
Mandible
,
, MPT

Location of This tender point is located at the junction of the lambdoid the temporoparietal
Tender Point sutures approximately 3 cm ( 1 .2 in.) posterior to the external auditory meatus, in a
depression on the skull. Pressure is applied medially.

Position of The patient lies on the unaffected side with a small roll under the opposite zygo
Treatment matic area. The therapist applies a force superior to the tender point, on the parietal
(Unilateral bone, in a cephalad and medial direction in order to rotate the skull away from the
tenderness) tender point side. Counterpressure is applied medially on the ipsilateral mastoid pro
cess with the other hand.

Position of The patient lies supine with the therapist at the head of the table. The therapist
Treatment applies bilateral compression with the palms on both sides of the skull posterior to
(Bi lateral the ears (see bottom right photo on p. 57).
tenderness)
C E RVI C A L S P I N E
be traced to dennatomal patterns associated with the nerve
, CERVICAL DYSFUNGION rOOt distribution of the brachial plexus.
Bipedal posture has afforded human beings numerous evolu, To locate specific segments of the cervical spine, the fol
tionary advantages, including an increased range of visual lowing list of landmarks may be a helpful guide:
surveillance of the surroundings and an improved ability to C I : Transverse process just inferior to mastoid process
manipuitnc the materials in the environment. However, the and posterior to the earlobe.
raised center of gravity also causes greater translational forces CZ: Spinous process is located approximately 1 . 5 to Z
and resultant trauma to the poswral supportive tissues. The cm (0.6 to 0.8 in.) inferior to the midline of the
head and neck are particularly vulnerable to horizontal occiput. This is a wide, bifid spinous process.
forces, which can be induced by falls or blows to the body. C3: Located at the level of the hyoid anteriorly. On
The relatively large mass of the head is a source of significant extension, spinous process remains palpable.
inertial force in the event of trauma to the cervical region. C4: Located at the level of the superior border of the
The bane of modem existence, the automobile, provides thyroid cartilage anteriorly. On extension, spinolls
unique opportunities for especially severe trauma to rhe rela, process is not palpable.
tively delicate supportive elements of the cervical spine. C5: Located at the level of the inferior border of the
Parnspinai muscles in the anterior, posterior, and lateral com, thyroid cartilage anteriorly. Spinous process
partmcntsj the suboccipital musculature; the paravertebral, remains palpable on extension.
capsular, and ligamentous elements; and the superficial fascia C6: Located at the level of the cricoid cartilage anteri
may be variously compromised depending on the direction orly. Spinous process is easily palpable on extension
and magnitude of the displacing forces .l1 and is often bifid.
It appears that the deep, intrinsic tissues related to the C7: Prominent bifid spinous process. To differentiate
intervertebral segment arc the particular focus of persisting from T I , perform cervical extension. The C7
dysfunction, and it is [Q this level that therapeutic interest is spinous moves anteriorly Inore than T I . J,I'1
directed. I The multifidus and rotatores posteriorly, the
scalenes anteriorly and laterally, the longus capitis and longus
colli anteriorly, and the suboccipitals are the active tissues
, TREATMENT
that have the greatest scgmental motor and sensory effect on Positioning of the cervical spine involves using the tcnder
the cervic..1 1 spine, I I Palpation of the tender points on the point as a fulcrum about which all of the componenr move
posterior, infcrior aspect of the spinous processes may ncccs ments {flexion, extension, rotation, and lateral flexion} are
sitate slight flexion of the neck, and both sides of the bifid focused. Treatment of anterior lesions consists of precise
proccs> should be examined. flexion of the cervical spine ar the level of the tender point.
Clinical expressions of cervical dysfunction include neck With scalene involvement, the addition of contralateral
pain, restriction of cervical motion, upper limb symptoms rotation and a variable amounr of lateral flexion are also
(pain, paresthesia, paresis), upper thoracic pain, headaches, induced. Posterior dysfunction may involve the posterior
dysphagia, nonproductive cough, vertigo, and tinnitus. The suboccipitals, multifidus, or rota[Qres. These are treated
neck seems especially prone to stressrelated responses and using varying degrees of extension and often the addition of
patients who arc anxious should be evaluated for psychologic rotation and lateral flexion away from the tender point side.
factors.16 Headache patterns, according to Jones,9 follow a Occipital flexion, by retracting the patient's mandible,
segJ1'lental pattern, with C 1 , 2 associatcd with frontal should be maintained throughom any positions involving
headache, C3,4 with lateral head pain, C4 with occipital cervical extension. The sternocleidomastoid may need to be
pain, and C5 with whole head pain. Joncs9 also points out pushed laterally or medially in order to palpate the anterior
that dysfunction at the level of C3 is often assoc iated with tender points. The patient's neck should be relaxed during
earache, tinnitus, or vcrtigo.9 Upper limb involvement may palpation and treatment.

64
ANT E RI O R C E R V I C A L S P I N E Tender Points

Anterior View

AC I

Lateral View
Anteri or Cervi cal S p i n e

20. Anterior First Cervical ( AC l ) Rectus Capitis Anterior

Coronal suture
TPA Parietal bone ---..c
Frontal bone
Temporal bone Sphenoid bone
Lambdoidal ...... "" Nasal bone
TPP J
suture t--"d-- Lacrimal bone
SH Occipital bone ;;;-.::;f'-1'1::: Maxi
r1
Zygomatic bone
la
_--....--- MAS
"-;'1__+----""""""_'+-- AC I
Mental
foramen
ZygomatiC Mandible
arch

l location of This tender point is located on the posterior aspect of the ascending ramus of the
Tender Point mandible approximately I cm (0.4 in.) superior to the angle of the mandible. Pres
sure is applied anteriorly.

l
Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the sides of the patient's head and rotates the head markedly away from
the tender point side. Fine-tuning may include slight cervical flexion, extension, or
lateral flexion.

66
Treac:ment PrOCedtTes CHAPTER 6 67

2 1 . Anterior Second Cervical (AC 2 ) Longus Colli

Rectus capitis
anterior
Rectus capitis
lateralis
AC2
ACl capitis -1-1"-1...dl lb AC2
AC4 --e AMC Sternocleido
mastoid
ACS --e
AC6 --e Middle scalene Clavicle
First rib
Second rib
'-AC7
--ACe
Location of This tender point is located on the anterior surface of the tip of the transverse pro
Tender Point cess of C2. This is located approximately I em (04 in.) inferior to the tip of the mas
toid process. Pressure is applied posteromedially.

Position of The patient is supine with the therapist sitting at the head of the table. The therapist
Treatment grasps the sides of the patient's head and rotates the head markedly away from the
tender point side. This treatment is similar to that for AC I except that slightly more
flexion is used.
68 CHAPTER 6 Trearment Procedures

Antenor Cervical Spine

2 2 . Anterior Third Cervical ( AC3 ) Longus Capitis, Longus Colli

Rectus capitis
anterior
Rectus capitis
lateral is
AC2
LOngUs;'l
capitis --\-'
ACJ \'!LC/!'f"fi.,
..-I ":::' C I
n-:;,
" C2
AC4 -- Sternocleido C3
mastoid C4 ACJ
ACS __ WIr!IiCO;S Longus Colli
. 1It::,::Ii>!
AC6 __
Clavicle

First rib
Posterior
scalene Second rib
O-AC7
- -AC8

1 Location of This tender point is located on the anterior surface of the tip of the transverse pro
Tender Point cess of C3 at the level of the hyoid. This area may usually be found directly posterior
to the angle of the mandible. Pressure is applied posteromedially.

1
Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and produces marked flexion to the level of C3, rota
tion away from the tender point side, and lateral flexion away from or toward the
tender point side.

Note: The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures CHAPTER 6 69

23. Anterior Fourth Cervical ( AC4) Scalenus Ant., Longus Capitis,


Longus Colli

Rectus capitis

---\::r
anterior
Rectus capitis
lateralis
AC2 Longus
capitis -;-..c:;
fl'lj,y'
AC3

AC4 ___ Sternocleido


mastoid
ACS ___

AC6 ___ Middle scalene


Anterior sCailene_

First rib
Posterior
scalene Second rib

Location of This tender point is located on the anterior surface of the tip of the transverse pro
Tender Point cess of C4 at the level of the superior border of the thyroid cartilage. This area is
usually found just inferior and posterior to the angle of the mandible. Pressure is
applied posteromedially.

Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and produces moderate cervical flexion to the level of
C4 (cervical extension may be required for this segment), rotation, and lateral
flexion away from the tender point side.

Note: The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
70 CHAPTER 6 Treatment Procedures

Antenor Cervical Spine

24. Anterior Fifth Cervical ( AC5 ) Scalenus Ant., Longus Capitis,


Longus Colli

Rectus capitis
anterior

AC2
capitis -i-'a fJs>_
AC3

AC4 _ AMC Sternocleido


mastoid
ACS _

AC6 _ Middle scalene


Clavicle

First rib
Posterior
scalene Second rib
O-AC7
--ACe

", Location of This tender point is located on the anterior surface of the tip of the transverse pro
Tender Point cess of CS at the level of the inferior border of the thyroid cartilage. Pressure is
applied posteromedially.

Position of The patient lies supine with the therapist sitting at the head of the table. The thera
l Treatment pist grasps the patient's head and produces cervical flexion down to the level of the
tender point and rotation and lateral flexion away from the tender point side.

Note: The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
Treatment Procedures CIIAPTER 6 71

25. Anterior Sixth Cervical ( AC6) Scalenus Ant., Longus Colli

Kectus capltJs
anterior

AC2
capitis -""t-\"I...c.:'Dt Y.
AC3 _

AC4 AMC Sternocleido


mastoid
AC5

AC6 _ Middle scalene


Anterior ,c.,lon.,_

First rib
Posterior
scalene Second rib
::'-AC7
- -ACe

l Location of This tender point is located on the anterior surface of the tip of the transverse pro
Tender Point cess of C6 at the level of the cricoid cartilage. Pressure is applied posteromedially.

Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and produces cervical flexion down to the level of the
tender point and rotation and lateral flexion away from the tender point side.

Note: The therapist may support the head on the therapist's forearm by passing it
under the head from the non-tender point side and resting the palm of the
hand on the patient's anterior shoulder on the tender point side.
72 CHAPTER 6 Treatment Procedures

Anterior Cervical Spine

26. Anterior Seventh Cervical ( AC 7 ) Sternocleidomastoid

Rectus capitis
anterior
Rectus capitis
lateralis
AC2 Longus
capitis -1-fl.":;flil"'r::;'
AC3

AC4 AMC Sternocleido


mastoid
;:;::!- Longus Colli
ACS __
AC7
AC6 __ Clavicle

First rib

Second rib

- -ACS

l Location of This tender point is located on the posterior superior surface of the clavicle approx
Tender Point imately 3 cm ( 1 .2 in.) lateral to the medial head of the clavicle. Pressure is applied
anteriorly and inferiorly.

Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist supports the patient's midcervical area and markedly flexes and laterally flexes
the cervical spine toward the tender point side, rotating the cervical spine slightly
away from the tender point side.
Treatmenr Procedures CHAPTER 6 73

27. Anterior Eighth Cervical (AC8) Sternohyoid, Omohyoid

Rectus capitis
anterior Basilar part of
occipital bone
Rectus capitis
lateralis
AC2
Longus
AC3 capitis -"i-'JJ ,,.....::;;:)

AC4 _ AMC Sternocleido


mastoid
AC5 _

AC6 _ Middle scalene


Anterior swlene_

First rib
Posterior
scalene Second rib

--Ace

'1 location of This tender point is located on the medial surface of the proximal head of the clav
Tender Point icle. Pressure is applied laterally.

l Position of The patient lies supine with the therapist at the head of the table. The therapist grasps
Treatment the patient's head and flexes the cervical spine slightly, laterally flexes slightly away from
the tender point side, and rotates markedly away from the tender point side.
74 CHAPTER 6 Treatment Procedures

A N TERIOR MEDIAL CERVICAL

28. Anterior Medial Cervical ( AMC ) Longus Colli, Infrahyoid

Rectus capitis
anterior Basilar part of
Rectus capitis occipital bone
lateralis
AC2 Longus
capitis -i-'C4
AC3

AC4 __ Sternocleido
mastoid
WJ.iIl:::;?- Longus Colli AMC
ACS __

AC6 __ Middle scalene


Clavicle

First rib
Posterior
scalene
Second rib
O-AC7
Ace
___.....I
Location of These tender points are found along the lateral aspect of the trachea. The trachea is
Tender Point pushed slightly to the side to palpate the point. Pressure is applied posteriorly.

l Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and markedly flexes the neck while adding slight side
bending toward and rotation away from the tender point side.
Treatment Procedures CHAPTER 6 75

LATERAL CERVICAL

29. Lateral First Cervical (Le I ) Rectus Capitis Lateralis

LC I----' ...-+ - - MAS

= --cl
AC I
- - . MPT

location of This tender point is located on the lateral aspect of the transverse process of C I .
Tender Point Pressure is applied medially.

Position of The patient is supine with the therapist sitting at the table. The therapist grasps the
i Treatment patient's head and laterally flexes the head toward or away from the tender point
side depending on the response of the tissues.
76 CHAPTER 6 Trearmem Procedures

LATERAL CERVICAL

30. Lateral Cervical ( LC26) Scalenus Medius

LCI
LC2
LC3
SH - - - LPT LC4
MAS C4

ce'--Cl
ACI
cs
LCS
--. MPT
LC6
C6

l Location of These tender points are located on the lateral aspect of the articular processes of
Tender Point the cervical vertebrae. Pressure is applied medially.

Position of The patient is supine with the therapist at the head of the table. The therapist grasps
Treatment the patient's head and side bends the head and neck toward or away from the
tender point side depending on the response of the tissues. Flexion, extension, or
rotation may be needed to fine-tune the position.
P 0 S T E RI O R C E R V I C A L S P I N E Tender Points

Posterior
Rectus minor
capitis Posterior
major
PC 2
::S;
,,", -/
:\''"it't---f- :Superior
)
Obius
Transverse capitis
'- '-_ Inferior
process of C I
PC3 -rl-i]
PC4
)
Lonus Rotatores
BrevIs cervicis

==:::-
PC6
PC7 Letor
PCB

77
Posteri o r Cervi cal S p i n e

3 1 . Posterior First Cervical-Flexion (PC 1 ,F)


Rectus Capitis Anterior

PCI

PCI-t--_ PCI-E


PC6 -----..

PC7
___
pca --

Location of This tender point is located on the base of the skull on the medial side of the inser
Tender Point tion of the semispinalis capitis approximately 3 cm ( 1 .2 in.) inferior to the posterior
occipital protuberance. Pressure is applied laterally and superiorly.

1
Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head by putting one hand on the occiput and pulling in a
cephalad direction and the other hand on the frontal bone pushing caudad. This will
create marked occipital flexion. Fine-tuning may include slight side bending toward
and rotation away from the tender point side.

78
Treatment Procedures HAPTER 6 79

32. Posterior First Cervical-Extension ( PC l E)


Obliquus Capitis Superior

PCI

PC I -E -_--' PC I -E
PC2 ---


PC6----

PC7
.----.
PC8 -

Location of This tender point is located on a flat portion of the occipital bone approximately
Tender Point I to 1.5 em (0.4 to 0.6 in.) medial to the mastoid process. Pressure is applied in a
cephalad direction.

Position of The patient lies supine with the head resting on the table. The therapist sits at the
Treatment head of the table. The therapist then places the hand under the patient's head with
the fingers pointing caudally. With pressure from the heel of the hand, the therapist
pushes caudally on the head in such a manner as to induce a local extension of the
occiput on C I . The therapist can also add moderate rotation and slight side bending
away from the tender point side to fine-tune.

Note: One hand may be used to palpate the tender point and to apply caudal pres
sure on the top of the posterior aspect of the head; the other hand is posi
tioned on the frontal bone to assist the movement (not shown).
80 CHAPTER 6 Treatment Procedures

Postenor Cervical Spine

3 3 . Posterior Second Cervical ( PC 2 ) Rectus Capitis Posterior


Major/Minor

PC I -F 1,.-;;...--r PC2
....

PCI-E-----.;

PC3

_. . .
PC6
-
--
-

..
.
-


PC7 - ---

-


Pce------

l Location of This tender point is located on the base of the skull on the lateral side of the inser
Tender Point tion of the semispinalis capitis. Pressure is applied medially and superiorly. Another
tender point may be found on the superior surface of the spinous process of C2.
Pressure is applied inferiorly.

l
Position of The patient lies supine with the head resting on the table. The therapist sits at the
'
Treatment head of the table. The therapist then places the hand under the patient's head with
the fingers pointing caudally. With pressure from the heel of the hand, the therapist
pushes caudally on the head in such a manner as to induce a local extension of the
occiput on C I . The therapist can also add moderate rotation and slight side bending
away from the tender point side to fine-tune.

Note: One hand may be used to palpate the tender point and to apply caudal pres
sure on the top of the posterior aspect of the head; the other hand is posi
tioned on the frontal bone to assist the movement (not shown).
Treatment Procedures CHAPTER 6 81

34. Posterior Third Cervical ( PC3 )


Rotatores, Multifidus, Interspinalis

PCI-F

PC I-E--_-.:
J...-- PC3


PC6----

PC7
___
pca--

Location of This tender point is located on the inferior surface of the spinous process of C2
Tender Point (pressure applied superiorly) or on the articular process of C3 (pressure applied
anteriorly). Slight flexion may be needed to allow the tender point to be accessible.

l
Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and extends the cervical spine to the level of C3 and
laterally flexes and rotates it away from the tender point side. This lesion may
require flexion, in which case the treatment is identical to that for AC3.
82 CHAPTER 6 Treatment Procedures

Posterior Cervical Spine

3 5 3 8. Posterior Fourth, Fifth, Sixth, and Seventh Cervical


(PC4 7 ) Rotatores, M u ltifidus, Interspinalis

PC4 r_


--

PC5
------I --: t:2
--

PC6
PC7 -----:;:;
PC6-- --..
-

PC7
____
pcs--

l Location of This tender point is located on the inferior surface of the spinous process of verte
Tender Point brae above (pressure applied superiorly) or on the articular process of the involved
vertebral segment (pressure applied anteriorly). Slight flexion may be needed to
allow the tender point to be accessible.

Position of The patient lies supine with the therapist sitting at the head of the table. The thera
Treatment pist grasps the patient's head and extends it moderately and laterally flexes and
rotates it away from the tender point side. Extension is increased progressively as
one treats progressively caudal lesions.
Trearmenr Procedures CHAPTER 6 83

39. Posterior Eighth Cervical (PCB) Levator Costorum

PCI-F

PCI-E-_-.:

PC3 ---:-


PC6-----
PC7 --- ----. . .
PCB
___
pcs-

location of The therapist palpates anterior to the upper portion of the trapezius to locate the
Tender Point upper border of the first rib_ The tender point is found by palpating medially toward
the base of the neck until the transverse process of C7 is encountered and then
moving onto the posterosuperior surface of the transverse process_ Pressure is
applied anteriorly on the posterior surface of the transverse process of C7_

1
Position of The patient lies supine with the therapist Sitting at the head of the table. The thera
Treatment pist grasps the patient's head and induces marked lateral flexion and slight rotation
away from the tender point side along with slight cervical extension.
THO R ACIC S PIN E AN D RIB C AG E

HHORACIC DYSFUNCTION
The thoracic spine and rib cage contain no less than 84 syn; syndrome, carpal tunnel-like syndrome, and respiratory and
ovial joints. They form a protective housing for several vital cardiovascular dysfunction. It is important to assess for and
organs. are the site of the origin of the sympathetic nervous treat any significant thoracic lesions when there is upper
system, and are an important structural link with the upper limb involvement. In general. treatment of the thoracic
limb. Although gross motion of the thoracic spine is limited spine and rib cage may be determined by postural distortion,
by the presence of the ribs, physiologic and nonphysiologic if present. Therefore a hyperkyphotic upper back will usu
mocion arc crucial [0 the respiratory, cardiovascular. and ally be treated in flexion, and a hypokyphotic ;pine will
digestive organs. Trauma. postinfectious visceral adhesive usually be treated in extension.2J The rules of priority, as
pathology, and surgical intervention are possible causes of detennined by the scanning evaluation and by the applica
local lesions.7 Assessment of spinal and rib mmion may be tion of the rules of treatment, will ultimately dC[ermine
useful in determining the site of clinically significant areas where and how to treat.
of fixation.
Posterior tender points may be found on the spinous pro;
cesses, in the paraspinal musculature, on the transverse pro HREATMENT
cesses, over the rib heads, or on the posterior angles of the Posterior lesions are treated in extension, and head and
ribs. Anterior tender points are usually found on the ante shoulder position is used to localize the release of the
rior aspect of the ternum, over the sternocostal joints, on involved tissues at the level of the dysfunction. From
the anterior angles of the ribs, or on the anterolateral mar appearances, it may seem, in some cases, that the area being
gins of the ribs. The tender points on the sternum are treated is under stretch; however, review of the pertinent
reflexly related to the anterior aspect of the thoracic spine, anatomy will clarify the rationale used. Through its myofas
which is of course inaccessible to direct palpation. cial connections to the rib cage, the ipsilateral arm, when
As a guide to palpation, it should be noted that T2 is elevated, causes the ribs to elevate, which in turn elevates
usually located at the level of the superior, medial angle of the lower attachments of the levator costOTUm or multifidus
the scapula, TJ at the level of the spine of the scapula, and toward their insertions on the lamina of the vertebrae one
T7 at the level of the inferior border of the scapula. The or twO segments above.17 Anterior lesions are treated with
eleventh rib is usually found at the level of the iliac crest.J" varying degrees of flexion with the addition of rotation or
Clinical manifestations of thoracic dysfunction include lateral flexion to fine-tune the position.
back pain, neck pain, shoulder and arm pain, thoracic outlet

84
AN T E RIO R THO R AeI C S PIN E Tender Points

Upper Anterior Thoracic Region

Lower Anterior Thoracic Region


85
Anterior Thoracic Spine

40,42. Anterior First, Second, and Third Thoracic (ATl,3)


Internal Intercostal, Sternothyroid

..
ATI

Internal ATl
intercostals ATl

Transversus
thoracis
External
intercostals

l Location of This tender point is located on the superior surface of the suprasternal notch. Pres
Tender Point sure is applied inferiorly.
(All)

Location of This tender point is located on the anterior surface of the manubrium. Pressure is
Tender Point applied posteriorly.
(An)

l Location of This tender point is located on the anterior surface of the sternum on or just infe
Tender Point rior to the sternomanubrial joint. Pressure is applied posteriorly.
(All)

l Position of
Treatment
The patient sits in front of the therapist with knees flexed and hands on top of the
head. A pillow may be used between the patient and therapist for comfort. The ther
apist places his or her arms around the patient and under the patient's axillae. The
patient leans back toward the therapist, and the therapist allows the patient to slump
into marked flexion down to the level of the tender point. The patient's trunk is
folded over the tender point. Fine-tuning is accomplished with the addition of rota
tion or lateral flexion.

Note: AT 1-6 may be performed in the supine or lateral recumbent positions with
minor modifications.

86
Treatment Procedures CHAPTER 6 87

43A5. Anterior Fourth, Fifth, and Sixth Thoracic (AT4,6)


Internal Intercostal

ATI
An
AT3 Internal
AT4 intercostals
ATS
AT6 AT4
Transversus ATS
AT7 thoracis AT6
External
intercostals

location of This tender point is located on the anterior surface of the sternum at the level of
Tender Point the fourth interspace. Pressure is applied posteriorly.
(AT4)

location of This tender point is located on the anterior surface of the sternum at the level of
Tender Point the fifth interspace. Pressure is applied posteriorly.
(ATS)

1 location of This tender point is located on the anterior surface of the sternum at the level of
Tender Point the sixth interspace. Pressure is applied posteriorly.
(AT6)

1
Position of The patient is seated in front of the therapist with the knees flexed and the arms
Treatment extended off the back of the table. A pillow may be used between the patient and the
therapist for comfort. The patient leans back toward the therapist. The therapist
places pressure on the patient's upper back to create thoracic flexion down to the
level of the tender point. The flexion is progressively increased as the level of treat
ment proceeds caudally. Local flexion may be augmented by grasping one or both of
the patient's arms and applying caudal traction and internal rotation or by having the
patient clasp his or her hands behind the therapist's knee. Fine-tuning is accomplished
with the addition of rotation or lateral flexion (see photo above left). The photo
above right illustrates an alternate, lateral recumbent position.
88 CHAPTER 6 Treacment Procedures

Anterior Thoracic Spme

4648. Anterior Seventh, Eighth, and Ninth Thoracic (AT7 9)


Diaphragm, Diaphragmatic Crura

ATI

l Location of This tender point is located on the inferior, posterior surface of the costochondral
Tender Point portion of the seventh rib (pressure applied anteriorly and superiorly), approximately
(AT1) I cm (0.4 in.) inferior to the xyphoid process and I cm (0.4 in.) lateral to the mid
line. Pressure is applied posteriorly.

Location of This tender point is located approximately 3 to 4 cm (1.2 to 1.6 in.) inferior to the
Tender Point xyphoid process and 1.5 cm (0.6 in.) lateral to the midline. Pressure is applied
(AT8) posteriorly.

l Location of This tender point is located approximately 1.5 cm (0.6 in.) superior to the umbilicus
Tender Point and 1.5 cm (0.6 in.) late
.
(AT9)

l Position of Assume, for the purposes of illustration, that the tender point is on the right side.
Treatment The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests his or her legs on the table with the
knees pointing to the left while the left arm rests on the therapist's left thigh. The
therapist flexes the patient's trunk down to the level of the tender point and side
bends the trunk to the right by translating it to the left. The therapist then rotates
the patient's trunk to the left by having the patient bring the right arm across the
body and grasp the left wrist.
Note: A physical therapy ball or chair may be used to support the arm for AT 7-9.
Treacmem Procedures CHAPTER 6 89

49,51. Anterior Tenth, Eleventh, and Twelfth Thoracic


(ATI0,12) Psoas, Iliacus

::-;Jr+- AT7
'-F-f- AT8
An
ATI ATiO
ATII

location of This tender point is located approximately 1.5 cm (0.6 in.) caudal to the umbilicus
Tender Point and I .S cm (0.6 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlO)

1 location of This tender point is located approximately 4 cm (1.6 in.) caudal to the umbilicus and
Tender Point 2 cm (0.8 in.) lateral to the midline. Pressure is applied posteriorly.
(ATlI)

1 location of This tender point is located on the inner table of the crest of the ilium at the midax
Tender Point illary line. Pressure is applied caudally and laterally.
(ATl2)

1 Position of The patient is supine and the therapist stands on the tender point side. The head of
Treatment the table may be raised or a pillow may be placed under the patient's pelvis. The
patient's hips are markedly flexed and may be rested on the therapist's upraised
thigh. The thighs are rotated toward the tender point side, and lateral flexion may be
toward or away from the side of the tender point.

