HEMME APPROACH TO SOFT-TISSUE THERAPY
HEMME APPROACH TO SOFT-TISSUE THERAPY
HEMME APPROACH TO SOFT-TISSUE THERAPY
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<strong>HEMME</strong> <strong>APPROACH</strong><br />
<strong>TO</strong><br />
<strong>SOFT</strong>-<strong>TISSUE</strong><br />
<strong>THERAPY</strong>
ii<br />
INSTRUCTIONS FOR THE ANSWER SHEET<br />
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<strong>THERAPY</strong> COURSE, the first 12-hour course in the <strong>HEMME</strong> <strong>APPROACH</strong> series.<br />
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thank you again for taking the course.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
iii<br />
<strong>HEMME</strong> <strong>APPROACH</strong> <strong>SOFT</strong>-<strong>TISSUE</strong> ANSWER SHEET<br />
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<strong>HEMME</strong> <strong>APPROACH</strong><br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
iv<br />
<strong>HEMME</strong> <strong>APPROACH</strong> <strong>TO</strong> <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong><br />
EVALUATION FORM<br />
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<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
v<br />
<strong>HEMME</strong> Approach to<br />
Soft-Tissue Therapy<br />
Copyright, David H. Leflet, 1992<br />
Revised 2005<br />
All rights reserved<br />
Published by <strong>HEMME</strong> <strong>APPROACH</strong> PUBLICATIONS<br />
3334 Spring Valley Lane<br />
Bonifay, FL 32425<br />
Office: 850-547-9320<br />
Toll-Free Number: 888-547-9594<br />
Our web site is www.hemmeapproach.com<br />
The author grants permission to photocopy limited portions of<br />
this manual for personal use. Beyond this consent, no portion<br />
of this manual may be copied or reproduced in any form<br />
without written permission from the author.<br />
Although the author has made every effort to ensure the accuracy of<br />
the information herein, science is progressive and theories change<br />
with time. Practitioners are advised to consult appropriate<br />
information sources if they have any questions concerning the<br />
information or principles presented in this manual.<br />
It is also the responsibility of the practitioner to determine the<br />
appropriateness of any principle or technique in terms of personal<br />
competency and scope of practice. Written medical opinions are the<br />
best way to resolve any questions concerning conditions that indicate<br />
or contraindicate soft-tissue therapy, and written legal opinions are the<br />
best way to resolve any questions concerning the law.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
vi<br />
PREFACE<br />
This manual is a "why and how-to book" that teaches the powerful and<br />
productive principles behind soft-tissue therapy and how to apply them. These<br />
principles are taken from physical medicine, osteopathy, chiropractic, and<br />
physical therapy, and then uniquely applied to soft-tissue therapy. No other<br />
book has ever compiled, organized, or summarized the principles of soft-tissue<br />
therapy the way they appear in this manual.<br />
By learning the principles behind trigger point therapy, neuromuscular<br />
therapy, connective tissue therapy, range-of-motion stretching, and exercise,<br />
practitioners will be able to provide patients with the best care possible. The<br />
principles in this step-by-step manual are simple to use, yet more powerful in<br />
some cases than either medication or surgery. Practitioners will learn how to<br />
help patients who have never been able to find help before and give them a<br />
chance to live normal, productive lives.<br />
This manual is organized around the acronym <strong>HEMME</strong>. This acronym<br />
completely summarizes the five major steps in soft-tissue therapy:<br />
• History: medical history.<br />
• Evaluation: physical evaluation.<br />
• Modalities: thermotherapy, cryotherapy, and vibration.<br />
• Manipulation: trigger point therapy, neuromuscular therapy,<br />
connective tissue therapy, and range-of-motion stretching.<br />
• Exercise: therapeutic exercise.<br />
The <strong>HEMME</strong> <strong>APPROACH</strong> is a problem-solving approach. History and<br />
Evaluation define the problem that Modalities, Manipulation, and Exercise<br />
solve. Understanding the <strong>HEMME</strong> <strong>APPROACH</strong> is the first major step toward<br />
mastering the art and science of soft-tissue therapy.<br />
The five main goals of soft-tissue therapy are (1) reduce pain, (2) increase<br />
or maintain a pain-free range of motion, (3) increase or maintain strength, (4)<br />
improve the quality of movement, and (5) restore normal function. The<br />
<strong>HEMME</strong> <strong>APPROACH</strong> was designed specifically to achieve these goals and do it<br />
effectively without hours of memorizing useless information or years of<br />
pointless study. The power behind the <strong>HEMME</strong> <strong>APPROACH</strong> is getting to the<br />
point and keeping it simple.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
vii<br />
TABLE OF CONTENTS<br />
Section<br />
Page<br />
INTRODUCTION ........................................................................................ 1<br />
PAIN CYCLES .......................................................................................... 4<br />
CHAPTER SUMMARY................................................................................. 13<br />
<strong>HEMME</strong> <strong>APPROACH</strong>............................................................................... 15<br />
<strong>HEMME</strong>GON.............................................................................................. 18<br />
CHAPTER SUMMARY................................................................................. 19<br />
HIS<strong>TO</strong>RY .................................................................................................... 20<br />
CHAPTER SUMMARY................................................................................. 25<br />
EVALUATION ........................................................................................... 26<br />
MUSCLE TESTING...................................................................................... 29<br />
CONTRAINDICATIONS ............................................................................... 38<br />
PAIN ......................................................................................................... 41<br />
CHAPTER SUMMARY................................................................................. 47<br />
ALTERNATIVES...................................................................................... 49<br />
CHAPTER SUMMARY................................................................................. 52<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
viii<br />
Section<br />
Page<br />
MODALITIES ............................................................................................ 53<br />
CONTRAST APPLICATIONS ........................................................................ 53<br />
THERMO<strong>THERAPY</strong>..................................................................................... 54<br />
CRYO<strong>THERAPY</strong> ........................................................................................ 56<br />
HEAT VS. COLD ........................................................................................ 59<br />
VIBRATION ............................................................................................... 60<br />
CHAPTER SUMMARY................................................................................. 61<br />
MANIPULATION ...................................................................................... 63<br />
THE PRINCIPLES OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong> ............................................... 63<br />
HIGH-VELOCITY MANIPULATIONS............................................................. 65<br />
DYNAMICS OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong>....................................................... 68<br />
METHODS OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong> ........................................................ 74<br />
TRIGGER POINT <strong>THERAPY</strong>............................................................................... 75<br />
TRIGGER POINT VS. CROSS-FIBER FRICTION .............................................. 83<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
ix<br />
Section<br />
Page<br />
NEUROMUSCULAR <strong>THERAPY</strong>........................................................................... 84<br />
INHIBI<strong>TO</strong>RS .......................................................................................... 90<br />
FACILITA<strong>TO</strong>RS...................................................................................... 97<br />
SUMMARY.......................................................................................... 100<br />
CONNECTIVE <strong>TISSUE</strong> <strong>THERAPY</strong>..................................................................... 101<br />
SUPERFICIAL <strong>TO</strong>RQUE............................................................................. 106<br />
SKIN ROLLING ........................................................................................ 106<br />
CROSS-FIBER FRICTION........................................................................... 107<br />
PARALLEL OR PERPENDICULAR STRETCHING .......................................... 107<br />
LYMPHATIC DRAINAGE........................................................................... 108<br />
STRETCHING ................................................................................................ 109<br />
MODALITIES AND STRETCHING ............................................................... 114<br />
TRIGGER POINTS AND STRETCHING......................................................... 115<br />
NEUROMUSCULAR AND STRETCHING...................................................... 116<br />
CONNECTIVE <strong>TISSUE</strong> AND STRETCHING................................................... 116<br />
BALLISTIC STRETCHING.......................................................................... 117<br />
INDIRECT TECHNIQUES ........................................................................... 118<br />
PROGRESSIVE MOVEMENT ...................................................................... 118<br />
CHAPTER SUMMARY............................................................................... 119<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
x<br />
Section<br />
Page<br />
EXERCISE ................................................................................................ 124<br />
THE OVERLOAD PRINCIPLE ..................................................................... 126<br />
THE INTENSITY PRINCIPLE ...................................................................... 128<br />
THE FREQUENCY AND DURATION PRINCIPLE........................................... 130<br />
THE SPECIFICITY PRINCIPLE.................................................................... 130<br />
THE TRAINING PRINCIPLE ....................................................................... 131<br />
CHAPTER SUMMARY............................................................................... 132<br />
OBJECTIVES SATISFIED OR NOT SATISFIED.............................. 133<br />
BIBLIOGRAPHY..................................................................................... 135<br />
GLOSSARY............................................................................................... 149<br />
QUIZ .......................................................................................................... 162<br />
INDEX....................................................................................................... 172<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
1<br />
INTRODUCTION<br />
Soft-tissue therapy is the manipulation of soft or superficial tissue for<br />
therapeutic purposes. According to most medical dictionaries, manipulation<br />
refers to any skillful and dexterous treatment involving the hands. Unlike<br />
chiropractic adjustments that are typically high-velocity, high-impact thrusting<br />
movements, the manipulations in soft-tissue therapy are low-velocity pushing<br />
or pulling movements.<br />
Since chiropractic physicians theorize that skeletal malpositions are<br />
corrected by forcefully moving bones "into place that are out of place,"<br />
chiropractic adjustments are directed at the osseous tissues. Skeletal<br />
malpositions are also called subluxations. According to chiropractic theory,<br />
subluxations cause pressure on nerves or nerve roots that interferes with<br />
sensory or motor input. Chiropractors use high-velocity, high-impact<br />
manipulations to correct subluxations.<br />
Soft-tissue therapy postulates that alignment can be corrected by<br />
normalizing the soft-tissue components of the body that cause distortion.<br />
Manipulations in soft-tissue therapy are directed at muscles, fascia, tendons, or<br />
ligaments to relieve pain and correct myofascial dysfunction. Instead of<br />
dealing with bones out of place, soft-tissue therapy treats the causes of<br />
malposition such as spasm, contracture, trigger points, and weakness.<br />
Soft-tissue therapy can be done with or without electrical or mechanical<br />
devices. Thermotherapy, cryotherapy, and chemical preparations are optional.<br />
Like manipulations, modalities produce a combination of physical,<br />
physiological, and psychological effects. Modalities are most effective when<br />
used just prior to manipulation to control edema, reduce pain, relax spasm, or<br />
increase tissue extensibility. Since the effects of modalities without<br />
manipulation are seldom long-term, modalities are used to supplement, but not<br />
supplant, manipulation.<br />
The problems treated by soft-tissue therapy are called soft-tissue<br />
impairments. Soft-tissue impairments are similar to what osteopathic<br />
physicians call lesions or somatic dysfunctions. By definition, soft-tissue<br />
impairments are pathologic conditions that originate or manifest in soft tissue<br />
and prevent normal or customary function or usage of the body. These<br />
impairments are characterized by (1) pain, (2) limited range of motion, and (3)<br />
weakness and often cause incoordination and poor-quality movement.<br />
Soft-tissue impairments can result from many causes: trauma, disease,<br />
postural defects, muscular imbalance, abnormal movements, and overuse<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
injuries. Factors that contribute to soft-tissue impairments are fatigue,<br />
psychological stress, environmental factors, and somatic or visceral reflexes.<br />
Some impairments develop without apparent cause (idiopathic conditions),<br />
while others are caused by inappropriate treatment (iatrogenic disorders).<br />
Most soft-tissue impairments are caused by trauma and the most common<br />
sequel is tissue damage, spasm, edema, pain, and ultimately myofibrosis.<br />
The onset of soft-tissue impairments can be rapid or insidious. An<br />
example of rapid onset is trauma where the causes for impairment are easy to<br />
identify and sudden. Insidious onset implies the symptoms are few and the<br />
causes for impairment are gradual and subtle. An example of insidious onset<br />
is neck and shoulder pain caused by incorrect posture.<br />
The two most common complaints in soft-tissue therapy are pain and loss<br />
of movement. Characteristic signs of soft-tissue impairment are decreased<br />
range of movement (hypomobility), increased muscle tone (hypertonia),<br />
adhesions, contractures, edema, and trigger points. Signs of sympathetic<br />
hyperactivity such as perspiration, pilomotor responses, and changes in skin<br />
color or temperature are common in acute cases, and complaints of general<br />
weakness (asthenia), rapid fatigue, and depression are common in chronic<br />
cases. Symptoms reported by the patient are normally less reliable as<br />
indicators of a soft-tissue impairment than signs witnessed by the examiner.<br />
Various medical terms describe conditions with characteristics similar to<br />
those found in soft-tissue impairments.<br />
• Fibrositis: inflammation of fibrous tissue.<br />
• Myositis: inflammation of voluntary muscles.<br />
• Fibromyositis: inflammation of fibromuscular tissue.<br />
• Myofibrositis: inflammation of the perimysium.<br />
• Perimyositis: inflammation of connective tissue around a muscle.<br />
• Fascitis: inflammation of fascia.<br />
• Myofibrosis: replacement of muscle tissue by fibrous tissue.<br />
• Muscle rheumatism: muscular conditions characterized by pain,<br />
tenderness, local spasm, stiffness, myalgia, and myofibrosis.<br />
2<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
These conditions point out three characteristics common to most softtissue<br />
impairments: (1) inflammation of soft tissue, (2) replacement of<br />
muscle tissue by fibrous tissue, and (3) pain. These three factors contribute<br />
to a self-perpetuating sequence called a pain cycle.<br />
During the initial stage of an injury (acute stage, one to three days), trauma<br />
is followed by inflammation, edema, impaired circulation, spasm, ischemia,<br />
hypoxic damage, and pain. The effects of hypoxic damage are similar to those<br />
precipitated by the injury that caused stage one.<br />
By stage two (sub-acute stage, three to seven days), the victim's range of<br />
motion is limited by pain, muscle guarding, and splinting. In stage three (early<br />
chronic stage, seven days to six weeks), if limitations on range of motion<br />
continue, movements become even more restricted as proliferation of<br />
connective tissue produces scar tissue, adhesions, or contractures. During stage<br />
four (late chronic stage, longer than six weeks), small movements are<br />
sometimes enough to irritate or rupture restricted tissues and reproduce the<br />
physiologic changes characteristic of stage one. Entrapment neuropathies and<br />
myofascial trigger points develop in stage four.<br />
By stage four, disuse atrophy may or may not be present, depending on the<br />
extent of disability. Even if present, atrophy can be difficult to identify if<br />
losses in muscle mass are offset by fluid accumulation. When this occurs, the<br />
circumference of an injured part may be smaller after treatment than before<br />
treatment if therapy dissipates collected fluids to other body parts.<br />
With the advent of modern science came two different types of medicine:<br />
emergency and rehabilitation medicine. Emergency medicine seeks to<br />
preserve life and rehabilitation medicine seeks to improve the quality of life<br />
after survival. The purpose of therapy is to support the parts of the wound<br />
healing that are beneficial and to limit the parts that cause disability.<br />
Whereas acute pain can be useful because it warns the body of actual or<br />
potential tissue damage, chronic pain can be disabling. Without therapy, acute<br />
pain can generate self-perpetuating pain cycles that may continue for years.<br />
Once pain becomes chronic, the initial causes are difficult to identify or treat.<br />
Painkillers, anti-inflammatories, and muscle relaxants are rarely efficacious,<br />
and surgery without definitive laboratory evidence is more likely to aggravate<br />
than correct the problem. Unlike conservative, noninvasive forms of<br />
treatment, surgery traumatizes the body and precipitates scar tissue.<br />
3<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
4<br />
PAIN CYCLES<br />
Seven reasons why pain cycles are difficult to treat:<br />
1. The mechanisms that cause pain cycles are difficult to locate.<br />
2. Pain cycles are both chronic and acute at the same time.<br />
3. Muscular imbalance perpetuates pain cycles.<br />
4. Reflexogenic activity perpetuates pain cycles.<br />
5. Setbacks and reversals are common when treating pain cycles.<br />