Note: Treatments for AT I 0-12 are similar, with slight variation in fine-tuning. A phys
ical therapy ball may be used to support the legs. AT7-9 may be performed in
the supine or lateral recumbent position.
AN T E RIO R AN D M E D I A L RIB S Tender Points

AR2
----1t
AR3--....w...

ARS -_
AR6- . ...._--
MR3-IO
AR7---\,e
ARB ----'Ie'___
AR9 --,.::.;
ARlO--1i;,:L..._i==k1).J
Anterior Rib Cage

Posterior view of anterior chest wall


Relationship of tender points

90
Anterior, Medial Ribs

52. Anterior First Rib (ARl) Scalenus Anterior, Scalenus Medius

ARI :::---..
AR2 __ ARI
AR3_
AR4-.-. MR3-IO Internal
ARS intercostals
AR6

AR7 Transversus
ARB thoracis
AR9 External
ARlO intercostals

Location of This tender point is located on the first costal cartilage immediately inferior to the
Tender Point proximal head of the clavicle. Pressure is applied posteriorly.

l Position of
Treatment
The patient may be supine or sitting. The therapist grasps the head and places the
patient's neck in slight flexion, marked lateral flexion toward the tender point, and
slight rotation (usually toward the tender point) to fine-tune the position.

91
92 CHAPTER 6 Treatment Procedures

Antenor Medial Ribs

53. Anterior Second Rib (AR2) Scalenus Posterior

AR I :::::----..
AR2 __
AR3_
AR4-. MR3-IO Internal
AR5
intercostals
AR6
AR7 Transversus
ARB thoracis
AR9 External
ARlO intercostals

l Location of This tender point may be found in two locations. One is on the superior surface of
Tender Point the second rib inferior to the clavicle on the midclavicular line (pressure is applied
inferiorly and posteriorly). Another tender point may be found on the lateral aspect
of the second rib high in the medial axilla (pressure is applied medially).

Position of The patient may be supine or sitting. The therapist grasps the head and places the
Treatment patient's neck in slight flexion, marked lateral flexion toward the tender pOint, and
slight rotation (usually toward the tender point) to fine-tune the position.
Treamlenr Procedllres CHAPTER 6 93

54,61. Anterior Third through Tenth Ribs (AR3,lO)


Internal Intercostal

ARI _____
AR2 __
AR3_
AR4_ MR3IO ;;[2r
Internal -
intercosta Is
-AR3
ARS- to::::;S:;Q,
:; c AR4
AR6
AR7 :

Transversus>

thoracis
""""f3 l - -ARS
AR8

AR9
External AR6
ARlO intercostals""-..":>---7 """ tJL -AR7
j;",q:j=",\L-
'
ctf'-AR9
AR8
\."'l
\'<!Ii/'---ARI 0

l Location of These tender points are located on superior aspects of the ribs from the anterior
Tender Point axillary line to the midaxillary line at the corresponding levels for ribs 3 through 10.
Pressure is applied inferiorly and posteromedially or medially.

Position of Assume, for the purposes of illustration, that the tender point is on the right side.
l Treatment The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests his or her legs on the table with the
knees pOinting to the left while the left arm rests on the therapist's left thigh. The
therapist flexes and side bends the patient's trunk to the right down to the level of
the tender point by translating it to the left. The therapist then rotates the patient's
trunk to the right.

Note: A physical therapy ball or chair may be used for support.


94 CHAPTER 6 Treatment Procedures

Anterior Medial Ribs

62,69. Medial Third Through Tenth Ribs (MR3,lO)


Transversus Thoracis, External Intercostal

ARI
AR2 __
AR3_
AR4- MR1-1
ARS
AR6
AR7
ARB MR3-IO
AR9
ARlO

location of These tender points are located on or between the costal cartilages near the ster
Tender Point nocostal joints just lateral to the sternum at the corresponding level for each rib.
Pressure is applied posteriorly.

Position of Assume, for the purpose of illustration, that the tender point is on the right side. The
Treatment patient sits in front of the therapist with the therapist's left foot on the table to the
left side of the patient. The patient rests his or her legs on the table with the knees
pOinting to the left while the left arm rests on the therapist's left thigh. The therapist
flexes and side bends the patient's trunk to the right, down to the level of the tender
point, by translating it to the left. The therapist then rotates the patient's trunk to
the left by having the patient bring his or her right arm across the body and grasp
the left wrist.

Note: A physical therapy ball or chair may be used for support.


P 0 S T E RIO R THO R AeI C S PIN E Tender Points

PT I-2

9S
Posterior Thoracic Spine

70, 71. Posterior First and Second Thoracic (PTl,2)


Interspinales, Multifidus, Rotatores

PTI-2
PRI I

PR2 .---- PTI
PRJ _PTl
.-PTJ
PR4 Multifidi
PRS '-PH Scapula External
PR6 -PTS intercostals
-PT6
PR7 ..---
PR8
PR9



!::PT7
PT8
Levator costae
}
Brevis Lev.tores
PRIO PT9 Longus costarum
PTIO
PRI . PTI I
PRI I PTI

Location of These tender points are located on the side of the spinous process (pressure is
Tender Point medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for each
segment_

Position of The patient lies prone with the arms alongside the trunk or abducted to 90 off the
l Treatment sides of the table. The therapist stands at the head of the table and supports the
patient's head on the therapist's hand and forearm. The therapist extends the
patient's head to the level of involvement and rotates and laterally flexes the head
away from the tender point side.

Note: PT I , 2 may be treated in the supine position by extending the head off the end
of the table and rotating and laterally flexing away from the tender point side.
96
Treaunenr Procedures CHAPTER 6 97

72,74. Posterior Third, Fourth, and Fifth Thoracic (PT3,5)


Interspinales, Multifidus, Rotatores

PRI I
Interspinales
PR2 PTI
.--
PRJ _PT2 Multifidi
PR4 ._PTl Scapula External
PRS _PT" intercostals
PTJ
-PTS
PR6 PT4
. . -PT6 Levator costae
PR7
PRe
---
___ PT7
. . ......
PT8
PTS
}
BreviS Levatores
Longus costarum
PR9 .. m
PRI O PTI O
PRI2 . PTI I
PRI I

"I Location of These tender points are located on the side of the spinous process (pressure is
Tender Point medial), in the paraspinal area (pressure is anterior), or on the posterior aspect
of the transverse processes (pressure is anterior) at the corresponding levels for
each segment.

l
Position of The patient lies prone with the arms on the table along the side of the head to
Treatment create more spinal extension. The therapist stands at the head of the table and sup
ports the patient's head with the therapist's hand and forearm. The therapist extends
the head to the level of involvement, markedly rotates, and moderately laterally
flexes the head away from the tender point side.
98 CHAPTER 6 Treatmem Procedures

Posterior ThoraCic Spine

75,78. Posterior Sixth through Ninth Thoracic (PT6,9)


Multifidus, Rotatores
Clavicle
PRI I i I
PR2 ..-- PTI
PR3 _PT2
..-PT3 Scapula External
PR4
PRS "-PT4 intercostals
-PT5
-PT6 Levator costae
PR8 ........
---. PT7
...
____.... PTa
}
Brevis Levatores
Longus costarum
PT9
PTIO
. PTII
PTll

Location of These tender points are located on the side of the spinous process (pressure is
Tender Point medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for
each segment.

l
Position of The patient lies prone with a cushion under the chest and with the arm on the
Treatment tender point side resting alongside the head. The opposite arm is abducted to 90
resting off the side of the table or is placed alongside the trunk. The therapist stands
near the head of the table between the patient's head and shoulder on the side
opposite the tender point. The therapist grasps the axilla on the affected side and
pulls the shoulder posteriorly and in a cephalad direction, producing traction, exten
sion, rotation, and lateral flexion away from the tender point side.

Note: The more lateral the tender point, the more flexion and rotation will be used.
Treafmem Procedures HAI'TER 6 99

79,81. Posterior Tenth, Eleventh, and Twelfth Thoracic


(PT10, 12) Multifidus, Rotatores, Quadratus Lumborum
PRI I Clavicle

PR2 ....-PTI Incerspinales
..-PT2
PR3
PR4 ..- PT3 _ Multifidi
..- PT4 Scapula Excernal
PRS -PTS incercostals
PR6 -PT6
PR7 .. ---
:r;:o.,...;:-c-""""')\- Levacor costae
PRB ____
PR9
PT7
......... PT8 Brevis L Levacores

PT9 PTI 0 --\iW:7Z:;1
ilW..."....,...,,,,,- LongusJ costarum
PRIO ..
PT I I -jj
'fi';;z;..o'b

. PTI
PRI I PTI 2 -f,

1 Location of These tender points are located on the side of the spinous process (pressure is
Tender Point medial), in the paraspinal area (pressure is anterior), or on the posterior aspect of
the transverse processes (pressure is anterior) at the corresponding levels for
each segment.

1 Position of The patient lies prone with the head end of the table raised or with cushions under
Treatment the patient's chest. The therapist stands at the level of the patient's pelvis opposite
the tender point side. The therapist reaches across the patient and grasps the ante
rior ilium on the involved side and pulls posteriorly and toward the therapist, cre
ating a rotation of the pelvis of 30 to 45. For lateral tender points additional lateral
flexion may be needed. This is accomplished by moving the patient's legs along the
table away from the tender point side (see photo above left).

Alternatively, the hip on the tender point side may be abducted and flexed (see
photo above right.)
P 0 S T E RIO R RIB S Tender Points

PRI

PR2I O

100
Posterior Ribs

82. Posterior First Rib (PR1) Scalenus Medius, Levator Costorum

PRI I
PR2 PTI
..--
PR3 _PT2 Multifidi
PR4 ..-PTJ Scapula External
PRS "-PT4 intercostals
PR6 -PTS
-PT6 levator costae
PR7
PR8
.........
____.
____. PT7
PT8
}
Brevis Levatores
Longus costarum
PR9
PT9
PRI O
PRI 2 O
PTI
.PTI
PRI I

l location of This tender point is located on the superior aspect of the first rib deep to the ante
Tender Point rior margin of the upper portion of the trapezius. Pressure is applied inferiorly.

Position of The patient is sitting with the therapist standing behind the patient. The therapist
Treatment places his or her foot on the table at the side of the patient opposite the tender
point side. The patient's axilla rests on the therapist's thigh, and the therapist trans
lates the patient's trunk away from the tender point side. The therapist supports the
patient's head against the therapist'S chest and places the neck in slight extension
and fine-tunes the position with lateral flexion (usually away) and rotation (usually
toward) the tender point side.
1 01
1 02 CHAPTER 6 Treatment ProcedlTes

Posterior Ribs

8391. Posterior Second through Tenth Ribs (PR210)


lntercostals, Levator Costorum

PRI I Clavicle
PR __ ..--PTI i I
PRJ ___ -__ PT2
;
!r Multifidi
PR4-- -- _ PTJ
External
- -- ... - -_ PT4
I'K"i r-_
_ --_ PTS
intercostals
PR'7-jI----__ _..;. -__
PR,'-ir--_-...:. -- ---. PT6 PR2IO i 'D'Y.-
-,\- Levator costae
__
__
__
!::::: PT7
PTa Brevis L Levatores
-rti\- LongusJ COStarum
PRln-lIl- -- PT9
PR 12 -1-1;--. --
PRI I
.... -PTI O
PTI I

l Location of These tender points are located on the posterior angles of the ribs. To access ribs 2
Tender Point through 10 it may be necessary to protract the ipsilateral scapula by adducting the
involved arm across the chest. Pressure is applied anteriorly.

l
Position of Assume, for the purposes of illustration, that the tender point is on the right side.
Treatment The patient sits in front of the therapist with the therapist's right foot on the table
to the right side of the patient. The patient rests the legs on the table with the knees
pointing to the right while the right arm rests on the therapist's right thigh. The ther
apist side bends the patient's trunk to the left by translating it to the right. The ther
apist then rotates the patient's trunk to the left.
Treatmem Procedlres CHAPTER 6 103

92, 93. Posterior Eleventh, Twelfth Ribs (PRll,12)


Intercostal, Levator Costorum, Quadratus Lumborum

PRI Clavicle
I
PR2 ...--PTI
PR3 _PT2
e-
Multifidi
PR4 PT3 Scapula External
PR5 e-PT4 intercostals
PR6 -PTS
-PT6
PR7 ......... Levator costae
PRB
PR9
...... PT7
____... PT8
}
Brevis Levatores
Longus costarum
PT9
PRIO PTIO
PRI . PTI
PRII

l Location of These tender points are located on the tips of ribs I I and 12. Pressure is applied
Tender Point posteriorly or medially.

Position of
l
Assume, for the purposes of illustration, that the tender point is on the right side.
Treatment The patient sits in front of the therapist with the therapist's left foot on the table to
the left side of the patient. The patient rests the legs on the table with the knees
pointing to the left while the left arm rests on the therapist's left thigh. The therapist
flexes and side bends the patient's trunk to the right, down to the level of the tender
point, by translating it to the left.
UPP E R LIMB
elmical presentations involving the upper limh Include
UPPER LIMB DYSFUNCTION pain, pareMhesia, weakness, restriction of morian, repetitive
Pam and resfric[(on of motion 10 the upper limb can strain injuries, thoracic outlet symptoms, hursltis, arthritis.
arise from Jr,my sources. Local articular changes and syn tendonitis, and "frozen shoulder."
ovialfcapsu:ar mOammatory processes can produce reflex With peripheral joint mvolvement, (he tender point will
muscular hypertonicity. Pain can originate III any of the soft often be found on the opposite side of the perceived ten
tisues: joint capsules. tendons. musculotendinous regions, demess. In general, it is advised that significant thoracic
muscle. fascia, and even in intraosseous lesions of the long and cervical lesions be treated first according to the general
honcs.'i rules and principles. (See Chapter 4.)
The wide range of motion mherent in the upper limb
aff",ded by the bipedal posture of the human has allowed
for increased case of manipulation am.! control of the cnvi#
'hEATMENT
rooment. As 111 all of nawre, every advamagc has its price. Essentially, PRT is "applied anatomy" and trc..llment is
ThiS IIlcreased range of motion exposes us to an increased directed toward reproducing the action of and shortenmg
risk of trauma. The myriaJ uses of this versatile limh (in the involved tissues. In many cases the position IS accom#
the quadruped ItIi use is limited primarily to iOCOll'lOtion) pllShed simply by folding the body over the tender pomt.
..;,ubjecl<; uS [0 a variety of potential strain forces. Sudden Careful attention to the local anatomy will clarify and facil
trauma such as falls, blows, and rapid, overextended mOtion, Itate the position of comfort. It is strongly recommended
as well as repetitive stram injuries, can re."iulr in reflex hyper; that significant lesions of the thoracic spine and rlh cage,
tonicity and tlysfunction. This vulnerability to trauma is espe when of equal or greater tenderness than the lesion in the
cially prevalent in the region of the shoulder. upper limh, be treared first. Thi will greatly improve [he
Dysfunction of the upper limb is assessed on the basis of efficiency of the treatment program. In many cases, treat
active and pa..;,sivc ranges of motion ant! treng(h .lO ment of the higherpriority thoracic lesion resolves the
Assuming that strength IS within normal "mits, restricted tender point in the upper Iimh.
range of morion anti the assessment of jomt play affords the
most preCise mformation with respect to the specific tissues
Involved in the dysfunction.

104
SH0U L0ER Tender Points

YIii/-f-- MHU
,eI-+--I- - SUB

Anterior Shoulder Region

MSC
SSM PAC


1:
1 J?:""

+lSs SSL
ISS
"'>'-f-- ISM
TMI
'-+-ISI
TMA

LD

Posterior Shoulder Region

105
Shoulder

94. Trapezius (TRA) Trapezius (Upper Fibers)

TRA
SCl

MC TRA
BlH Subclavius

BSH
PMI
? Deltoid

Pectoralis

{
minor (cut) +4J-h/...jf.4- \
PMA --- long
Biceps head
brachii
SER Short

head

Serratus
anterior

l Location of These tender points are located along the middle portion of the upper fibers of the
Tender Point trapezius. Pressure is applied by pinching the muscle between the thumb and fingers.

Position of The patient is supine with the therapist standing on the side of the tender point. The
Treatment patient's head is laterally flexed toward the tender point side. The therapist grasps
the patient's forearm and abducts the shoulder to approximately 90 and adds slight
flexion or extension to fine-tune.

106
Treatment Procedures CHAPTER 6 107

95. Subclavius (SCL)

TRA
SCl

AAe

BLH SCL Subclavius

/
Subscapularis

Deltoid
BSH
PMI


Pectoralis


minor (cut) -\,1HHJICt
ong
PMA ---

head
Biceps
brachii
Short
SER head

Serratus
anterior

"I Location of This tender point is located on the undersurface of the middle portion of the clav
Tender Point icle. Pressure is applied superiorly and somewhat posteriorly.

l Position of
Treatment
I . The patient is supine and the therapist stands on the opposite side of the tender
point. The therapist adducts the arm obliquely across the body approximately 30
and adds slight traction caudally. (See photo above left.)
2. The patient is lateral recumbent with the tender point on the superior side. The
therapist stands behind the patient and places the affected arm in slight extension
behind the patient's back. Pressure is applied to the affected shoulder to cause it
to be adducted in the transverse plane. R etraction or protraction and flexion or
extension are added for fine-tuning. (See photo above right.)
108 CHAPTER 6 Trearmenr Procedures

Shoulder

96. Anterior Acromioclavicular (AAC) Anterior Deltoid,


Pectoralis Minor

TRA
SCL

AAC
AAC
BLH

BSH 7 Deltoid


PMI
Pectoralis
minor(cut) -+-\f-IHJR-

ong
PMA --- Biceps head
brachii
Short
SER head

l Location of This tender point is located on the anterior aspect of the acromioclavicular joint
Tender Point near the distal end of the clavicle. Pressure is applied posteriorly.

l
Position of I . The patient is supine. The therapist stands on the opposite side of the tender
Treatment point and grasps the patient's affected arm above the wrist. The therapist then
slightly flexes and adducts the arm obliquely across the body at an angle of
approximately 30 and adds a moderate amount of caudal traction in the direc
tion of the opposite ilium.
2. The patient is supine and the therapist stands on the side of the tender point. The
therapist grasps the affected forearm and flexes the arm to approximately 90
and fine-tunes with slight adduction and internal rotation.
Treatment Procedures CHAPTER 6 109

97. Supraspinatus Lateral (SSL) Supraspinatus Tendon

SSL ----

h;:"-"<lI_ SSl

"I Location of This tender point is located deep to the belly of the lateral deltoid muscle just infe
Tender Point rior to the acromion process. The therapist must flex or abduct the arm to approxi
mately 90 in order to slacken the deltoid sufficiently to allow for palpation of the
tender point. Pressure is applied inferiorly.

Position of The patient is supine. The therapist produces a combination of flexion and abduction
Treatment of the arm to approximately 120 and adds slight external rotation to fine-tune.
liD CHAPTER 6 Treatment Procedu.res

Shoulder

98. Biceps Long Head (BLH)

TRA
SCL
MC
BLH
Subclavius

?
Subscapularis
Deltoid
BSH


PMI Pectoralis
minor (cut) -\-%I-.fF;'-\; \

PMA ong
---
Biceps head
brachii Short
SER head

Serratus
anterior

l Location of This tender point is located on the tendon of the long head of the biceps in the
Tender Point bicipital groove. Pressure is applied posteriorly.

l Position of The patient lies supine with the therapist standing on the side of the tender point.
Treatment The therapist flexes and abducts the patient's shoulder and flexes the elbow, and the
dorsum of the patient's hand is placed on the patient's forehead. The therapist grasps
the patient's elbow and fine-tunes the pOSition by varying the amount of abduction
and internal or external rotation.
Treatmem Procedures CHAPTER 6 III

99. Subscapularis (SUB)

Subscapularis

Deltoid

Pectoralis
minor (cut) SUB
SUB
ong
Biceps head
br;achii
Short
h..d

Serraws
anterior

Location of This tender point is located on the anterior surface of the lateral border of the
Tender Point scapula. Pressure is applied medially and then posteriorly.

Position of The patient is supine with the lateral aspect of the trunk on the involved side even
Treatment with the edge of the table. The therapist stands or sits on the tender point side and
grasps the forearm of the patient and places the shoulder in approximately 30 of
extension. adduction. and internal rotation.The shoulder may be elevated to fine
tune the position.
liZ CHAPTER 6 Treatment Procedures

Shoulder

100. Serratus Anterior (SER)

TRA-_----,
SCL
AAC-_.1A
BLH
Subscapularis
?

BSH Deltoid
PMI
Pectoralis
mincr (cut) ---+4fJ-H.P"t

PMA---

SER
SER

l Location of These tender points are located on the costal attachments of the serratus anterior
Tender Point on the anterolateral aspects of ribs 3 through 7. Pressure is applied medially.

l Position of
Treatment
The patient is seated or supine. The therapist contacts the tender point with his or
her ipsilateral hand and then grasps the involved arm anteriorly with the other hand.
The arm is drawn across the chest in horizontal adduction and flexion.

Note: These tender points are located on the lateral aspect of the ribs, whereas the
anterior rib tender points are located on the superior aspect of the ribs.
Treatment Procedures CHAPTER 6 113

101. Medial Humerus (MHU) Glenohumeral Ligaments

Subclavius
Subscapularis
Deltoid

t
Pectoralis
SUB minor (cut) -'c--tf;fHlI"t MHU

ong
Biceps head
brachii Short
head

Serratus
anterior

"I location of This tender point is located high in the axilla on the medial aspect of the head of the
Tender Point humerus. Pressure is applied laterally.

l
Position of The patient is supine with the therapist standing on the side of the tender point. The
Treatment therapist applies a cephalad compressive force on the elbow through the long axis of
the humerus. This position results in increased adduction of the glenohumeral joint
by reducing the scapulohumeral angle.

Note: This lesion may be associated with frozen shoulder.


1 14 CHAPTER 6 Treacmem Procedures

Shoulder

102. Biceps Short Head (BSH)

TRA
SCL
MC
Subclavius
BLH
Subscapularis
aSH

aSH
PMI
Deltoid

Pectoralis
minor (cut) -+'W-IHj'
ong
PMA--- Biceps head
brachii Short
SER head

Serratus
anterior

l Location of This tender point is located on the inferior lateral aspect of the coracoid process.
Tender Point Pressure is applied superiorly and medially.

Position of The patient is supine. The therapist stands or sits on the side of the tender point,
Treatment flexes the patient's shoulder to approximately 90 with the elbow flexed, and adds
moderate horizontal adduction.
Treatment Procedures CHAPTER 6 115

103. Pectoralis Major (PMA)

TRA
SCL
AAC
BLH Subclavius

;;:;:::;;::J
Subscapularis
?
Deltoid
BSH
PMI


Pectoralis
minor (cut) -\-wtf-ll"i"

ong PMA
PMA---
Biceps head
brachii Short
SER head

Serratus
amerior

l Location of This tender point is located along the lateral border of the pectoralis major muscle,
Tender Point just anterior to the anterior axillary line. Pressure is applied medially.

l
Position of The patient may be seated or supine. The therapist stands or sits at the side of the
Treatment patient on the side of the tender point. The therapist flexes and adducts the patient's
involved arm across the chest and pulls the arm into hyperadduction. The therapist
fine-tunes with variable flexion.
116 CHAPTER 6 Treatment Procedures

Shoulder

104. Pectoralis Minor (PMI)

TRA
SCL

1
AAe Subclavius
Subscapularis PMI
BLH

/
Deltoid



BSH Pectoralis
PMI minor (cut) -I-ffi-l-ll."""
ong
Biceps head
PMA --- brachii Short
head
SER
Serratus
anterior

Location of This tender point is located on the medial inferior aspect of the coracoid process
Tender Point (pressure applied superiorly and laterally) or on the anterior aspect of ribs 2. 3. and
4 just lateral to the midclavicular line (pressure applied posteriorly and medially).

l
Position of The patient is sitting in front of the therapist.The therapist grasps the forearm
Treatment and pulls it behind the patient in a hammerlock position in order to extend and
internally rotate the shoulder.The therapist then protracts the shoulder by pushing
the elbow or shoulder forward. abducting slightly and pushing anteriorly on the
involved shoulder.
Treatment Procedures CHAPTER 6 117

105. Latissimus Dorsi (LD)

IlISSSSMI
"--{

TMI
TMA
LD

"I Location of This tender point is located on the anterior medial aspect of the humerus just
Tender Point medial to the bicipital groove (pressure applied posterolateraliy). Another point may
be found 2 to 3 em (0.8 to 1.2 in.) lateral to inferior angle of the scapula. Pressure is
applied anteriorly.

Position of The patient is supine with the lateral aspect of the trunk on the involved side, even
Treatment with the edge of the table. The therapist stands or sits on the tender point side,
grasps the forearm of the patient, and places the shoulder in approximately 3D of
extension, adduction, and internal rotation. Long-axis traction is then applied to
the arm.
1 18 CHAPTER 6 Treatmenr Procedures

Shoulder

106. Posterior Acromioclavicular (PAC) AC Ligament

----ISS
_---;=
r--- Levator
=
e-----t- ISM scapulae
lSI
TMI rfI.PAC Infraspinatus
Supraspinatus

e-ilf---LD Teres minor


11---t-T
- eres major

l Location of This tender point is located on the posterior aspect of the acromioclavicular joint
Tender Point near the distal end of the clavicle. Pressure is applied anteriorly.