6. The methods for treating soft-tissue injuries are often deficient.<br />
7. More research is needed to validate methods of therapy.<br />
The mechanisms that cause pain cycles are difficult to locate.<br />
(A) The areas where patients feel pain are rarely the origins of pain. Pain<br />
felt in the shoulder, elbow, or hand is often referred to these areas by injuries<br />
to the neck. Treating the pain without treating the causes of pain produces<br />
little more than symptomatic relief. The key to effective therapy is treating the<br />
sources of pain first and the symptoms last.<br />
(B) It is possible to have multiple sources of pain. A patient can<br />
experience local pain and referred pain in the same body part at the same time.<br />
Not only can untreated sources act synergistically to intensify pain, but they<br />
can also reactivate sources that became quiescent after treatment. If all sources<br />
of pain are not neutralized concurrently, the pain is likely to continue.<br />
(C) The areas where patients feel pain can migrate during the course of<br />
therapy. As muscles in one area become more functional, antagonistic or<br />
synergistic muscles may experience unaccustomed loading, stretching, or<br />
compression that causes pain. As hypersensitive areas become less sensitive<br />
to pain because of therapy, areas of lower sensitivity become more apparent.<br />
It is also possible for areas of high sensitivity to be obscured by<br />
widespread pain. If the tissue damage that triggered a pain cycle is confined to<br />
a single area, the last tissues to normalize are frequently those that suffered the<br />
initial insult and propagated the widespread pain.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
(D) Although pain cycles are seldom self-limiting, they may become<br />
quiescent for long periods of time. The mechanisms that reactivate a pain<br />
cycle are often difficult to identify. Possibilities include fatigue, abnormal<br />
movements, maximal exertions, psychological stress, disease, rapid changes in<br />
atmospheric conditions, or latent trigger points.<br />
Entrapment neuropathies can also restart a pain cycle. If nerve<br />
entrapments develop because of fibrosis or spasm, neurovascular compression<br />
can irritate nerves and reactivate pain cycles. If the pressure on nerves is<br />
intermittent, nerve conduction remains intact and possible symptoms are pain,<br />
paresthesia, or sympathetic hyperactivity.<br />
If pressure is more continuous than intermittent, possible symptoms are<br />
partial paralysis (paresis), complete paralysis, or anesthesia. Continuous<br />
pressure increases the risk of vascular ischemia and decreases nerve<br />
conduction velocities. Even if autonomic continuity is not interrupted,<br />
continuous pressure is more likely to cause sensory or motor loss than pain.<br />
(E) The body is so interconnected by muscles, fascia, and reflex patterns<br />
that treating a single muscle or any single tissue is normally pointless if not<br />
impossible. Most soft-tissue impairments involve agonistic, antagonistic,<br />
synergistic, and compensatory muscles simultaneously. Contralateral or<br />
ipsilateral muscles that share a common reflex pattern or muscles that cross the<br />
same joint cannot be isolated from each other. Holistic treatment is the only<br />
way to approach soft-tissue impairments.<br />
In low back pain, the primary muscles or muscle groups contributing to the<br />
pain cycle are gluteals, hamstrings, quadriceps, iliopsoas, and erector spinae.<br />
Secondary muscles are latissimus dorsi, quadratus lumborum, abdominals,<br />
tensor fascia latae, soleus, and gastrocnemius. Since even this list is only<br />
partial, it should be apparent that treating the erector spinae alone will not be<br />
enough to interrupt a pain cycle that is causing low back pain.<br />
Pain cycles are both chronic and acute at the same time.<br />
Although the onset may have been years ago and the patient's condition is<br />
classified as chronic, the traumas and microtraumas occurring on a regular<br />
basis because of stretching and tearing are acute. Each time contracted<br />
5<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
tissues are stretched beyond their limit, the injuries caused by tearing<br />
reactivate or reinforce chronic pain cycles. As a result, pain cycles are a<br />
sequence of injury followed by healing, on one hand, and injury followed by<br />
re-injury on the other.<br />
Failure to understand this principle can lead to inappropriate therapy if<br />
acute cases are treated as chronic cases. Heat, for instance, is normally used in<br />
chronic cases but not acute cases. If preexisting scar tissue is torn and<br />
subcutaneous bleeding is present, heating modalities would only intensify the<br />
inflammatory reaction. This principle can also explain why proximal causes<br />
for pain and disability in chronic cases are sometimes mistakenly diagnosed as<br />
psychogenic and not physical.<br />
Muscular imbalance perpetuates pain cycles.<br />
This factor relates to muscular imbalance and the fact that most muscles or<br />
muscle groups work in pairs. If a muscle goes into spasm for any reason,<br />
opposing movements that are forceful enough to cause stretching may also<br />
cause tearing. The inflammation caused by tearing exacerbates the existing<br />
spasm, increases hypoxic damage, and irritates surrounding tissue.<br />
If the sarcoplasmic reticulum surrounding a muscle fiber tears, the release<br />
of calcium ions causes a strong attraction between actin and myosin filaments<br />
that results in contraction. While metabolic demands are increasing because of<br />
contraction, circulation is decreasing because of muscle shortening and the<br />
release of histamines and serotonin from injured cells.<br />
Muscle shortening reduces circulation by compressing blood vessels and<br />
causing ischemia. Sensitizing agents such as serotonin reduce circulation by<br />
causing vasoconstriction. Because of localized ischemia, adenosine<br />
triphosphate (ATP) becomes depleted, which makes it even more difficult for<br />
the actin and myosin filaments to separate.<br />
On the positive side, sustained muscle contractions caused by depletion of<br />
ATP may help to protect an injured body part from movement by making it<br />
rigid. Splinting is the fixation of a body part to avoid pain caused by<br />
movement, and guarding is the stiffening of a body part to avoid pain or<br />
further injury caused by movement. The fixation or stiffening of a body part is<br />
normally caused by reflex spasm. The short-term benefits of reflex spasm<br />
6<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
and protective muscle shortening are stabilization of an injured part and<br />
protection against usage. In a primitive environment, protective spasm may<br />
help to encourage survival by minimizing hemorrhage, stabilizing potentially<br />
dangerous bone fragments, and forcing the victim to rest the injured part.<br />
On the negative side, involuntary contractions that are strong enough to<br />
protect a muscle from movement by making it rigid will also limit the muscle's<br />
range of motion. If the muscle remains shortened for extended periods of<br />
time, contractures may form that make the muscle highly resistant to active or<br />
passive stretch and cause a permanent decrease in mobility.<br />
If agonist muscles shorten and weaken because of spasm or contracture,<br />
antagonistic muscles have a tendency to weaken because of inactivity and<br />
lengthen because of tension. Weakness and shortness of the agonist combined<br />
with weakness and lengthening of the antagonist militate against movement.<br />
Until the agonist is lengthened and strengthened and the antagonist is<br />
shortened and strengthened, the balance needed for normal movement cannot<br />
be achieved and the pain cycle is likely to continue.<br />
As to which is more important, lengthening or strengthening, it appears<br />
clinically that lengthening a muscle by stretching should always precede<br />
strengthening a muscle by exercise. Besides spasm and contracture, possible<br />
reasons for muscle shortness include central mechanism involvement, muscle<br />
memory, and proprioceptive feedback from muscle spindle cells. Regardless<br />
of cause, exercising a shortened muscle is likely to have very little effect on<br />
restoring function or reducing pain.<br />
Except for minor and self-limiting injuries, manipulation and stretching are<br />
needed to normalize tissue length before exercise. Even though modalities can<br />
be used effectively in combination with exercise, total reliance on modalities<br />
and exercise to the exclusion of soft-tissue manipulation is both dangerous and<br />
counterproductive.<br />
Reflexogenic activity perpetuates pain cycles.<br />
Reflexogenic changes occur because of a neural pathway between a joint<br />
and the muscles that move the joint. It is difficult to say which comes first,<br />
pathologic conditions in a joint that cause muscle splinting or pathologic<br />
conditions in surrounding muscles that irritate the joint. Irrespective of which<br />
7<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
comes first, inflammation of the joint and periarticular tissue is likely to<br />
continue until hypertonic muscles surrounding the joint relax and lengthen.<br />
Continued shortness in a muscle that crosses a joint (1) reduces joint space,<br />
(2) causes abnormal friction, (3) inflames the joint capsule, and (4) erodes<br />
articular cartilage. Treatments such as high-velocity manipulation that have no<br />
permanent effect on surrounding muscles and related tissues will do nothing<br />
more than provide temporary relief. If joints and related muscles are not<br />
treated together as a unit, the body cannot heal itself and pain cycles that cause<br />
weakness and limited range of motion are likely to continue.<br />
Setbacks and reversals are common when treating pain cycles.<br />
Even without secondary gain or litigation neuroses, progressive<br />
improvement will sometimes reverse itself for no apparent reason. The<br />
leading cause appears to be higher levels of activity. As patients improve, they<br />
feel better, become more active, and place more demands on the body. Despite<br />
feelings of well-being, patients should be advised to avoid strenuous activities<br />
until the entire body can handle the added stress. The deconditioning effects<br />
of inactivity are difficult to overcome. Besides pain-free range of motion,<br />
patients need strength, muscular endurance, aerobic endurance, and<br />
coordination to function normally.<br />
The methods for treating soft-tissue injuries are often deficient.<br />
In many cases, soft-tissue therapy begins too late or the methods of<br />
treatment are not appropriate for the problem. If an injury is not mobilized as<br />
soon as possible, pain, spasm, and fibrosis may limit the victim's range of<br />
motion and decrease activity. Extended periods of inactivity may cause<br />
deconditioning—weakness, atrophy, incoordination, or stiffness—and other<br />
pathologic changes that lay the groundwork for a long and durable pain cycle.<br />
Modalities or medication used without manipulation are seldom effective, and<br />
splints or braces worn for more than a few days retard healing, decrease range<br />
of motion, and may cause contractures or capsular adhesions.<br />
Another form of inappropriate treatment is too much focus on reports of<br />
pain by the patient and not enough concentration on restoring function.<br />
8<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Although "train, don't strain" is more popular today than "no pain, no gain,"<br />
some forms of therapy are both necessary and painful. While any competent<br />
practitioner tries to minimize pain during treatment, the patient needs to<br />
understand that improvement without pain is not always possible. This<br />
includes pain that occurs during treatment and sometimes even after treatment.<br />
The best ways to help patients accept unavoidable pain are (1) advise the<br />
patient that treatments may be painful, (2) explain why the treatment is<br />
necessary, and (3) suggest methods for minimizing or dealing with the pain.<br />
The stronger the bond between patient and practitioner, the easier it is for the<br />
patient to accept the reality that progress may not occur without pain.<br />
More research is needed to validate methods of therapy.<br />
The seventh and final reason pain cycles are difficult to treat is a lack of<br />
valid research studies that support the effectiveness of soft-tissue therapy.<br />
Most arguments supporting soft-tissue therapy are based on anecdotal<br />
evidence or clinical observations. One of the major obstacles to conducting a<br />
valid research study is funding. Drug companies and medical equipment<br />
suppliers are more likely to fund research on projects involving medication or<br />
surgery than to support projects dealing with manual medicine.<br />
Another problem is terminology. The terminology describing soft-tissue<br />
therapy is not consistent, and many techniques are poorly described and<br />
documented. Good books on anatomy, physiology, and psychology are more<br />
common than good books on soft-tissue therapy, and many of the better books<br />
cover only one or two basic techniques. A truly comprehensive book on softtissue<br />
therapy that covers the entire range of techniques possible has yet to be<br />
published. Such a book would be based on principles found in physical<br />
medicine, osteopathy, chiropractic, and massage therapy and would cover<br />
applied anatomy and physiology as well as evaluation and techniques.<br />
Despite its many problems, a large number of people are using and<br />
recommending soft-tissue therapy. For most patients with soft-tissue<br />
impairments, soft-tissue therapy creates an environment for the body to heal<br />
itself. Many of these people have musculoskeletal problems that are not<br />
9<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
esponsive to other forms of treatments. Even those who cannot be cured can<br />
at least find enough relief to improve the quality of their lives.<br />
Rather than abandon these patients to ineffective or dangerous methods of<br />
treatment because definitive research that validates soft-tissue therapy is not<br />
available, practitioners should continue treating patients to the best of their<br />
ability. Techniques that are beneficial, and do the patient no harm, should not<br />
be denied. By the same token, practitioners should support scientific research<br />
and look for ways to prove or disprove the effectiveness of each technique.<br />
Even though some of these studies may have a negative impact on profitability<br />
by discrediting a popular but useless technique, the positive impact on patient<br />
care should outweigh the loss of income.<br />
Despite the amazing and sometimes even miraculous results, soft-tissue<br />
therapy is not without limitations. First, soft-tissue therapy is not a panacea.<br />
The three main goals of soft-tissue therapy are less pain, a normal pain-free<br />
range of motion, and good quality movement. Second, if soft-tissue<br />
impairments are symptoms of a serious pathologic condition, treatments are at<br />
best palliative and symptoms are likely to recur. In some cases, surgery and<br />
medication are the only possible answers.<br />
Yet unlike surgery or medication, soft-tissue therapy is a conservative,<br />
non-invasive form of treatment with very few side effects. For qualified and<br />
conscientious practitioners, the possibilities for helping a patient are great and<br />
the chances of harming a patient are small.<br />
Another factor that limits research is the profitability of the activity itself.<br />
More money is normally spent validating activities that are highly profitable<br />
than validating activities that are less profitable. Drug companies, for instance,<br />
spend tremendous amounts of money validating a cure for common diseases<br />
because of the high profit margin but seldom spend the same amount of money<br />
validating a cure for rare diseases.<br />
As a therapeutic activity, low-velocity manipulations are normally less<br />
profitable than high-velocity manipulations. Where the average low-velocity<br />
treatment takes about 15 to 55 minutes, the average high-velocity treatment<br />
takes about 5 to 10 minutes. This would partially explain why in a field like<br />
chiropractic that uses both high-velocity and low-velocity manipulations, the<br />
majority of research focuses on high-velocity manipulations.<br />
10<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The same trend applies to allopathic medicine. Since surgery and<br />
medication are clearly more profitable than physical medicine, it logically<br />
follows that more money is being spent to validate surgical procedures or<br />
pharmacology than manual medicine. The same trend can also be applied to<br />
the field of manual medicine itself.<br />
Physical therapy, for instance, uses a combination of modalities,<br />
manipulation, and exercise. Since using manipulation because of its onetherapist-to-one-patient<br />
ratio is often less profitable than using modalities or<br />
exercise with a one-therapist-to-multiple-patients ratio, it logically follows that<br />
more money is being spent to validate modalities and exercise than to validate<br />
hands-on manipulation.<br />
Despite the prevailing trend in medicine to validate the activities that are<br />
most profitable, at least three factors seem to be operating that are changing<br />
this trend: Federally funded research groups, health care insurance groups,<br />
and groups of dissatisfied patients. Using money provided by taxpayers, the<br />
Federal government (1994) conducted a research project that concluded<br />
surgery is rarely indicated for low back pain and that conservative methods,<br />
including modalities and manipulation, are often beneficial.<br />
The health care insurance industry is starting to recognize that even though<br />
soft-tissue therapy is labor-intensive, it can still be cost-effective. Regardless<br />
of time and labor, methods that achieve success are always more cost-effective<br />
than methods that fail. Many insurance companies are finding that<br />
conservative methods such as soft-tissue therapy are less expensive than<br />
surgery and get patients back to work. Findings of this nature encourage<br />
insurance companies to research soft-tissue therapy as a way to save money.<br />
Dissatisfied patients are probably the largest single group responsible for<br />
encouraging soft-tissue therapy research. Many patients spend years of their<br />
life and thousands of dollars on various treatments before they discover that<br />
soft-tissue therapy is the only method of treatment that works for them and<br />
gets them back to work. For many patients, soft-tissue therapy is their last<br />
resort. Dissatisfaction with conventional medicine is forcing the health care<br />
industry to explore new options and consider the possibilities.<br />
Even if soft-tissue therapy is validated by research, the problem of finding<br />
competent practitioners to provide the service will still remain. Allopathic<br />
doctors, in general, have little or no interest in manual medicine.<br />
11<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Most medical schools do not teach manipulation and most medical doctors do<br />
not have the time or patience to practice manual medicine. Most chiropractors<br />
are more interested in spinal adjustments than soft-tissue therapy, and most<br />
physical therapists use modalities and exercise more than manipulation.<br />
Despite their long tradition of physical medicine, even some osteopaths are<br />
moving away from manual medicine in favor of medication and surgery. This<br />
trend is perhaps the greatest loss of all. More than any other group, osteopaths<br />
have pioneered the study of soft-tissue manipulation. Founded by Dr. A. T.<br />
Still (1828-1917), osteopathy is the largest single source of most knowledge<br />