Position of The patient is prone and the therapist stands on the side opposite the tender point.
Treatment The therapist grasps the patient's involved arm and pulls it obliquely across the body
approximately 30 and applies caudal traction toward the opposite hip.
Treatment Procedures CHAPTER 6 1 19

107. Supraspinatus Medial (SSM) Supraspinatus Muscle

-{
---1- 55
----+
1 ISM c--- Levator scapulae

,.f.17
MOC _---.1..,. 51 Supraspinatus
e--_TMI Infraspinatus

Teres minor

04-- T."., major

l Location of This tender point is located in the belly of the supraspinatus muscle in the
Tender Point supraspinous fossa or at the musculotendinous junction just medial to the posterior
aspect of the acromioclavicular joint. Pressure is applied anteriorly and inferiorly.

l Position of The patient lies supine. The therapist is on the side of the tender point. The therapist
Treatment grasps the forearm near the elbow and places the shoulder into 45 of flexion,
abduction, and external rotation.
120 CHAPTER 6 Treatment Procedures

Shoulder

108. Medial Scapula (MSC) Levator Scapula, Rhomboid

e-/o
SSM
PAC

---{
---.--- ISS
1\--- Levator scapulae
j
e----T ISM
_ = ISI
C5:?;4
-;= MSC Supraspinatus
TMI
Infraspinatus
_--r----'TMA
"'f--.....- LD Teres minor

1"":>1-+-Teres major

l Location of These tender points are located on the superior vertebral angle of the scapula and
Tender Point along the medial border of the scapula. Pressure is applied caudally, laterally, or both.

l
Position of I . The patient is prone and the therapist stands on the side of the tender point. The
Treatment affected arm is grasped above the wrist, extended 20 to 30, internally rotated,
and tractioned caudally.
2. The patient is prone and the therapist stands on the side of the tender point. The
patient's forearm is flexed at the elbow and the hand is placed under the affected
shoulder. The therapist pushes the lateral aspect of the inferior angle of the
scapula medially and cephalad.
3. The patient is supine. The therapist flexes the shoulder to approximately I 10
to 120 with the elbow flexed and fine-tunes the position with internal or
external rotation.
Treatment Procedures CHAPTER 6 121

109. Infraspinatus Superior (ISS) Infraspinatus (Superior Fibers)

:;;- PAC
--
.. --.- 155 ,---- Levator scapulae

rfi Infraspinatus
---- ISM

Supraspinatus
151
_-;:==:,
TMI
__-+ --'
-

e-#-----,,- LD Teres minor


;.4-+-- Teres major

l Location of This tender point is located along the inferior border of the spine of the scapula.
Tender Point Pressure is applied anteriorly.

The patient is supine and the therapist is on the side of the tender point. The thera
l
Position of
Treatment pist grasps the forearm and flexes the shoulder to approximately 90 to 100 with
moderate horizontal abduction and slight external rotation.
122 CHAPTER 6 Treannent Procedures

Shoulder

1 1o. Infraspinatus Middle (ISM) Infraspinatus (Middle Fibers)

55M PAC
1\---- Levator scapulae
-----0-155 Supraspinatus
---- I S M

_--;==3151 Infraspinatus
TMI
'--r-'T
-- MA
ISM -++-\L--.. Teres minor
Mf---L- D
04'--+-T
- eres major

Location of This tender point is located in the upper portion of the infraspinous fossa. Pressure
Tender Point is applied anteriorly.

The patient is supine and the therapist stands on the side of the tender pOint. The
l
Position of
Treatment therapist grasps the forearm and flexes the shoulder to approximately I 100 to 1200
with moderate horizontal abduction and slight external rotation.
Treatment Procedures CiIAI'TER 6 123

111. Infraspinatus Inferior (lSI) Infraspinatus (Inferior Fibers)

H-{

ISS
1TMS
51
ISM

TMA
Levator scapulae
Supraspinatus
Infraspinatus

LD Teres minor
IS Teres major

l Location of This tender point is located in the central or lower portion of the infraspinous fossa.
Tender Point Pressure is applied anteriorly.

Position of The patient is supine and the therapist stands on the side of the tender point. The
Treatment therapist grasps the forearm, flexes the shoulder to approximately 1300 to 1400, and
fine-tunes with slight abduction/adduction and internal/external rotation.
124 CHAPTER 6 Treatment Procedures

Shoulder

1 12. Teres Major (TMA)

--- 155
--- 15M
--,
1\---- Levator scapulae
Supraspinatus
- -- 151
--

--TMI
- Infraspinatus

Teres minor
TMA -t-t--<.\ 1-/-- Teres major

latissimus
dorsi

l location of This tender point is located along the lateral aspect of the inferior angle of the
Tender Point scapula. Pressure is applied anteromedially.

l
Position of The patient sits in front of the therapist. The therapist grasps the patient's forearm,
Treatment bends the arm at the elbow, and produces marked internal rotation, adduction, and
slight extension (hammerlock position). Internal rotation may be augmented by
pulling the forearm posteriorly.
Treatment Procedures CHAPTER 6 125

113. Teres Minor (T MI)

SSM PAC
........-
.e---ISS
E:8'l-- Levator scapulae
e-----.-ISM
_---..) lSI Infraspinatus
ee---TMI

TMA
e--...r-- TMI Teres minor
H-- LD ;4--l---- Teres major

dorsi

Location of This tender point is located on the upper third of the lateral border of the scapula
Tender Point or along the posterior, inferior border of the axilla. Pressure is applied anteriorly,
medially, or both.

Position of The patient sits in front of the therapist. The therapist grasps the involved forearm,
Treatment which is bent at the elbow. The shoulder is extended to approximately 30,
adducted, and markedly externally rotated.
E L BO W Tender Points

MEP
LEP -'"

LCD --H-.... 1fII.<--- MCD


RHS. RHP --t'<'\.\

MOL----I, u)--- LOL

126
Elbow

1 14. Lateral Epicondyle (LEP)

"I Location of This tender point is located on the supracondylar ridge superior to the lateral epi
Tender Point condyle. Pressure is applied medially.

RHS
LEP __

RHP
-.II
__ _

,.1
lE P ---,

1
Position of Treatment is directed to the first thoracic segment or the first rib. (AT I . PT I .AR I .
Treatment PR I). Check for tender points in these areas and treat according to the general
rules. Monitor the LEP tender point during and after the treatment.

127
118 CHAPTER 6 Treatment Procedures

Elbow

1 1S. Medial Epicondyle (MEP)

l Location of This tender point is located on the supracondylar ridge superior to the medial epi
Tender Point condyle. Pressure is applied laterally.

LEP ___..
RHS ___
RHP MEP

l Position of Treatment is directed to the fourth thoracic segment or the fourth rib. (AT4. PT4.
Treatment AR4. PR4. MR4). Check for tender points in these areas and treat according to the
general rules. Monitor the MEP tender point during and after the treatment.
Treatment Procedures CHAPTER 6 129

1 16. Radial Head Supinator (RHS) Supinator

Brachialis

LEP ___I.

RHP
RHS __ _

RHS
Supinar.or """",!}Y Pronator
teres

Pronator ____j
quadratus 1.
(..u


l Location of This tender point is located on the anterior surface of the proximal head of the
Tender Point radius. Pressure is applied posteriorly.

Position of The patient may be seated or supine. The therapist grasps the patient's forearm and
l Treatment elbow, markedly supinates the forearm, and mildly extends the elbow. Abduction
(valgus) is used to fine-tune the position.
130 CHAPTER 6 Treatment Procedures

Elbow

117. Radial Head Pronator (RHP) Pronator Teres

', Brachialis
,

RHP
Supinator -""g[ Pronator
teres

Pronator ---f':a
quadratus

1 location of This tender point is located on the anterior surface of the proximal head of the
Tender Point radius. Pressure is applied posteriorly.

l
Position of The patient is sitting or supine. The therapist grasps the forearm and elbow and pro
Treatment duces marked pronation and flexion at the elbow with the dorsum of the patient's
hand coming to rest on the patient's lateral trunk.
Treatment Procedures CHAPTER 6 13 1

118, 119. Lateral/Medial Coronoid (MCDjLCD) Brachialis

II
,, \
,,
,
Brachialis
,,
,
RHS ___

RHP LCD MCD

$upinator"""""Mi--M Pronator
teres

de
quadratus -IT-
.--,
Pronator ,

b J

a
1 Location of These tender points are located on the medial and lateral aspects of the coronoid
Tender Point process of the ulna. Pressure is applied posteriorly.

1
Position of The patient is sitting or supine. The therapist markedly flexes the elbow, pronates the
Treatment forearm to turn the palm forward, and externally rotates the humerus.
132 CHAPTER 6 Treatmem Procedures

Elbow

120, 121. Lateral/Medial Olecranon (MOL/LOL) Triceps

,,,I/a+-1+-- Medial head

Long head -++,1'


II! ,n'. 4J4.-- Lateral head

Medial head -t-;,

MC'L-t.f.r-- LOL

"IIl-l--- Anconeus

l Location of These tender points are located on the lateral and medial aspect of the olecranon
Tender Point process. Pressure is applied medially or laterally.

l Position of The patient is seated or supine. The therapist hyperextends and adducts (varus) or
Treatment abducts (valgus) the elbow and adds slight supination to fine-tune.
W R 1 S T AND H AN 0 Tender Points

Anterior (Palmar) View Posterior (Dorsal) View

133
Wrist and Hand

122. Common Flexor Tendon (CFT)

eFT

RHS ___
Common
RHP flexor tendon
Flexor carpi ---/-i,1,.,
radialis
Palmaris longus

Opponens
pollicis
Abductor pollicis
(cut) f--- Palmar aponeurosis
,k(/fJ.:l!interossei

Palmar
(cut)

l location of This tender point is located on the anterior medial aspect of the forearm, just distal
Tender Point to the medial epicondyle. Pressure is applied posterolaterally.

l Position of The patient is supine or seated. The therapist markedly palmar flexes the wrist with
Treatment the greatest force being exerted on the hypothenar side. Pronation/supination and
abduction/adduction are used to fine-tune the position.

134
Treatment Procedures HAPTER 6 135

123. Common Extensor Tendon (CET)

"_ ;
I
radialis
carpi
_ longus

Extensor
carpi ulnaris Extensor carpi
radialis brevis
Extensor
digitorum--lr:-.11-
!t\"-Ir- Extensor pollicis longus
Extensor_-,...".,
indicis Extensor pollicis
brevis

DIN
Interossei --O!f:ti:t\Jn

IP

1 Location of This tender point is located on the posterior lateral aspect of the forearm, just distal
Tender Point to the radial head. Pressure is applied anteromedialiy.

1 Position of
Treatment
The patient is supine or seated. The therapist markedly extends the wrist, with the
greatest force being exerted on the thenar side. Pronation/supination and abduc
tion/adduction are used to fine-tune the position.
136 CHAPTER 6 Trearmem Procedures

Wnst and Hand

124. Palmar Wrist (PWR) Wrist Flexors

RHS ___

RHP

Location of These tender points are located along the palmar surface of the carpals. Pressure is
Tender Point applied posteriorly.

l
Position of The therapist faces the dorsum of the patient's wrist. The therapist palmar flexes the
Treatment wrist over the tender point. Fine-tuning is accomplished with siding, pronation or
supination, and radial/ulnar deviation.
Treatment Procedures CHAPTER 6 137

125. Dorsal Wrist (DWR) Wrist Extensors

DIN

IP

1 Location of These tender points are located along the dorsal aspect of the wrist. Pressure is
Tender Point applied anteriorly.

Position of The therapist doriflexes the wrist with slight side bending toward the tender point.
Treatment Fine-tuning is accomplished with pronation or supination and radial/ulnar deviation.
138 CHAPTIR 6 Treatment PTocedltre

Thumb

126. First Carpometacarpal (eMl)


Flexor Pollicis Brevis, Opponens Pollicis

1 Location of This tender point is located in the thenar eminence on the palmar surface of the
Tender Point first metacarpal. Pressure is applied posterolaterally.

Position of The therapist flexes (see photo above left) or opposes (see photo above right) the
Treatment thumb over the tender point and fine-tunes the position with abduction/adduction
and internal/external rotation.
Treatmenr Procedures CHAPTER 6 139

Fingers

127. Palmar Interosseous (PIN) Metacarpophalangeal Joints

MEP
eFT
RHS ___

RHP

PIN

l location of These tender points are located within the palm of the hand, on the medial and lat
Tender Point eral sides of the shafts of the metacarpals. Pressure is applied posteromedially or
posterolaterally.

Position of The therapist markedly flexes the fingers over the tender point with the addition of
Treatment lateral flexion toward the tender point and rotation to fine-tune the position.
140 CHAPTER 6 Treatment Procedures

Fingers

128. Dorsal Interosseous (DIN) Metacarpophalangeal Joints

DIN[

...._IP
...

l Location of These tender points are located on the dorsum of the hand. on the medial and lat
Tender Point eral sides of the shafts of the metacarpals. Pressure is applied anteromedially or
anterolaterally.

Position of The therapist markedly extends the finger over the tender point with the addition of
Treatment lateral flexion toward the tender point and rotation to fine-tune the position.

Note: The metacarpophalangeal joints may also be treated in a similar manner.


Treatment Procedures CHAPTER 6 141

129. Interphalangeal Joints (lP) Capsular Ligaments

w Leo

.
-'r. .
Meo
MEP
Common
flexor
OJ', tendon
eFT

'i
Flexor carpi
RHS ___
radialis
Palmaris
RHP
,..
longus

Opponens
"' .. pollicis carpi
ulnaris
Abductor
pollicis Palmar
(cut)


- PWR
,
"'
.

PIN
..
}IP
- J \.- IP
.
..-l._

l Location of These tender points are located on the capsule to the proximal. middle. or distal
Tender Point interphalangeal joints. Pressure is applied over the tender point toward the center of
the finger.

c+

Position of The therapist folds the more distal phalanx over the tender point. and rotation and
Treatment lateral flexion are added to fine-tune the position.

Note: The metacarpophalangeal joints may also be treated in a similar manner.


II LOWER QUADRANT
PRT Lower Body Evaluation
Patient's name Practitioner

Dates 2 3 4 5

. Extremely sensitive e . Very sensitive - Moderately sensitive o - No tenderness


\ - Right /- Left + - Most sensitive (; - Treatment
Xl. Anterior Lumbar Spine (pages 144-149)

130_ All 00000 132. AL2 00000 134. AL4 00000 00000
131. ABL2 00000 133. AL3 00000 135. AL5 00000 00000

XlI. Anterior Pelvis & Hip (pages 150-158)

136.IL 00000 138.SAR 00000 140.SPB 00000 142.LPB 00000


137.GMI 00000 139.TFL 00000 141.IPB 00000 143.ADD 00000

XIII. Posterior Lumbar Spine (pages 159-165)

144.PLl 00000 147.PL4 00000 150.PL3-1 00000 153.LPL5 00000


145.PL2 00000 148.PL5 00000 151.PL4-1 00000 00000
146.PL3 00000 149.QL 00000 152.UPL5 00000 00000

XIV. Posterior Pelvis & Hip (pages 166-173)

154.SSI 00000 156. lSI 00000 158. PRM 00000 160.GME 00000
155.MSI 00000 157.GEM 00000 159.PRL 00000 161.ITB 00000

XV. Posterior Sacrum (pages 174180)

162.PSI 00000 164.PS3 00000 166.PS5 00000


163. PS2 00000 165.PS4 00000 167.COX 00000

XVI. Knee (pages 182-192)

168. PAT 00000 171.LK 00000 174.PES 00000 177.POP 00000


169. PTE 00000 172.MH 00000 175.ACL 00000 00000
170.MK 00000 173. LH 00000 176.PCL 00000 00000

XVII. Ankle (pages 193-203)

17S. MAN 00000 lSI. TAL 00000 I S4. FDL 00000 IS7. EDL 00000
179.LAN 00000 182.PAN 00000 185.TBA 00000 00000
180.AAN 00000 183.TBP 00000 186.PER 00000 00000

XVlll. Foot (pages 204-219)

ISS. MCA 00000 194.PNV 00000 200.PCN3 00000 206.PMTI 00000


189. LCA 00000 195.DCNI 00000 201.DMTl 00000 207.PMT2 00000
190. PCA 00000 196.DCN2 00000 202.DMT2 00000 208.PMTJ 00000
191. DCB 00000 197.DCN3 00000 203.DMT3 00000 209.PMT4 . 00000
192.PCB 00000 19S.PCNI 00000 204.DMT4 00000 210.PMT5 00000
193.DNV 00000 199.PCN2 00000 205.DMT5 00000 00000

142
LUMB A R S PINE, P E LV I S, AN D H I P

, LUMBAR AND PELVIC DYSfUNCTION and weihthearing mechanism and also as a hou..,mg for the
Low back pam " a lead 109 cause of dlSab,"ty and lost pro pelVIC vIScera. Ir should be borne in mind that uterine,
ductivity in our IDCicry. The lumbar spine has been the sub ovarian, prostate, bladder, and lower howcl dysfunction or
jeer of extensive !-.tudy and a wide range of medical inter# mflammation may have an Important heaTIng un the fllnc
vemions. Modem unagmg methods arc able to detect tion of the pelvis. These organs have direct contact With
structural abnormalities with great resolution. Surgical can .. the mtTlnsic muscles and ligaments of the pclvi'l, notahly
oiuarcs are seiecreJ much more carefully, and many sur .. the levator am and the piriformis.614
geons recognize th,n the detection of significant structural Clinical manifestations of lumbar and pclvic involvc
pathology is no guarantee of causation or a positive surgical ment mclude low back pain, scoliosis, hip and lower lllnh
outcome.l It is gradually becommg accepted that myofascial pain, bursitis, paresthesia, and numerous reflex visceral
dysfunction IS the cause of (he vast majority of painful can .. symptoms, mcludmg cystitis, irTltable bowel syndrome, and
dltions of the low back anu that surgical procedures arc dysmenorrhea.
inappropriate in most cases. 16
11,e major focus of soft tissue therapy has been the pos
terior musculature of the lumbar spine. These therapies
, TREATMENT
have met With some degree of success. This type of mter Posterior lumhar tender pomts are locatcd on thc spmous
ventlon often recommends the use of extension, which IS proces-<;cs, m the paraspmal area, or on thc tips of the trans
also an Importam part of the therapeutic approach 10 PRT verse processes (attachment of the quadratus lumhorum).
In certam cas. TI'lC diagnostic method used 10 PRT, how Accessory reflex tender points associateU with Ll, 4, and 5
ever, is precise 10 providmg ,iIrection to the use of extension are al located in the gluteal region. Postcrior Icsion lre
or flexion dcpendmg on the presemation and the location treated III extension, With the addition of rot<uion or side
of the primary tender pomts. bending away from the side of the tender pomt.
Modem human; ,pend the majority of the" waking l,ves Anterior lumbar tender points arc found in relation ttl
m the seated JXlsition. The effect on the lumbar flexor), the anterior aspect of the pelvis. The tender points for the
over time, Will be an accommodative shortening. TI'le effect second, third, and fourth lumbar are located on the P""lS ilS
of sudden or excessive extension in the case of intermittent It pas,o,es over the anterior inferior diac spine. Trcatment IS
exertion or trauma on these shortened flexors is often mag accomp"shed by varying degrees of flexion WIth the addI
ntfleU because of the lowered proprioceptive threshold and tion of rotation and side bendmg. These positions are
the contracted state of the fascia. Positional release therapy accomplllhed by uSing the lower "mbs as lever> to mduce
provides a powerful tool to address this common and often lumber and pelvic movement.
overlooked cause of low back pain. Pelvis and hip tender points are located antcriorly and
Weight-bearing problems associated with abnormal postcTlorly on the pelViS, on the greater tnx:hantcr, or on
function of the feet may also have an Impact on the spine the femur. Positioning reproduces the action of the
and pelv". The human foot dlStrtbutes weight throughout Involved muscles, and the leg, are used for added leverage.
1[5 length, from heel [0 mc, by way of an energyefficient The sacral tender points were discovercd by MauTlce
longitudinal arch. It should be noted that humans are the Ramirez, D.O., a brilliant osteopath whom one of us (Roth)
only 31l1mai that walks on its heels. Unfortunately, the ..uti met while both were studymg with Harold Schwanz,
ficial. hard, flat walkmg surfaces present in modern urban D.O.," at an osteopathic hospital in Ohio. These lender
settings afford no support for this structure. am.! the detcri points are associated with the levator am, and lesions are
oration of the arches of the feet may, in time, destabilize the treated by simply toggling the sacrum by compressmg ante
biomechalllcal effiCiency of the entire pelvis and spine.2Q riorly on an area across from the tender pemt. The coccyx
The pelvII is pre<enteU here along with the hIp because IS treated by compressing the sacral apex antenorly and
the mu<;(.ularure berween the two IS mterdependent. The toward the tender point. IS
pelvis has chnical significance as an Important locomotion

143
ANT E R IO R L U MB A R S PIN E Tender Points

ALI
lliacus --\<H\\
AL2
.rla!!_ AL3
- AL4

144
Anterior Lumbar Spine

130. Anterior First Lumbar (ALI) Iliacus

ASIS
(landmark)

SAR AL3
GMI AL4
SPB
LPB
ALS
IPB
ADD

"I Location of This tender point is located medial to the anterior superior iliac spine. Pressure is
Tender Point applied posteriorly just medial to the ASIS and then laterally on the ASIS.

Position of I . The patient is supine. The therapist stands on the side of the tender point. The
Treatment patient's hips are flexed markedly, rotated to the side of the tender point, and lat
erally flexed toward or away from the tender point side.
2. The head of the table may be raised, pillows placed under the patient's pelvis, or a
physical therapy ball used to support the legs to facilitate the treatment (see
photo above right).
145
146 CHAPTER 6 Treatment Procedures

Anterior Lumbar Spine

131. Abdominal Second Lumbar (ABL2) Psoas

IL
ASIS
(landmark)

SAR?
GMI AL4
,..--,..--+--- SPB
'----;-- LPB
---- -f-- ALS
==t-- 1PB
ADD

Location of This tender point is located in the abdominal area approximately 5 em (2 in.) lateral
Tender Point and slightly inferior to the umbilicus on the lateral margin of the rectus abdominus.

Position of The patient is supine. The therapist stands on the side of the tender point. The ther
Treatment apist flexes the hips to 90 and rotates the hips approximately 60 toward the -
tender point side. and laterally flexes the hips away from the tender point side by
elevating the feet. The head of the table may be raised. or pillows placed under the
patient's pelvis.
Treatmem Procedures CHAPTER 6 147

13Z. Anterior Second Lumbar (ALZ) Iliopsoas

IL """f--.
ASIS
(landmark)
SAR? AL4
GMI --+-- SPB
--+- L- PB
ALS
r---"';-
---:--- IPB
ADD

Location of This tender point is located on the medial surface of the anterior inferior iliac spine.
Tender Point The hips may be flexed 45 to facilitate location of the point. Pressure is applied pos
teriorly just medial to the AilS, then laterally on the bone.

i
Position of The patient is supine. The therapist stands on the opposite side of the tender point.
Treatment The therapist flexes the patient's hips to approximately 90, rotates the hips approxi
mately 60 away from the tender point side, and allows the feet to drop toward the
floor to produce lateral flexion away from the tender point side. The head of the
table may be raised, or pillows placed under the patient's pelvis.
148 CHAPTER 6 Treatment Procedures

Antenor Lumbar Spine

133, 134. Anterior Third and Fourth Lumbar (AL3,4) Iliopsoas

IL
ASIS
(landmark)

SAR?
GMI AL4
""""'-
'-- ---,,- LPB S-1-- PS
-:"'-' -'--- ALS
- -

ADD '---
':-- -

IPS

l Location of The tender point for AL3 is located on the lateral aspect of the anterior inferior iliac
Tender Point spine. The hips may be flexed 45 to facilitate location of the point. Pressure is
applied posteriorly just lateral to the AilS, then medially on the bone. The tender
point for AL4 is located on the inferior aspect of the anterior inferior iliac spine. The
hips may be flexed 45 to facilitate location of the point. Pressure is applied posteri
orly just inferior to the AilS, then superiorly on the bone.

Position of The patient lies supine. The therapist stands on the side opposite the tender pOint.
Treatment The therapist flexes the patient's hips to approximately 70 to 90 and rests the
patient's legs on the therapist' thighs or on a physical therapy ball. The hips are later
ally flexed away from the tender point side by pulling the legs toward the therapist.
Fine-tuning is added by slightly rotating the hips toward or away from the tender
point side.
Treatment ProcedHres CHAPTER 6 149

135. Anterior Fifth Lumbar (ALS)* Iliopsoas

IL

ASIS
(landmark)

SAR -/ AL4
GMI SPB
LPB
ALS
IPB
ADD

Location of This tender point is located on the anterior surface of the pubic bone approximately
Tender Point 1.5 em (0.6 in.) lateral to the symphysis pubis. Pressure is applied posteriorly.

l
Position of The patient lies supine with the therapist standing on the side of the tender point.
Treatment The therapist flexes the hips to approximately 900 to 1200 and rotates the hips
toward and laterally flexed away from the tender point side.
ANT E RIO R P E L V I S AN D HI P Tender Points

GMI --#J.

Anterior View

TFl

Lateral View

1 50
Anterior Pelvis and Hip

136. Iliacus (IL)


Iliacus

IL IL

IL Gluteus
minimus and
ASIS medius
(landmark) Tensor
ALl fasciae
SAR ? AL4 latae
GMI SPB Iliopsoas

LPB Rectus
ALS
femoris
ADD
IPB

l Location of This tender point is located approximately 3 cm ( 1.2 in.) medial to the ASIS and
Tender Point deep in the iliac fossa. Pressure is applied posteriorly and laterally.

Position of The patient lies supine with the ankles supported on the therapist'S thighs (see photo
Treatment above left) or on a physical therapy ball (see photo above right) or chair. The therapist
stands on the tender point side and produces extreme flexion and external rotation
of both hips. Rotation toward the tender point side may be added to fine-tune.

151
152 CHAPTER 6 Treannen! Procedures

Antenor Pelvis and Hlp

137. Gluteus Minimus (GMI) Gluteus Minimus (Anterior Fibers)

GMI .... GMI


ASIS -

(landmark)

SAR
GMI
-;;:;
ADD

1 Location of This tender point is located approximately I cm (0.4 in.) lateral to the anterior infe
Tender Point rior iliac spine. The hips may be flexed 45 to facilitate location of the point. Pressure
is applied posteriorly.

Position of The patient is supine. The therapist stands on the side of the tender point. The ther
Treatment apist flexes the hip markedly (approximately 130) with no abduction or rotation.
Treatment Procedures CHAPTER 6 153

138. Sartorius (SAR)

IL
ASIS
(landmark)

SAR?
GMI

ADD ------'

1 Location of This tender point is located approximately 2 em (0.8 in.) lateral to the AilS. The hips
Tender Point may be flexed 45 to facilitate location of the point. Pressure is applied posteriorly.

Position of The patient is supine with the therapist standing on the side of the tender point. The
Treatment therapist flexes the hip to 90 and adds moderate abduction and external rotation.
154 CHAPTER 6 Treatment Procedures

Anterior PelvIs and Hip .