relating to soft-tissue therapy, followed by massage therapy, chiropractic, and<br />
physical therapy.<br />
The group most likely to dominate the field of soft-tissue therapy appears<br />
to be massage therapy. As a rapidly growing health care profession, massage<br />
therapy is the only group practicing soft-tissue therapy that focuses on lowvelocity<br />
manipulations more than surgery, medication, modalities, exercise, or<br />
high-velocity manipulations. Even though chiropractors are expanding their<br />
use of low-velocity techniques, it appears likely that soft-tissue therapy will<br />
always be secondary to spinal adjustments. While it may be true that<br />
osteopaths are moving away from high-velocity techniques in favor of lowvelocity<br />
techniques, osteopathy as a profession is also moving away from<br />
manual medicine in favor of surgery and medication.<br />
If massage therapy comes to dominate the field of soft-tissue therapy, as<br />
appears likely, it must pick up the torch and carry on the research started by<br />
other health care professions. This means using a language common to other<br />
health care professions, following the scientific method, publishing<br />
information, and making its principles and techniques openly available for<br />
scrutiny by any member of the medical or scientific community.<br />
As a growing and responsible health profession, massage therapy can no<br />
longer be satisfied with knowing that something works without making a<br />
conscientious effort to understand why. In other words, massage therapy must<br />
try to prove what most people who practice soft-tissue therapy already know:<br />
soft-tissue therapy is a safe, simple, economical, and effective way to make a<br />
difference by correcting soft-tissue impairments and helping improve the<br />
quality of a patient's life.<br />
12<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
13<br />
CHAPTER SUMMARY<br />
THREE SIGNS OR SYMP<strong>TO</strong>MS OF <strong>SOFT</strong>-<strong>TISSUE</strong> IMPAIRMENT<br />
• Pain<br />
• Limited range of motion<br />
• Poor-quality movement<br />
SIX FAC<strong>TO</strong>RS THAT CAUSE <strong>SOFT</strong>-<strong>TISSUE</strong> IMPAIRMENTS<br />
• Trauma<br />
• Disease<br />
• Postural defects<br />
• Muscular imbalance<br />
• Abnormal movements<br />
• Overuse injuries<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
14<br />
THREE CHARACTERISTICS OF <strong>SOFT</strong>-<strong>TISSUE</strong> IMPAIRMENT<br />
• Inflammation of soft-tissue<br />
• Replacement of muscle tissue by connective tissue<br />
• Pain<br />
SEVEN REASONS WHY PAIN CYCLES ARE DIFFICULT <strong>TO</strong> TREAT<br />
• The mechanisms that cause pain cycles are difficult to locate.<br />
• Pain cycles are both chronic and acute at the same time.<br />
• Muscular imbalance perpetuates pain cycles.<br />
• Reflexogenic activity perpetuates pain cycles.<br />
• Setbacks and reversals are common when treating pain cycles.<br />
• The methods for treating soft-tissue injuries are often deficient.<br />
• More research is needed to validate methods of therapy.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
15<br />
<strong>HEMME</strong> <strong>APPROACH</strong><br />
Soft-tissue therapy cannot be effective without some type of systematic<br />
approach that progresses logically from problem to solution. The <strong>HEMME</strong><br />
<strong>APPROACH</strong> was created to satisfy this need. The word <strong>HEMME</strong> (pronounced<br />
hem as in hem and me as in me) is an acronym that stands for<br />
H<br />
E<br />
M<br />
M<br />
E<br />
HIS<strong>TO</strong>RY<br />
EVALUATION<br />
MODALITIES<br />
MANIPULATION<br />
EXERCISE<br />
More than just a series of steps, the <strong>HEMME</strong> <strong>APPROACH</strong> is based on what<br />
system theory refers to as a plain language model. Language models are used<br />
when complex ideas cannot be formulated mathematically. The purpose of a<br />
language model is to simplify the process of converting knowledge into action<br />
and measuring the results. Language models can be used to (1) identify<br />
problems, (2) collect information, (3) formulate theories, and (4) test possible<br />
solutions by using feedback.<br />
The six steps that hold the model together like glue are:<br />
(1) ENTER PATIENT (4) OBJECTIVES SATISFIED<br />
(2) ALTERNATIVES (5) OBJECTIVES NOT SATISFIED<br />
(3) FEEDBACK (6) OUTSIDE INFORMATION<br />
In the <strong>HEMME</strong> <strong>APPROACH</strong> model (<strong>HEMME</strong>GON), the five basic steps<br />
HIS<strong>TO</strong>RY, EVALUATION, MODALITIES, MANIPULATION, and EXERCISE are in<br />
bold letters and the other six steps are in outline letters. The starting point, the<br />
step titled ENTER PATIENT, is boxed.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Lines and arrows show which directions of movement are possible within<br />
the model. Therapy begins when the patient enters the system. Step one is<br />
titled ENTER PATIENT. The first two basic steps in the model, titled HIS<strong>TO</strong>RY<br />
and EVALUATION, define the patient's problem. History refers to medical<br />
history and evaluation refers to physical evaluation.<br />
The next step in the model is ALTERNATIVES. This step is a link between<br />
the problem as defined by HIS<strong>TO</strong>RY and EVALUATION and possible solutions<br />
as defined by MODALITIES, MANIPULATION, and EXERCISE.<br />
Alternatives should be specifically defined. If modalities, manipulation, or<br />
exercise are needed, practitioners should know specifically which modalities,<br />
manipulations, and exercises are needed. Workable plans for therapy should<br />
include goals, timetables, and measurable results. If therapy involves more<br />
than one practitioner, responsibilities are assigned.<br />
The steps MODALITIES, MANIPULATION, and EXERCISE are situated on one<br />
line to emphasize that therapy can include one or more of these three steps.<br />
MANIPULATION was given a central position because soft-tissue therapy<br />
focuses on manipulation, with modalities and exercise secondary.<br />
The next step is FEEDBACK. Like homeostatic mechanisms that regulate<br />
blood pressure, the <strong>HEMME</strong> <strong>APPROACH</strong> uses positive and negative feedback to<br />
regulate the course of therapy. Positive feedback validates the course of<br />
therapy being followed and negative feedback indicates a need for change.<br />
Changes can be made in several ways: (1) repeat steps (2) change the sequence<br />
for using steps, (3) seek new information and reenter the system, or (4) exit the<br />
system.<br />
The step for entering new information, upper left-hand corner of the<br />
<strong>HEMME</strong>GON, is titled OUTSIDE INFORMATION. Like any living system, the<br />
<strong>HEMME</strong> <strong>APPROACH</strong> is capable of receiving and processing input from the<br />
outside. This step can be used to enter outside information from sources such<br />
as consultation, research, or laboratory testing. After receiving and processing<br />
the new information, the practitioner can enter the model at four points: (1)<br />
HIS<strong>TO</strong>RY, (2) EVALUATION, (3) ALTERNATIVES, or (4) FEEDBACK.<br />
Practitioners can exit the system by using FEEDBACK to reach the steps<br />
titled OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives of<br />
therapy are not satisfied, the patient may exit the system or reenter at any of<br />
the five basic steps. HIS<strong>TO</strong>RY and EVALUATION can be reentered directly,<br />
16<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
whereas MODALITIES, MANIPULATION and EXERCISE are reentered by using<br />
the step titled ALTERNATIVES. If the objectives of therapy are satisfied, the<br />
patient exits the system.<br />
From the step titled HIS<strong>TO</strong>RY you can go directly to OBJECTIVES NOT<br />
SATISFIED or EVALUATION. If contraindications are discovered, the step titled<br />
OBJECTIVES NOT SATISFIED would be used to exit the model. If soft-tissue<br />
therapy is indicated, the next step is EVALUATION.<br />
From EVALUATION you can return to HIS<strong>TO</strong>RY, if more history is needed,<br />
or go directly to the steps titled OBJECTIVES NOT SATISFIED or ALTERNATIVES.<br />
OBJECTIVES NOT SATISFIED would be used if therapy is contraindicated and<br />
ALTERNATIVES would be used if therapy is indicated.<br />
Even though any combination is possible, a typical sequence for soft-tissue<br />
therapy is (1) modalities, (2) manipulation, and (3) exercise. Another<br />
possibility is to use manipulation without modalities or exercise. Modalities<br />
and exercise, on the other hand, are seldom used without manipulation.<br />
Regardless of which sequence is followed, the next step is FEEDBACK.<br />
If the patient's problem is solved, OBJECTIVES SATISFIED can be used to exit<br />
the patient from the system. If the problem is not solved, OBJECTIVES NOT<br />
SATISFIED can be used to exit the patient from the system or continue therapy<br />
by repeating any or all steps connected by lines and arrows.<br />
There is no limit on the number of times a step can be repeated. Even after<br />
a case is closed, the same patient may reenter the system with a new problem<br />
or the recurrence of an old problem. Soft-tissue therapy is an ongoing process<br />
that requires enough flexibility to make changes. To apply the same routine to<br />
all patients ignores the fact that each patient is an individual and that no two<br />
people are exactly the same.<br />
Even though soft-tissue therapy is not easy, the <strong>HEMME</strong> <strong>APPROACH</strong> is a<br />
powerful way to organize the elements of therapy into a single working model.<br />
With nothing more than five basic steps, even the most complex therapeutic<br />
problems can be simplified. For the small amount of time needed to master<br />
the <strong>HEMME</strong> <strong>APPROACH</strong>, the results more than justify the effort.<br />
The <strong>HEMME</strong> <strong>APPROACH</strong> can be applied to any type of soft-tissue therapy<br />
regardless of what techniques are being used. While the <strong>HEMME</strong> <strong>APPROACH</strong><br />
provides an outline or framework for doing soft-tissue therapy, the principles<br />
and techniques provide the substance.<br />
17<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
<strong>HEMME</strong> Approach to Soft-Tissue Therapy<br />
18
19<br />
CHAPTER SUMMARY<br />
FIVE STEPS IN THE <strong>HEMME</strong> <strong>APPROACH</strong><br />
• History<br />
• Evaluation<br />
• Modalities<br />
• Manipulation<br />
• Exercise<br />
FOUR WAYS <strong>TO</strong> USE MODELS<br />
• Identify problems<br />
• Collect information<br />
• Formulate theories<br />
• Test possible solutions by using feedback<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
20<br />
HIS<strong>TO</strong>RY<br />
The first step in the <strong>HEMME</strong> <strong>APPROACH</strong> is HIS<strong>TO</strong>RY. Background<br />
information such as vital statistics, lifestyle, and general health should be<br />
entered by the patient on a standard form before the interview starts. Other<br />
items to include are previous injuries, operations, and past medical treatments.<br />
In particular, have patients advise if they are currently under medical care or<br />
aware of any conditions that might contraindicate soft-tissue therapy. There<br />
should be a blank space at the bottom of the form for the patient to add further<br />
information if needed. A practitioner should always read the completed<br />
medical history form prior to interviewing a patient.<br />
During the first few minutes of contact between the practitioner and<br />
patient, both parties form impressions that are difficult to change. Practitioners<br />
will evaluate the patient's honesty, intelligence, personality, and motivation.<br />
Patients will evaluate the practitioner's competency, attitude, demeanor, and<br />
communication skills. Negative opinions formed by either party can adversely<br />
affect the entire course of therapy.<br />
If practitioners decide too early that patients are motivated by litigation or<br />
secondary gain, legitimate signs of illness or injury may not be acknowledged.<br />
A premature diagnosis of hysteric conversion may cause practitioners to<br />
identify psychogenic symptoms but totally disregard organic signs. The initial<br />
interview is a time for collecting information, not making final decisions. The<br />
mind should remain open, objective, and focused.<br />
If patients, on the other hand, decide too early that practitioners are<br />
incompetent, uncaring, or unprofessional, subsequent attempts to regain the<br />
patient's confidence may be futile. Even if patients continue to use the services<br />
of someone they dislike or distrust, their willingness to cooperate will be less,<br />
especially in cases requiring self-care.<br />
Although difficult to say how much of any treatment is physical versus<br />
psychological, placebo effects cannot be overlooked. Since the effectiveness<br />
of any placebo depends on what the patient believes, and belief depends<br />
largely on the patient's attitude toward the person recommending treatment, the<br />
relationship between the practitioner and patient can clearly affect the final<br />
outcomes. Good relationships often produce good therapeutic results.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Since little can be done to change the way patients present themselves<br />
during the interview, practitioners should be alert, but open-minded, when<br />
trying to evaluate what they see and hear. Clever patients may be skillful<br />
enough to deceive practitioners during the initial stages of an interview, while<br />
other patients may present totally honest symptoms that give the appearance of<br />
duplicity. Even though preliminary theories are reasonable, and even<br />
necessary, during the initial stages of an interview, practitioners must always<br />
be willing to change any belief that is later contradicted by evidence.<br />
Practitioners do have some control over the way they present themselves.<br />
The best ways to establish rapport are (1) present a professional appearance,<br />
(2) help the patient relax by asking non-threatening questions, (3) be<br />
agreeable, (4) smile and use appropriate humor, and (5) maintain eye contact<br />
with the patient. Since the importance of eye contact cannot be<br />
overemphasized, the following test of eye contact is highly recommended.<br />
After speaking to a patient for several minutes, look away and try to recall the<br />
patient's eye color. Failure to do so may suggest eye contact was faulty.<br />
Most patients should be allowed to sit or lie down unless other positions<br />
are more comfortable. If the patient is nervous and prone to movement,<br />
practitioners should seat the patient and remain standing themselves. This<br />
limits the patient's mobility and helps to establish authority. Some patients<br />
respond well to shaking hands or a light touch on the shoulder, while others<br />
prefer distance. Watching the way patients conduct themselves may suggest<br />
what behaviors are acceptable to the patient.<br />
A therapist should be able to empathize with patients but have enough ego<br />
strength and confidence to make difficult decisions when needed. Two<br />
attitudes that are strongly recommended are sincerity and caring. Other<br />
concerns tend to become secondary if patients believe that practitioners truly<br />
care about helping them. As someone once said, "Patients don't care how<br />
much you know until they know how much you care."<br />
Rapport implies trust, confidence, and cooperation. Once rapport has been<br />
established, review the patient's written history, ask questions about the<br />
questionnaire if necessary, and listen carefully to what the patient says. A<br />
common failing in the health care field is failure to listen.<br />
When conducting an interview, separate the patient from the problem and<br />
focus on the problem. Medical histories are taken to evaluate the patient’s<br />
21<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
condition and not the patient. The personality or circumstances surrounding<br />
the patient should not be allowed to bias the investigation.<br />
After reviewing the patient's medical history, the examiner should ask<br />
questions requiring more than a "yes or no" answer. Questions concerning (1)<br />
the problem or chief complaint and (2) the quality of past or present treatment<br />
will give the examiner a good place to start. Open-ended questions about pain,<br />
loss of motion, and changes in lifestyle will further define the problem. Almost<br />
every patient can provide at least some information that is helpful enough to be<br />
recorded as part of the patient's permanent medical history.<br />
Open-ended Questions for Medical History<br />
• What is the nature of the problem?<br />
• Are you under a doctor's care?<br />
• Has this problem been treated before?<br />
• Do you have any other medical problems?<br />
• Are you taking any medication?<br />
• What type of treatments do you think might help?<br />
• How does the problem affect your life?<br />
The acronym PDQ summarizes the first three questions above:<br />
P-Problem<br />
D-Doctor's care<br />
Q-Quality of past treatment<br />
Interviews should normally proceed from general to specific. After asking<br />
open-ended questions about the patient's condition, the interviewer should<br />
continue with questions that are more specific, such as questions concerning<br />
the mechanism of injury. By this point, most practitioners will have formed at<br />
least one or two preliminary theories concerning the patient's condition. Even<br />
if the patient's information is not complete, any information provided will<br />
make it easier to reconstruct the mechanism of injury. The acronym FIRST<br />
can be used to assess the mechanism of injury.<br />
22<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
23<br />
MECHANISM OF INJURY<br />
F FORCE Direction of force<br />
I INTENSITY Magnitude of force<br />
R REGIONS Body parts affected by the force<br />
S SEVERITY Degrees of injury or loss of function<br />
T TIME Frequency and duration of force<br />
Reconstructing an automobile accident may be helpful. If the patient's<br />
vehicle struck a fixed object while moving forward, the neck was probably<br />
flexed during the impact and then extended during the rebound. High rates of<br />
acceleration increase the force of impact and potential for injury. If the patient<br />
saw the accident coming and braced for impact, then wrist, elbow, and<br />
shoulder injuries can be expected. The quality of pain and changes in mobility<br />
and lifestyle will indicate severity, whereas time since the onset of injury may<br />
indicate chronicity and possibly severity. Seemingly small and insignificant<br />
injuries sometimes become more severe with time.<br />
The time elapsed since an injury occurred is also important for another<br />
reason: injuries of long-standing duration are normally more difficult to treat<br />
than injuries of short duration. As a rule, when a body part loses mobility,<br />
fibrotic changes and atrophy increase with time.<br />
Another line of questioning involves pain.<br />
• Where do you feel the pain?<br />
• When did the pain first occur?<br />
• When do you feel the pain?<br />
• How does the pain feel (sharp, dull, aching, etc.)?<br />
• What makes the pain feel better or worse?<br />
• How does the pain affect your life?<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
During the final stages of the interview, practitioners need to construct<br />
increasingly definite preliminary theories concerning the patient's condition.<br />
These theories will dictate the types of physical evaluation that are appropriate<br />
in step number two (EVALUATION).<br />
Even though objectivity and open-mindedness are important, because of<br />
limited resources it is not practical to start a physical evaluation without<br />