139. Tensor Fascia Lata ( T FL:

TFL

GME ..,

TFL

ITB

Location of Lateral and inferior to the ASIS and superior to the greater trochanter. on the ante
Tender Point rior border of the tensor fascia lata. Pressure is applied posteriorly and medially.

The patient lies supine. The therapist stands on the side of the tender point. The
l
Position of
Treatment therapist then flexes the hip to 90 and adds moderate abduction and marked
internal rotation by pulling the ipsilateral foot laterally.
Treatment Procedures CHAPTER 6 l55

140. Superior Pubis (SPB) Pubococcygeus

IL
ASIS
(landmark)

SAR ? AL4
GMI --4-- SPS
"'"----::----
- LPS
r- --':'-- ALS
ADD ____
_--".'--- IPS
SPB j
Puborectalis
Pubococcygeus Levator Ani
Iliococcygeus

l Location of This tender point is located on the superior aspect of the lateral ramus of the pubis
Tender Point approximately 2 cm (0.8 in.) lateral to the pubic symphysis. Pressure is applied poste
riorly above the pubic bone and then inferiorly.

l Position of The patient is supine. with the therapist standing on the same side as the tender
Treatment point. The therapist flexes the hip to 900 to 1200 with no abduction or rotation.
156 CiIAPTER 6 Treatment Procedures

Antenor PelvIs and HIp

141. Inferior Pubis (IPB) lliococcygeus

ASIS
(landmark)

SAR
GMI
-/
ADD j
Puborecta lis
Pubococcygeus LevatorAni
Iliococcygeus

l Location of This tender point is located on the medial surface of the descending ramus of the
Tender Point pubis. Pressure is applied superiorly and laterally.

Position of The patient is supine, and the therapist stands on the tender point side. The thera
l Treatment pist flexes, abducts, and externally rotates the affected hip.
Treatment Procedures CHAPTER 6 157

142. Lateral Pubis (LPB) Obturator Extemus, Pectineus

ILi--+::--
_
ASIS
(landmark)

SAR
GM I
-? AL4
o------i-- SPB
'----I- LPB
r--!.-- ALS
----i- IPB
AOO ---.......

Location of This tender point is located on the lateral surface of the body of the pubic bone on
Tender Point the medial margin of the obturator foramen. Pressure is applied medially.

Position of The patient is supine. The therapist stands on the same side as the tender point and
Treatment flexes the patient's hips to approximately 90. The therapist places his or her foot on
the table and rests the patient's legs on the therapist's thigh. The unaffected leg is
crossed over the affected leg. The therapist then uses the affected leg to internally or
externally rotate the femur.

Note: A physical therapy ball or a chair may be used to support the patient's legs.
158 CHAPTER 6 Treatment Procedures

Anterior PelvIs and Hip

143. Adductors (ADD)

IL
ASIS
(landmark)

SAR ? AL4
GMI "-:---:lI!-- SPS
"---'+--- LPB
e--- '::';-_ ALS
"",*
ADD -- -- IPS

l Location of This tender point is located on the anterolateral margin of the pubic bone and the
Tender Point descending ramus of the pubis (pressure applied posteromedially) or on the lower
third of the adductor muscle belly on the medial aspect of the thigh (not shown).

Position of The patient is supine with the therapist standing on the side opposite the tender
Treatment point. The therapist reaches across the patient and grasps the patient's distal tibia
(extended knee) or the lateral aspect of the involved knee (flexed knee) and adducts
it by pulling the leg medially.
P 0 S T E RIO R L U MB A R S PIN E Tender Fbints

Posterior View

G luteus medius

PL3-1 --#..
PL4-1 --li'qW,-,)
Tensor
-,1,,..1- fasciae
Gluteus latae
maximus ---'"""
(cut)

Iliotibial --I---l+
tract

Lateral View
159
Posterior Lumbar Spine

144, 148. Posterior Lumbar (PL 1,5)


Interspinales, Rotatores, Multifidus

- -PLI
-PL2
QL { -

-pu

PSIUPLS
-

- _ L4

PS3PS2 ....SSILPLS
-

PL3-1 Rotatores
PS4PSS _PL4-1
151 -MSI
_PRM

l Location of These tender points are located on the lateral aspect of the spinous processes
Tender Point (pressure applied medially), in the paraspinal sulcus or on the posterior aspect of the
transverse processes (pressure applied anteriorly).

i
Position of The patient lies prone. The head of the table is raised, or pillows are placed under
Treatment the patient's chest. The therapist stands on the side opposite the tender point. The
therapist grasps the anterior aspect of the pelvis on the tender point side and pulls
it posteriorly to create rotation of the pelvis of approximately 30 to 45.

Note: Tender points closer to the midline of the body are treated with more pure
extension; lateral tender points are treated with the addition of more lateral
flexion and rotation.
160
Treatment Procedures CHAPTER 6 16 1

149. Quadratus Lumborum (QL)

- -PlI
-- -Pl2
-- -PLl
__ -PL4

PS2
PS3
=====:i
-- -Pt.5

PS'I
PSs------'
ISI ------..,,,.,

Location of These tender points are located on the lateral aspect of the transverse processes
Tender Point from L I to L5. Pressure is applied anteriorly and then medially.

l Position of
Treatment
I . The patient is prone with the head of the table raised or a pillow placed under
the patient's chest. The therapist stands on the side opposite the tender point and
reaches across to grasp the ilium of the affected side. The therapist then instructs
the patient to flex and abduct the ipsilateral hip to approximately 45 (see photo
above left).
2. The patient is prone with the trunk laterally flexed toward the tender point side.
The therapist stands on the side of the tender point. The therapist places his
or her knee on the table and rests the patient's affected leg on the therapist's
thigh. The patient's hip is extended and abducted, and slight rotation is used to
fine-tune (see photo above center).
3. The patient is lateral recumbent on the unaffected side with the hips and knees
flexed to approximately 90. The therapist stands behind the patient and grasps
the ankles and lifts them to induce moderate side bending of the torso. The
patient's shoulder on the affected side is protracted or retracted to fine-tune (see
photo above right).
162 CHAPTER 6 Treatment Procedures

Posterior Lumbar Spine

150. Posterior Third Lumbar, Iliac (PL3I)* Multifidus, Rotatores

- -PLI
-- -Pl2
-- -PL3
-PL4

======1
_

- -PLS UPLS
PS 2 LPl5
....
.- SSI
PS3
PS4
PU.I
PS5 ---
.-PL41
e___MSI
IS I -----::"'" e___ PRM
PRL
GEM

Location of This tender point is located approximately 3 cm ( 1.2 in.) below the crest of the ilium
Tender Point and 7 cm (2.8 in.) lateral to the posterior superior iliac spine. Pressure is applied
anteriorly and medially.

The patient lies prone while the therapist stands on the same side (see photo above
i
Position of
Treatment left) or the opposite side (see photo above right) of the tender point. The therapist
then extends the thigh on the affected side and supports it with the therapist's leg
or a pillow. The therapist then moderately adducts and markedly externally rotates
the thigh.
Treatment Procedures CHAPTER 6 163

15 1. Posterior Fourth Lumbar, Iliac (PL4,I)*


Multifidus, Rotatores

Gluteus medius
{ _ -PLI
- -Pl2
PL41
QL - -PLJ
- -PL4 PSI
Tensor
PS2 Gluteus
PSPSS3 =======1
551 fasciae
PL3-1 maximus latae
PS4 - "
.-PL4-1 (cut)
.--
151 ---4
PL4-1

Iliotibial --1-4'1-
tract

"I Location of This tender point is located approximately 4 cm (1.6 in.) below the crest of the ilium
Tender Point and just posterior to the tensor fascia lata.

Position of The patient lies prone while the therapist stands on the same side of the tender
Treatment point. The therapist then extends the thigh on the affected side and supports it with
the therapist's leg or a pillow. The therapist then slightly adduces and moderately
externally rotates the thigh.

Note: Pl31 and PL41 may also be performed in the lateral recumbent position.
164 HAI'TER 6 Treannenr PTocedlTes

Postenor Lumbar Spine

152. Upper Posterior Fifth Lumbar (UPL5)


Multifidus, Rotatores, SI Ligaments

- -PLI
-- -PLl

-- -Pl3

-Pl4
- PSI
==== -PL5

-

PS2 LPl5
PS3 " SSI
PS4
PL3-1
PS5 .-PL4-1
MSI
lSI PRM

location of This tender point is located on the superior medial surface of the posterior supe
Tender Point rior iliac spine. Pressure is applied inferiorly and laterally.

l
Position of The patient lies prone with the therapist standing on the opposite or same side of
Treatment tenderness. The therapist extends the hip on the affected side and supports the
patient's leg on the therapist's thigh. The therapist then slightly adducts the patient's
leg and adds mild external rotation to fine-tune the position.

Note: The primary movement is extension. The treatment may also be performed in
the lateral recumbent position.
Treatment Procedures CIIAPTER 6 165

153. Lower Posterior Fifth Lumbar (LPL5) Iliopsoas, SI Ligaments

QL
{ - e e e-PLI
- -pu
- -PlJ
- e e e -Pl4 PSI
PS 2 ====:=
- eee
"'
s
SSI

PS3
PS4 ...-P-.- L3-1
PS5 e-PL4-1
ISI --- _MSI

LPLS

"I Location of This tender point is located approximately 1.5 cm (0.6 in.) inferior to the posterior
Tender Point superior iliac spine in the sacral notch. Pressure is applied anteriorly.

l
Position of I. The patient lies prone. The therapist. seated on the tender point side. asks the
Treatment patient to move to that side of the table so that the affected leg can be dropped
off the edge of the table. The therapist then grasps the ipsilateral leg. flexes the
hip to approximately 90. and adds slight adduction and internal rotation. The
opposite ilium may be retracted slightly to fine-tune.
2. The patient lies prone. The therapist stands on the opposite side of the tender
point and grasps the ilium. at the level of the ASIS. on the side of the tender
point. The patient is instructed to flex and abduct the leg on the affected side. The
ilium is then retracted and rotated toward the tender point side.

Note: This is a flexion dysfunction with a tender point located posteriorly.


P 0 S T E R IO R P E L V I S AN D H IP Tender Points

SSI
GME
Gluteus
minimus
/; .,-"-+- MSI
;;:;5--;- Piriformis
, .q- PRM
1

"-

Superior
gemellus
PRL
Quadratus
femoris
Obturator
internus

Posterior View

.---I--".l'!f- ITS

Lateral View
166
Posterior Pelvis and Hip

154. Superior Sacroiliac (SSl) Gluteus Medius

- -PLI
- -Pll
-PL3

--
- PSI-PL4

PS3 :====::::jJ 'SSI


- UPLS Gluteus
PS2 LPLS ",.y..- minimus
PL3-1 ----i't- Piriformis
'---!-.;) gemell
PS4
PS5------' PL4-1
Superior
ISI -------::""" us

Quadratus
internus Inferior femoris
gemellus

l Location of This tender point is located on the lateral aspect of the posterior superior iliac
Tender Point spine (PSIS). Pressure is applied anteriorly approximately 3 cm ( 1.2 in.) lateral to the
PSIS and then medially.

l Position of The patient is prone, and the therapist stands on the side of the tender point. The
Treatment therapist places his or her foot or knee on the table and supports the patient'S
extended thigh on the therapist's thigh. The hip is moderately extended and slightly
abducted.

167
168 CHAPTER 6 Treatment Procedures

Posterior Pelvis and HIp

155. Middle Sacroiliac (MSI) Gluteus Minimus

- -Pl.1
-- -PL2
-- -PL3


PSI
PS2 :====3 "551
-Pl.4
- -Pl5
UPL5
LPL5
Gluteus
minimus
PS3 t-."---f-- MSI
PS4
PL3-1 ""'--""'!--:fl-- Pirifor mis
PSS
151-----:
PL4-1
'-r----) gemel
Superior
lus

Quadratus
femoris

1 location of This tender point is located in the center of the buttocks. Pressure is applied anteri
Tender Point orly and medially.

i
Position of The patient is prone, and the therapist stands on the side of the tender point. The
Treatment therapist grasps the patient's leg and markedly abducts the thigh. The therapist fine
tunes the position with a slight amount of flexion/extension or internal/external
rotation.
Treatment Procedures HAPTER 6 169

156. Inferior Sacroiliac (lSI) Coccygeus, Sacrotuberous Ligament

- -PLI
... -Pl2

PSILPLS
- -P\.3
- -P1.4

- -P\.5
UPLS
PS2
=-====
PS5-----'
PS3 551
PS4 -
PL3-1
"

151 ---7"lI

Location of This tender point is located in a line along the sacrotuberous ligament from the
Tender Point ischial tuberosity to the posterior aspect of the inferior lateral angle of the sacrum.
Pressure is applied anteriorly and laterally.

Position of The patient is prone with the therapist on the side opposite the tender point. The
Treatment therapist reaches across to grasp the leg on the involved side and extend. adduct.
and externally rotate it across the uninvolved leg. This position may be performed in
the lateral recumbent posture with the involved side up.
170 CHAPTER 6 Treatment Procedures

Postenor Pelvis and H,p

157. Gemelli (GEM) Gemelli, Quadratus Femoris

--
-



-PI.I
-PLl
QL{ --




-PlJ
-Pl4
(
-PlS
PS2
PS3
PS4
PSS

151

l Location of This tender point is located on a line from the lateral inferior surface of the ischial
Tender Point tuberosity to the medial aspect of the posterior surface of the greater trochanter of
the femur. This is along the gluteal fold. Pressure is applied anteriorly.

I . The patient is prone. The therapist stands on the opposite side of the tender
l
Position of
Treatment point, places the patient's ankle in the therapist's axilla, and grasps the patient's
flexed knee. The therapist extends, adducts, and externally rotates the hip. (See
photo above left.)
2. The therapist stands on the same side as the tender point and supports the
patient's thigh on the therapist's thigh (which is resting on the table) and pro
duces extension, adduction, and external rotation. (See photo above right.)
Treatment Procedures CHAPTER 6 171

158, 159. Piriformis-Medial (PRM) Piriformis


Piriformis-Lateral (PRL) Piriformis Insertion

-- Pll
{ ---
-


-Pll

(

QL -P\.3
-PL4 PSI
UPL5
PS2 LPLS
... 551
PS3 PRM PRM
PS4
PL3-1
PS5 .-PL4-1
PRl PRL
____M
__ 51
151

Location of This tender point is found in the belly of the piriformis approximately halfway
Tender Point between the inferior lateral angle of the sacrum and the greater trochanter. Pressure
(PRM) is applied anteriorly.

l Location of This tender point is located on the posterior, superior, lateral surface of the greater
Tender Point trochanter. Pressure is applied anteriorly.
(PRL)

l Position of
Treatment
I . PRM: The patient is prone, and the therapist is seated on the tender point side.
The ipsilateral leg is suspended off the table with the bent knee resting on the
therapist's thigh. The hip is flexed to approximately 60 to 90 and abducted.
Internal/external rotation is used to fine-tune the position. (See photo above left.)
2. PRL: The patient is prone, and the therapist stands on the tender point side. The
ipsilateral thigh of the patient is extended and abducted and supported on the
therapist's thigh, which is resting on the table. The therapist brings the patient's
thigh as close as possible to the therapist's hip and then rolls the patient's thigh
down toward the table to produce marked external rotation. (See photo above
right.) (This treatment may also be used for PRM.)

Note: Piriformis is an external rotator when in extension and an abductor when in


flexion.
172 Ci IAfYrER 6 Treacment Procedures

Posterior Pelvis and Hip

160. Gluteus Medius (GME)


::><:::.. GME
GME __-.

Ifh-TFL

ITS

l Location of These tender points are located on a line approximately I em (0.4 in.) inferior to
Tender Point the iliac crest and 3 to 5 em ( 1. 2 to 2 in.) on either side of the midaxillary line. Pres
sure is applied medially.

i
Position of The patient lies prone, and the therapist stands on the same side as the tender
Treatment point. The therapist extends and abducts the hip and supports the patient's leg on
the therapist's thigh. The hip is pOSitioned in marked external rotation for tender
points located posterior to the midaxillary line (see photo above left) and in internal
rotation for those located anterior to the midaxillary line (see photo above right).
Treatment Procedures CIIAPTER 6 173

161. Iliotibial Band (ITB)

GME ---...
.. ..
.....,

"r-- TFL
hl---fjl- ITB

ITB

l Location of These tender points are located on the iliotibial band along the lateral aspect of the
Tender Point thigh on the midaxillary line. Pressure is applied medially.

l
Position of The patient may be supine or prone. The therapist stands on the side of the tender
Treatment point, grasps the patient's leg, and produces marked hip abduction and slight hip
flexion with internal or external rotation to fine-tune the position.
P 0 S T E R IO R S AC RU M Tender Points

----- 2
;------- 3
4

Posterior View

Pubis
Puborecta lisj
Pubococcygeus Levator Ani
Iliococcygeus

Obturator internus

=-----JT- Ischium

Piriformis

Coccygeus
Superior View

174
Posterior Sacrum

162. Posterior First Sacral (PS1 ) Levator Ani

-
-

-P1.1
-Pll
Short posterior
sacroiliac ligaments
PSI
QL{ -
- PU s::s:/
-
- -P1.4
-PLS

PS2
PS3
PS4
PSS

151
Long
posterior
sacroiliac
ligament

Sacrotuberous
ligament
Sacrococcygeal
Tendon of
ligaments
biceps femoris

l Location of This tender point is located in the sacral sulcus. medial and slightly superior to the
Tender Point PSIS. Pressure is applied anteriorly.

l Position of
Treatment
The patient is prone. The therapist applies an anterior pressure on the inferior
lateral angle opposite the tender point side. resulting in rotation around an oblique
axis.

175
176 CHAPTER 6 Trearment PrOCedtlTeS

Posterior Sacrum

163. Posterior Second Sacral (PS2) Levator Ani

- -Pl.1

- -PL2

QL{ - - PlJ

- - Pl.4

- -PlS

PS3
PS4

151

1 Location of This tender point is located on the midline of the sacrum between the first and
Tender Point second sacral tubercles. Pressure is applied anteriorly.

The patient is prone.The therapist applies an anterior pressure on the sacral apex in
1
Position of
Treatment the midline. producing rotation around a transverse axis.
Treatment Procedures CHAPTER 6 177

164. Posterior Third Sacral (PS3) Levator Ani


-
-PLI

-
-
- P1.2
QL { -

-
PLJ
-PL

-PLS
-

PS2


PSS

151

"I Location of This tender point is located in the midline of the sacrum between the second and
Tender Point third sacral tubercles. Pressure is applied anteriorly.

1
Position of The patient is prone. The therapist applies an anterior pressure on the apex (or
Treatment occasionally the base) of the sacrum in the midline. resulting in rotation around a
transverse axis. Alternatively. the patient may be placed in sacral extension by raising
the head end of the table and the foot end of the table or by using pillows to sup
port the patient's trunk and lower limbs in extension. with the third sacral segment
as the fulcrum.
178 CHAPTER 6 Treatment Procedures

Posterior Sacrum

165. Posterior Fourth Sacral (PS4) Levator Ani

- ...-
QL{ - ..
-
,-
-PLl
-
-
- Pl."
-PLS
PS2
PS3
PSS
lSI

1 Location of This tender point is located in the midline of the sacrum just above the sacral hiatus.
Tender Point Pressure is applied anteriorly.

1 Position of The patient is prone. The therapist applies an anterior pressure on the sacral base in
Treatment the midline. producing rotation around a transverse axis.
Treatment Procedures CIIAf'fER 6 179

166. Posterior Fifth Sacral (PS5) Levator Ani


-
-PI.I
- -pu
QL {
-
-pu

- -PL4
- -PLS
PS2
PSJ
f>S.4

151

1 Location of This tender point is located approximately I cm (0.4 in.) superior and medial to the
Tender Point inferior lateral angle of the sacrum. Pressure is applied anteriorly.

The patient is prone. The therapist applies an anterior pressure on the sacral base
1
Position of
Treatment on the side opposite the tender point, resulting in rotation around an oblique axis.
180 CHAPTER 6 Treatment Procedures

Posterior Sacrum

167. Coccyx (COX)


Pubococcygeus, Sacrotuberous Lig., Sacrospinous Lig.

QL{ -

PS2
PS3
PS4
PSS

151

cox

location of This tender point is located on the inferior or lateral edges of the coccyx. Pressure
l Tender Point is applied superiorly or medially.

Position of The patient is prone. The therapist applies an anterior pressure on the sacral apex in
l Treatment the midline. Rotation or lateral flexion of the sacrum, usually toward the tender
point side, may be added to fine-tune the position.
DMT2,3
7
The Use of Positi onal Release
Therapy in Clinical Practice
How to Incorporate Positional Can Po itional Release
Release Therapy with Therapy Address Repetitive
Other Modalitie 221 Strain lnjurie ? 224

The Use of Reality Checks 222 What Happens If You Are Unable
to Locate Significant Tender
How Do You Communicate with
Points and Yet the Patient
Patients Regarding Positional
Has Pain? 224
Release Therapy? 222
What Happens If Pain or Other
What Happens If a Tender Point
Sensations Occur during the
Does Not Shut Off? 222
Treatment while the Patient Is
How Do You Treat in a Position of Comfort? 225
Conflicting Points? 223
What Activities Can the
Any Suggestions When Working Patient Perform after a
with Obese Patient ? 223 Positional Release Therapy
Any Further Sugge tions with Treatment Session? 225
Regard to Ergonomics and What Can Patients Do about
Proper Body Mechanics? 223 Posttreatment Soreness? 225
Does Positional Release Do You Offer Any Home
Therapy Specifically Treat Programs to Your Patients? 225
Soft Tissue Damage? 224
Summary 225

, How TO INCORPORATE POSITIONAL RElEASE reduced in the first few visits so that the patient can
progress with cardiovascular fitness, strengthening,
THERAPY WITH OTHER MODALITIES mobility, and range#of,motion exercises. Modalities may be
Positional release therapy helps normalize inappropriate used for pain management and swelling or to help promote
proprioceptive activity and promotes the release of muscle soft.tissue healing. Positional release therapy may not be
guarding and fascial tension, thus increasing soft tissue flex# the primary treatment for all conditions, but it will help
ibiliry, improving joint mobility, decreasing pain, increasing many patients overcome certain aspects of the dysfunction.
circulation, and decreasing swelling. By using PRT, the Based on the evaluation and determination of the calise
patient's muscle, fascia, and articular components are struc# of the dysfunction, other modalities may be introduced. In
rurally normalized to a point where the therapist can start the case of persisting articular restriction, these may include
to implement a functional rehabilitation program. It is manipulation, mobilization, or muscle energy. If the cranial
essential to perform a thorough reevaluation at each visit. structures are not fully corrected or the dural tube is under
In most cases the patient's pain level will be dramatically (ension, cranial osteopathy or craniosacral (herapy may be

221
222 CHAPTER 7 The Use of Positional Release Therapy in Clinical Practice

applied. With visceral or fascial involvement, the appro tion that either through various injuries sustained in the
priarc soft tissue technique is used. If the patient demon past or from the present injury, the tissues may have become
s[rares muscle weakness, a strengthening program should be injured and are in a shortened, tense position. This can
instituted. Frequently, massage and general exercise pro result in the tissues being tender to the touch. If these tis,
grams can further release tight, overused muscles, ease fas# sues (muscles, ligaments, etc.) become short and tense, they
cial tension, and help promote increased circulation. will create joint stiffness and limit movement.
Modalities slich as ice, heat, and electrical stimulation can Patients will realize that trauma obtained in the past can
aid in relaxing the patient and can help resolve inflamma result in accumulated restrictions throughout the body. To
rion, posureatment soreness, and other reactions. explain areas of dysfunction that are remote from the per,
ceived symptoms, the analogy of a pulled garment, such as
a sweater or blouse, can be used. This demonstrates that fas,
HHE USE OF REALITY CHECKS cial restrictions, like fabric, can cause lines of tension to
Reali!y checks are orthopedic and functional tests used to radiate from the source and thus cause strain in surrounding
confirm various Outcomes. These tests must be objective "reas. (See Chapter 2, Fig. 2-4.)
and measurable. The pain scale from 0 to to may be used Once the patient understands the purpose of the full,
(0 being no pain and 10 being the most severe) or a range body evaluation, the therapist should proceed to explain
of,motion test (the patient lifts his arm over his head while what the patient can expect during and after the treatment
the practitioner uses a goniometer to measure the range in session. It is suggested that the therapist find a tender point
degrees). Joint hypomobility tests (spinal or sacral spring to demonstrate the PRT technique and gently bring the
tests) and functional tests (doing a deep squat or going up patient into and Ollt of the position of comfort. This shows
and down stairs) can also be used. If a patient has low back the patient that the tenderness will disappear in the posi
pain, the range of motion should be evaluated in each of the tion of comfort and demonstrates that the treatment is
three planes. If it is found that there is pain at *0 on left side gentle and safe. It is important to explain that the patient
bending and extension at X range, these are two reality may experience release phenomena consisting of pulsation,
checks that can be used to confirm the outcome of treat, vibration, paresthesias, pain, or heat while in the position of
ment. Therefore when using PRT it is now possible to mon, comfort. These sensations will dissipate when a release in
itor left side bending and extension after treatment to see if the soft tissues is completed. The patient should be
there is a change in the pain level or range of motion. Thus informed that there should be a significant reduction in
it is important to find two or three objective measurements tenderness. The patient should be relaxed, more comfort,
throughout the treatment program. It is also important to able, and able to move more freely. During the 24 to 48
make the patient aware of these reality checks because this hours after the first treatment, approximately 40% of
will be helpful in motivating the patient as changes occur. patients report some increased discomfort. Reassure the
patient that this discomfort will disappear after a day or two