knowing what directions to follow in terms of collecting information. These<br />
directions, of course, can always be changed during the course of therapy. If<br />
feedback or new information show preliminary theories are incorrect, new<br />
directions may be needed. If contradictions appear, therapy should be stopped<br />
immediately. Unlike standard routines that tend to be fixed and constant, the<br />
<strong>HEMME</strong> <strong>APPROACH</strong> is flexible enough to allow for changes.<br />
24<br />
It is no coincidence that Sir Arthur Conan Doyle, a medical doctor, and<br />
Sherlock Holmes, his famous fictional detective, had many traits in common.<br />
A good doctor or therapist is also a good detective. As far back as the 1800s,<br />
Sherlock Holmes was using principles of logic and reasoning that are similar<br />
to those used by medical investigators today. These principles can be used by<br />
any scientific investigator (including a soft-tissue therapist) who is seeking to<br />
learn the truth. The <strong>HEMME</strong> <strong>APPROACH</strong> is based on similar principles.<br />
1. Do not draw final conclusions before the investigation is complete.<br />
2. Collect facts that are relevant, trustworthy, and material.<br />
3. Listen carefully to all the statements, regardless of the source.<br />
4. Place more value on physical evidence than verbal or written statements.<br />
5. Little things are often the most important.<br />
6. Draw conclusions based on deductive logic and facts.<br />
7. Be able to defend your conclusions with logic and facts.<br />
Sherlock Holmes was famous for quoting a principle that dates back to<br />
Aristotle called reductio ad absurdum: After eliminating the impossible,<br />
whatever remains, however improbable, must be the truth.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
25<br />
CHAPTER SUMMARY<br />
THREE WORDS THAT FORM THE ACRONYM PDQ<br />
• Problem<br />
• Doctor's care<br />
• Quality of past treatment<br />
FIVE WORDS THAT FORM THE ACRONYM FIRST<br />
• Force: Direction of force.<br />
• Intensity: Magnitude of force.<br />
• Regions: Body parts affected by the force.<br />
• Severity: Degrees of injury or loss of function.<br />
• Time: Frequency and duration of force.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
26<br />
EVALUATION<br />
The second step in the <strong>HEMME</strong> <strong>APPROACH</strong> is EVALUATION. Whereas<br />
medical histories are based on information provided by the patient, physical<br />
evaluations are based on observations made by the examining practitioner. A<br />
similar distinction is made between symptoms and signs: symptoms are<br />
indications of illness as perceived by the patient and signs are evidence of<br />
disease or dysfunction discovered by the examiner. Even though not<br />
completely objective, physical evaluations and signs are considered more<br />
objective than medical histories and symptoms.<br />
The classical methods of physical evaluation are (1) percussion, (2)<br />
auscultation, (3) palpation, and (4) inspection. Percussion is a method of<br />
tapping sharply on the body and either listening or feeling for resonance.<br />
When resonance is detected by listening, the process is called auscultatory<br />
percussion. When resonance is detected by touch, the process is called<br />
palpation percussion. Percussion is most commonly used on the chest and<br />
back to examine the heart and lungs.<br />
Auscultation, by itself, is a method of listening for abnormal sounds such<br />
as crepitus or the clicking of a tendon. When aided by a stethoscope, the<br />
examiner can hear sounds of blood rushing through a vessel (bruits) and<br />
sounds of muscular contraction.<br />
The cracking or popping sound made when joints move is not considered<br />
diagnostic. Reasons for the sound include breaking a vacuum in the joint or<br />
releasing nitrogen gas. It normally takes about twenty minutes for the same<br />
joint to reset before it can pop again.<br />
Palpation is any form of examination done by touching or feeling with the<br />
hands or fingers. When done with skill, palpation can reveal spasms, contractures,<br />
adhesions, crepitus, and tremors or fasciculations. Palpation can also<br />
detect changes in the temperature, texture, tightness, and moisture of skin and<br />
variations in the thickness, density, symmetry, and compliance of underlying<br />
tissues. Changes in surface topography may suggest atrophy, swelling, or a<br />
pathologic growth. Palpation is frequently used in soft-tissue therapy to locate<br />
trigger points, tender points, indurated muscles, scars, or edema. During<br />
palpation patients may report pain, numbness, or itching.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The sensitivity of the hand varies from part to part. The finger pads are<br />
most sensitive to touch, the dorsum of the hand is most sensitive to changes in<br />
temperature, and the palmar aspects of the metacarpophalangeal joints are<br />
most sensitive to movement. The central palm is most sensitive in terms of<br />
stereognosis, the ability to recognize the gross shape of an object by touch.<br />
Motion palpation combines palpation with active or passive movement.<br />
Abnormalities that are imperceptible when body parts are static and relaxed<br />
are sometimes more discernible when body parts are moving. Restrictions, in<br />
particular, become more apparent if movement causes stretching that helps the<br />
examiner identify tissues that are too short or too tight. The most common<br />
restrictions are found in muscles, fascia, ligaments, joint capsules, and skin.<br />
Hypertonic scalene muscles are easier to palpate when the head is rotated to<br />
the opposite side. The muscles may feel taut when palpated and range of<br />
motion may be limited. Motion can also change the position or thickness of<br />
overlying tissues.<br />
A principle of palpation that is frequently overlooked is progressive<br />
penetration. Tissues cover the body in layers. Examiners must first penetrate<br />
the superficial layers to reach the deep layers. Active or passive movements<br />
that stretch superficial muscles such as the trapezius will make it easier to<br />
palpate deeper muscles such as the rhomboids. If the iliopsoas is hypertonic,<br />
reducing the tension on superficial tissues will make it easier to palpate the<br />
muscle. Progressive penetration requires concentration and manual dexterity.<br />
The two most common errors during palpation are too much pressure and not<br />
moving the hand slowly enough. Only rarely should palpation cause pain.<br />
Although palpation is probably the best and sometimes the only way to<br />
identify soft-tissue impairments, it is also the method of evaluation medical<br />
doctors seem to use least. As allopathic physicians become more reliant on<br />
instrumentation, palpation is losing ground. This could explain why so many<br />
soft-tissue impairments are diagnosed as psychogenic and not organic.<br />
Inspection refers to examining the patient with the eyes. Observation of<br />
posture may show defects in symmetry or alignment, whereas observation of<br />
movement may identify defects in flexibility or coordination. Inspection can<br />
also detect atrophy, enlargements, lesions, and changes in coloration.<br />
Even though inspection is a valuable source of information, examiners<br />
should remember that bodies are not symmetric and deviations in alignment<br />
27<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
may or may not be clinically significant. It is common for the shoulder on the<br />
dominant side to be lower than on the opposite side and the hip on the same<br />
side to be higher than the opposite side and slightly rotated posteriorly. The<br />
upper extremity muscles on the strong side (normally the right side) are almost<br />
always larger than muscles on the weak side (normally the left side).<br />
Functional leg length is seldom equal, and the cervical spine tends to show<br />
lateral flexion in one direction more than the other. Even though deviations<br />
from the ideal should always be noted, they are not always symptomatic.<br />
Of the four classic methods of physical evaluation, palpation and<br />
inspection are used more in soft-tissue therapy than either percussion or<br />
auscultation. Even though palpation is probably more important in soft-tissue<br />
therapy than inspection, many forms of orthopedic and neurologic testing use<br />
both. Inspection is normally the first method of evaluation used.<br />
Even though active motion testing is mainly inspection, passive motion<br />
testing uses both inspection and palpation. In determining the five classic<br />
signs of inflammation—heat, redness, swelling, pain, and loss of function—<br />
heat is determined by palpation; redness by inspection; swelling by either<br />
palpation or inspection; pain by seeing, hearing, or feeling indications of pain<br />
during palpation; and loss of function by inspection and palpation.<br />
Although pain is more of a symptom than a sign, painful areas can be<br />
identified by using (1) palpation to induce the pain and (2) inspection to note<br />
the patient's response to palpation. If trigger points are located by palpation,<br />
heavy pressure may cause the trigger point to become insensitive in the same<br />
way that ischemic pressure neutralizes a trigger point. To avoid combining<br />
palpation with treatment, trigger points should be located with light pressure<br />
and then treated with heavier pressure.<br />
The combination of inspection and palpation can also be used to locate<br />
landmarks that help to identify specific parts of the body such as muscles,<br />
tendons, and bones. Specific vertebrae can be located as follows.<br />
• The most prominent cervical vertebra is C-7.<br />
• The vertebra level with the inferior angles of the scapulae is T-7.<br />
• The vertebra level with the lower insertion of the trapezius muscle is T-12.<br />
• The vertebra level with the iliac crests is L-4.<br />
• The vertebra level with the posterior superior iliac spines is S-2.<br />
28<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
29<br />
MUSCLE TESTING<br />
Manual muscle testing is a clinical method for measuring muscular<br />
strength and range of motion (ROM). Another name for muscle testing is<br />
resisted range-of-motion testing. Strength measures the patient's ability to<br />
hold steady or move against resistance. When patients hold against resistance,<br />
muscles contract isometrically without changing in length. When patients<br />
move against resistance, muscles contract isotonically and shorten.<br />
Muscles are composed of nerve tissue, muscle tissue, and connective<br />
tissue. Nerves transmit electrical impulses and muscle fibers produce force by<br />
contraction. Tendons and aponeuroses transmit the force to bones, and deep<br />
fascia separates and supports a muscle.<br />
Based on composition, the main factors affecting strength and weakness<br />
are (1) neurologic efficiency, (2) the ability of muscle fibers to contract, (3) the<br />
integrity of tendons and aponeuroses, and (4) the ability of deep fascia to reach<br />
a normal length.<br />
Even though joints are not part of a muscle, the integrity of joints can also<br />
affect strength and weakness. If a joint is irritated, locked, or unstable, a<br />
muscle crossing the joint may test weak even if the muscle itself is normal.<br />
Any condition that changes joint space above or below physiologic limits will<br />
adversely affect the joint's ability to produce normal movement.<br />
Range-of-motion testing measures joint movement by degrees of arc in a<br />
circle. The starting position is zero (neutral position) and degrees are added in<br />
the direction the joint moves from a starting position. Except for rotation, the<br />
starting position is normally the same as anatomical position.<br />
An example of range-of-motion testing is elbow flexion. Starting from<br />
anatomical position with the forearm vertical and the palm supinated<br />
(forward), elbow flexion is about 150 degrees for most people. Although the<br />
active ROM is normally less than passive ROM, both can be affected by pain<br />
tolerance or inhibition, training, and motivation.<br />
Joint angles can be measured with a goniometer. The accuracy of a<br />
goniometer depends on landmarks. Measurements are most accurate when<br />
landmarks are definite. Range of motion can be approximated by comparing<br />
opposite extremities or using a person of similar age, sex, and physique as a<br />
standard. Goniometers are normally used to measure a joint's passive ROM.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
If joints and the agonist are normal, the main factor limiting ROM is the<br />
tissue extensibility of the antagonist. If the antagonist fails to lengthen<br />
normally during contraction of the agonist, the joint's range of motion will be<br />
limited. This explains why active range-of-motion testing measures the<br />
strength of the agonist, the length of the antagonist, and the amount of motion<br />
available to a specific joint. The three main ways to increase the active ROM<br />
are strengthen the agonist, lengthen the antagonist, and loosen the joint.<br />
The following table defines active, passive, active-assisted, and resisted<br />
range-of-motion testing.<br />
Active range-of-motion testing: the force for the movement is provided by<br />
the patient without assistance or resistance from the examiner.<br />
Passive range-of-motion testing: the force for the movement is provided by<br />
the examiner without assistance or resistance from the patient.<br />
Active-assisted range-of-motion testing: the force for the movement is<br />
provided by the patient with some assistance from the examiner.<br />
Resisted range-of-motion testing: the force for the movement is provided by<br />
the patient and works against resistance from the examiner.<br />
For the safety of the patient, active, passive, and active-assisted range-ofmotion<br />
testing should always be done first, and resisted range-of-motion<br />
testing last. Active range-of-motion testing gives the examiner a chance to<br />
observe the patient's ROM with gravity as the only outside force. If the active<br />
ROM is normal, the final step is resisted range-of-motion testing.<br />
If the patient fails active range-of-motion testing, the next step is using<br />
passive range-of-motion testing to evaluate the ROM. If the patient's ROM is<br />
incomplete, the probable causes are joint dysfunction, spasm, or contracture. If<br />
the patient's range of motion is normal, active-assisted range-of-motion testing<br />
can be used to identify weakness. Possible causes for weakness are neurologic<br />
dysfunction, lack of motivation, pain, disuse atrophy, or fatigue. If a patient<br />
fails muscle testing at any level, it is normally better to stop and treat the<br />
problem than to continue with muscle testing.<br />
30<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
31<br />
(1) Active Range-of-Motion Testing<br />
Postural muscles can be tested as a group by using active range-of- motion<br />
testing against gravity. A patient who completes active range-of- motion<br />
testing without incident can then be safely tested using resisted range-ofmotion<br />
testing. The following five tests evaluate the strength of muscle groups<br />
that are often connected with low back pain.<br />
• Upper abdominal muscles (without psoas): bent-leg sit-ups.<br />
• Upper abdominal muscles (with psoas): straight-leg sit-ups.<br />
• Lower abdominals: leg lifts.<br />
• Upper back muscles: upper body extension from prone position.<br />
• Lower back muscles: lower body extension from prone position.<br />
If the patient is unable to move a body part against gravity, the same<br />
movement should not be tested against manual resistance. Additional<br />
resistance may traumatize tissue and cause the patient needless discomfort.<br />
The next logical step is passive range-of-motion testing. If active range-ofmotion<br />
testing is normal, passive and active-assisted range-of-motion testing<br />
are optional. The tester can move directly from active range-of-motion testing<br />
to resisted range-of-motion testing.<br />
(2) Passive Range-of-Motion Testing<br />
If the examiner applies moderate force and finds the patient's range of<br />
motion is still restricted, the three most likely causes are joint dysfunction,<br />
spasm, or contracture. The way body parts feel as they reach the end of their<br />
range of motion will sometimes show which structure is most culpable, the<br />
joint or muscle.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The end-feel for most joints is either hard like elbow extension or soft like<br />
elbow flexion. End-feels that are soft when they should be hard or hard when<br />
they should be soft indicate joint dysfunction. If the problem appears to be<br />
joint dysfunction, palpate the joint for signs of heat, swelling, or pain. Normal<br />
joints are never swollen and normal ligaments are not painful when palpated.<br />
The next possibility to investigate is spasm or contracture. Spasms can<br />
result from calcium deprivation (carpopedal spasm), sewing or writing<br />
(occupational spasm), spasmodic contraction of muscles (intentional spasm),<br />
disease (myopathic spasm), or trauma (charley horse). Contractures, on the<br />
other hand, are caused by tissue fibrosis (ischemic contracture), sleeping in or<br />
maintaining a position that allows the muscles to shorten (functional<br />
contracture), or the effects of heat or chemicals (physiological contracture).<br />
Both spasm and contracture restrict joint movement by increasing resistance to<br />
passive stretch.<br />
The initial end-feel for spasm or contracture is more like stretching a<br />
spring than either hard or soft: the greater the stretch, the greater the<br />
resistance. If properly applied, slow and steady tension will cause a decrease<br />
in resistance. The key points are (1) apply moderate force directly against the<br />
resistance and (2) use slow and steady pressure. Unlike pathologic joints that<br />
normally become more painful with stretching, muscles in a state of spasm or<br />
contracture often become less painful as tissues approach their normal length.<br />
(3) Active-Assisted Range-of-Motion Testing<br />
If the patient's passive ROM is normal, the next step is active-assisted<br />
range-of-motion testing. If a full range of motion is possible with assistance<br />
from the examiner, the implication is muscular weakness. Having the patient<br />
move as far as possible in one direction and then using manual assistance to<br />
complete the range of motion will help to identify which muscles or muscle<br />
groups are weak. The normal approach at this point is using facilitation<br />
techniques or therapeutic exercise to strengthen weak muscles. Facilitation<br />
techniques such as methods for activating spindle cells and repeated<br />
contraction are part of neuromuscular therapy. Therapeutic exercises to<br />
strengthen weak muscles are called progressive resistance exercises.<br />
32<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
33<br />
(4) Resisted Range-of-Motion Testing<br />
If the patient's active range of motion is normal, the final step is resisted<br />
range-of-motion testing. Even if active, passive, and active-assisted range-ofmotion<br />
testing are normal, weakness may still exist because of injury, disuse,<br />
or disease. Resisted range-of-motion testing (muscle testing) is the best way to<br />
identify weakness.<br />
In resisted muscle testing, strength is measured by having a muscle hold or<br />
move against manual resistance. Holding against resistance is easier to apply<br />
than moving against resistance and less likely to involve joints than moving<br />
against resistance. To hold against resistance, the examiner applies an<br />
isometric force and the patient applies an isometric counterforce.<br />
Resisted muscle testing is seldom used to measure the patient's maximum<br />
strength unless the muscle is abnormally weak. Nor should muscle testing<br />
ever be used as a form of competition between the patient and the examiner.<br />
Since leverage should normally favor the examiner, care should be taken not to<br />
injure the patient by using excessive force.<br />
Even though some systems for measuring muscle testing apply percentages<br />
to each grade and use pluses and minuses to create more levels, the most<br />
workable grading system for muscle testing uses six levels of measurement<br />
that range from 5 to 0. Despite claims to the contrary, manual muscle testing<br />
is far more subjective than muscle testing that uses machines.<br />
MUSCLE TESTING BY GRADE<br />
NORMAL 5 Hold against gravity and full resistance<br />
GOOD 4 Hold against gravity and some resistance<br />
FAIR 3 Complete range of motion against gravity<br />
POOR 2 Complete ROM with gravity eliminated<br />
TRACE 1 Evidence of contraction only<br />
ZERO 0 No evidence of contraction<br />
Note: Normal is a higher grade than Good.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The difficulty in using this scale is knowing whether to grade a muscle<br />
as normal (5) or good (4). A strong patient with serious disability may<br />
sometimes test higher than a weak patient with a minor disability. A strong<br />
patient can lose a greater percentage of strength than a weak person and still<br />
hold against gravity and give the appearance of normal strength. Bilateral<br />
comparison is one way to cross-check the results of muscle testing.<br />
If only one side of the body is involved, check the muscles on the<br />
impaired side before checking muscles on the opposite side. If the muscles<br />
on the impaired side are the weakest, a grade of 5 for the impaired side may<br />
be too high. If muscles on both sides of the body test the same, a grade of 4<br />
for the impaired side may be too low.<br />
Because of handedness, the tendency to use one hand in preference to<br />
the other, dominant side muscles are normally stronger than weak side<br />
muscles. Since most people are right-handed, the left side testing stronger<br />
than the right side may indicate weakness on the right.<br />
Muscle testing is based on the premise that no two muscles perform<br />
exactly the same function. According to theory, each muscle can be tested<br />
separately if direction of force, amount of force, and position of patient are<br />
correct. The direction of force is normally opposite the direction of pull for<br />
the muscle being tested. Deviation from this direction allows the patient to<br />
substitute other muscles for the muscle being tested. The amount of force<br />
used will vary with size and condition of the patient. Examiners will learn<br />
how much force to use by experience. Since leverage normally favors the<br />
examiner, using too much force is more likely to cause inaccuracy than<br />
using too little force.<br />
Three types of positioning are used in muscle testing: (1) positioning to<br />
prevent substitution, (2) positioning to reinforce fixator muscles, and (3)<br />
positioning to create active insufficiency.<br />
(1) Positioning to Avoid Substitution<br />
Positioning isolates the muscle being tested by using stabilization to<br />
prevent substitution. If the muscle being tested is weak, stabilization<br />
prevents other muscles from contributing to the same movement by not<br />
allowing the body to change position. If the initial body position favors the<br />
34<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
pull of the muscle being tested, other muscles cannot be effective without<br />
repositioning the body to change their direction of pull. An example of<br />
stabilization is holding the elbow in place when testing the biceps brachii. If<br />
the elbow joint moves, upper arm flexors may substitute for elbow flexors.<br />
(2) Positioning to Reinforce Fixator Muscles<br />
Positioning combined with body weight and manual force can be used to<br />
reinforce fixator muscles that allow the insertion to move by locking the<br />
origin of a muscle in place. When a muscle contracts, tension pulls equally<br />
on both the origin and insertion. To produce movement, stabilizing the<br />
origin leaves the insertion, and the bone the insertion attaches to, free to<br />
move. If fixator muscles are weak, muscle testing will not be accurate.<br />
Fixator muscles are often antagonistic to the muscles being tested. If the<br />
muscles that stabilize the scapula (trapezius and serratus anterior) are weak,<br />
manual force should be used to fixate the scapula when testing the deltoid.<br />
(3) Positioning to Create Active Insufficiency<br />
Active insufficiency is the failure of any muscle to generate normal<br />
tension because the origin and insertion are too close. In certain positions,<br />
muscles that cross two joints cannot exert enough tension to produce a full<br />
range of motion in both joints simultaneously. If one- and two-joint muscles<br />
both perform the same function, placing the two-joint muscle at a<br />
mechanical disadvantage can be used to isolate the one-joint muscle. Twojoint<br />
muscles can be mechanically neutralized by using positioning to bring<br />
their origin and insertion closer together. Since muscles produce movement<br />
by generating tension, the slack created by approximating origin and<br />
insertion prevents the two-joint muscles from generating adequate tension to<br />
move both joints through their entire range of motion at the same time.<br />
As an example, both the one-joint gluteus maximus muscle and the twojoint<br />
hamstring muscle extend the hip. When the knee is flexed, the<br />
hamstring muscle cannot generate sufficient tension to extend the hip. This<br />
means that when the knee is flexed, the hamstring muscle is neutralized and<br />
the gluteus maximus can then be tested by using hip extension.<br />
35<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The same principle applies to the soleus and gastrocnemius. Though<br />
both muscles plantar flex the foot, the soleus is a one-joint muscle and the<br />
gastrocnemius is a two-joint muscle. When the knee is flexed: (1) slack in<br />
the gastrocnemius reduces plantar flexion strength by about 70 percent, and<br />
(2) the soleus can be partially isolated and tested by testing plantar flexion.<br />
● Three points are important for the safety of the patient:<br />
1. Apply resistance slowly (easy on).<br />
2. Do not break the patient's contraction.<br />
3. Remove resistance slowly (easy off).<br />
Resistance should be applied slowly to give the patient enough time to<br />
apply a counterforce. Force applied too quickly may break the patient's<br />
contraction and cause tissue damage. As a rule, the examiner should stop<br />
counterforce when the patient's contraction changes from isometric to<br />
eccentric and the muscle starts to yield. On the opposite side, force removed<br />
too quickly may cause a rebound effect and cause tissue damage.<br />
Isometric resistance is normally applied when a muscle is at or slightly<br />
beyond normal resting length. Because of the arrangement of myofilaments<br />
in the sarcomeres and the viscoelastic properties of a muscle, most muscles<br />
are strongest when the muscle is at or near resting length and weakest when<br />
the muscle is fully stretched or fully shortened. Resting length is normally<br />
about midway between fully contracted and fully stretched. The biceps<br />
brachii approaches resting length when the elbow is flexed to about ninety<br />
degrees.<br />
As a caution, testing a muscle when distal and proximal insertions are<br />
not far enough apart to keep tension on a muscle during contraction may<br />
cause cramping. Any condition that allows actin and myosin myofilaments<br />
to overlap seems to encourage painful spasm. This can be demonstrated by<br />
placing the elbow joint in full flexion (sagittal plane) and then slowly and<br />
carefully contracting the biceps brachii. With only mild contraction, the<br />
biceps will normally start to cramp.<br />
Although high degrees of precision are sometimes required, most<br />
muscles can be tested as a group. According to Beevor's axiom, the body<br />
36<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
knows nothing of individual muscles but thinks only in terms of movement.<br />
Since movements depend on muscles working in combination with each<br />
other, muscles that perform a similar movement can often be tested as a<br />
group by testing a movement. The most commonly tested movements are:<br />
• Flexion and extension<br />
• Supination and pronation<br />
• Abduction and adduction<br />
• Inversion and eversion<br />
• Medial and lateral rotation<br />
Muscle testing by group is most effective when combined with feedback<br />
and palpation to identify the muscles that are most affected. If contraction<br />
causes pain, both contractile structures and closely related non-contractile<br />
tissues are probably involved. The most likely non-contractile tissues to be<br />
implicated are tendons and aponeuroses.<br />
Palpation can be used to identify offending tissues. Involved muscles<br />
are normally indurated, ropy, and painful. In severe cases, palpation of<br />
irritated muscles will cause fasciculations or twitching and the patient will<br />
show signs of a sympathetic response such as perspiration, changes in skin<br />
temperature, or pilomotor activity (erection of hairs and goose flesh).<br />
If contraction is painful, the examiner should palpate for signs of<br />
impairment when the muscle is relaxed. Even though most muscles are<br />
easier to palpate when relaxed, impairments are sometimes more<br />
conspicuous when muscles are contracted. When using palpation, start with<br />
light pressure and use moderate or heavy pressure only if needed.<br />
Even though observation should always be used with palpation, visible<br />
signs are often less reliable than kinesthetic signs. Involved muscles may be<br />
larger than normal because of swelling or smaller than normal because of<br />
atrophy. The tissues related to affected muscles may be red (flushed) and<br />
hot because of inflammation and vasodilation or pale (blanched) and cold<br />
because of anxiety and vasoconstriction. The tissues related to affected<br />
muscles may also appear to be normal. This makes using infrared<br />
thermography to identify irritated tissues extremely difficult, since the<br />
temperatures of the affected tissues can be hot, cold, or normal.<br />
37<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
38<br />
CONTRAINDICATIONS<br />
Even though diagnosis is not considered part of soft-tissue therapy,<br />
evaluations are necessary for two reasons: (1) to decide if soft-tissue<br />
therapy is contraindicated for any reason and (2) to identify the best course<br />
of therapy for each patient. Without evaluations, patients could be exposed<br />
to potentially dangerous treatments because of failure to identify<br />
contraindications. Even if soft-tissue therapy is indicated, the quality of<br />
treatment is likely to suffer if the patient's condition is not properly<br />
evaluated.<br />
Soft-tissue therapy is contraindicated by the vast majority of serious<br />
pathological findings. The ones most frequently cited are malignancies,<br />
cardiac or circulatory disease, and severe respiratory disease. Even though<br />
soft-tissue therapy is less likely to cause bone damage than high-velocity,<br />
low-amplitude manipulations, the risk of fracture is always present,<br />
especially if bones are weak because of disease or recent trauma.<br />
Soft-tissue therapy is contraindicated by spinal cord lesions, nerve root<br />
damage, or severe neurologic dysfunction. These conditions are often<br />
characterized by extreme pain that remains constant regardless of position,<br />
paresthesia, anesthesia, or weakness that occurs with or without pain.<br />
Conditions involving acute inflammation, infection, or bleeding are<br />
normally contraindicated. The signs of inflammation are pain, swelling,<br />
heat, redness, and loss of function. Soft-tissue therapy is contraindicated if<br />
treatments cause unexplained sickness, dizziness, nausea, or disorientation.<br />
Some conditions, diseases, or injuries are contraindicated when acute but<br />
indicated when subacute. Pregnancy, age, general health, and psychological<br />
fitness can also be factors. If there is any doubt, refer the patient to a<br />
specialist and get a written prescription before treatment.<br />
The following conditions may contraindicate soft-tissue therapy.<br />
acute bursitis Active inflammation of the bursa.<br />
agenesis of the odontoid process Failure of the odontoid process to<br />
develop properly.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
39<br />
cardiac decompensation Failure of the heart to maintain adequate<br />
circulation.<br />
cellulitis Inflammation of cellular or connective tissue.<br />
communicable disease Diseases transmitted directly or indirectly<br />
from one person to another.<br />
degenerative bone disease A disease characterized by impairment<br />
or deterioration of the bone.<br />
degenerative joint disease A disease characterized by impairment or<br />
deterioration of the joint.<br />
Down's syndrome A chromosomal abnormality that may involve<br />
cervical deformation.<br />
encephalitis Inflammation of the brain.<br />
fever Elevation of temperature above normal.<br />
hernia Projection of an organ or part through the wall of a cavity that<br />
normally contains it.<br />
infections Invasion of a body by a pathogenic agent that multiplies and<br />
causes injury.<br />
infectious arthritis Arthritis because of infection.<br />
inflammatory edema Edema because of inflammation.<br />
kidney failure Reduced or complete loss of kidney function.<br />
laceration A jagged wound caused by tearing.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
40<br />
lesions An injury or pathologic change in tissue.<br />
nonunion fracture A fracture that has failed to knit.<br />
osteoarthritis Degenerative joint disease characterized by<br />
degeneration of articular cartilage and overgrowth of bone.<br />
phlebitis Inflammation of a vein.<br />
rash A skin eruption that is normally red in color.<br />
recent surgery A condition characterized by acute trauma.<br />
rheumatoid arthritis An extension of synovial tissue over articular<br />
cartilage that causes deformity and disability.<br />
severe burns Serious tissue injury caused by thermal, chemical,<br />
electrical, or radioactive agents.<br />
severe hypertension Blood pressure judged to be significantly higher<br />
than normal.<br />
severe hypotension Blood pressure judged to be significantly lower<br />
than normal.<br />
synovitis Inflammation of a synovial membrane.<br />
thrombus A blood clot obstructing a vessel or cavity of the heart.<br />
vertebral artery disorder A dysfunction of the vertebral artery.<br />
vertigo A sensation that objects are spinning or whirling around the<br />
person (objective vertigo) or the person is moving around in space<br />
(subjective vertigo).<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
41<br />
PAIN<br />
Pain is often defined as the perception of an unpleasant or disquieting<br />
sensation. Most people seek therapy because of pain and most patients<br />
judge the effectiveness of therapy by how it affects their pain. Patients are<br />
more likely to complain about pain than loss of function. In severe cases,<br />
pain becomes a disease in its own right, with characteristic signs and<br />
symptoms. An understanding of pain is invaluable to a therapist since pain is<br />
often the only indicator of underlying pathology. Left untreated, pain is a<br />
frequent cause of physical and psychological disability.<br />
Pain results from stimulation of specialized nerve endings called<br />
nociceptors that are sensitive to noxious stimuli such as changes in<br />
temperature (thermosensitive), mechanical stress (mechanosensitive), or<br />
noxious chemicals (chemosensitive). Nociceptors transmit a signal to the<br />
central nervous system that alerts the organism to actual or potential tissue<br />
damage. Nociceptors have myelinated axons that respond to thermal or<br />
mechanical stimuli or unmyelinated axons (polymodal receptors) that<br />
respond to all three types of noxious stimulation—thermal, mechanical, and<br />
chemical. Though very little is completely understood about pain receptors,<br />
two of the most common causes for soft-tissue pain are spasm and ischemia.<br />
In terms of mechanical stress, tension and compression can both cause<br />
pain. Passive movements are more likely to cause pain by stressing inert<br />
tissues such as ligaments and fascia, while active movements are more likely<br />
to cause pain by stressing contractile structures such as muscles, tendons, or<br />
aponeuroses.<br />
When traumatized, tissues release pain-producing substances such as (1)<br />
histamine, (2) serotonin, (3) bradykinin, (4) proteolytic enzymes, and (5)<br />
potassium ions. Injured tissues also release arachidonic acid, which<br />
stimulates production of prostaglandins. Steroids and salicylates such as<br />
aspirin (acetylsalicylic acid) relieve pain by interfering with the production<br />
of prostaglandins. Methyl salicylate is found in oil of wintergreen.<br />
Pain can be beneficial when it protects the body from tissue damage by<br />
causing the victim to withdraw from a harmful stimulus or to remove the<br />
stimulus. When tissue damage becomes so severe that pain receptors are<br />
destroyed, the absence of pain makes it difficult for victims to avoid injury.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Pain can be debilitating and lead to a loss of function long after the<br />
original injury has apparently healed. Continuation of pain in this manner is<br />
called a pain cycle because the pain continues to perpetuate itself for no<br />
apparent reason. It is common to find this condition mistakenly diagnosed<br />
as some form of neurosis. In a patient with no history of mental illness, pain<br />
is more likely to be the cause of neurosis than to be the effect. Regardless of<br />
origin—organic or psychogenic—pain is always subjective.<br />
A twelve-point sequence that explains self-perpetuating pain cycles<br />
involves (1) trauma, (2) inflammation, (3) edema, (4) impaired circulation,<br />
(5) spasm, (6) ischemia, (7) hypoxic damage, (8) proliferation of connective<br />
tissue, (9) adhesions, (10) contractures, (11) entrapment neuropathies, and<br />
(12) myofascial trigger points. This sequence is fairly consistent from one<br />
patient to another and each step contributes directly or indirectly to pain.<br />
Although pain for most people is more than just imaginary, the<br />
psychological component of pain cannot be ignored. Different people<br />
respond to pain differently because of culture, personality, experience, and<br />
motivation. High-intensity pain for one person may be low-intensity pain<br />
for another. Concentrating on pain seems to intensify the effects, whereas<br />
focusing attention elsewhere seems to minimize the effects. As most<br />
practitioners can testify, distraction does more to lessen the patient's<br />
perception of pain than telling a patient to relax and not worry. Focusing on<br />
the possibility of pain seems to intensify the pain.<br />
Because of differences in the way people perceive pain, a therapist<br />
should try to estimate the patient's pain tolerance. One way is to apply a<br />
mildly painful stimulus and note the results. The lowest intensity of<br />
stimulation that causes pain is called the pain threshold. Responses sooner<br />
than normal indicate hyperalgesia and responses later than normal indicate<br />
hypalgesia. This information will make it easier for the therapist to evaluate<br />
complaints of pain before, during, and after treatment.<br />
Purely psychogenic pain is possible, but far less common than once<br />
supposed. Absence of signs, exaggeration of symptoms, increased bed rest,<br />
denial of emotional factors, and refusal to cooperate or be touched may<br />