, How Do You COMMUNICATE WITH PATIENTS and that an improvement in the original symptoms will be
noticed. It is helpful to advise the patient that the discom,
REGARDING POSITIONAL RELEASE THERAPY? fort may be felt directly in the area treated or that it may be
Communication is one of the most important aspects in felt elsewhere. For example, if the sacrum is treated, the
dealing with the public. On the first visit, it is crucial that patient may feel discomfort in the sacrum, neck, shoulder,
the subjective evaluation of the painful areas be recorded. It or other areas of the body.
should also be noted whether the pain is constant, periodic, If these pretreatment discllssions are omitted, the proba,
or occasional. Have the patients grade pain from 0 to 10, bility of future problems with the patient is extremely high.
with 0 being no pain and 10 being the most severe. What Thus it is necessary to prepare the patient and make Sllre that
do they expect to get from therapy? As health care he is aware of the different sensations he may experience.
providers, we must keep our patients focused on their own When the practitioner clearly explains what is to be ex
goals. Also, they must decide what they are prepared to do pected, the patient feels respected and included in the treat'
to obtain these goals. How will they know if they have ment program. He appreciates that the technique is gentle
obtained their goals? What reality checks will be used? It and that immediate results may be felr. The pariem values
must be made clear [Q patients how their bodies will move the time taken, and this ensures satisfaction and confidence
and what they should feel. Some patients have no idea what with both the practitioner and the rehabilitation program.
wellness feels like. Each patient's expected outcome of
therapy should be discussed and recorded by the practi
'WHAT HAPPENS IF A TENDER POINT
tioner to ensure that the goals will be met.
It is important to discuss the rationale of PRT. The
DOES NOT SHUT OFF?
patient must understand why a full,body evaluation is crit, ClinicaHy, this has been found to be a rare occurrence. From
ical even when a specific site is so obviously painful. Men- our experience, when a therapist is unable to shut off a
The Use of Positional Release Therapy in Clinical Practice CIIAPTER 7 223

tender pOint, she must first establish if she is palpatmg the tender TXllnt, The practitioner shllulJ he alert to this
exact location of the tcnder point. Some pomL'; aTC close possibility if the tissues UO not responu as expected.
rogcrher. For example. the anterior third lumbar, which is on Further ilwestigations or an appropnate referral may
the lateral aspect of the amerior mferior lilac spme. is In he required.
close proximity [0 the [cm.lcr point for (he gluteus minnnus,
which is I em lateral to the anterior inferior iliac spine. To
treat an anterior
, How Do You TREAT CONFLICTING POINTS? third lumbar.
c,,1 hIp l1exlon of 90 Jegree, anJ siJe bent ,harply away A paticnt who has experienced a whiplash rype of mJury, for
from the tender pom[ siJe (p. 148). To treat a gluteus example. may have tender pOints 111 the anteTlor and rx)stc
mmimus. only the involved hip is flexed [0 approximately rior aspects llf the neck. The practitioner may find that an
DO degrees with 0 degrees of abduction and rmarion attempt to treat the anterior lesion hy flexing the patient's
(p. 152). In this situation, these two points are In close prox# neck ll"'I<ly cause the posterior pam ur tenderness to I11tcnsify.
Imiry. yet their treatments arc different. It is essential that This IS a case of conflictlllg tenuer points and may he dlf(j
the practitioner know exactly which point is being treated. cult [0 treat. This situation may warrant searching elsewhere
Second, the practttioner may be on the desired pOint but in the boJ.y for an equally scn....itive tender pt.lint. Trci.1ting
the [echniquc is not being perfonneJ properly, or palpation of another equally sensitive tendcr p{)lnt remote from thl"'l area
the comfort zone has not been successfully auamed to may cause one of the conflicting P1l1l1tS m release, and [reat
achieve the ideal polnon of relaxation. Standard procedure ment may then continue. If treatment of an eqwllly :;en!)l
might call for only 90 degrees of l1exlon, but a particular tive tender point docs not facilitMe a change, the theri-Ij1lst
patient may need 120 degrees of flexion to shut that point off. shoulu rry other treatment modalities. such a craniosacral
Therefore It IS important that the camforl zone be carefully therapy, myofascial release, or muscle energy technique. It is
palpated and that the therapist he aware of the maximal tis.l:iue IInpornlllt to remember that the patient mUSt he comfnrr
relaxation, uSlIlg thIS as a guide to finetune the technique. ahle anJ rdaxeJ whtle betng trcateJ, anJ If there IS any paIn
TI'lfd, are all the general rul", beIng followOO properly? Is wI-Hie being placed mto the pO"'ltion of comfort. it is n con
the most severe tender P01l1t or area of greatest accumulation traindlcation to that particular rreatment.
of tender P01l1ts being treated first? Is the treatment being
perforrnOO from proXImal to Jista!! Maybe the POInt being
' ANY SUGGESTIONS WHEN WORKING
treated will not shut off because there is another point that is
dominant and must be treated before thiS one.
WITH OBESE PATIENTS?
Fourth, there Will be occasions when the ue:sireu POInt The size of the patient must be considereu. Aistivc device.
has been Identified anu the appropriate treatment is such a a physioball or chair on which to ret the patlcnt's
attempteu, but for some reason It does not work. It is Impor leg.', should be employeJ to prevent the thempl;t from
tant to remember that "the panent is always right." The hearing the weight. In some cases, an assistant may be helpful
panent's body knows mure about its needs than the thera for the treatment, The rherapist should never try to support"
pis[ docs, and It IS vital [Q liMen to what It tells you, The the weight with only hIS hanus or arms. lie should Imng the
treatment positions have evolved from over 40 years of clln weight in close to his l:x"Kly and usc the larger muscle groups,
Ical experience and were developed by testing different such as the trunk and legs, for upport, It is important to be
positions on patients and finding which positions seemed to sure that the table is at an appropriate height to prevent
decrease the tenderne and relax the tissues. In most cases injury [0 the therapist. The safety of the therapist mu.,t
there will he a position thlt will shut the tender point off always remalll a consideration. Specialized posltlonmg
and relax the pattern's tISSUCS. (See the followmg section on table., ,uch a. the one JC\'e!opeJ by one of us (Roth), may
conl1icting pom[s.) The [herapist shoulJ start off WIth he of great vi:lluc in reducing stram (.see the Appendix),
flexion Jmi extension anu determine which relaxes the tis With regard [0 palpation of tender pom( on ohese
sues more. Then she shoulu add rotation to the left and to people, a thorough grar of anatomy j:., mandatory. Gently
the right. To which movement does the patient's boJy smk the fingers into the tlS.!lUC, sprc<1C..llIlg some of the fat our
responJ better? Next the therapist .hould adJ ,iJe henJ of the way to locate the ucslrcd point. Palpation may be
IIlg to [he left and right and then fine tune the position, slightly more difficult and time consummg, but It IS fl(]sslhle,
As the therapist learns to uialogue with the tissues amI gain
expertence through her hands, she will be able to develop
'ANY FURTHER SUGGESTIONS WITH REGARD TO
new treatment poSitions for ptlillts that are not covered
ERGONOMICS AND PROPER BODY MECHANICS?
III

thIS book.
If the lender poinr returns Immediately after treatment, Throughout the treatment section in this hook, rccommen
there may be a facihtateu segment, suggesting that an Jations are mauc [hat will help the therapi( ergonomically.
Inflammation or pathologic process is accentuating the sen The height of the practitioner, the size of the pmient, and
sitivity of the myofascial ti......ues
.. and creating a seconuary the height of [he tahle may vary. I[ " imperative that [he
224 CHAPTER 7 The Use of Positional Release Therapy in Clinical Practice

praclitioner always remam an a comfortable (reatment posi the part of the employee. Repetitive motion and sustained
tion. An adjustable table is ideal; however, a footstool can posture on production lines within the manufacturing
compensate for some differences. It is important to employ sector and clerical and technical occupations associated
proper fulcrums and bear the weight properly without Oi5# with the use of computer terminals are common factors
comfort. The therapIst should never try to support weight causing high risk for CfD. Muscular, (ascial, articular, and
wIth outstretched hands or arms. The weight should be neural inflammation have been Implicated as the sources
hrought in as close to the therapist's body as possible and of symptoms.
the larger muscles used (or support. A large physioball or It is the opinion of the authors that symptoms often arise
chaIT may be used to support the patient's legs. The ball or In a certain part of the body because of the complex inter
chaiT can be moved easily to assist the patient in side actions of the tissues. This IS m response to an aberrant dis
bending and rotation. Differenc#sized wedges, pillows. and tribution of forces related to background centers of fixation.
chairs may be employed to support the patient's body These areas o( fixation (dysfunction) would result m com
weight. When using the hands to apply pressure, the wrists pensatory hypermobiliry o( structures m other areas o( the
should be locked in extension, elbows extended, and shoul body. These secondary areas would be subject to excessive
ders placed directly over the hands when performing com motion and stretching of tissues (strain). This excessive
pression so that the larger muscle groups are used to deliver motion, especially if repetttlve, could lead to the micro
the (orce and not the hands. trauma and the ensuing release of nociceptive chemical
In the event that a heavy body part requires lifting, the mediators associated with the production of palO.
therapist should extend the elbows, lean back, and use her Depending on the pattern of compensation. certain activi..
own I:x:'k.ly weight (0 create mechanical advanrage. ties may directly engage muscular tissues resulting in over'
stretching of these structures. This would lead to a myo..

, DOES POSITIONAL RELEASE THERAPY static reflex response of IOcreased contraction, tissue
ischemia, anaerobic metabolism, metabolic waste accumu'
SPECIFICALLY TREAT SOFT TISSUE DAMAGE? lation, and the release of pam producing chemical sub
Positional release therapy mamly treats inappropriate propri stances. Depending on the pattern o( dysfunction, this
ocelnive acriviry and fascial tension and thus decreases pro, reflex contraction may result in direct impingement of a
tective muscle spasm. increases strength, decreases swelling, nerve tract, leading to parasthesia and weakness.
Increases circulation, and improves joint mobility. It Positional Release Therapy can help to address the com
removes many barriers to allow the body to use more of ics plex pattern o( symptoms associated with CfD by re"evlng
resources to assist the healing process. If there is tom tissue, the background myofascial dysfunction, which can set the
PRT may (acilitate a berrer environment (or healing, but stage for the onset of this disorder. Ir is important to empha
the technique docs not directly repair the tissue damage. size that, with CfD or RSI as with any other clmical
TI1e tissues require time to heal on their own or may require disorder, it is the dysfunction rather than the symptoms
surgical Intervention 111 rare cases. that must guide the therapeutic intervention. Postural eJu
According to Levin, neuromusculoskelc[31 dysfunction cation, proper ergonomics, job management, and preventa..
is a nonlmear event. This means that it is mediated by tive exercise, along with the appropriate application of
neural and clectrochclnlcal changes that require a minimal therapeutic principles such as those presented in this text,
amount of time to develop (i.e., a sudden strain) and almost can help to address this significant source of absenteeism,
no time to resolve once a corrective intervention is applied. reduced productivity, and unnecessary drain on health
linear processes, such as fractures, tears, and lacerations, care resources.
require a suhstantial time interval for the healing process to
effect a repair of the tissue damage. Positional release
therapy is a nonlinear therapy and addresses the nonlinear , WHAT HAPPENS I F You ARE UNABLE TO
aspect o( the inJUry. LOCATE SIGNIFICANT TENDER POINTS AND
YET THE PATIENT HAS PAIN?
, CAN POSITIONAL RElEASE THERAPY
It is important to remember that we have listed more than
ADDRESS REPETITIVE STRAIN INJURIES? ZOO tender points. These are by no means all the tender
The is,ue of repetitive strain injury (RSl), also referred to as points in the body, bur these are the ones that are explained
cumulative traUlna tfuorder (CfD), is in the forefront o( in detail, because they appear most conSIstently. I( none o(
industrial health care and is a subject o( much speculation. these points is found to be tender, it may be necessary to
Symproms of pain, parasthesia, and weakness are associated reevaluate the patient for tender points til other locations.
with repetitive occupational activities and are seen in many In these cases, the general rules should be used t<l treat any
Industrial settings. These conditions appear to be associated new point that is found. If no tenderness is found, other sys
With a combination of ergonomic and behavioral factors terns may be screened (the craniosacral system, myofascial
mcluding sustained posture and poor body mechanics on system, articular system, etc.), or a more thorough diag
The Use of PositimUlI Release Therapy in Clinical Practice CHAPTER 7 225

no tic workup or appropriate referral may be required to accumulated metabolites such as histamines. Other tech#
rule out possible pathology or infection. niqucs that encourage circulation, the efficient elimination
of toxins, and mental and physical relaxation may be
extremely valuable in minimizing posttreatment reactions.
'WHAT HAPPENS IF PAIN OR OTHER Hydrotherapy, in the form of ice and heat, whirlpool baths,

SENSATIONS OCCUR DURING THE TREATMENT WHILE contrast or epsom salt baths, and alternating hot and cold
showers, has been effective in providing relief to many
THE PATIENT Is IN A POSITION OF COMFORT? patients. Relaxation and breathing exercises can be taught
If a patient complains of pain while the therapist is seeking to patients. The application of therapeutic modalities, such
a position of comfort, some ti ue that is in dysfunction is as ultrasound, interferential current, diathermy, and
being stressed and the patient should not be kept in this microcurrent, may be useful in treating possible reactions.
position. This is a contraindication [0 that position. If it is In certain cases, over#the#counter analgesics may be neces#
possible [0 get the patient in[Q a position of comfort sary to help diminish the inflammatory process.
without pain bur a pain, ache. or paresthesia develops
while the patient is being treated, this is acceptable. It is
'00 You OFFER ANY HOME PROGRAMS
oftcn part of the release phenomena and will not last more
than a few minutes. The patient may also feel heat, vibra,
TO YOUR PATIENTS?
[ions. pulsations, or an internal movement of the myofas, Yes. For example, if a patient has a psoas muscle that has
cial component. Upledger calls this unwinding. If any of been in spasm for several years and that docs not fully
these sensations occur, it is important CO maintain the release during the treatlllent session, the patient will be
position of treatment until the sympcoms subside and a given home positional release exercises to further relax that
release is felt. The patient may experience these various muscle. A patient who keeps stressing a certain muscle
sensations spontaneously in different regions of the body because of the type of repetitive action or positioning at
throughout the treatment session. It is important to reas, home or work could also benefit from a home program.
sure the patient that these sensations are part of the release These home PRT exercise programs are also highly recom#
phenomena and will not continue after the release has mended for those individuals who experience muscle ten#
been completed. sion because of traveling or muscle soreness resulting from
exercise or athletics. Instead of doing stretching exercises,
the patient will perform tissue#shortening exercises and
, WHAT ACTIVITIES CAN THE PATIENT then a series of other exercises to strengthen the muscles

PERFORM AFTER A POSITIONAL RElEASE and mobilize the jOints.


Home exercises also give some responsibility to patients
THERAPY TREATMENT SESSION? for their own wellness. This can help focus their attention
Clinically it has been found that a cessation of strenuous in a positive wayan their bodies, instead of the negative
activity for the next 24 to 48 hours is recommended. The association with pain. This combination can provide a
body is still extremely sensitive, and the protective muscle valuable source of motivation for continuing the rehabilit3#
spasm can easily return. The tissues may also be connected tion program and returning CO norlllal activities more
to a facilitated segment that may be vulnerable to reactiva, quickly. Patients who experience an acute flare#up will be
tion and require time to resolve. The patient may benefit able to help themselves until they can obtain medical
from heat, massage, gentle mobilization, "aquabics," and attention, if necessary.
range#of,morion exercises, as well as cardiovascular exer#
cises, such as treadmill, bicycle, or upper#body cycle. These
forms of treatment help increase circulation, mobility, and
flexibility; help decrease stiffness; and may alleviate post This chapter has outlined several commonly asked ques
treatment soreness, as long as the exercises are gentle and tions that we have had to address during seminars. We have
there is no strenuous component. provided a quick reference guide for solutions to problems
that therapists frequently encounter. This chapter has also

'WHAT CAN PATIENTS 00 ABOUT addressed the importance of patient-practitioner communi


cation and the need to identify treatment goals and expec#
POSTTREATMENT SORENESS? tations. Measures to reduce practitioner strain injury have
Posttreatment soreness usually lasts for approximately a day been discussed, and specific ergonomic suggestions have
or two and can be somewhat relieved by gentle exercise and been provided. In addition, we have outlined specific clin
consuming water to assist the body in the elimination of ical challenges and methods to facilitate optimal results.
8
New Horizons
Listen ing to the Tissues-Treating
the Dysfunction 227

Adaptability and the Role


of Exercise 228

Developing the Art and Science


of Positional Release Therapy 228

, LISTENING TO THE TISSUES indirectly related to the source of the condition. In acute
cases, however, treatment directed to the area of symptoms
TREATING THE DYSFUNCTION IS often at least partially appropriate.
The goal of posititional release therapy (PRT) is to be able The appearance of symproms is a dilemma to the thera
to identify the primary dysfunction and to direct therapy to pist. We listen to the history of the patient and would like
the source of the dysfunction. The scanning evaluation is a to remove the discomfort or pain. This, for many of us, is
useful tool that al!ows the practitioner [0 develop an objec OUf raison d'(Te. We live for the moment when we can
rive basis for determining the primary tender points, which come to the rescue and alleviate the suffering of our
are an indication of the primary dysfunctions. This makes it patiems. We are, however, not always as successful as we
possible to unravel the compensatory patterns that manifest would like to be. In many cases, when symptoms do abate,
as the presenting condition of the patient. Positional release we would like to believe that it was through our efforts, but,
therapy is one of a growing group of therapies that have if we are honest with ourselves, we mUSt acknowledge thar
evolved in recent years which recognize the inherent prop there may have been several orher factors responsible fOf
erties of organic tissue and attempt to work in harmony the apparent change. To be symptom oriented in practice is
with them co restore optimal function. to be set up for failure. We are in constant doubt of ollr SUC
The primary dysfunction is exemplified by fixation and cesses and failures because of the very nature of symptoms,
loss of physiologic and non-physiologic motion. Fascial and which are the elusive and changeable outer manifestations
neuromuscular 111echanisms have been altered to resist of dysfunction.
deformation in the body's attempt to limit furrher destruc Symptoms are variable, often self-limiting, and subjec
tive potential from ongoing or subsequent trauma. These tive by their very definition. However, the underlying dys
changes result in the development of an area of persisting function does not vary, is not selflimiting, and is totally
hypomobility. Over time, this area of relative fixation cre objective by definition. Efficient diagnosis and appropriate
ares a new, abnormal center of motion in the body and rhus therapeutic intervention directed toward the dysfunction
induces overstretch, aberrant motion, and hypermobility in should be the goal of therapy. For example, any firefighter
surrounding tissues. Pain rarely arises in tissue that is fixed. will teli you that when confronted with flames, the extin
Putting a cast on a broken bone attests to this. It is the tis guisher should be directed to the base of the flame, and if
sues and joints above and below the cast that become fuel is feeding the flames, this should be turned off first. This
uncomfortable. Overstretched, straineJ, and hypermobile is an appropriate analogy to our clinical experiencei m.uch
tissues around the area of fixation become inflamed and of the frustration and failure to which we have all been
symptomatic. Thus, when we focus our attention on the subject could be greatly reduced if we would adopt a sim
area of symproms in chronic conditions, we are usually ilar attitude-that is, focus on the cause of the condition:
dealing with secondary compensations and decompensation the dysfunction.

227
228 CHAPTER 8 New Horizons

The implications of the tensegrity model (see the cific exercise programs, requires the active participation and
Appendix, p. 246) from a clinical perspective are that all cooperation of the patient.
tissues share certain characteristics and that the artificial Most people acknowledge the importance of exercise as
separation of tissue types and the application of particular part of a program to restore function after an injury and to
therapeutic interventions to an isolated tissue may be COlm maintain optimal health. Many, however, find it difficult to
terproductive. Indeed, this model clearly confirms that all motivate themselves to follow through on this aspect of their
tissues are alike at the fundamental level and arc in[ercon rehabilitation program. The active component of therapy is
neeted in terms of the transmission of (orces and possibly often introduced before structural restoration has occurred,
the conduction of electrochemical impulses. With regard to and these patients frequently experience an aggravation of
the usc of PRT, we feel that any tissue may be implicated in their symptoms. This is a common mistake in therapy and
the produccion of the apparent clinical presentation. is a significant reason for failure of the rehabilitation pro
Focusing on the dysfunction. no maner where it may cess. Positional release therapy and other structural thera
appear, will liberate us from the tyranny of the elusive pies are necessary to prepare the tissues so that they can tol
symptom and allow us to direct our energies co the cause of erate exercise. It may be difficult to motivate patients to
the condition rather than the effects. incorporate exercise into their lives. However, education
and diligence in formulating programs that are achievable
and enjoyable are keys to overcoming this obstacle.
, ADAPTABILITY AND THE ROLE Of EXERCISE A sedentary individual may also lack the coordination
Positional release therapy is a form of structural therapy necessary to perform certain activities in a smooth and effi#
that can help restore freedom of motion and functional dent manner. This can be a factor leading to an increased
integrity to the body. This is accomplished by releasing ten susceptibility to injury. An athletic individual, on the other
sion in the fascial, muscular, and articular sy tems. Posi hand, may have a much greater tolerance to exercise. The
tional release therapy removes barriers that restrict normal active program must therefore be matched to the patient's
elasticity and tone of the tissues, thus allowing the patient fitness level: gradual and progressive in the case of the
to tolerate more easily, and benefit from, other aspects of sedenmry person and challenging enough to motivate the
the rehabilitation program. athlete and the physically fit subject.
The body has the ability to adapt to minor stresses but, A person who is flexible, strong, coordinated, and in a
as the number is increased, the body has less room to adapt general state of optimal health is less vulnerable to the
until, a point is reached where the body cannot adapt any development of dysfunction as the result of injuries. Such a
further. These stresses include environmental factors, emo person may, indeed, be less likely to be injured in the first
tiona I stress, and the effects of a sedentary lifestyle (i.e., lack place because of a heightened state of mental alertness and
of physical fitness). a higher level of physical coordination. An individual who
A sedentary lifestyle tends to make a person more vul# is fit has a greater adaptable range in the ability to compen
nerable to injury. Lack of physical activity is associated with sate for the effects of an injury and therefore is more likely
reduced flexibility and strength within the musculoskeletal to recover quickly and has a reduced tendency to have per
system and a deterioration of the posture. It is also associ# sisting dysfunction.
ated with diminished cardiovascular fitness and disturbances Although PRT is a passive therapeutic intervention, it is
in other systems (hormonal balance, glucose regulation, cir possible to incorporate it into the active part of the pro
culation, digestive function, etc.). Restriction of motion gram. Certain PRT treatments can be adapted to be per
and joint fixation result in an uneven distribution of forces fonned by the patient, especially in cases where repetitive
throughout the body during activities such as gait, exercise, trauma (RSI) may be unavoidable in the patient's occupa
lifting, and repetitive movements. This imbalance in forces tion or lifestyle. This aspect of the program can be intro
may result in a reduced ability of the body to sustain duced once the major dysfunctions have been addressed.
injuries, crearing a greater possibility for the development of These exercises may be gradually augmented by progressive
dysfunction. Emotional stress, metabolic disturbances, and mobility exercises and strengthening regimens.
visceral pathophysiology mediated by a facilitated segment,
may also feed into the panern of dysfunction and further , DEVElOPING THE ART AND SCIENCE Of
reduce the adaptability of the individual.
A complete rehabilitation program should include both
POSITIONAL RELEASE THERAPY
srrucCI<raL and functional therapies. The goal of stnlctural A new paradigm is emerging in our understanding of the
therapy is to restore symmetry and freedom of motion to the structure and function of the musculoskeletal system and
body. The goal of functional therapy is to develop strength, how this relates to the etiology and resolution of dysfunc#
balance, and vitality within the tissues and restore optimal tion. The underlying nature of the body tissues, both under
function within the COntext of the individual's occupation normal conditions and as they express dysfunction, reflect
and activities of daily living. Structural therapy is a passive an inherent wisdom and order beyond our inadequate
process, whereas functional rehabilitation, including spe# attempts to force them into our models or belief systems.
New Horizons CHAPTER 8 229

We are beginning to appreciate the dynamic, selfregulating, As with any skill. diligent practice will gradually lead to
and imerdependem nature of all living tissue. This new proficiency. We urge the practitioner to learn the scanning
paradigm represents an acknowledgment of the intrinsic evaluation, which when mastered can be completed in a
wisdom of the body and its inherent. self-healing potential. few minutes. This will reveal the hidden truth behind the
As our understanding of the nature of dysfunction has presenting symptoms. Practicing the treatment positions
evolved, we are adapting our therapies into greater congru and developing good body mechanics take time. The posi
ency with this evolving reality. tive response of your patients will, we hope, motivate your
Several clinicians and researchers have been instnlmental persistence in developing these skills.
in revealing the nature of the human body and directing us to In conclusion, we recommend that this text be lIsed as a
open a dialogue with the tissues in order to access these handy desk reference. The scanning evaluation can be
truths. Instead of forcing the patient's body into compliance, copied and used for each patient. and the tcnder point body
when it resists, we now have several powerful techniques that charts can be copied and laminated for quick reference. The
work in harmony with the natural, self-corrective processes treatment section of the book can be readily referred to by
inherent in the tissues. These methods have been gradually nipping it open to the appropriate page and following the
gaining acceptance in many branches of physical medicine directions for the dominant tender points. We urge you to
because of their effectiveness and non traumatic nature. wear this book out. By the time that occurs, you may find
Positional release therapy has the potential to address that you no longer need to refer to it. For those imerested in
many resistant cases of musculoskeletal dysfunction. The hands-on instruction and the development of advanced
use of the tender points affords it a high degree of diagnostic skills, the authors present seminars internacionally. For infor
accuracy and predictability. Achieving the comfort zone is mation about these programs please contact the authors.
readily discernible by the practitioner and the pmiem, and
attention to the release process will ensure consistent results.
Appendix

Positional Release Therapy Scanning Evaluation 232

Tender Point Body Charts 234

Anatomy/Positional Release Therapy


Cross-Reference 236

Strain/Collnterstrain/positional Release Therapy


Cross-Reference 239

Application of Strain and Counterstrain (or


Positional Release Therapy) to the Neurologic
Patient-Sharon Weiselfish, Ph.D., P.T. 242

The Importance of Soft Tissues for Structural


upport of the Body-Stephen M. Levin, M.D. 244

Osteopathic Positioning Table 250


Positional Release Therapy Scanning Evaluation

Patient's name: Practitioner:

Dates: 2 3 4 5

# Extremely sensitive e, Very sensitive Q. Moderately sensitive o . No tenderness

\ Right I . Left + # Most sensitive 6 # Treatment

I. Cranium (p.45)
I. OM 00000 6. DG 00000 11. NAS 00000 16. AT 00000
2. 0CC 00000 7. MPT 00000 12. SO 00000 17. PT 00000
3. PSB 00000 8. LPT 00000 13. FR 00000 18. TPA 00000
4. LAM 00000 9. MAS 00000 14. SAG 00000 19. TPP 00000
5. SH 00000 10. MAX 00000 15. LSB 00000 00000

II. Anterior. Medial. Lateral Cervical Spine (p. 66)


20. ACI 00000 23. AC4 00000 26. AC7 00000 29. LCI 00000
21. AC2 00000 24. AC5 00000 27. AC8 00000 30. LC -
00000
22. AC3 00000 25. AC6 00000 28. AMC 00000 30. LC - 00000

III. Posterior Cervical Spine (p. 78)


31. PCIF 00000 34. PC3 00000 37. PC6 00000 00000
32. PCIE 00000 35. PC4 00000 38. PC7 00000 00000
33. PC2 00000 36. PCS 00000 39. PC8 00000 00000

IV. AntenorThoracic Spine (p.86)


40. ATI 00000 43. AT4 00000 46. AT7 00000 49. ATIO 00000
41. ATZ 00000 44. ATS 00000 47. AT8 00000 50. ATII 00000
42. AD 00000 45. AT6 00000 48. AT9 00000 51. ATl2 00000

V. Antenor and Medial RJbs (p.9 1)


52. ARI 00000 57. AR6 00000 62. MRJ 00000 67. MR8 00000
53. AR2 00000 58. AR7 00000 63. MR4 00000 68. MR 9 00000
54. AR3 00000 59. AR8 00000 64. MRS 00000 69. MRIO 00000
55. AR4 00000 60. AR9 00000 65. MR6 00000 00000
56. AR5 00000 61. ARlO 00000 66. MR7 00000 00000

VI. Anterior Lumbar Spine (p. 145)


130. ALI 00000 132. AU 00000 134. AL4 00000 00000
131. ABU 00000 133. AU 00000 135. AL5 00000 00000

VII. Anterior PelvIS & Hip (p. 15 I)


136.IL 00000 138. SAR 00000 140. SPB 00000 142. LPB 00000
137. GMI 00000 139. TIL 00000 141. IPB 00000 143. ADD 00000

VIII. Knee (p. 183)


168. PAT 00000 171.LK 00000 174. PES 00000 177. POP 00000
169. PTE 00000 In.MH 00000 175. ACL 00000 00000
170. MK 00000 173. L H 00000 176. PCL 00000 00000

232
IX. Ankle (p. 194)
178. MAN 00000 181.TAL 00000 184. FDL 00000 187.EDL 00000
179. LAN 00000 182.PAN 00000 185. TBA 00000 00000
180. AAN 00000 183.TBP 00000 186. PER 00000 00000

X. Foot (p.205)
188.MCA 00000 194.PNV 00000 200. PCN3 00000 206.PMTl 00000
189. LCA 00000 195.DCNI 00000 201. DMTl 00000 207.PMTZ 00000
190. PCA 00000 196. DCN2 00000 202.DMTZ 00000 208.PMT3 00000
191. DCB 00000 197. DCN3 00000 203. DMT3 00000 209.PMT4 00000
192. PCB 00000 198. PCNI 00000 204. DMT4 00000 210.PMT5 00000
193. DNV 00000 199.PCN2 00000 205.DMT5 00000 00000

Xl. Shoulder (p. I 06)


94. TRA 00000 99. SUB 00000 104. PMI 00000 109. ISS 00000
95. SCL 00000 100. SER 00000 105. LD 00000 110. ISM 00000
96. AAC 00000 101. MHU 00000 106. PAC 00000 I I I. lSI 00000
97. SSL 00000 102. BSH 00000 107. SSM 00000 112. TMA 00000
98. BLH 00000 103. PMA 00000 108. MSC 00000 113. TMl 00000

XII. Elbow (p. 127)


114. LEP 00000 116. RHS 00000 118. MCD 00000 120. MOL 00000
115. MEP 00000 117. RHP 00000 119. LCD 00000 121. LOL 00000

XIII. Wrist & Hand (p. 134)


122. CFT 00000 124. PWR 00000 126. CMI 00000 128. DIN 00000
123. CET 00000 125. DWR 00000 127. PIN 00000 129. IP 00000

XIV. Posterior Thoracic Spine (p.96)


70. PTl 00000 73. PT4 00000 76. PT7 00000 79. PTlO 00000
71. PTZ 00000 74. PT5 00000 77. PT8 00000 80. PTlI 00000
n. PT3 00000 75. PT6 00000 78. PT9 00000 81. PTl2 00000

XV. Posterior Ribs (p. 10 I)


82. PRI 00000 85. PR4 00000 88. PR7 00000 91. PR10 00000
83. PR2 00000 86. PRS 00000 89. PR8 00000 92. PRII 00000
84. PR3 00000 87. PR6 00000 90. PR9 00000 93. PRI2 00000

XV I. Posterior Lumbar Spine (p. I 60)


144. PLl 00000 147. PL4 00000 150. PL31 00000 153.LPL5 00000
145. PL2 00000 148.PL5 00000 151. PL41 00000 00000
146. PL3 00000 149.QL 00000 152. UPL5 00000 00000

XVII. Posterior Pelvis & Hip (p. 167)


154. SSI 00000 156. lSI 00000 158. PRM 00000 160.GME 00000
155.MSI 00000 157. GEM 00000 159.PRL 00000 161. ITB 00000

XVIII. Posterior Sacrum (p. 175)


162. PSI 00000 164. PS3 00000 166. PS5 00000 00000
163. PS2 00000 165.PS4 00000 167.COX 00000 00000

233
N
'"
...
Cranial Points Spine/pelvis/Rib Tender Points ---1
m

e-+- 13.FR
32.PCI-E
Z
o
17.PT


--.
t .I'
15 .LSB

16.AT 2S . A M
21.AC 2
22.AC3
23.A C 4 C 2-6
m
.-n-__f\ '< ' 24.A C 5 :::u
J\ 2S.AC6

t
27ACS
26.AC 7
5.SH \J
=--=::::
S2.PRI

o
29.LCI 70.PTI
4 0.ATI

I
52.ARI 71.PT2
30.LC 41.AT2

:: 0
53.AR2

"t::--
20.ACI 72.PTJ

Z
lL
42ATJ 73.PH
54.AR3

r ---1
Lateral 43.AH 74.P T5
55.AR4

, F :\l
44.AT5 75.PT6

13.FR --t:;--. 45.AT6


cA!n- 56.AR5
76 . P Tl c:P
---lv'r-
o
57.AR6 77 . P TS

iil
12.S0 46.AT7
7S.PT9

o
II.NAS ----1,f-\-l 47.ATS
5S.AR7
79.PTIO

1t''<Q''0{
I O.MAX '-r'e
-<
59.ARS


SO.PT I I
9.MAS - ".",,,',,,..--u
1i0l;r-
60.AR9
4S.AT9
0- ,
'\:.- 61.ARIO SI. PTI2

()
Anterior
49.ATIO PI f.'I1; o I
149.QL
14.SAG 5 0.ATII
( '01":j !WI),
.
S3.-93.

:::u
/\ 5 1.ATI2 162.PSI
130.ALI 150.PL 3- 1

nr
---1
I 32.AL2

<
4LAM
3.PSB
--I33.AL3
IH.AL4 160.GME
154 .sSI
155.MSI
(J)

-{
15S.PRM
2.0 C C
I.OM
, I 35.AL5
159.PRL

:/,
141.IPB
140. SPB 143.ADD
7.MPT 142.LPB
6. D G I 64.PS3
.J> 166.PS5 165 . P S4

Posterior Anterior Posterior


-;
Knee Tender Points Ankle/Foot Tender Points Shoulder Tender Points m
Z
0
m
;IJ
17S.ACl "

106.PAC 0
107.s 5M 94.TRA Z


-;
9S.S Cl
tp
I 7 6PCl 96 . A A
0


104.PMI 0
173.l H I72.M H 109.15 5 -<
102.B SH
Lateral I 13.TMI-
-r- n
I 77.PO P 1I'
----r-r-T 9B.Bl H I
-=::t::t=-:
IIO.l5M
103.P MA
II I.ISI
-;
112.TMA V>

10S.lD 100.sER I
n
IB3.TBP
0
I84.FDl z
--1

Anterior Medial

Posterior Anterior

207 .20B.PM T2.3


Elbow/Wrist/Hand
G:ll "---'\ IBO.AAN
Tender Points

1 6B.PAT
120M
. Ol
IIS . M EP 114.l EP
121.l0l
IIBM
. CD
116.R H S 119.lCD
170M
. K--
206.207.
201.202 . t" t 117.R H P
PMTI.2

.
209.210 DMTI.2
'1" 204.205.
169.P TE PMH.S
DMH.S

19B-2oo.

t-t-r-
IH.P E I 92.PCB S --
PCNI .2.3

y
IBS.TBA

I-t-I-- IB7E
. Dl
I 94.PNV

190P
. C 203 . 204. DMT3.4 A
- -IB6.PE R

IB2.PAN
N
'-'
Posterior Plantar Dorsal Dorsal Palmar
236 ApPENDIX

'ANATOMy/ POSITIONAL RELEASE THERAPY CRoss.REFERENCE


Muscles are listed by name only; other tissues are specified (bone,joint,etc.).

Anatomic Reference Positional Release Therapy Reference Page


Acromioclavicular joint AAC, PAC 108,118
Adductor hallucis PMTl 217
Adductors ADD 158
Anconeus LOL,MOL IJ2
Anterior cruciate ligament ACL 190
Biceps BLH, BSH 110,114
Brachialis LCD,MCD 131
Coccygeus ISI,COX 169,180
Common extensor tendon CET 135
Common flexor [cndon CFT 134
Coracoacromial ligamenr AAC 108
Coron",1 suture FR 57
Cuboid (bone) DCB, PCB 208, 209
Cuneiform (bones) DCN 1-3, PCN 1-3 212,213
Deltoid anterior AAC 108
Deltoid ligament MAN 194
Diaphragm AT7-9 88
Digastric DG 50
Dorsal calcaneocuboid ligament DCB 208
Dorsal cuneounavicular ligament DCN 1-3 212
Dorsal interossei DIN, DMT2,3, DMT4,5 140,215,216
Extensor digitorum longus AAN, EDL
DMT2,3, DMT4,5 196,203,215,216
Extensor hallucis longus AAN,DM T l 196,214
Flexor digiti minimi brevis PMT4,5 219
Flexor digiwrum brevis PCA, DMT2,3, DMT 4,5 207,215,216
Flexor digitorum longus FDL 200
Flexor pollicis brevis CMI 138
Frontal bone FR 57
Frontonasal joint SO 56
Gastrocnemius PAN 198
Gemelli GEM 170
Glenohumeral ligaments MHU 113
Gluteus medius GME,SSI 172, 167
Gluteus minimus GMI,MSI 152, 168
Hamstrings, latcral LH 188
Hamstrings, medial MH 187
Iliacus IL, ALI 151, 145
IIiococcygeus IPB, LPL5 156,165
Iliopsoas AL2-5, LPL5 147,165
Iliotibial band ITB 173
Infraspinatus ISS,ISM,151 121,122,123
Intercostal, external MRJ-IO 94
Intercostal, internal ATI-6, AR3-10 86, 87, 93
Interphalangeal joints IP 141
Interspinalis, cervical PC3-7 81, 2
Interspinalis, lumbar PLI-5 160
Interspinalis, thoracic PTI-12 96
Lambdoid suture LAM,acC 48,46
Lateral collateral ligament LK 186
ApPENDIX 237

Anatomic Reference Positional Release Therapy Reference Page


Lateral pterygoid LPT 52
Latissimus dorsi LD 117
Levator ani PSI-5 175
Levator cestaTum PC8, PRI-12 83,101
LevatOr scapula MSC 120
Longus capitis AC3-5 6
Longus colli AC2-6, AMC 67,74
Lumbricals (foor) PMT2,3 218
Masseter MAS 53
Maxilla (bone) MAX 54
Medial collateral ligament MK 185
Medial pterygoid MPT 51
Metacorpophalangeal joints PIN,DIN 139,140
Metatarsal (bones) DMT,PMT 214,217
Multifidus,cervical PC3-7 81
Multifidus,lumbar P L l -5,PL3,PL4-1,UPL5 160, 162,163,164
Multifidus,thoracic PTI-12 96
Nasal bones NAS,SO 55,56
Navicular (bone) DNV,PNV 210,211
Obliquus capitis superior PCI-E 79
ObruramT extemus LPB 157
Occipital bone OCC,LAM 46,48
Occipimmasroid suture OM 45
Opponens pollicis CMI 138
Palmar interossei PIN 139
Patellar retinaculum PAT 183
Patellar tendon PTE 184
Pectineus LPB 157
Pectoralis major PMA 115
Pectoralis minor PMI 116
Peroneus LAN, PER 195,202
Peroneus tertius DMT4,5 216
Piriformis PRM,PRL 171
Plantar calcaneocuboid ligament PCB 209
Plantar calcaneonavicular ligament PNV 211
Plantar cuneonavicular ligament PCN 213
Popliteus POP 192
Posterior cruciate ligament PCL 191
PronatOr teres RHP 130
Psoas ATIO-12,ABLZ 89,146
Pubococcygeus COX,SPB 180,ISS
Quadratus femoris GEM 170
Quadratus lumborum ATI2, QL, PL3-I, PL4-1, PT IO-12,UPL5,
PRI I ,12 89,161,162,163,99,164,103
Quadratus plantae PCA 207
Quadriceps femoris PAT,PTE 183,184
Rectus capitis anterior ACI,PCI-F 66,78
Rectus capitis lareralis LCI 75
Rectus capitis posterior PC2 80
Rhomboid MSC 120
Rotatores, cervical PC3-7 81
Rotatores,lumbar PLI-5, PL3,PL4-1,UPL5 160,162, 163, 164
Rotatores,thoracic P T I-12 96
Sacroiliac ligaments UPL5,LPL5 164,165
2,8 ApPENDIX

Anatomic Reference Positional Release Therapy Reference Page


Sacrospinolls ligament cox 180
Sacrotuberous ligament COX,ISI 180,169
Sagirtal suture SAG 58
Sartorius SAR 153
Scalenus anterior AC46 69
Scalenus medius LC26, ARI 76,91
Scalenus posterior AR2,PRI 92,101
Serratus anterior SER 112
Soleus PAN 198
Sphenobasilar suture PSB, LSB 47, 59
Sternocleidomastoid AC7 72
Sternothyroid ATI 86
Stylohyoid SH 49
Subclavius SCL 107
Subscapularis SUB I II
Supinator RHS 129
Supraspinatus SSM,SSL 119, 109
Talocalcaneal joint MCA, LCA, PCA 205,206, 207
Talofibular ligament LAN 195
Talonavicular ligament DNV 210
Temporalis MAS, AT, PT 53,60,61
Temporomandibular jOint 00, MPT, LPT, MAS, MAX 50,51,52,53,54
Temporoparietal joint TPA,TPP 62,63
Tensor fascia law TFL 154
Tentorium cerehclli OM 45
Teres major TMA 124
Teres minor TMI 125
Tibialis anterior TAL,TBA 197,201
TIbialis posterior TBP 199
Transversus [horae is MR3IO 94
Trapezius TRA \06
Triceps LOL,MOL 132
Wrist extensors DWR 137
Wrist flexors PWR 136
Zygomatic bone AT,PT 60,61
ApPENDIX 239

, STRAIN/COUNTERSTRAIN/POSITIONAL RELEASE THERAPY CROSS-REFERENCE

Strain/Counterstrain Terminology Positional Release Therapy Terminology Page


Abdominal second lumbar (Ab2L) Abdominal second lumbar (ABL2) 146
Adductors (ADD) Adductors (ADD) 158
Anterior acromioclavicular (AAC) Anterior acromioclavicular (AAC) 108
Anterior cruciate ligament (ACL) Anterior cruciate ligament (ACL) 190
Anterior eighth cervical (A8C) Anterior eighth cervical (AC8) 73
Anterior eighth thoracic (A8T) Anterior eighth thoracic (AT8) 88
Anterior eleventh thoracic (A II T) Anterior eleventh thoracic (ATI I ) 89
Anterior fifth cervical (A5C) Anterior fifth cervical (AC5) 70
Anterior fifth lumbar (A5L) Anterior fifth lumbar (AL5) 149
Anterior fifth thoracic (A5T) Anterior fifth thoracic (AT5) 87
Anterior first cervical (A I ) Anterior first cervical (ACI) 66
Anterior first lumbar (AI L) Anterior first lumbar (AL l ) 145
Anterior first rib (AIR) Anterior first rib (AR I ) 91
Anterior first thoracic (AI T) Anterior first thoracic (ATI) 86
Anterior fourth cervical (A4C) Anterior fourth cervical (AC4) 69
Anterior fourth lumbar (A4L) Anterior fourth lumbar (AL4) 14
Anterior fourth thoracic (A4T) Anterior fourth thoracic (AT4) 87
Anterior lateral trochanter (ALT) Sartorius (SAR)' 153
Anterior medial trochanter (AMT) Gluteus minimus (GMI)' 152
Anterior ninth thoracic (A9T) Anterior ninth thoracic (AT9) 88
Anterior second cervical (A2C) Anterior second cervical (AC2) 67
Anterior second lumbar (A2L) Anterior second lumbar (AL2) 147
Anterior second rib (A2R) Anterior second rib (AR2) 92
Anterior second thoracic (A2T) Anterior second thoracic (AT2) 86
Anterior seventh cervical (A 7C) Anterior seventh cervical (AC7) 72
Anterior seventh thoracic (A7T) Anterior seventh thoracic (AT7) 88
Anterior sixth cervical (A6C) Anterior sixth cervical (AC6) 71
Anterior sixth thoracic (A6T) Anterior sixth thoracic (AT6) 87
Anterior tenth thoracic (A lOT) Anterior tenth thoracic (ATIO) 89
Anterior third cervical (A3C) Anterior third cervical (AC3) 68
Anterior third lumbar (A3L) Anterior third lumbar (AU) 148
Anterior third thoracic (A3T) Anterior third thoracic (AT3) 86
Anterior third to sixth rib Anterolateral third to tenth rib
(A3R-A6R) (AR3-10)' 93
Anterior twelfth thoracic (A12T) Anterior twelfth thoracic (ATI 2) 89
Bursa (BUR) Supraspinatus lateral (SSL)' 109
Coccyx Coccyx (COX) 180
Coronal (C) Sagittal suture (SAG)' 58
Cuboid (CUB) Plantar cuboid (PCB)' 209
Dorsal cuboid (DCU) Dorsal cuboid (DCB)" 208
Dorsal fourth, fifth metatarsal (DM4,5) Dorsal fourth, fifth metatarsal (DMT4,5) 216
Dorsal metatarsal (DM) Dorsal first metatarsal (DMTI)' 214
Dorsal metatarsal (DM) Dorsal second, third metatarsal (DMT2,3) 215
Dorsal wrist (DWR) Dorsal wrist (DWR) IJ7
Elevated first rib Posterior first rib (PRI)' 101
Elevated second to sixth ribs Posterior second to tenth ribs (PR2-10)' 102
Extension ankle (EXA) Posterior ankle (PAN)' 198
Extension carpometacarpal (ECM) Dorsal interossei (DIN)' 140
First carpometacarpal (CMI) First carpometacarpal (CM I) 138
Flexed ankle (FAN) Anterior ankle (AAN)' 196
Flexion calcaneus (FCA) Plantar calcaneus (PCA)' 207
Flexion medial calcaneus (FM Tibialis posterior ( TBP)" 199
240 ApPENDIX

Strain/Countmtrain Terminology Positional Release Therapy Terminology Page


Frontal (F) Frontal (FR)* 57
Frozen Shoulder (F H) Medial humerus (MHU)* 113
Gluteus medius (GM) Gluteus medius (GME)* I7Z
Gluteus minimus (GMI) Tensor fascia lata (TFL)* 154
High flareout 51 (HFO-SI) Inferior sacroiliac (151)* 169
High ilium-sacroiliac (HISI) Superior sacroiliac ( 5 1)* 167
High navicular (H.NAV) Dorsal navicular (DNV)* 210
Iliacus (lL) Iliacus (lL) 151
Infraorbital (10) Maxilla (MAX)* 54
Inguinal ligament (lNG) Lateral pubis (LPB)* 157
Inion Posterior first cervical. flexion (PCI-F)* 78
Interossei (lNT) Palmar interossei (PIN)* 139
Interspace rib (4 Int-6 Int) Medial third to tenth rib (MRJ-IO)* 94
Lambdoid (L) Lambda (LAM)* 48
Lateral (1C) Lateral first cervical (LCI) 75
Lateral ankle (LAN) Lateral ankle (LAN) 195
Lateral ankle (LAN) Peroneus (PER)* 202
Lateral calcaneus (LCA) Lateral calcaneus (LCA) 206
Lateral canthus (LC) Anterior temporalis (AT)* 60
Lateral epicondyle (LEP) Lateral epicondyle (LEP) 127
Lateral hamstring (LH) Lateral hamstring (LH) 18
Lateral/medial coronoid (LCD/MCD) Lateral/medial coronoid (LCD/MCD) 131
Lateral meniscus (LM) Lateral knee (LK)* 186
Lateral olecranon (LOL) Lateral olecranon (LOL) 132
Lateral trochanter (LT) Iliotibial band (lTB)* 173
Latissimus dorsi (LD) Latissimus dorsi (LD) 117
Long head of biceps (LH) Biceps long head (BLH)* 110
Low ilium-flareout (LIFO) Inferior pubis (lPB)* 156
Low ilium-sacroiliac (L1SI) Superior pubis (SPB)* 155
Lower pole fifth lumbar (LP5L) Lower posterior fifth lumbar (LPL5)* 165
LTS2 Infraspinatus superior (1 5 5)* III
Masseter (M) Masseter (MA )* 53
Medial ankle (MAN) Medial ankle (MAN) 194
Medial ankle (MAN) Tibialis anterior (TBA)* ZOI
Medial calcaneus (MCA) Medial calcaneus (M A) 205
Medial coracoid (MC) Pectoralis minor (PMI)* 116
Medial epicondyle (MEP) Medial epicondyle (MEP) 128
Medial hamstring (MH) Medial hamstring (MH) 187
Medial meniscus (MM) Medial knee (MK)* 185
Medial olecranon (MOL) Medial olecranon (MOL) l3Z
Metatarsal Plantar metatarsal (PMTl-5)* 217
Midpole sacroiliac (MPSI) Middle sacroiliac (MSI)* 168
MTS2 Medial scapula (MSC)** 120
Nasal (N) Na al (NAS)* 55
Navicular (NAV) Plantar navicular (PNV)* 211
Occipitomastoid (OM) Occipitomastoid (OM) 45
Patella (PAT) Patella (PAT) 183
Patellar tendon (PTE) Patellar tendon (PTE) 184
Pes anserinus (PES) Pes anserinus (PES) 189
Piriformis (PIR) Piriformis medial (PRM)* 171
Point on spine (POS) Infraspinatus middle (lSM)* 122
Posterior acromioclavicular (PAC) Posterior acromioclavicular (PAC) liB
Posterior auricular (PA) Temporoparietal. post. (TPP)* 63
Posterior cruciate ligament (PCR) Posterior cTuciate ligament (PeL) 191
ApPENDIX 241

Strain/Counterstrain Terminology Positional Release Therapy Terminology Page


Posterior eighth cervical (P8C) Posterior eighth cervical (PC8) 83
Posterior fifth to seventh cervical Posterior fifth to seventh cervical (PC5-7) 82
(P5C, P6C, P7C)
Posterior fi"t cervical (PIC) Posterior first cervical, ext. (PCI-E)* 79
Posterior fi"t, second lumbar (PI-2L) Posterior first to fifth lumbar (PLI-5)** 160
Posterior fi"t, second thoracic (PI-2T) Posterior first, second thoracic (PTI-2) 96
Posterior fourth cervical (P4 ) Posterior fourth cervical (PC4) 82
Posterior fourth lumbar (P4L) Posterior fourth lumbar, iliac (PL4-1)* 163
Posterior medial trochanter (PMT) Gemelli (GEM)* 170
Posterior occipital (PO) Occipital (OCC)* 46
Posterior sacrum I (P I) Posterior sacrum I (PSI) 175
Posterior sacrum 2 (PS2) Posterior sacrum 2 (PS2) 176
Posterior sacrum 3 (PS3) Posterior sacrum 3 (PS3) 177
Posterior sacrum 4 (P 4) Posterior sacrum 4 (PS4) 178
Posterior sacrum 5 (PS5) Posterior sacrum 5 (PS5) 179
Posterior second cervical (P2C) Posterior second cervical (PC2) 80
Posterior sixth to ninth thoracic Posterior sixth to ninth thoracic (PT6-9) 98
(P6-9T)
Posterior tenth to twelfth thoracic Posterior tenth [Q twelfth thoracic
(PIO-I 2T) (PTI 0-12) 99
Posterior third cervical (P3C) Posterior third cervical (PC3) 81
Posterior third lumbar (P3L) Posterior third lumbar, iliac (PL3-I)* 162
Posterior third to fifth thoracic (P3-5T) Posterior third to fifth thoracic (PT3-5) 97
Posterolateral trochanter (PLT) Piriformis lateral (PRL)* 171
Radial head (RAD) Radial head pronator (RHP)* 130
Radial head (RAD) Radial head supinator (RHS)* 129
Short head of biceps (SH) Biceps short head (B SH)* 114
phenobasilar (SB) Posterior sphenobasilar (PSB)* 47
Sphenoid (SP) L"eral sphenobasilar (LSB)* 59
Squamosal (SQ) Temporoparietal, ant. (TPA)* 62
Stylohyoid (SH) Stylohyoid (SH) 49
Subclavius (SUBC) Subclavius (SCL)* 107
Subscapularis (SUB) Subscapularis (SUB) III
Supraorbital (SO) upraorbital (SO) 56
Supraspinatus (SPI) Supraspinatus medial (SSM)* 119
Talus (TAL) Talus (TAL) 197
Teres major (TM) Teres Major (TMA)* 124
Teres minor (TMI) Teres minor (TMI) 125
Tracheal (TR) Anterior medial cervical (AMC)* 74
TS3 Infraspinatus inferior (ISI)* 123
Upper pole fifth lumbar (UP5L) Upper posterior fifth lumbar (UPL5)* 164
Wrist (WRI) Palmar wrist (PWR)* 136
Zygoma (Z) Posterior temporal is (PT)* 61

*Change In tennmoIOb'Y_
242 ApPENDIX

'ApPLICATION OF STRAIN AND COUNTERSTRAIN (OR POSITIONAL RELEASE


THERAPY) TO THE NEUROLOGIC PATIENT
Adapted from Sharon Weiselfish, Ph .D., P.T.