indicate a need for psychological or psychiatric counseling.<br />
On the opposite side, failure to identify the causes of pain should not be<br />
automatic grounds for claiming psychogenic origin. Historically, many<br />
42<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
cases of soft-tissue pain and disability were diagnosed as psychogenic<br />
because doctors were unable to identify the organic causes for pain. Now<br />
that most doctors recognize the organic nature of soft-tissue pain, the quality<br />
of treatment is far better. When acute soft-tissue injuries are treated<br />
correctly, there is less chance of chronic pain.<br />
Although many descriptive words can be used to describe pain, the<br />
characteristics of superficial pain and deep pain are different. Superficial<br />
pain is often described as sharp prickling pain, whereas deep pain is<br />
described as dull aching pain. Superficial pain is normally well defined and<br />
corresponds more closely with points of origin than deep pain. Deep pain,<br />
on the other hand, is likely to be highly diffuse and produce autonomic<br />
responses such as pallor, hypotension, diaphoresis (perspiration), or nausea.<br />
Another expression used to describe pain is a prickling or tingling<br />
sensation that resembles "pins and needles." This feeling called paresthesia<br />
is normally caused by pressure on a central or peripheral nerve. Physical<br />
examination of the patient may reveal anesthesia or partial paralysis.<br />
Pain felt at some distance from the point of origin is called referred pain.<br />
The origin of pain seldom corresponds exactly with the patient's perception<br />
of where the pain is located. As a rule, the closer the offending tissue is to<br />
the surface of the body, the greater the correlation between the origin of pain<br />
and feelings of pain. At the level of the spinal cord, visceral organs and the<br />
skin frequently share a common synapse. For this reason, pain originating<br />
from visceral organs is sometimes referred to the skin and vice versa. The<br />
gallbladder refers pain to the tip of the right shoulder.<br />
According to Hilton's law, the nerve trunk that supplies a joint also<br />
supplies the muscles that move the joint and the skin that covers the<br />
insertions of the muscles that move the joint. Pain originating from one<br />
structure—joint, muscle, or skin—can be referred to the other structures.<br />
Except for elbow and knee pain that radiates in all directions and<br />
cervical pain that radiates upward, most pain radiates away from the midline<br />
and downward. As pain becomes more intense, radiation seems to increase.<br />
The source of pain that radiates simultaneously to both sides of the body is<br />
more likely to be central in origin than unilateral.<br />
Another source of referred pain is the irritation of either a nerve root or<br />
peripheral nerve. Nerve roots can be irritated by disc protrusions or bony<br />
43<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
osteophytes. The effects will depend on which type of nerve root is<br />
affected: sensory or motor. Irritation of a sensory nerve root can result in<br />
pain or anesthesia. Irritation of a motor nerve root can facilitate motor<br />
activities that cause pain or spasm. Irritation of a peripheral nerve because<br />
of nerve entrapment or injury can also result in pain or anesthesia.<br />
Whether pain or anesthesia occurs depends on what part of the nerve is<br />
affected. End organs and nerve endings are sensitive to pain, whereas<br />
pressure on the axon may cause paresthesia, hypoesthesia, anesthesia, or<br />
paresis. In sciatica, pain results from pressure on nerve endings in the dural<br />
sheath (lumbar spine), and not from direct pressure on the axon itself.<br />
Irritation of nerves will often radiate pain in characteristic patterns of<br />
distribution called sclerotomes, myotomes, or dermatomes. These patterns<br />
are based on segments that develop during embryonic growth. Intense pain<br />
radiated by deep somatic structures will follow a vague pattern of surface<br />
distribution called sclerotomes. Musculoskeletal pain is less difficult to<br />
localize and radiates pain segmentally by patterns called myotomes. Pain<br />
arising from the skin corresponds closely to the origin or source of pain.<br />
Skin pain is the easiest to localize and radiates patterns called dermatomes.<br />
With few exceptions, segmental pain refers distally from its point of<br />
origin. Pain originating in a segment can be referred distally to any part of<br />
the segment. Irritation of a nerve root radiates pain distally and normally<br />
downward. The same rule applies to spinal reflexes, which spread pain<br />
more easily down the cord than up the cord.<br />
Nerve root damage in the cervical spine from C-4 down is referred to the<br />
neck, shoulders, and down the arms. The thoracic spine refers pain in<br />
circular segments that have a posterior-to-anterior downward slope. Nerve<br />
root damage to the lumbar spine is referred to the hips and down the legs.<br />
The sacral spine refers pain to the buttocks and down the legs.<br />
Nerve root damage above C-4 can refer pain upward to the head.<br />
Tension-type or muscle-contraction headaches can sometimes be treated by<br />
relaxing the neck and back muscles with attachments that cross C-4.<br />
Segmental patterns are not always well defined, and one segment will<br />
sometimes overlap another segment. If one segment becomes dysfunctional<br />
because of nerve root damage, overlap from adjacent segments may be<br />
enough to cover the lost segment.<br />
44<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The distribution of pain within a segment can vary with the intensity of<br />
stimulation. Strong stimulus is more likely to involve the entire segment<br />
and overflow to adjacent segments than weak stimulus. According to Head's<br />
law, painful stimulus applied to areas of low sensitivity may not be felt<br />
where the stimulus is applied, but may be felt in adjacent areas of high<br />
sensitivity. This means the areas where pain originates and the areas where<br />
pain is felt may not be the same.<br />
Treating pain but ignoring the causes will seldom produce long-term<br />
benefits. Understanding how pain radiates will make it easier to locate the<br />
origins of pain and treat the origins. Understanding which structures are<br />
most sensitive to pain is another way to locate the origins of pain.<br />
45<br />
STRUCTURES MOST SENSITIVE <strong>TO</strong> PAIN<br />
HIGH SENSITIVITY<br />
MODERATE SENSITIVITY<br />
LOW SENSITIVITY<br />
Periosteum and joint capsule<br />
Ligaments, tendons, and muscles<br />
Articular cartilage and fibrocartilage<br />
The structures most sensitive to nociceptive stimulation are the<br />
periosteum and joint capsule. Ligaments and tendons are moderately<br />
sensitive to pain and muscles are less sensitive. Articular cartilage and<br />
fibrocartilage are almost insensitive to noxious stimulation.<br />
Severe pain resulting from spasm is more likely to implicate the tendon's<br />
periosteal attachment than implicate the muscle. In such a case, treating the<br />
tendon alone will be less effective than treating both the muscle and the<br />
tendon. Relaxing the muscle will ease tension on the tendon.<br />
Times of occurrence and quality of pain can also be factors when trying<br />
to locate the origins of pain. Daytime pain that intensifies with activity and<br />
then diminishes as the activity continues indicates spasm or muscle soreness.<br />
Activity seems to "loosen up" the muscles.<br />
During periods of inactivity, muscles tend to shorten and become less<br />
painful. With renewed activity, muscles that become short during inactivity<br />
are suddenly stretched and become painful again. With continued activity,<br />
the muscles return to their normal length and become less painful. This<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
explains why people with spasms are told to move about frequently rather<br />
than remain stationary for extended periods of time. Muscles that shorten<br />
during sleep, such as the gastrocnemius or soleus, often cause pain when a<br />
person gets up and starts to walk about. Because of the Achilles (calcaneal)<br />
tendon, pain may be felt in the heel that resembles the pain from a heel spur.<br />
Pain that continues both day and night, and wakes the patient during the<br />
night, is more likely to indicate joint damage or tissue inflammation than<br />
spasm. Morning stiffness involving the hands and feet is more likely to<br />
indicate rheumatoid arthritis than spasm. It should be noted, however, that<br />
muscular pain, like joint pain, may become worse during the day if spasm<br />
recurs or the muscle is aggravated by overuse.<br />
Another method for identifying the source of pain is to reproduce the<br />
movements that cause the pain and then determine which structures are<br />
involved. If pain occurs during contraction, the cause is possibly agonistic<br />
or synergistic muscles being contracted or antagonistic muscles being<br />
stretched. If the pain is not being generated directly by the muscles, it can<br />
also be generated indirectly by any movements that stretch or compress<br />
sensitive tissue. Tremors during contraction may indicate pain.<br />
If pressing a point refers pain to another part of the body and ice applied<br />
to the same point eliminates the pain, the point being tested is probably the<br />
origin of pain. If cervical muscles are causing headaches, pressure on the<br />
muscles may cause headaches and ice applied to the same muscles may<br />
cause relief. Deep inhibitory pressure can sometimes be used in place of ice<br />
if the patient reacts poorly to ice or ice is not available. Patients are often<br />
surprised to find that the areas where they feel pain are not the origins of<br />
pain and that treating the origin relieves the pain.<br />
If the origin of pain is correctly identified and treated, the pain as<br />
perceived by the patient will normally disappear. If the pain continues, treat<br />
the painful area. There may be two origins of pain: (1) a proximal site<br />
where the patient perceives pain and (2) a distal site that refers pain.<br />
If therapy is applied and the pain disappears, the origin of pain has<br />
probably been located and treated. If therapy is applied and only part of the<br />
pain disappears, the method of therapy may be wrong or the pain may have<br />
more than one origin. If therapy is applied and the pain remains the same,<br />
the method may be wrong or the origin of pain may not have been treated.<br />
46<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
47<br />
CHAPTER SUMMARY<br />
FOUR CLASSICAL METHODS OF PHYSICAL EVALUATION<br />
• Percussion<br />
• Auscultation<br />
• Palpation<br />
• Inspection<br />
SIX GRADES OF MUSCLE TESTING ( 5 to 0)<br />
• Normal: Hold against gravity and full resistance ................................ 5<br />
• Good: Hold against gravity and some resistance................................. 4<br />
• Fair: Complete range of motion against gravity 3<br />
• Poor: Complete range of motion with gravity eliminated ................... 2<br />
• Trace: Evidence of contraction only .................................................... 1<br />
• Zero: No evidence of contraction......................................................... 0<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
48<br />
THREE POINTS CONCERNING MUSCLE-TESTING SAFETY<br />
• Apply resistance slowly (easy on).<br />
• Do not break the patient's contraction.<br />
• Remove resistance slowly (easy off).<br />
TWO TYPES OF PAIN<br />
• Superficial pain ....................................................... sharp prickling pain.<br />
• Deep pain........................................................................dull aching pain.<br />
THREE LEVELS OF SENSITIVITY <strong>TO</strong> PAIN<br />
• High sensitivity ........................................ Periosteum and joint capsule.<br />
• Moderate sensitivity .......................... Ligaments, tendons, and muscles.<br />
• Low sensitivity .............................Articular cartilage and fibrocartilage.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
49<br />
ALTERNATIVES<br />
The <strong>HEMME</strong> <strong>APPROACH</strong> is a method for matching therapeutic problems<br />
with practical solutions. Once the first two steps, HIS<strong>TO</strong>RY and EVALUATION,<br />
define the problem, the next three steps define the solution:<br />
M<br />
M<br />
E<br />
MODALITIES<br />
MANIPULATION<br />
EXERCISE<br />
The word ALTERNATIVES is not written in bold letters because it represents a<br />
choice and not a step. Even though a therapist can use any sequence that<br />
seems appropriate, the normal sequence is MODALITIES first, MANIPULATION<br />
second, and EXERCISE third. Modalities prepare the body for manipulation<br />
and then manipulation prepares the body for exercise.<br />
The three basic modalities used in the <strong>HEMME</strong> <strong>APPROACH</strong> are<br />
thermotherapy, cryotherapy, and vibration. If modalities are not appropriate,<br />
the therapist can proceed directly to the step titled MANIPULATION. Because of<br />
its flexibility, there is nothing in the <strong>HEMME</strong> <strong>APPROACH</strong> that prevents a<br />
therapist from bypassing a step or returning to a previous step if needed.<br />
The step titled MANIPULATION covers the four basic methods of<br />
manipulation used in the <strong>HEMME</strong> <strong>APPROACH</strong>: trigger point therapy,<br />
neuromuscular therapy, connective tissue therapy, and range-of-motion<br />
stretching.<br />
<br />
<br />
<br />
<br />
<strong>HEMME</strong> <strong>APPROACH</strong> MANIPULATIONS<br />
Trigger point therapy (trigger points)<br />
Neuromuscular therapy (nerve and muscle tissue)<br />
Connective tissue therapy (connective and epithelial tissue)<br />
Range-of-motion stretching (trigger points and all four tissues)<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The four categories under manipulations are based on anatomy and<br />
physiology. Trigger points are based on physiology. They have no discernible<br />
structure and cannot be dissected or biopsied. Neuromuscular and connective<br />
tissue therapy are based on anatomy. Neuromuscular therapy focuses on nerve<br />
and muscle tissue, and connective tissue therapy focuses on connective and<br />
epithelial tissue. Range-of-motion stretching affects all four types of tissue:<br />
nerve, muscle, connective, and epithelial tissue.<br />
If feedback shows therapy is not effective, other decisions can be made by<br />
using the model and taking the next appropriate step. If contraindications are<br />
discovered, discontinue treatment and exit the patient from the model by using<br />
the step titled OBJECTIVES NOT SATISFIED.<br />
If the objectives are not satisfied and the patient wishes to continue<br />
therapy, the patient can reenter the model at the step titled ENTER PATIENT.<br />
The step titled NEW INFORMATION is used to introduce new information from<br />
an outside source. Possible sources include other health care professionals,<br />
medical reference books, professional journals, and research papers.<br />
Reentering at any of the five basic steps can mean (1) taking additional<br />
history, (2) expanding the evaluation, or (3) changing the way modalities,<br />
manipulation, or exercise are used. Taking additional history or expanding the<br />
evaluation may be needed to redefine the problem. Changing the way<br />
modalities, manipulation, or exercise are used may be needed to redefine the<br />
solution. The two main reasons for therapeutic failure are (1) failure to<br />
identify the problem, and (2) failure to administer appropriate therapy.<br />
Effective reasoning combines logic and intuition with knowledge and<br />
experience. In therapy, intuition and right-brain thinking are often more<br />
productive than logic and left-brain thinking. While nothing guarantees<br />
perfection, certain procedures can make it easier to deal with a complex<br />
situation such as solving a therapeutic problem. These procedures can be<br />
applied mentally or in writing. The acronym SOS defines the three steps<br />
needed to simplify complex situations and find acceptable solutions:<br />
50<br />
S<br />
O<br />
S<br />
Separate the problem into parts.<br />
Organize the parts.<br />
Simplify the problem.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
First, separate the problem into parts. Most complex problems are nothing<br />
more than a series of smaller problems. Computer programmers are famous<br />
for breaking down complex programs into smaller parts or modules.<br />
Second, organize the parts by creating three categories: problems,<br />
principles of therapy, and solutions. Problems may change, but the principles<br />
of therapy are fairly constant. Workable solutions are principles of therapy<br />
that are correctly applied to the problem. Solution: If a muscle is short and<br />
weak (problem), lengthen first and strengthen second (principle).<br />
Third, simplify the problem by eliminating useless information. Eliminate<br />
facts that are not related to the problem and principles that are not needed to<br />
solve the problem. Some people use lines to connect usable facts with usable<br />
principles and Xs to eliminate useless information.<br />
Even though logic is the backbone of scientific investigation, intuition can<br />
be priceless. With a good scientific background and practical experience,<br />
practitioners may find that solutions appear by intuition after all attempts to<br />
reach a logical solution have failed. Intuition seems to be strongest when hard<br />
work and concentration are followed by rest. Since many famous inventors<br />
claim that some of their greatest ideas appeared to them in a dream, the value<br />
of dreaming as a source of insight should not be taken lightly.<br />
Regardless of how solutions are formed, where they come from, or who<br />
does the research, all solutions must be judged by the same scientific standard.<br />
The best way to meet objective, scientific standards is by using the scientific<br />
method. The purpose of the scientific method is to make logical connections<br />
between facts and theories. The scientific method implies:<br />
1. Completely identify the problem.<br />
2. Formulate preliminary theories by using experience.<br />
3. Collect relevant facts by using careful observation.<br />
4. Formulate final theories by using logic or intuition.<br />
5. Evaluate final theories by testing the consequences.<br />
6. Draw conclusions and formulate a solution.<br />
When correctly used, the scientific method produces solutions that are (1)<br />
objective, (2) verifiable, (3) reproducible, and (4) highly productive. The<br />
<strong>HEMME</strong> <strong>APPROACH</strong> itself is built on the scientific method.<br />
51<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
52<br />
CHAPTER SUMMARY<br />
TWO <strong>HEMME</strong> <strong>APPROACH</strong> STEPS THAT DEFINE THE PROBLEM<br />
• HIS<strong>TO</strong>RY<br />
• EVALUATION<br />
THREE <strong>HEMME</strong> <strong>APPROACH</strong> STEPS THAT DEFINE THE SOLUTION<br />
• MODALITIES<br />
• MANIPULATION<br />
• EXERCISE<br />
FOUR TYPES OF MANIPULATION IN <strong>HEMME</strong> <strong>APPROACH</strong><br />
• Trigger point therapy<br />
• Neuromuscular therapy<br />
• Connective tissue therapy<br />
• Range-of-motion stretching<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
53<br />
MODALITIES<br />
Modalities are used in soft-tissue therapy to improve the effectiveness of<br />
manipulation. Although seldom curative when used alone, modalities prepare<br />
patients for manipulation by reducing pain, controlling edema, reducing<br />
muscle spasm, and decreasing tissue viscosity.<br />
Manipulations are normally executed during or shortly after the<br />
application of modalities. When heat or cold are used, thermal effects are<br />
measured by calculating changes in body temperature above or below normal.<br />
Since large thermal effects produce more physiological changes than small<br />
thermal effects, time is critical. If too much time passes between the use of<br />
modalities and manipulation, temperatures return to normal, thermal effects<br />
diminish, and the benefits of using modalities are lost.<br />
On the negative side, thermal effects that are too large cause tissue<br />
damage. Tissue temperatures above 113°F may cause burning, and tissue<br />
temperatures below 32°F may cause frostbite. If patients are conscious and<br />
sentient, frostbite is potentially more dangerous than burning. Since ice<br />
produces analgesia, pain alerts patients to burning but not to freezing.<br />
CONTRAST APPLICATIONS<br />
Contrast applications produce large changes in body temperature. The<br />
cycle is normally four minutes of heat (104°F) followed by one minute of cold<br />
(55°F). This cycle is repeated four times, always starting with heat and ending<br />
with cold. At the same time contrast applications improve circulation, reduce<br />
edema, increase local metabolism, and hasten healing, they also act as a tonic<br />
and neuromuscular stimulant. Modalities that relax the neuromuscular system<br />
are often more conducive to soft-tissue manipulation than stimulants.<br />
A second problem with contrast applications relates to exposure. Four<br />
minutes of heat is not long enough to increase tissue extensibility and one<br />
minute of cold will not produce analgesic effects. Although frequently<br />
acclaimed as one of the most potent procedures in hydrotherapy, the ability of<br />
contrast applications to prepare the body for manipulation is limited. At best,<br />
contrast applications, such as a contrast bath, reduce muscle spasm and relieve<br />
pain by improving circulation and reducing edema.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
54<br />
THERMO<strong>THERAPY</strong><br />
Common methods for applying therapeutic heat include silicon gel packs,<br />
whirlpools, paraffin baths, and infrared light. Since moist air conducts heat<br />
more rapidly than dry air, moist heat is generally more penetrating than dry<br />
heat. Certain electric heating pads produce moist heat by trapping vapor that<br />
escapes from the body during the heating process. Although less popular than<br />
moist heat, infrared lamps do have certain advantages. First, they radiate<br />
continuous heat without producing pressure, and second, tissues can be heated<br />
and manipulated concurrently.<br />
Heat produces physiological, psychological, and reflex effects that<br />
influence the entire body. These include reduction of pain and spasm,<br />
vasodilation, increased phagocytosis, and perspiration. Most patients find that<br />
soaking in a hot bath (100°F-104°F) produces feelings of relaxation and wellbeing.<br />
These effects are mostly psychological. Temperatures above 104°F are<br />
very hot for most people and difficult to tolerate. Temperatures high enough<br />
to increase tissue extensibility are normally between 105°F and 110°F. Tissue<br />
damage normally starts when tissue temperatures reach 113°F and<br />
temperatures at this level are normally painful.<br />
When physical agents are being used, tissue temperature refers to the<br />
temperature of tissues and not the temperature of the heating or cooling<br />
modalities. A hot foot bath reaching temperatures as high as 115°F does not<br />
elevate tissue temperatures in the feet much higher than about 110°F. With<br />
exposure limited to the feet and soaking time 30 minutes or less, circulation of<br />
cooler blood from other parts of the body is adequate to cool the feet.<br />
Since most heating modalities in soft-tissue therapy are applied<br />
superficially, the effects of heat are normally topical. Three exceptions to this<br />
rule are (1) hydrostatic effect, (2) exposing the body to large volumes of heat,<br />
and (3) reflex effects.<br />
(1) Hydrostatic Effect<br />
The effects of heat can be systemic if heat causes vasodilation that<br />
increases blood flow from one body part to another. Hydrotherapy defines<br />
hydrostatic effect as fluids shifting within the body because of environmental<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
changes in temperatures. This explains why using a hot foot bath or hot sitz<br />
bath can relieve pulmonary congestion, restore normal breathing, and relax the<br />
patient. When circulation shifts heated blood from lower extremities to the<br />
chest, heated blood dilates blood vessels in the chest and relieves congestion.<br />
(2) Exposing Large Portions of the Body to Moist Heat<br />
Superficial heating becomes systemic if large portions of the body are<br />
exposed to moist heat for long periods of time. Immersed in a hot bath or<br />
sitting in a steam cabinet, the body may not be able to dissipate excess heat<br />
because (1) radiation, conduction, and convection are ineffective at<br />
temperatures above 95°F, (2) evaporation is ineffective when surrounding air<br />
is fully saturated with moisture and relative humidity reaches 100 percent, and<br />
(3) circulation stops cooling when core temperatures reach environmental<br />
temperatures.<br />
For patients who can tolerate the heat, the benefits are general relaxation,<br />
reduction of spasm, and greater tissue extensibility. Therapeutic stretching<br />
while patients are still immersed in hot water is more effective than stretching<br />
after they dry off and start to cool. After the patient has cooled, general<br />
relaxation may decrease or remain the same, reduction of spasm may continue,<br />
and tissues become less extensible and more difficult to stretch.<br />
(3) Reflex Effects<br />
Local heating produces reflexogenic changes in distal parts of the body.<br />
These include changes in muscular activity, circulation, enzymatic activity,<br />
and pain levels. Temperatures higher than 104°F and exposures longer than<br />
five minutes are needed to produce distal heating effects. Distal heating<br />
effects are not as vigorous as local heating effects.<br />
By lowering viscosity, heat increases tissue extensibility and decreases<br />
resistance to active or passive stretch. This makes it easier for patients to<br />
attain full range of motion with less force. As a caution, people using heating<br />
pads or hot water for pain relief on a long-term basis are likely to experience<br />
continuous pain and stiffness if the tissues cool at or below resting length.<br />
55<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Once tissue temperatures are elevated, restricted tissues should be actively or<br />
passively stretched and allowed to cool while fully extended. Tissues cooled<br />
at or below resting length have a tendency to become abnormally short.<br />
The contraindications for heat are bleeding, malignancy, inflammation,<br />
vascular insufficiency, edema, burns, fever, tuberculosis, general weakness,<br />
and debilitating diseases such as heart disease. Heat is contraindicated for<br />
patients who are insensitive to pain or unable to communicate pain.<br />
• Indications for heat modalities:<br />
A. Muscle Spasm<br />
B. Pain<br />
C. Contracture<br />
D. Vascular stasis<br />
CRYO<strong>THERAPY</strong><br />
Ice cubes, vapocoolant sprays, and ice packs are common ways to produce<br />
therapeutic cold. Ice massage refers to the practice of using pieces of ice to<br />
massage the body. By producing thermal effects and mechanical effects<br />
simultaneously, ice massage combines modality with manipulation.<br />
Applied for less than five minutes, ice massage increases muscle tone by<br />
reflex action and cools the skin. Since ice often produces burning pain before<br />
numbing takes effect, ice can be classified as a counterirritant. By acting as a<br />
counterirritant, ice massage relieves pain in the same way acupuncture relieves<br />
pain. The effects of vapocoolant sprays are similar to the short-term effects of<br />
ice massage. Applied for more than twenty minutes, ice massage produces<br />
long-term effects such as vasoconstriction, analgesia, and loss of tonus.<br />
Unlike heat, cold causes vasoconstriction that reduces blood flow and<br />
prevents circulation from warming the exposed body parts. Because of<br />
vasoconstriction, cold is more likely to penetrate deeply than heat. While deep<br />
cooling often requires about twenty to thirty minutes, cold penetrates small<br />
body parts, such as digits, more rapidly than large or fleshy body parts.<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The term hunting reaction implies that cold produces vasodilation when<br />
temperatures are low enough to cause tissue damage. Even if cold-induced<br />
vasodilation occurs, this principle is seldom applied to soft-tissue therapy<br />
because the practical uses of this concept (if true) are limited.<br />
The rebound effect is another way that cold produces vasoconstriction.<br />
When tissues are chilled by using a vapocoolant spray, blood vessels quickly<br />
vasodilate (rebound), as shown by capillary flare. The therapeutic value of this<br />
effect is difficult to assess. If the rebound effect in some way causes reflex<br />
inhibition, this could partially explain why less than five minutes of<br />
vapocoolant spray (or ice massage) seems to facilitate stretching.<br />
During the early stages of injury, cold reduces secondary hypoxic damage<br />
by decreasing tissue metabolism and neutralizing the effects of histamine and<br />
prostaglandin. These chemicals promote edema by increasing fluid infiltration<br />
from capillaries to intercellular spaces. Since prostaglandin is also a painproducing<br />
(algogenic) substance, cold reduces pain by slowing the conversion<br />
of arachidonic acid to prostaglandin.<br />
Cold-induced analgesia encourages exercise by controlling pain and<br />
reducing muscle spasm. Many patients refuse to use ice and most patients<br />
experience a burning or aching pain prior to analgesia. Cold reduces spasm by<br />
slowing nerve-conduction velocities and retarding the neural impulses from<br />
muscle spindles (spindle-shaped end organs in skeletal muscle that help to<br />
control tonus). This reduces facilitation and relaxes the muscle. Nerve<br />
conduction stops completely at tissue temperatures below 50°F.<br />
On the negative side, by increasing tissue viscosity, cold reduces tissue<br />
extensibility. If controlling pain and reducing spasm are more important than<br />
increasing tissue extensibility, cold can be used to prepare body parts for<br />
exercise. It will also help to control edema before, during, and after exercise.<br />
Cold is even more effective in controlling edema when combined with<br />
rest, elevation, and compression. The acronym RICE stands for (1) Rest, (2)<br />
Ice, (3) Compression, and (4) Elevation. These are the four main steps used in<br />
treating sports injuries. In sports medicine, crushed ice is normally applied to<br />
stabilized body parts for about twenty to thirty minutes with compression and<br />
elevation. Ice treatments are normally continued for about two days.<br />
Unlike heat, cold tends to decrease hemorrhage (bleeding) by causing<br />
vasoconstriction. If tissue edema and subcutaneous bleeding are present, cold<br />
57<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
is safer to use than heat. If tissue edema and subcutaneous bleeding are not<br />
present, either can be used to relieve muscle ache or spasm. Unlike cold, heat<br />
stimulates circulation by causing vasodilation, and many people prefer heat.<br />
Though not in the same way as heat, cold reduces pain by relaxing muscle<br />
spasm. By slowing the rate of discharge from the muscle spindle and<br />
increasing the rate of discharge from the Golgi tendon organs, cold reduces<br />
facilitation and increases inhibition. While heat reduces pain by acting as a<br />
counterirritant, cold relieves pain by slowing nerve-conduction velocities.<br />
Because it penetrates deeper, cold is more likely to relieve deep pain than heat.<br />
By acting as counterirritants, heat and cold can mediate pain chemically by<br />
causing the release of endorphins that produce analgesia.<br />
Where time is a factor and subcutaneous bleeding is not present, heat<br />
reduces muscle spasm faster than cold. Heat works by reflex effect on the<br />
gamma system and requires only enough time for shallow penetration. Cold<br />
works by slowing nerve conduction velocities and requires enough time for<br />
deep penetration. Cold applied briefly can trigger a stretch reflex that<br />
aggravates spasm and makes treatment even more difficult.<br />
During the later stages of injury, heat promotes healing by causing<br />
vasodilation that increases blood flow and raises tissue temperatures enough to<br />
accelerate metabolism. Vasodilation aids in the resolution of inflammatory<br />
infiltrates and metabolic waste. Prolonged use of cold after the acute stages of<br />
an injury may actually retard wound healing by restricting blood flow and<br />
slowing metabolism.<br />
To simplify the question of heat or cold, acute injuries are normally treated<br />
by cold and subacute injuries are treated by heat. Acute injuries become<br />
subacute when edema stops forming, normally about 36 to 48 hours after the<br />
injury. An exception to this rule is low back pain. Based on clinical<br />
experience, heat is often used during the acute stage to relieve spasm and cold<br />
is often used for the subacute stage to relieve chronic inflammation.<br />
Another point to consider is the difference between injury and re-injury. A<br />
condition may be subacute in terms of when the original injury occurred, but<br />
acute in terms of re-injury. Even if the original injury occurred three months<br />
ago, any condition resulting from the re-injury of poorly healed scar tissue<br />
should be treated as acute, not subacute.<br />
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Contraindications specifically for therapeutic cold are people with cold<br />
sensitivities, heart disease, and signs of general weakness. When people with<br />
sensitivities are exposed to cold, release of histamine causes edema and cold<br />
urticaria. Another contraindication to cold is Raynaud's disease, which causes<br />
abnormal vasoconstriction when extremities are exposed to cold.<br />
• Indications for cold modalities:<br />
A. Muscle spasm<br />
B. Pain<br />
C. Edema<br />
D. Trauma<br />
HEAT VS. COLD<br />
The following table explains why cold is recommended during the acute<br />
stage when body parts are swollen and heat is recommended during the<br />
subacute stage when circulation is needed to expedite healing.<br />
Normal Effects of Heat and Cold<br />
1. Relax muscle spasm.....................................................heat and cold<br />
2. Reduce pain..................................................................heat and cold<br />
3. Vasodilation ................................................................................heat<br />
4. Increase local metabolism ..........................................................heat<br />
5. Increase local circulation............................................................heat<br />
6. Increase edema............................................................................heat<br />
7. Increase inflammation ................................................................heat<br />
8. Increase tissue extensibility........................................................heat<br />
9. Vasoconstriction .........................................................................cold<br />
10. Decrease local metabolism..................................................cold<br />
11. Decrease local circulation....................................................cold<br />
12. Decrease edema ...................................................................cold<br />
13. Decrease inflammation........................................................cold<br />
14. Decrease tissue extensibility................................................cold<br />
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60<br />
VIBRATION<br />
Vibration has a relaxing effect on muscles and relieves pain. When<br />
patients cannot tolerate compression or stretching, vibration prepares the<br />
patient for manipulation by desensitizing the offending tissues. Part of the<br />
pain-relieving effect of vibration relates to the stimulation of A-beta nerve<br />
fibers that block conduction of the electrical impulses that transmit deep pain.<br />
Another part may relate to the heat produced by friction as vibration moves<br />
one molecule against another.<br />
By improving circulation, vibration reduces edema and hastens the<br />
resolution of inflammation. Resolution of inflammation refers to stopping<br />
inflammation by absorbing and removing the products of inflammation. To<br />
resolve inflammation, vibration should be applied at points distal to the<br />
inflammation, not directly to the inflammation.<br />
Mechanical vibration is normally more effective and less tiring than<br />
manual vibration. To sedate muscles, relax spasm, relieve pain, and stimulate<br />
circulation, vibratory treatments should be at least three minutes long.<br />
Treatments that are less than three minutes long may stimulate more than<br />
sedate. On one hand, regardless of which method of vibration is being used—<br />
mechanical or manual—small amounts of force normally sedate and large<br />
amounts of force normally stimulate. On the other hand, though heavy<br />
vibration tends to stimulate, the periods of time that follow heavy vibration are<br />
often characterized by relaxation and a visible decrease in muscle tonus.<br />
While stimulation, such as heavy vibration, tends to increase functional<br />
activity, overstimulation can have the opposite effect and decrease functional<br />
activity. Even though the Arndt-Schultz law is now considered obsolete, this<br />
law does mention that a strong stimulus can retard physiologic activity.<br />
Contraindications for vibration include: inflammation, heart disease,<br />
open lesions, blood clots, hemorrhage, infection, malignancy, cerebellar<br />
dysfunction, infants, and overly sensitive or inelastic skin. Applying<br />
mechanical vibration with too much downward pressure can increase the<br />
risk of tissue damage and decrease the frequency of vibration.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
61<br />
CHAPTER SUMMARY<br />
FOUR INDICATIONS FOR HEAT MODALITIES (THERMO<strong>THERAPY</strong>)<br />
• Muscle spasm<br />
• Pain<br />
• Contracture<br />
• Vascular stasis<br />
FOUR INDICATIONS FOR COLD MODALITIES (CRYO<strong>THERAPY</strong>)<br />
• Muscle spasm<br />
• Pain<br />
• Edema<br />
• Trauma<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
62<br />
SEVEN MAJOR CONTRAINDICATIONS <strong>TO</strong> HEAT<br />
• Bleeding<br />
• Malignancy<br />
• Inflammation<br />
• Vascular insufficiency<br />
• Edema<br />
• General weakness<br />
• Heart disease<br />
FOUR MAJOR CONTRAINDICATIONS <strong>TO</strong> COLD<br />
• Cold sensitivities<br />
• Heart disease<br />
• General weakness<br />
• Raynaud's disease<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
63<br />
MANIPULATION<br />
Soft-tissue therapy is based on a series of scientific principles that are often<br />
called axioms or laws. Although principles can make it easier to simplify<br />
complex ideas, they do change. Pflüger's Laws of Unilaterality, Symmetry,<br />
Intensity, and Radiation are classical examples.<br />
Written in 1853 by the German physiologist Edward Pflüger, these laws<br />
were widely accepted for more than 50 years. When all four laws were<br />
shown to be invalid by Dr. Charles Sherrington in 1915, these laws became<br />
scientific history. This explains why the Laws of Unilaterality, Symmetry,<br />
Intensity, and Radiation are no longer taught in medical schools or found in<br />
medical textbooks or dictionaries today.<br />
Another law that has recently been questioned is the Arndt-Schultz law:<br />
Weak stimulus causes activity, moderate stimulus increases activity, strong<br />