I COMMON STRAIN AND COUNTERSTRAIN OR PRT TECHNIQUES FOR THE


NEUROLOGIC PATIENT
Upper Quadrant
The muscles of the upper quadrant. which, when treated with strain and CQunrcrsrrain [Cch
niques, (or PRT) most efficiently affect spasticity, are as follows:

SCS Terminology PRT Terminology Page

Anterior cervicals AC 65-74

Lateral cervicals (scalenes) LC 75,76

Anterior first thoracic ATI 86

Elevated first rib PRI 101

Second depressed rib AR2 92

Pectoralis minor PMI 116

Subscapularis SUB III

Latissimus dorsi (subluxed hemiplegic shoulder) LD 117

Third depressed rib AR3 93

Biceps BLH, BSH 110,114

Lower Quadrant
The muscles of the lower quadrant, which, when tceated with strain and coumerstrain tech
niques, (or PRT) most efficiently affect spasticity. are as follows:

SCS Terminology PRT Terminology Page

Sacral tender points PSI-PS5 COX 175-180

Quadratus lumborum QL 161

Iliacus IL 151

Piriformis PRM,PRL 171

Adductor ADD 158

Medial hamstrings MH 187

Quadriceps PAT 183

Gastrocnemius (extended ankle) PAN 198

Medial ankle MAN 194

Flexed calcaneus PCA 207

Medial calcaneus MCA 205

Talus TAL 197


ApPENDIX 243

I I PATHOKINESIOLOGIC MODEl
EXAMPLES
I. I f the patient has a protracted shoulder girdle and there is a limitation in hori
zontal abduction, it is assumed that the pectoralis minor is hypertonic with short'
ened and contracted muscle fibers. The technique of a second depressed rib would
be utilized to decrease the gamma gain of the pectoralis minor.
2. I f the patient has an anteriorly displaced humeral head with an internally rotated
shoulder joint and limitation in external rotation, the technique for subscapularis
would be utilized.
3. If the patient has a limitation in shoulder abduction and a depressed humeral he," or
a caudal subluxation/dislocation of the glenohumeral joint, the techniques for the
latissimus dorsi and the third depressed rib would be utilized.
4. If the patient has an elevated shoulder girdle and there is a limitation 10 cervIcal
side bending to the opposite side, the lateral cervical techniques would be utili zed,
to decrease the gamma gain for the medial scalenes, which elevate the first rib.
5. If the proximal head of the first rib is elevated, rib excursion with respiration is inhlb,
ired. and lower cervical range of motion-especially rotation-is limited, the tech,
nique for an elevated first rib {PRO can be utilized.
6. I f the patient has a flexed elbow joint and a limitation in elbow extension, the
technique for the biceps can be utilized.
7. If the patient has a pronated forearm and a limitation of forearm supination, the
pomts for the medial epicondyle can be utilized. Often the proximal radial head is
displaced anterior, as a compensatory movement. The technIque for the rodial head
(RHS, RHP) can be utilized.
8. If the patient has an elevated pelvic girdle with a limitation of lumbar side bending
to the opposite side, the technique for the quadratus lumborum (the anterior
twelfth thoracic tender point) can be utilized.
9. If the patient has a hip flexion tightness or contracture with a limitation of hip exten#
sion, the technique for the iliacus can be utilized.
10. If the patient has an adducted and internally rotated hip and there is a limitation
of external rotation of the hip, the technique for the adductor can be utilized.
II. If the patient has a flexion synergic pattern of spasticity at the knee and there IS a
limitation of knee extension, the point for the medial hamstrmgs can be utilized.
12. If the patient has an extensor synergic pattern of spasticity at the knee with a Iimlta#
tion of flexion, the technique for the quadriceps (patella extenso,,) can be utilIZed.
13. If the patient has an equinus posture with a plantar flexed foot and a limitation in
dorsiflexion, the technique for the medial gastrocnemius (PAN) can be utilized.
14. If the patient has an equinovarus foot posture with a limitation in eversion. the
technique for the medial ankle and medial calcaneus can be utilized.
IS. If the patient has a clubfoot with an internal rotated and dropped talus, the tech
nique for [he talus can be utilized.
244 ApPENDIX

'THE I MPORTANCE OF SOFT TISSUES FOR STRUCTURAL


SUPPORT OF THE BODY
Stephen M. Levin, M.D.
Most of us view the skeleton as rhe frame upon which the soft tissues are draped. The POS[
from the Potomac Back
Center andbeam construction of a skyscraper is the favored model for the spinel! and is used for all
Vienna, Vlrglnlil biologic structures-the upright spine is regarded as the highest biomechanical achievement.
Reprint requests to: The soft tissues are regarded as stabilizing "guy wires," similar to the curtain walls of steel
Stephen M. leYln. M.D. framed buildings (Fig. I).
Director
PotoC Back Center Skyscrapers are immobile, rigidly hinged, high-energy--consuming, vertically oriented
1 S77 Springh ill ROild
structures that depend on gravity to hold them together. The mechanical properties are New
Vienna. VA 22182
tonian, Hookian, and Iinear.4.S A skyscraper's flagpole or any weight that cantilevers off the
building creates a bending moment in the column that produces instability. The building
must be rigid to withstand even the weight of a flag blowing in the wind. The heavier or far;
ther Out the cantilever, the stronger and more rigid the column must be (Fig. 2). A rigid
column requires a heavy base to support the incumbent load. The weight of the structure pro;
duces internal shear forces that are destabilizing and require energy just to keep the structure
intact (Fig. 3).

A B FIG. I (left). Adult thoracolumbar ligamcmous


spine, fixed m the base and {ree at top, under tier;
tica/loading, and restramed (It midthoracic and
midlumbarleels in the antero/X)sterior plane. A,
before loading. 8, during loading. C, stability
failure occuring under a load of 2.04 kg. 0, /ateral
view showing amerolX)sterior reSlrainr.s. (From Morris
0.9 Meters JM. Mukolk Kl: Biomechanics of the lumbar spine. In Amer
iean Academy of Orthopaedic Surgeons: Adu of Orthotics:
Blomechanical Principl es and Application. St. louis, Mosby,
1975: with permission.)

0.9 Meters

11

[J
FIG. 2 (Above, left).
[J
Befuiing stresses in a beam. (From Gallleo: Discord e dlmonstnzioni matematiche lI'ltomo
due nuove sdenze. leiden. 1638.)
a

FIG, 3 (Above, right). \Vhen simple coml}Tessitle load is apt>lied, bofh coml}Tessive wui shear smsses 1fI1L'if
cxist on t>/anes that are oriemed obliquely fO fhe line of application to fhe load..

SPINE: State of the Art Reviews-Vol. 9. No. 2 May 1995


.

Phil adel phia. Hilnley & 8elfus. Inc.


ApPENDIX 245

FIG. 4. A log of 200 kg Iocaced 40 em from the ful


crum requires a muscle reacrion farce of 8 x 200 =

kg. The erectores spinae group can generate a farce of


abow 200-400 kg, whc i h
FIG. 5. Bird Skeleton. (Courtesy of Califomia Aademy
du! force Utal is necessary. There/ore, muscle power of Sciences, San Francisco.)
alone cannm. lift such a load, and another Slt/>(>OTting
member is reqtlircd. (Courtesy of Serge Gr.tcovetsky, PhD.)

+
1 FIG. 7. Loading a squlIre and a triangular (lnUS)
frame.
"" .......... ," "" "'"

FIG. 6. Balancing comtJTe5siw loads.

Biologic structures are mobile, flexibly hinged, lowenergy-consuming, omnidirectional


structures that can function in a gravityfree environment. The mechanical properties arc non
Newtonian, non-Hookian, and nonlinear. S If a human skeletal system functions as a lever,
reaching ou[ a hand or casting a fly at the end of a rod is impossible. The calculated forces with
such acts break bone, rip muscle, and deplete energy (Fig. 4). A post-and-beam
cannot be lIsed to model the neck of a flamingo,the tail of a monkey, the wing of a bat,or
rhe spine of a snake (Fig. 5). Because invertebrates do nOt have bones,there is no satisfactory
model to adequately explain the structural intergrity of a worm. Postand;beam modeling in
biologic Structures could only apply in a perfectly balanced,rigidly hinged,upright spine (Fig. 6).
Mobility is out of the equation. The forces needed to keep a column whose center of gravity
is constantly changing and whose base is rapidly moving horizontally are overwhelming to
contemplate. If we add that the column is composed of many rigid bodies that are hinged
together by flexible,almost frictionless joints, the forces are incalculable.2 The complex can;
tilevered beams of horizontal spines of quadrupeds and cervical spines in any vertebrate
require tall,rigid masts for support1 that are not usually available.
Since postand;beam construction has limited use in biologic modeling, other structural
models must be explored to determine if a marc widely applicable construct can be found.
Thompsonli and,later,Gordon" use a truss system similar ro those used in bridges for modeling
the quadruped spine. Trusses have clear advantages over the postand;lintel construction of
skyscrapers as a structural support system for biologic tissue. Trusses have flexible,even fric
tionless hinges with no bending moments about the joint. The support elements are either in
tension or compression only. Loads applied at any point are distributed about the truss as ten;
sian or compression (Fig. 7). In post-and-beam construction, the load is locally loaded and
246 ApPENDIX

A
B

c D

FIG. 8. A, tetrahedron, B, ocwhedron, (, icosahedron,


and D, (ensionvectored icosahedron tuirh compression ele
menrs wi!hin Ute tension shell.

creates leverage. There are no levers in a truss, and the load is distributed throughout the
structure. A truss is fully triangulated, inherently stable, and cannot be bem without pro
dueing large deformations of individual members. Since only trusses are inherently stable
with freely moving hinges,it follows that any stable structure with freely moving hinges must
be a truss. Vertebrates with flexible joints must therefore be constructed as tfusses.
When the tension elements of a truss 8rc wires or ropes, the truss usually becomes uni#
diredtional (see Fig. 7); the element that is under tension will be under compression when
turned topsy[Urvy. The tension elementS of the body (the soft tissues-fascia, muscles,liga;
ments,and connective tissue) have largely been ignored as construction members of rhe body
frame and have been viewed only as the motors. In loading a truss the elements rhat are in
tension can be replaced by flexible materials such as ropes,wires, or in biologic systems,liga
ments, muscles, and fascia. Therefore, the tension clements are an imegral part of rhe con
struction and not just a secondary support. However, ropes and soft tissue can only function
as tension elements, and most trusses constructed with tension members will only function
when oriented in one direction. They could not function as mobile, omnidirectional struc;
rures necessary for biologic functions. There is a class of trusses called censegrityJ structures
that are omnidirectional so that the tension elements always function in tension regardless of
the direction of applied force. A wire bicycle wheel is a familiar example of a tensegrity struc
ture. The compression elements in tensegrity structures "float" in a tension network JUSt as
the hub of a wire wheel is suspended in a tension network of spokes.
To conceive of an evolutionary system construction of tensegrity trusses that can be used
to model biologic organisms, we must find a tensegriry truss that can be linked in a hierar
chical construction. It must start at the smallest subcellular component and must have the
potential, like the beehive, to build itself. The structure would be an integrated tensegrity
truss that evolved from infinitely smaller trusses that could be, like the beehive cell, both
structurally independent and interdependent at the same time. This repetion of forms,like in
a hologram, helps in visualizing the evolutionary progression of complex forms from simple
ones. This holographic concept seems to apply to the truss model as well.
Architect Buckminster FullerJ and sculptor Kenneth Snelsonu described the truss that fits
these requirements,the tensegrity icosahedron. In this structure,the outer shell is under tcn
sian, and the vertices are held apart by internal compression !istrutS" that seem to float in the
tension network (Fig. 8).
The tensegrity icosahedron is a naturally occurring, fully triangulated, three-dimensional
truss. It is an omnidirectional, gravity-independent, flexibly hinged structure whose mechan
ical behavior is nonlinear, non-Newtonian, and non-Hookian. Independently, Fuller and
ApPENDIX 247

FIG. 9. The icosahedral slTUcture of a virus .

FIG. 1 0. Indefinieely extensive array of tensegriry icosahedra. (From


Fuller RB: Synergetics. New York. Macmillan. 1975: with permission.)

Snelson use this truss [0 build complex structures. Fuller's familiar geodesic dome is an
example, and Snelson 12 has used it for artistic sculptures that can be seen around the world.
Ingber7.16 and colleagues use the icosahedron for modeling cell construction. Research is
underway [Q use this structure in more complex tissue modeling, 16 Naturally occurring exam#
pies that have already been recognized as icosahedra arc the selfgenera[ing fullerenes
(carbon 0 organic molecules),S viruses,17 clemrins,' cells, IS radiolari3,6 pollen grains, dandelion
6
balls. blowfish. and several other biologic structures (Fig. 9).
Icosahedra are stable even with frictionless hinges and, at the same time, can easily be
altered in shape or stiffness merely by shortening or lengthening one or several tension ele
ments. Icosahedra can be linked in an infinite variety of sizes or shapes in a modular or hierar
chical pattern with the tension elemems (the muscles, ligaments, and fascia) forming a con
tinuous interconnecting network and with the compression elements {the bones} suspended
within that network (Fig. to). The structure would always maintain the characteristics of a
single icosahedron. A shaft, such as a spine, may be built that is omnidirectional and can fune..
rion equally well in tension or compression with the intemal stresses always distributed in
tension or compression. Because there are no bending moments within a tensegrity structure,
they have the lowest energy COSts.
248 ApPENDIX

f'iiCt ___ shoulder

/
humerus

ulna
\

/'
elbow
r
radius

Fig. I I . lco.ro arm.

FIG. 1 2. E#C column. (Courtesy of Kenneth Snelson.)

Viewed as a model for the spine of human:, or nny vertehrate :-,pecics, the tl'llsion Icoahe#
lIron space truss (Fig. II) with the hones acting ilS rhe compressive tdcmcnr and the soft ris
MIl'S as the tenSIOn elements will be swble in <lny position, even With muluple Joint.... They
can be vertical or horizontal ami assume any posture from ramrod slraight [() a !oiigmllid curve
(Fig. 12). Shortening one soft tissue element has a Tlpplmg effect throughout rhe structure.
Movement IS crc<.Ucu and a new, Instantly stahle shape IS achicvcu. It IS highly mohile, (lmrll
directional, and consumes low energy. TenSIOn icosahedrons arc unique S[fUelures who!'.c con
MTtlctS, when used a a hiologlc model, would conform t() the nawral law!'. of Icast energy, law"!
of mechanic!<!, and the distinct characteristics llf hioll)glc tISUCS. The icosahedron space trus
is present in biologic struc[Ure at the cellular, subcellular, and multicellular Icvcl.... Recent
research on the molecular structures of organisms such as Vlfuses, subcellular org.mel lcs, md
whole orgarHsms has shown them to be Icosahedra. The very hudding block o( lXlIlC, hydroxy
apatite, is an icosahedron. In the spine, each subsystem ( vertebrae, dbks, sort tissues) would
be suhsystems of the spme metasystem. Each would function as ;.In Icosahedron IIldepcndcntly
and as part of the larger system, as in the beehive analogy.
The icosahedron space tru spmc model is a universal, illl:xiuhu, hicmrdHcal ystCill that
has the widest application with the least energy cost. As the simplest <lnd least cnergy-cnn
suming system, It becomes the metasystem to which a l l other systems and suhsystem!'. must he
judged and, if they are not simpler, more adaptable, and less energy con!'.Ullllllg, rejected.
Smce this system always works With thc least energy requirement'l, there would he no benefit
to nature for spines to function sometimes as a post, sometimes as a hearn, sometimes a"i a tnl"iS,
or to function thfferenrly for dif(erenr species, conformmg to the minimal IIwcnrory-m..lx#
imum diverSity concept of Pearce10 and evolutionary theory.
The Icosahedron space truss model could be extended to lI'lCorpOT'cltc other ilnatOlniC and
physiologic systems. For example, as a "pump" the icoaheJron functions rem<lTkahly like Glr#
diac and respiratory models, and, so, may he im even more fund<llncmal mer<1sy!'.tem for hio#
logic modeling. As suggested by Kroto,S the icosahedron template is "mysterious, uhll.luitolls.
anJ all powerful."
ApPENDIX 249

References
1. de Dlive C: A Guided Tour of the LIving Cell. Vol. 1. New York, Sciemific Books. 1984.
2. Fieldmg Wj. Burstem AH, Fr::mkel VH: The nuchal ligament. Spme 1:314, 1976.
J. Fuller, RB: Syncrgcllcs. New York, Macmillan, 1975.
4. Gordon. JE: Structures or Why Things Don't Fall Down. New York, Dc C'lpa Press, 1978.
5. Gordon, JE: The Science of Structures and Marcri;lls. New York. Scientific American library, 1988.
6. Hacckel E: Report on the scientific result:. of the voyage of [he H.M.S. Challenger. Vol 18. pt XL. Radio
lana, Edinburgh, 1887.
7. Ingber DE, Jamieson J : Cells as rcnsegriry Sfructures. Architectural regulation of hisrodiffercmiation by phys
ical (orces transduced over basement membrane. In Andersonn LL, Gahmberg eG. Kblom PE (cds): Gene
Expression Dunng Normal and Malignant Differentiation. New York, Academic Press, 1985, pp 1 330.
8. Ktoto H: Space, smfS, C6Cl, and soot. Science 242: 1 1 391 145, 1988.
9. levin SM: The icosahedron as {he three-dimensional finite clement in bio-mechanical support. Procccdmg
of the Society of General S's(ems Research Symposium on Mental Images, Values and Reality, Philadelphia,
1986. St. Louis, Society of General Systems Research. 1986, pp G 14-G26.
10. Pearce PL: Structure in Nature as a Strategy for DeSign. C1mbridgc. MA, MIT Press, 1978.
I I. Schultz AB: Biomechanics of the spine. In Nelson L (ed): Low Back Pain and Industrial and Social Disable
ment. London, American Back Pain Association, 1983, pp 20-25.
12. Schult! DO, Fox HN: Kenneth Snelson, Albnght-Knox Art Gallery (catalogue), Buffalo. 1 98 1 .
13. Snelson KD: Continuous tension, dlscontmuous compression structures. U.S. Patent 3 , 1 69,6 1 1 . Washington.
OC, U.S. Patem Office, 1965.
14. Thompson D: On Growth and Fonn. Cambridge, Cambridge UmvcrsllY Press, 1961.
15. Wnng N, Butler JP. Ingber DE: Microtranuction across the cell surface and through the cytoskeleton. Sci
ence 260, 1 1 2 4- 1 1 27. 1993.
16. Wendling S: Personal communication. L1boratory of Physical Mcchalllcs, Faculty of Science and
Technology, Paris.
17. Wildy P, Home RW: Srructure of animal Virus particles. Prog Med Virol 5: 1 -42, 1963.
250 ApPENDIX

, OSTEOPATHIC POSITIONING TABLE


Designed by Dr. George Roth and built by Hill Laboratories Co.

This table was specifically designed to reduce practitioner strain and facilitate the practice of PRT. It is available through
Hill Laboratories' in Frazer Pennsylvania. A few of the features and possible applications are listed below.

Multi#scctional Motorized thoracic elevation to 85 Leg section flexes to 75


Mocorized elevation 22" to 3Sn

. iI
\
'
- ./
-_
- ..
- -

Head piece adjustable through 135' Removeable pelvic section Wide "'nge of possible positions

Anterior/posterior cervical Rib treatment Posterior thoracic

Posterior lumbar Anterior lumbar/thoracic lliacu


-- --------
'
[;II LabornlOdes Co., 3 Bacton H;II Rd., F""e<. Penn., 1 9355 , (6 1 0) 644-2867.
G lossary
active myofascial trigger point: A focus of hyperirri searching for the position of greatest comfort in order to
tability in a muscle or its fascia. An active trigger point is normalize inappropriate proprioreceptive activity.
always tender, prevents full lengthening of the muscle, cranial technique: A descriptor suggested by W. G.
weakens the muscle. usually refers pain on direct com Sutherland. D.O.. that refers to management and care
pression, mediates a local response of muscle fibers when (therapy) using manipulative skills applied to the cranio
adequately stimulated, and often produces specific sacral mechanism. This form of treatment purports to
referred autonomic phenomena. generally in its pain create shifts in circulation and pressure dynamics of the
reference zone. cerebrospinal fluid and change or normalize pathophysio
acute somatic dysfunction: Immediate or short-term logic reflexes. structure. and body mechanics.
impairment or altered function of related components craniosacral therapy: John Upledger developed
of the somatic (body framework) system. Characterized craniosacral therapy. which integrates both the osseous
in early stages by vasodilation, edema, tenderness, pain, and membranous (i.e .. meningeal) environment of the
and contraction. central nervous system (I.e., brain and spinal cord). The
adaptation: The process of attaining homeostasis with cranial bones are used as handles to influence the
respect to changing internal or external circumstances. meninges and restore fleXibility to the dural tube and its
Adaptation uses the capability of the organism to operate related structures.
efficiently under altered conditions. craniosacral mechanism: A term used by W.G. Suther
anatomic barrier: The limit of motion imposed by land, D.O., to describe the synchronous movement of the
anatomic structure. sacral base with the cranial base. This synchrony is accom
articular strain: The result of forces acting on a joint plished by the attachment of the dural tube to the
beyond its capacity to adapt. Refers to stretching of joint foramen magnum and sacral canal, probably aided by cere
components beyond physiologic limits, causing damage. brospinal fluid fluctuation.
barrier (motion barrier): limit of unimpeded motion. direct technique: Engagement of the restrictive barrier
biomechanics: The application of mechanical laws to carrying the lesioned component toward or through the
living structures. The study and knowledge of biologic barrier. Thrust, articulatory, and muscle energy are exam
function from an application of mechanical principles. ples of direct techniques.
chiropractic: The science of treating human ailments by dysfunction: A state of continuing. though not neces
manipulation and adjustment of the spine and other struc sarily static, impaired function of a part of the body. Usu
tures of the human body. The uses of such other mechan ally involves many local and distant anatomic structures
ical, physiotherapeutic, dietetic, hygienic, and sanitary mea (muscle. fascia. ligaments. viscera. vascular components).
sure. except drugs and major surgery, as are incident to facilitated segment: The altered physiologic state of
the care of the human body. the neural spinal segment such that it has a lowered
chronic somatic dysfunction: Long-standing impair threshold to stimulation, being hyperirritable to any
ment or altered function of related components of the stimulation and causing abnormal function in parts it
somatic (body framework) system. Characterized by ten normally affects.
derness. itching. fibrosis. paresthesias. and contracture. facilitation: (I) An increase in afferent stimuli such that
comfort zone: The optimal position of ease. It is a posi the synaptic threshold is more easily reached; thus there is
tion where there is no tenderness and the tissues are increase in the efficacy of subsequent impulses in that
completely released. Also called a position of comfort pathway or synapse. The consequence of increased efficacy
compensation: Counterbalancing or making up for a is that continued stimulation produces hyperactive
defect in structure or function in the body. It may employ responses. (2) A clinical concept used by osteopathic
mechanisms that meet the definition of adaptation. but it physicians to describe neurophysiologic mechanisms that
more likely implies adjustment at the expense of efficiency create or are created by somatic dysfunction. Most often
and with greater likelihood of fatigue and wear and tear. used to describe enhancement or reinforcement of neuronal
Both functional and anatomic breakdown are more likely activity caused by increased or abnormal afferent input to a
to occur in a compensated situation segment or segments. Increased activity is often triggered
counterstrain technique: An indirect technique devel or enhanced by adrenergiC and sympathetic stimulation.
oped by Lawrence Jones, D.O.The operator moves the fine-tuning: Small increments in movement adjustments
patient or part passively away from the motion barrier (I.e., flexion, extension, rotation, lateral flexion. compres
toward and into the planes of increased motion. always sion. or distraction).

251
252 GLOSSARY

flat palpation: Examination by finger pressure that pro intentional or higher reflex muscle contraction orders, but
ceeds across the muscle fibers at a right angle to their also have senSitivity, or "gain control," which allows them
length while compressing them against a firm underlying to adapt to new load or new intentional signals from
structure, such as bone, Used to detect taut bands and higher centers.
trigger points. myofascial release: A whole body, hands-on approach
f10werspray endings: Muscle spindle sensory end for the evaluation and treatment of the fascial system. A
organs. three-dimensional soft tissue technique that addresses
gamma efferent: Autonomic nervous system fibers car tension in the connective tissue system and can be either
rying signals from the pyramidal centers, causing alter direct or indirect.
ations of sensitivity and length in the action of muscles via myotatic reflex arc: Stretch reflex of the muscle.
special organs called muscle spindles, osteopathy (osteopathic medicine): A system of
golgi endings: Sensory organs found in tendons of mus health care founded by Andrew Taylor Still ( 1 82B- 1 9 1 7).
cles. Act as muscle stretch overload protectors via the Based on the theory that the body is capable of making its
spinal reflexes. own remedies against disease and other toxic conditions
homeostasis: ( I ) Maintenance of static or constant when it is in normal structureal relationship and has favor
conditions in the internal environment. (2) The level of able environmental conditions and adequate nutrition.
well-being of an individual maintained by internal physio Uses generally accepted physical, pharmacologic, and sur
logic harmony. Result of a relatively stable state or equi gical methods of diagnosis and therapy; places strong
librium among the interdependent body functions. emphasis on the importance of body mechanics and
indirect technique: Any manual technique in which manipulative methods to detect and correct faulty struc
the treating force is directed away from the motion ture and function. Structure governs function: disturbances
restriction. Sutherland. functional, counterstrain, and posi of structure. in whatever tissue within the body. lead to
tional release therapy are examples of indirect techniques. disturbances of function in that structure. and in turn of
inhibition, reflex: ( I ) In osteopathic usage, a term that the function of the body as a whole. Supports the body's
describes the application of steady pressure to soft tissues inherent abilities to maintain homeostasis and to establish
to effect relaxation and normalize reflex activity. (2) Effect a protective response to disease or injury.
on antagonist muscles due to reciprocal innervation when osteopathic lesion (osteopathic lesion complex): A
the agonist is stimulated. disturbance in musculoskeletal structure or function, as well
joint hypermobility: Signifies increased joint movement. as associated disturbances of other biologic mechanisms.
joint hypomobility: Signifies joint stiffness or relative pain analog scale: Scale used to assist patients
restriction of motion. with determining level of pain (0 = no pain; 1 0 =
jump sign: A general pain response of the patient extremely painful).
(wincing, crying out, or withdrawal of a body part) in pathologic barrier: A functional limit within the
response to pressure applied on a trigger point. anatomic range of motion, which abnormally diminishes
latent myofascial trigger point: A focus of hyperirri the normal physiologic range. May be associated with
tability in muscle or its fascia that is clinically quiescent with somatic dysfunction.
respect to spontaneous pain. Painful only when palpated. physical (manual) therapy: Usually part of a multidisci
manipulation: Therapeutic application of manual force. plinary approach using a variety of maneuvers and manual
Also known as a therapeutic movement usually of a small techniques in conjunction with conventional physical
amplitude; accomplished at the end of the available range therapy modalities. Directed at restoring normal function
of motion but within the anatomic range, at a speed over and arthrokinematics of the somatic system.
which the client has no controL physiologic barrier: Functional limits within the
mobilization: Therapeutic movement of variable ampli anatomic range of motion. Soft tissue tension accumula
tude accomplished within the available range of motion at tion, which limits the voluntary motion of an articulation.
a speed over which the client has control. Further motion toward the anatomic barrier can still be
muscle energy technique: A direct technique devel induced passively.
oped by Dr. Fred Mitchell, Sr., D.O., used to treat joint physiologic motion: Normal changes in the position of
hypomobility. This technique involves passively positioning articulating surfaces taking place within a jOint or region.
the patient using muscle barriers in a precisely controlled positional release therapy: A passive and indirect
position. Once in this position, a gentle isometric contrac technique that places the patient's body, utilizing all three
tion in a specific direction against a specific resistance is planes of movement. into a position of greatest comfort.
required. This results in increased mobility of the pelvis, While in this position of comfort. there is a reduction and
spine, ribs, and peripheral joints. arrest of inappropriate proprioceptive activity and a
muscle spindles: The special neuromuscular organs release of fascial tension. This results in decreased hyper
scattered through the mass of muscle fibers that act not tonicity, relaxation, and elongation of involved muscle
only as a feedback sensor to allow spinal reflexes to adjust fibers. Decreases myofascial tension and helps restore
GLOSSARY 253

joint mobility. The result is increased functional mobility related vascular, lymphatic. and neural elements. The posi
and flexibility and decreased pain. tional and motion aspects of somatic dysfunction may be
position of comfort: The optimal position of ease. A described using three parameters: the position of the
position where there is no tenderness and the tissues are element as determined by palpation, the direction in
completely released. Also called the comfort zone. which motion is freer, and the direction in which motion
proprioception: The sensing of motion and where the is restricted.
body is positioned in space. spasm: An involuntary sudden movement or convulsive
proprioceptor: Sensory nerve terminals that give infor muscle contraction. Spasms may be clonic (characterized by
mation concerning movements and position of the body alternate contraction and relaxation) or tonic (sustained).
or posture.They occur chiefly in the muscles, tendons, spasticity: Increased tone or contractions of muscles
joints. and the labyrinth and provide information with causing stiff and awkward movement. The result of an
regard to changes in equilibrium and the knowledge of upper motor neuron lesion.
position. weight. and resistance of objects in relation to spindle afferent (fibers): Pick up information from the
the body. muscle spindle through annulospiral endings and flower
protective muscle spasm guarding: The muscle is in spray endings about the length and contraction of the
a state of contraction. incapable of allowing full resting spindle (and therefore the skeletal muscle fibers). which
length due to an inability to relax and elongate. Muscle will allows spinal reflex adjustment of muscle tasks desired by
resist passive elongation or stretch. higher intentional or reflex centers in the brain.
reality check: A positional movement or specific joint. strain: An overexertion trauma to a portion of the con
fascial. or muscle evaluation or a pain scale that is objec tractile musculotendinous unit or its attachment to the
tive and can be measured. It reproduces the patient's pain bone (tendinoperiosteal junction). Force that deforms a
or complaint. Used as a reference point to measure the body part or changes its dimension.
success of treatment. stress: Any force that tends to distort a body. It may be
reciprocal innervation: The inhibition of antagonist in the direction of either pulling apart or pressing
muscles when the agonist is stimulated. together. Thus skeletal structures (bones. ligaments. and
referred pain: Pain that is perceived at some distance muscles) may be subject to stress or may transmit a stress.
from the location of the cause. stretching: Separation of the origin and insertion of a
release phenomena: A normalization or softening of muscle or attachment of fascia or ligaments by applying
the tissue. During this process the patient may experience constant pressure at a right angle to the fibers of the
some or all of the following: pain. paresthesia. pulsations. muscle or fascia.
Vibrations, heat. perspiration, change in breathing or heart tender point: A tender edematous region located deep
rate. and eye motor activity. in muscle, tendons, ligaments, fascia, and bone. It can mea
restriction: A resistance or impediment to movement. sure I cm across or less, with most acute points being
segment: A portion of a larger body or structure set off about ] mm in diameter.
by natural or arbitrarily established boundaries. Often trigger point (myofascial trigger point): A small
equated with spinal segment. ( I ) A portion of the spinal hypersensitive site that when stimulated consistently pro
cord contained between two imaginary sections, one on duces a reflex mechanism that gives rise to referred pain or
each side of a nerve pair. (2) A portion of the spinal cord other manifestations. The response is specific. in a constant
to which a pair of spinal nerves is attached by dorsal and reference zone. and consistent from person to person.
ventral roots. Also used to describe a single vertebra. visceral manipulation: A soft tissue technique devel
namely, a vertebral segment. oped by lean Pierre Barral. D.O. Involves locating and
somatic dysfunction: Impaired or altered function of treating areas of fascial tension in the chest. abdomen,
related components of the somatic (body framework) and pelvic cavities to improve functional mobility and
system: skeletal, arthrodial. and myofascial structures and visceral function.
Index

A B landmarks (or, 64
lateral lender l'<lIllts 0(, 64, 65,
Acromioclavicular render points Back; see aLso Cervical spine; Lumbar 75-76
anterior, 105, 1 08 spine; Thoracic spine first, 65, 75
posterior, 105, I 1 8 pain, 1 43 ; see also Pain second through sixth, 65, 76
Acupuncture poims, 2 , 3 ; see also Ah Biceps long head tender point, 105, posterior rendcr points of, 64, 77;83
Shi points; Tender points; 1 10 eighth, 77, 83
Trigger poims Biceps shorr head tender point, /05, first, 77-79
Adductors tender point, 1 50, 158 1 14 fourth through sevcnth, 77, 82
Adhesive (ibrogenesis, 9 Bioenergetic exercises, I , 2; see also second, 77, 80
Ah Shi points, 2, 9; see also Exercises third, 77, 8 1
Acupuncture points; Tender Birth injuries Chapman's reflexc, 4
points; Trigger points treating, 4 3 Coccyx tender poinl, 174, 180
Ampulce patients Body charrs, 234-235 Comfort zone, 10, 29- 30, 32
treating. 24 Body positioning, i ;2j see also Po:>i, palpation of, 2 2 1
Anatomic crossrcferencc chart, tion of Comfort; Posture; Yoga Common cxtcn:.or tcndon tender
2 36-238 postures point, 1 3 3 , /35
Ankle Bone [issue, 8, 9 Common flexor tendon tender point,
dysfunction 0(, 1 8 1 133, 1 34
tender points 0(, 1 93-203 Core swhdi:auon, I
anterior, 193, 1 96 c CoronniJ tcnder points
extensor Jigirorum longus, 193, iareral/medial, 1 26 , 1 3 1
203 Calcaneus tender points COllntcrstrtlin, I
flexor digitorum longus, 193, 200 lateral, 204, 206 history of, 4;5; see also Strain/coun;
lateral, 1 93 , 195 medial, 204, 205 ter:,train
medial, 193, 194 plantar, 204 , 207 Cranium
peroneus, 193, 202 Carpomeracarpal tender point dysfunction of, 4 3
posterior, 193, 198 first, 1 33 , 1 38 tender poinrs 0(, 4 3 , 44-63
ralus, 1 93 , 197 Central nervous system digastric, 44, 50
tibialis, anterior, 1 93 , 20 I faciliated segments in, 1 3 , 1 3- 1 4 (mnt"l, 44, 57
tibialis, posterior, 193, 199 Cervical spine lambda, 44, 48
Annulospiral endings, I I , I I , 1 2 anterior tender points of, 64, masseter, 44 , 53
Arachidonic acid, 1 2 65-76 maxilla, 44, 54
Arm; see Elbow; Hand/wriSl; Shoulder eighth, 65, 73 nasal, 44, 55
Assistive devices, 2 2 3 , 250 fifth, 65, 70 occipital, 44, 46
Asymmetry first, 65, 66 OCCipitomastoid. 44, 45
postural, 40 (ourth, 65, 69 pterygoid, lateral, 44, 52
medial, 65, 74 pterygoid, medial, 44, 5 1
second, 65, 67 sagittal suture, 44, 58
seventh, 65, 72 sphenobasilar, laleral, 44, 59
Note: Page numbers in italics imlicarc sixth, 65, 71 sphenubasilar, posterior, 44, 47
illustrations; page numbers fol lowed third, 65, 68 stylohyoid, 44, 49
by Ht" indicate tables. dysfunction of, 64 slJpraorbi,"I, 44, 56

255
256 INDEX

tcmrorah,anterior, 44. 60 epIcondyle, medial, 1 26 , 1 28 cunciform,plantar, first through


tcmrorall, posterior, 44. 6 1 olecranon, lateral/medIal, 126, th"d, 204 , 2 1 3
temporoparietal anterior,44, 62 132 mC{atarsab, dorsal, first through
temporoparietal r()(erior. 44, 63 raJial head pronator, 1 26 , 1 30 fifth, 204, 2 1 4-2 1 6
Cn)S..reference charts raJlal hea" supinator, 1 26 , 1 29 metatarsals,plantar, firt through
for anatomy and positional release EpIcondyle tender POints ftfth, 204, 2 1 72 19
therapy, 236-238 lateral, 1 26 , 1 27 navicular, JONal, 204, 2 1 0
for stmm/countcrstr;'llll and pOSI meJial, 1 26, 1 28 navicular, plantar, 204 , 2 1 1
tional release therapy, Ergonomics,223-224 Frontal tender pOint,44, 57
239-241 Evaluation Functional diagnosis, Ji see also
Cruciarc ligament tender pmnts of lower body DiagnOSIs
anten"" 182, 190 form for, 142 Functional techniC, 3
pO>len"" 182, 1 9 1 scanning, 5, 35-38,232-233
CubniJ render points of lIpper body
dorsal,204 , 208 fom) for, 41 G
plantar, 204, 209 Exercises; see also Bioenergetic exer#
Cumul.ulvc trauma lhsordcr. 224; see cies Gamma bias, II
also Repetitive stram Injury at home, 225 Gamma effercnt neurons, I I
Cuneiform tender pOints role of, 228 Gemellt tenJer POlnl, 166, 1 70
Jor"'ll Extensor lJigitorum longus tender Gcriatric patients
first through third,204, 2 1 2 POint, 1 93 , 203 treatmg, 23
plantar Extensor tendon tender point, Global dysfunction,27; see also Mus
firS[ lhrough t1md,204, 2 1 3 common, 1 3 3 , 135 culoskelctal dysfunction;
Cupules,2 Extrafusal fibers, I I , I I Somauc dys(ucnllon; specific
anatomic areas
Global treatment,
D F vs. local treatmem,27, 27
Glossary, 251-25 3
Devices Facilitated segments, 1 3 , 11-14 Glutcus medlu tender [XHnt, 166,
,"Slstive,22 1, 250 Fascial matrix, effect of trauma on,8 172
Diagnosis; see also Scannmg Fascial system,8,9 Gluteus ml1llmU tem.ler [XHnt, 150,
evaluation Jysfunctlon of,14-15 1 5 2 , 168,
funcuonal. 3 tension of; see Facial ttnion Goigi tcndon organs, I I
protocol for, 40 Fascial teruion, 9
Digastric tender point. 44, 50 normalization of,20
Direct [cchni4ue. 2; see also Indirect patterns of,14, 1 5 H
technique Feldenkrais, I
Dominant tender POInt,27. 40; see Fibrogenesl Hamstring render POlllts
abo Tender pOlllt:-. aJheive,9 lateral, 182, 188
III '\C,mnmg evaluation, 3637 Fingers; see Ham.l/wrist medIal, 182, 187
Dynamic neutral position, 3 Flexor JigltOrum longus tender pOint, Hand/WrISt
DynamIC recIprocal balance, 3 193, 200 dysfunction of, 104
DY(lInction; see also Mlisculokeletal Flexor tendon tender POint tender pOints of, 104, 133- 1 4 1
JY(lInction; Somatic Jysfunc common, 1 3 3 , 134 carpometacarpal,first, 1 3 3 , 138
lion; specific anatomic areas Flower spray endings, II, I I common flexor tendon, 133 I

global,27 Foot 134


dysfunction of, 1 8 1 common extensor tendon,
tender points of, 1 8 1 , 204-2 1 9 1 3 3 , 135
E calcaneus, lateral, 204, 206 mterocolls, dorsal, 1 3 5 , 140
calcaneus,medial,204, 205 interosseous, palmar, 1 3 3 , 139
Elhow calcaneus, plantar, 204, 207 Interphalangeal JOInts, 1 33 ,
dyfunction of,104 cuboiJ, dorsal, 204, 208 141
tender pOints of, 104, 126-132 cubOId,plantar, 204, 209 WrI,t, dorsal, 1 3 3 , 1 3 7
coronOId, lateral/medial, 1 26 , 1 3 1 cuneiform, dorsal, fin:.t through WrISt, palmar, 1 3 3 , 136
epIcondyle, lateral, 1 26, 1 27 tlmJ, 204, 2 1 2 Head; see Cranium
INDEX 257

Highgain servomechanism, I I J dy,function of, 1 43


Hip/pelvis poterior tender points 0(, 1 4 3 ,
anterior tender points oC 1 4 3 , Joints; see also s/Jecific anatomic areas 1 5 9- 1 65
150-158 hypomobility of, 20 first through fifth, 159, 160
adductors, 150, 158 Jones neuromuscular model, I I , 1 2 , 1 2 fourth-iliac, 159, 163
iliacus, ISO, 1 5 1 Jump sign, 28, 36 lower fifth, 159, 165
gluteus minimus, ISO, third-iliac, 159, 1 62
152 upper fifth, 1 5 9 , 1 64
pubis, inferior, ISO, 156 K
pubis, lateral, ISO, 157
pubis, superior, ISO, 155 Kinectic chain theory, 8, 1 4 M
sartorius, ISO, 153 Knee
tensor fascia lata, 150, 154 dysfunction of, 1 8 1 Masseter tender point, 44, 53
dysfunction of, 1 4 3 [ender points of, 1 8 1 , 182-192 Maxilla tender point, 44, 54
posterior tender points of, 1 4 3 , cruciate ligament. amerior, Mechanoreceptors. 1 0
1 66-173 182, 190 Metatarsal tender points
gemelli, 1 66 , 1 70 cruciate I igament, posterior, dorsal, 204, 2 1 4- 2 1 6
gluteus medius, 1 66 , 1 72 182, 1 9 1 first, 204, 2 1 4
iliotibial band, 166, 1 73 hamstring, medial, 182, 187 fourth and fifth, 204 , 2 1 6
piriformis, lateral/medial, 166, hamstring, lateral, 182, 188 second and third, 204, 2 1 5
171 lateral, 182, 186 plantar, 204, 2 1 7- 2 1 9
sacroiliac, inferior, 1 66, 1 69 medial, 182, 185 fifth, 204, 2 1 9
sacroiliac, middle, 1 66 , 1 68 patella, 182, 183 first, 204, 2 1 7
sacroliac, superior, 1 66 , 1 67 patellar tendon, 182, 184 second and third, 204 , 2 1 8
Humerus tender pain[ pes anserinus, 182, 189 Mobiliry; see Hypomobility; Range
medial, lOS, 1 1 3 popliteus, 182, 192 o(l1lotion assessment
Hypomobility Muscle spasm
joint, 20 normalization of, 20
L protective, 1 9
Muscle spindles, I I , 1 I
L,mbda tender point, 44, 48 Muscular system, 8-9
Lmissimus dorsi tender point, 105, Musculoskeletal dysfunction, 7,
I l iacus tender point, ISO, 1 5 1 1 17 8- 1 0, 2 3 ; see also Global
I l iotibial band tender point, 1 66, Legs; see Ankle; Knee dysfunction; Soma[ic dys
1 73 Lesion; see Facilitated segments; function
The Importance of Sof' Tissues for Injury Myofascial Pain and Dysfunc,ion, 2
Stnlctural Suppor, of ,he Body, limbs; see Lower limb; Upper limb Myofascial pain syndrome. 9; see also
244-249 Lower body Pain
Indirect technique, I , 2-4 evaluation form for, 1 42 Myofascial skeletal truSS, 1 4- 1 5
Inflammation treatment of, 2 3 ; see also s/:>ecific Myofa!lcial [issue, 1 0
due to injury, 9-10, 1 2 anatomic areas
in somatic dysfunction, 8 Lower limb
Infraspinatus tender poinrs dysfunction of, 1 8 1 N
inferior, lOS, 1 23 tender points of, 2 3 , 1 8 1 , 182-
middle, lOS, 1 22 2 1 9; see also specific anatomic Nasal [ender point , 44, 55
superior, 105 , I 2 1 areas Navicular tender points
Injury Lumbar spine dorsal, 204, 2 1 0
mOtor vehicle, 2 3 anterior tender points of, 1 43 , plantar, 204, 2 1 1
tissue, 8- 10, 1 2 144-149 Neck; see Cervical spine
Interosseous tender points abdominal second, 144, 146 Neurologic pa[ients
dorsal, 1 33 , 140 fifth, 1 44 , 149 treating, 24, 242
palmar, 1 33 , 139 first, 144, 1 45 Neurolymphatic points, 9; see also
I nterphalangeal joints second, 144, 1 47 Acupuncture points; Ah Shi
tender points of, 133, 1 4 1 third, 2 2 3 points; Tender points; Trigger
Intrafusal fibers, I I , 1 1 third and fourth, 144, 1 4 8 poin[s
258 INDEX

Neurovascular poin[. 9; see also Popliteus tender point, 1 8 2 , 192 Q


Acupuncture points; Ah Shi Position of comfort, 1 0
points; Tender points; Trigger optimal, 30 Quadratus lumborum tender point,
points during treatment, 40; see aLm spe, 159, 1 6 1
NocicepmTs, 1 0 cific anatomic areas
i n somatic dysfunction, 1 2 1 3 for fascial dysfunction, 1 5
Nonlinear process length of treatment in, 1 2 , 30J I R
of positional release therapy, 8 Position of treatment; see Position of
comfort; Treatment procedures Radial head pronator tender point,
Positional release therapy, I , 20 1 26, 130
o activity level following, 2 2 5 Radial head supinator tender point,
advances in, 5 1 26, 1 29
Ohesity case srudies in, 3738 Range,oflllQ(ion assessment, 40
considerations in treatment, 2 2 3 comfort zone in, 2930, 30 Reality checks, 222
Occipital tender point, 44, 46 contra indications for, 2021 Reflex points, 39; see also Tender
Occipitomastoid tender point. 4445 crossreference charts for, 236241 poims
Olecranon tender points diagnosis protocol for, 40 Repetitive strain injuries, 2 1 ; see also
lateral/medial, 1 26 , 1 3 2 effects of, 10 1 5 , 20, 3 1 Cumulative trauma disorder
O'teopathic positioning table, 250 ergonomics in, 223224 Respiratory patients
Osteoporosis evaluation forms for, 4 1 42, 1 42 treating, 24
treatment 0(, 23 as global treatment, 27, 27 Rib cage
homebased, 2 2 5 dysfunction of, 84
indications for, 1 0 1 5, 2224, anterior tender points of. 90,
p 224 9 1 93
origins of, 1 5 first, 90, 9 1
Plin other modalities with, 2 2 1 222 second, 90, 92
arising during treatment, 2 2 5 pain arising during, 225 third through tenth, 90, 93
back, 1 4 3 patienr relationship in, 222 medial tender points of, 90, 94
effects of therapy on, 20 posttreatment reaction to, 3 1 , third through tenth, 90, 94
myofascial origins 0(, 8, 9, 1 2 2 2 2 2 2 3 , 225 posterior tender points of, 1 00103
posttreatmCrH, 225 scanning evaluation in, 3538 eleventh and twelfth, 100, 103
Patella tentler points, 182, 183 forms for, 232233 first, 100, / 0 1
Patellar tendon tentler points, 182, tender poims in; see Tender points second through tenth, 100, 102
184 treatment Ruffini receptors, 1 0 1 1
Pathokinesiologic determination phases of, 2 1 22
for treatment, 243 plan, 3 1 3 3, 3738, 40
Patients principles of, 29 s
amputee, 24 procedures, 3940; see also specific
communication widl, 222 anatomic areas Sacroiliac tender points
geriatric, 2 3 Positioning table, 250 inferior, 1 66 , 169
in mOtor vehicle accidcms, 2 3 Posnrearment, soreness, 222223, middle, 166, 168
neurologic, 242 225 superior, 1 66 , 167
obese, 223 Postural asymmetry, 40 Sacrulll
pediatric. 23 Posture, I ; see also Body positioning; posterior tender points of, 1 4 3 ,
respiratory, 24 Yoga postures 1 74180
with sports inj uries, 2 324 somatic dysfunction and, 8 coccyx, 174, 180
Pectoralis major tender point, /05, I 15 Proprioceptors, 1 0 1 2 fifth, 1 74 , 179
Pecroralis minor tender point, 105, 1 1 6 Protective muscle spasm, 1 9 first, 1 74 , 1 75
Pediatric patients PRT; see Positional release therapy fourth, 1 74 , 1 78
neating, 2 3 Pterygoid tender points second, 1 74 , 1 76
Pelvis; see Hip/pelvis lateral, 44, 52 third, 1 74, 1 77
Peroneus <ender point, 193 , 202 medial, 44 , 5 1 Sagittal suture tender point, 44, 58
Pes anserinus tender point, 182, 189 Pubis tender points SartOrius render points, 150, 153
Piriformis tender points inferior, 150, 156 Scanning evaluation, 3538
medial, 1 66, 1 7 1 lateral, 150, 157 form for, 232233
lateral, 166, 1 7 1 superior, 150, 155 procedure for, 5
INDEX 259

Scapula tender point Subscapularis tender point, 1 05 , seventh through ninth, 85,
medial, 105, 1 20 III 88
erratus anterior tender point, 1 05 , Supraorbital tender point, 44, 56 tenth through twelfth, 85, 89
1 12 Supraspinatus tender poilUS dysfunction of, 84
Servomechanism lateral, lOS, 109 posterior tender points of, 84,
high-gain, I I medial, 105, 1 1 9 95-99
Shoulder first and second, 95, 96
tender points of, 105-125 sixth through ninth, 95, 98
acromioclavicular, anterior, 1 05 , T tenth through twelfth, 95 , 99
108 third through fifth, 95, 97
acromioclavicular, posterior, 105, Tables, osteopathic positioning, 250 Thumb; see Hand/wrist
1 18 Talus tender point, 193, 1 97 Tibialis
biceps long head, 105, I 1 0 Temporalis tender points anterior tender point, 1 9 3 , 201
biceps short head, 1 05 , I 1 4 anterior, 44, 60 posterior tender point, 1 93 , 1 99
humerus, medial, 1 05 , 1 1 3 posterior, 44, 6 1 Tissue
infraspinatus inferior, 105, 1 23 Temporoparietal tender points injury to, 8 - 1 0, 1 2 , 2 3
infraspinatus middle, 1 05 , 1 22 anterior, 44, 62 myofascial, 1 0
infraspinatus superior, 105, 1 2 1 posterior, 44, 63 soft, 224, 244-248
latissimus dorsi, 105, 1 1 7 Tender points, I , 28, 40; see also types of, 8-9
pectoralis major, 1 05 , 1 1 5 Acupuncture points; Ah Shi Trapezius tender POilU, 1 05 ,
pectoralis minor, 105, 1 1 6 points; Reflex points; Trigger 106
scapula, medial, 1 05 , 1 20 points Trauma
serratus amerior, J 05, 1 1 2 body charts for, 234-235; see also musculoskeletal, 8- 10, 1 2
subclavius, 105, 107 specific anawmic areas of motor vehicle accident
subscapularis, 105, I I I conflicting, 2 2 3 cases
supraspinatus lateral, 1 05 , 109 dominant, 27, 40 treating, 2 3
supraspinatus medial, /OS, 1 1 9 grading system for, 28, 28 Treatmentj see Positional release
teres major, 105, 124 history of, 2 thcrapy, treatment; specific
teres minor, 105, 1 25 location of, 28; see also specific anatomic areas
trapezius, 105, 106 anaromic areas Trigger points, 2, 9i see also Acupunc
Soft tissue in musculoskeletal dysfunction, ture poimsi Ah Shi points;
treating, 224 9- 1 0 Tender points
for structural support, 244-249 palpating, 28
Somatic dysfunction, 78; sec also position of treatment for; see
Global dysfunction; Muscu under specific anatOmic u
loskeletal dysfunction areas
muscle spindles and, 1 1 - 1 2 in scanning evaluation, Upper body
treating, 229 36-37 evaluation form for, 4 1
Smai, I shutting off, 222-223 treatment of, 22-23; lee also specific
Sphenobasilar tender point Tensegrity anatomic areas
lateral, 44, 59 in lower limb dysfunction, 1 8 1 Upper limb
Spine; see Cervical spine; Lumbar model, 8, 1 4- 1 5, 228, 246-248, dysfunction of, 104
spine; Thoracic spine 247 tender points of, 22-23, 104,
Sports injuries Tension 1 05 - 1 4 1 ; see also specific
treating, 23-24 fascial; see Fascial tension anatomic areas
Sternocleidomastoid muscle, 23 icosohedron, 1 4- 1 5
Slmin and Cowllersrrain, 5 Tensor fascia lata tender point, 150,
Strain/coulUerstrain; see also Counter 154 w
strain Teres major tender point, 1 05 , 1 24
terminology crossreference chart Teres minor tender point, /OS, 1 25 Wrist; see Hand/wrist
for, 239-241 Thoracic spine
for treating neurologic patients, anterior tender points of, 84,
242 85- 9 y
Stylohyoid tender point, 44 , 49 first through third, 85, 86
Subclavius tender point, 1 05 , 107 fourth through sixth, 85, 87 Yoga postures, I , 1