stimulus retards activity, and very strong stimulus stops activity. While this<br />
law seems to explain the sequence that occurs when digital pressure is<br />
applied to trigger points—pain increases with increases in pressure until<br />
numbness occurs—other situations involving painful stimulation produce<br />
continuous pain instead of numbness. Stedman’s Medical Dictionary (26th<br />
ed.) shows the Arndt-Schultz law as obsolete.<br />
The following principles, on the other hand, are still widely accepted by<br />
medical science. These principles explain why forces applied to the human<br />
body produce certain changes that are beneficial.<br />
THE PRINCIPLES OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong><br />
The <strong>HEMME</strong> <strong>APPROACH</strong> is based on three fundamental laws:<br />
<strong>HEMME</strong>’s 1st law: Most conditions treatable by soft-tissue therapy are<br />
characterized by pain, limited range of motion, or weakness.<br />
<strong>HEMME</strong>’s 2nd law: Most conditions treatable by soft-tissue therapy can<br />
be identified and treated by using five basic steps: History, Evaluation,<br />
Modalities, Manipulation, and Exercise.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
<strong>HEMME</strong>’s 3rd law: Always be ready, willing, and able to disregard any<br />
law, principle, axiom, or belief that proves to be incorrect.<br />
Ten other principles that apply to soft-tissue therapy include:<br />
1. Beevor's axiom: The brain knows nothing of individual muscles, but<br />
thinks only in terms of movement.<br />
2. Creep: Deformation of viscoelastic materials when exposed to a slow,<br />
constant, low-level force for long periods of time.<br />
3. Facilitation-Inhibition:<br />
A. When a nerve impulse passes once through a set of neurons to<br />
the exclusion of other neurons, it usually takes the same path in<br />
the future and resistance to the impulse becomes less.<br />
B. As opposites, facilitation encourages a process and inhibition<br />
restrains a process.<br />
4. Head's law: If painful stimulus is applied to areas of low sensibility<br />
in close central connection with areas of high sensibility, pain may be<br />
felt where sensibility is high.<br />
5. Hilton's law: The nerve trunk that supplies a joint also supplies the<br />
muscles that move the joint and the skin that covers the insertions of<br />
the muscles that move the joint.<br />
6. Hysteresis: Energy loss in viscoelastic materials subjected to stress<br />
or to cycles of loading and unloading.<br />
7. Sherrington's laws:<br />
A. Every posterior spinal root nerve supplies one particular region<br />
on the skin, although fibers from segments above and below<br />
can invade this region.<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
65<br />
B. Reciprocal Inhibition: when the agonist receives an impulse to<br />
contract, the antagonist relaxes.<br />
C. Irradiation: nerve impulses spread from a common center<br />
and disperse beyond the normal path of conduction.<br />
Dispersion tends to increase as the intensity of stimulus<br />
becomes greater.<br />
8. Sherrington's reflex: A muscle contracts in response to passive<br />
longitudinal stretch. (also called stretch reflex or myotatic reflex)<br />
9. Thixotropy: Certain gels liquefy when agitated and revert to gel upon<br />
standing.<br />
10. Wolff's law: Bone and collagen fibers develop a structure most suited<br />
to resist the forces acting upon them.<br />
HIGH-VELOCITY MANIPULATIONS<br />
Soft-tissue therapy is broadly defined as manipulation of superficial or soft<br />
tissue for therapeutic purposes. Deep tissues are directly affected by<br />
superficial pressure and indirectly affected by reflex effects. Manipulations in<br />
soft-tissue therapy are normally low-velocity movements that push or pull<br />
tissues without high-velocity thrusting or impact.<br />
High-velocity manipulations are thought to relieve pain and spasm by<br />
stimulation of mechanoreceptors and reflex effects. By separating joints,<br />
breaking adhesions, and stretching ligaments, thrusting movements increase<br />
mobility and relieve pressure on nerves. In many cases, relief is short-term<br />
and patients develop long-term dependency on treatment.<br />
When forces strong enough to cause permanent deformation are applied<br />
slowly, tissues absorb the energy and deform plastically without tearing.<br />
When strong forces are applied rapidly, tissues have less time to absorb the<br />
energy and tearing becomes more likely than plastic deformation. Because of<br />
their rapid movements, high-velocity techniques are potentially more<br />
dangerous to use than low-velocity techniques.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Tearing debilitates a skeletal muscle in three ways: (1) a loss of voluntary<br />
control, (2) a loss of strength, and (3) a loss of tissue extensibility. First,<br />
connective tissue cannot contract or relax voluntarily. Contraction of<br />
connective tissue during wound healing or expansion of connective tissue<br />
during stretching are not the same as the voluntary contraction or relaxation of<br />
muscle tissue in response to commands from the central nervous system.<br />
Second, where muscle tissue has the ability to shorten, exert force, and<br />
counteract or overcome external resistance, the shortening that occurs in<br />
connective tissue has the ability to counteract resistance, but not the ability to<br />
overcome resistance. Even though connective tissue has the ability to<br />
counteract resistance by increasing a muscle's resistance to active or passive<br />
stretch—as in the case of scar tissue or contractures that increase tightness and<br />
decrease range of motion—connective tissue does not have the ability to<br />
overcome resistance and produce normal movement.<br />
Since one measure of strength is the ability of a muscle to exert force,<br />
overcome resistance, and produce movement, replacing muscle tissue with<br />
connective tissue may cause a decrease in strength. If a large percentage of<br />
muscle tissue is replaced by connective tissue, the affected agonist will<br />
normally test weaker because of less muscle tissue and the antagonist may test<br />
weaker because of tightness or shortness in the agonist.<br />
Third, since damaged muscle tissue is often repaired or replaced by<br />
connective tissue that is less extensible than muscle tissue, tearing within a<br />
muscle often reduces extensibility. As a result of tearing, muscles become<br />
weaker and more resistant to active or passive stretching unless range-ofmotion<br />
stretching is used to restore a muscle to its normal length.<br />
Constant tearing can also affect ligaments. After repeated bouts of tearing<br />
and overstretching, ligaments remain stretched and joints become<br />
hypermobile. Since most joints rely on ligaments more than muscles for<br />
stability, the results of ligament damage are (1) the joint becomes unstable and<br />
(2) muscles are forced to compensate for loss of ligamentous support.<br />
Compensating for loss of ligamentous support can lead to overexertion and<br />
spasm. When muscles are locked in spasm, high-velocity manipulations are<br />
more likely to cause tearing than relaxation. If torn muscles intensify the<br />
existing spasm, the cycle may become (1) spasm, (2) high-velocity<br />
manipulation, (3) tearing, and (4) spasm. As a result of this cycle, patients<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
experience another cycle: (1) pain and stiffness, (2) high-velocity<br />
manipulation, (3) short-term relief, and (4) pain and stiffness. This cycle often<br />
continues until the high-velocity treatments are stopped or joints become<br />
totally unstable.<br />
Even if high-velocity manipulations are stopped, the scar tissue laid down<br />
during tearing can still be a problem. Once scar tissue forms within a muscle,<br />
losses of strength and extensibility increase the risk of re-injury. Re-injuries<br />
may cause protective spasm that limits range of motion and causes pain.<br />
Indications of re-injury such as joint stiffness and pain normally occur within<br />
24 to 48 hours after the insult.<br />
Original injuries and re-injuries produce almost the same sequel. First,<br />
trauma releases pain-producing chemicals such as histamine and bradykinin.<br />
Second, spasm and edema restrict blood flow and cause secondary hypoxic<br />
damage from ischemia. Third, secondary damage releases more painproducing<br />
chemicals and spreads the edema. And fourth, as inflammation<br />
subsides and wound healing begins, connective tissue replaces muscle tissue<br />
and muscles lose extensibility and strength.<br />
High-velocity manipulations are also more likely to cause fracture,<br />
paralysis, and death than low-velocity manipulations. When bone cannot<br />
stretch fast enough to accommodate rapid loading, fractures occur along lines<br />
of weakness. Bone fragments can sever nerves or blood vessels and cause<br />
paralysis or death. In some cases, high-velocity cervical manipulations have<br />
caused nerve damage or death by traumatizing vertebral or basilar arteries<br />
(vertebrobasilar insult).<br />
Although some problems may require high-velocity manipulations, lowvelocity<br />
manipulations are normally safer and more effective. The risk of<br />
tissue damage is less and many patients require fewer treatments. If highvelocity<br />
manipulations are needed, low-velocity techniques can be used to<br />
relax and stretch tissues before and after thrusting.<br />
Despite the potential dangers from using high-velocity manipulations, the<br />
risk of causing serious injury or death is very small provided the doctor<br />
performing the manipulation is well trained. As a general rule, chiropractors<br />
and osteopaths are better qualified to perform high-velocity manipulations than<br />
medical doctors. In the case of low back pain, any form of manipulation is<br />
potentially safer (and often more effective) than medication or surgery.<br />
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68<br />
DYNAMICS OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong><br />
All forces used in soft-tissue therapy fall into one of four basic categories:<br />
(1) tension, (2) compression, (3) shear, or (4) torque. Unlike older methods<br />
that use imprecise terms such as stripping or stroking to classify<br />
manipulations, the <strong>HEMME</strong> <strong>APPROACH</strong> uses physics and biomechanics to<br />
describe each technique with as much precision as possible. The terms<br />
tension, compression, shear, and torsion can be used to describe any technique<br />
found in trigger point therapy, neuromuscular therapy, connective tissue<br />
therapy, or range-of-motion stretching. The periods of time before and after<br />
manipulation are classified as neutral: the absence of external force.<br />
Four Categories of Forces Used in Soft-Tissue Therapy<br />
Tension: A force that pulls objects apart (stretch).<br />
Compression: A force that pushes objects together (press).<br />
Shear: A force that causes parallel but opposite movement (slide).<br />
Torque: A force that causes rotation about an axis (twist).<br />
The above four categories of force combined with magnitude of force,<br />
direction of force, and rate of loading define any techniques possible in softtissue<br />
therapy. Some techniques are basically a single force acting on tissue<br />
such as heavy pressure in trigger point therapy (compression) or slow<br />
stretching in range-of-motion stretching (tension). Heavy refers to the<br />
magnitude of force and slow refers to rate of loading. Other techniques are<br />
two or more forces acting together: skin rolling (compression and tension) or<br />
cross-fiber friction (compression, tension, and shear). When applied to a joint,<br />
distraction refers to tension and approximation refers to compression.<br />
The main directions in soft-tissue therapy are parallel, perpendicular, and<br />
diagonal. Cross-fiber friction is normally perpendicular to a tendon, and<br />
connective tissue stretching is normally diagonal to the surface of the body<br />
(compression) and parallel to fascia (tension). When applied to skeletal<br />
muscles in neuromuscular therapy, slow-converging parallel forces inhibit<br />
(compression), rapid-diverging forces facilitate (tension), slow-perpendicular<br />
forces inhibit (tension), and rapid-perpendicular forces facilitate (tension).<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
69<br />
Table of Figures<br />
Figure 1: Belly of muscle with tendons (origin and insertion).<br />
Figure 2: Neutral position: no external force is acting on the muscle.<br />
Figure 3: Tension: used for range-of-motion stretching.<br />
Figure 4: Tension: quick tension that is used to facilitate muscles.<br />
Figure 5: Compression: slow compression that is used to inhibit muscles.<br />
Figure 6: Compression: pressure that is used to neutralize trigger points.<br />
Figure 7: Shear: parallel force that is used to stretch connective tissue.<br />
Figure 8: Torque: rotating force that is used to break scar-tissue adhesions.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
<strong>HEMME</strong> Approach to Soft-Tissue Therapy<br />
70
<strong>HEMME</strong> Approach to Soft-Tissue Therapy<br />
71
<strong>HEMME</strong> Approach to Soft-Tissue Therapy<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy<br />
73
Lack of precision when defining classical soft-tissue techniques has made<br />
scientific study difficult. By defining techniques more carefully, it is possible<br />
to draw correlations between the forces applied, the tissues affected, and the<br />
effects. Principles of therapy are the link between the forces applied to the<br />
body (cause) and how tissues are affected (effect). For example:<br />
(1) Passive tension (stretch) quickly applied longitudinal (parallel) to a<br />
muscle facilitates contraction: Sherrington's reflex.<br />
(2) Compressing tissue that overlies the insertion of a muscle tends to<br />
inhibit the muscle: Hilton's law.<br />
(3) Slow, constant, low-level force (tension) applied over long periods<br />
of time to connective tissue reduces tissue viscosity, decreases<br />
resistance to stretch, and causes a permanent increase in length: creep.<br />
METHODS OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong><br />
There are four basic approaches to soft-tissue therapy: (1) trigger point<br />
therapy, (2) neuromuscular therapy, (3) connective tissue therapy, and (4)<br />
range-of-motion stretching. Even though these four approaches cover all four<br />
types of tissue found in the human body—nerve, muscle, connective, and<br />
epithelial tissue—and trigger points, it is highly unlikely that any type of softtissue<br />
impairment can ever be treated effectively by using only one approach.<br />
Even if a body part responds to a single type of therapy, there is always a<br />
chance that treating only one body part will not correct the entire problem. The<br />
human body is so integrated that soft-tissue impairments in one body part<br />
often affect other body parts. Even if problems in one body part respond<br />
favorably to one type of therapy, the problems created in other parts by the<br />
original soft-tissue impairment may not respond to the same type of therapy.<br />
Even so, these four basic divisions are still useful in terms of organizing<br />
information and separating one set of procedures from another. In general<br />
terms, trigger point therapy deals with trigger points, neuromuscular therapy<br />
deals with nerves and muscles, connective tissue therapy deals with connective<br />
and epithelial tissue, and stretching deals with all types of tissue.<br />
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75<br />
TRIGGER POINT <strong>THERAPY</strong><br />
Trigger points are hyperirritable spots or zones that produce pain when<br />
stimulated by compression. When pressure is correctly applied, trigger points<br />
often refer pain to other areas. The patterns of pain referral produced by active<br />
trigger points are somewhat predictable and may overlap the pain referral<br />
patterns of other active trigger points.<br />
The onset of trigger points can be sudden or insidious, and trigger points<br />
are thought to be caused by fatigue, mechanical stress, changes in temperature,<br />
nutritional deficiencies, hormonal changes, infections, allergies, or ischemia.<br />
Regardless of the cause, most trigger points seem to have a lower<br />
concentration of oxygen than surrounding tissue.<br />
Trigger points can appear as nodules or palpable bands of tense, hard<br />
(indurated) tissue. When trigger points occur in muscles, the indurated tissue<br />
may be caused by trigger points interacting with muscle spindles. When<br />
activated by rapid stretching or noxious stimuli, muscle spindles may cause<br />
abnormal hardness within a muscle by facilitating the contraction of muscle<br />
fibers. Although not proven, trigger points within a tendon may also cause<br />
abnormal hardness within a muscle if trigger points interact with the Golgi<br />
tendon organs and stop the normal flow of negative feedback to a muscle that<br />
prevents contraction. Even though trigger points can occur in cutaneous,<br />
ligamentous, or periosteal tissue, the trigger points called myofascial trigger<br />
points that occur in muscles and fascia are probably the most common.<br />
While commonly called points, trigger points are more likely to occur as<br />
discrete zones than small discrete points. Sometimes a large portion of a<br />
muscle, or even the entire muscle, responds as a single trigger point.<br />
Neutralizing several points within a hypersensitive muscle will sometimes<br />
neutralize the trigger points that are not treated by pressure and relax the entire<br />
muscle. Even though trigger points are sometimes inactive for long periods of<br />
time, they are not considered self-limiting, and complete neutralization of a<br />
trigger point without treatment is rare.<br />
Trigger points normally produce deep aching pain as opposed to<br />
superficial pain. When pressure stimulates trigger points, the patient may<br />
recoil or experience autonomic responses such as vasoconstriction,<br />
perspiration, or dizziness. Activation of trigger points can also cause severe<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
spasm, muscular weakness in surrounding muscles, involuntary tremors,<br />
twitching, fasciculations, or difficult breathing (dyspnea). Pain can radiate to<br />
other parts of the body and stimulate satellite trigger points. Except for trigger<br />
points of the sternum, where pain-referral patterns are sometimes bilateral,<br />
pain-referral patterns for most trigger points are unilateral.<br />
Trigger points can produce changes in skin temperature, as evidenced by<br />
palpation or shown by thermograms. Temperatures higher than normal may<br />
indicate active inflammation or rapid metabolism. Temperatures lower than<br />
normal may indicate circulatory insufficiency or sluggish metabolism. Spasm<br />
and edema are two of the main causes for circulatory failure in soft tissue.<br />
High rates of metabolism and low rates of circulation produce ischemic<br />
damage that corresponds with pain and weakness. When trigger points are<br />
properly treated, temperatures normalize, circulation improves, pain<br />
diminishes, and muscles become stronger.<br />
Some trigger points are easier to locate when muscles are stretched. If<br />
stretching a body part produces a dull pain, palpate the stretched muscle for<br />
trigger points. If trigger points cannot be found, the origin of pain is possibly<br />
the joint or joint capsule. Trigger points normally produce intermittent pain as<br />
opposed to joint or capsular pain that is normally present day and night.<br />
Trigger points of recent origin are often easier to treat than trigger points<br />
of long-standing duration. In cases of chronic pain, most patients are more<br />
aware of general pain than specific pain. They often express surprise when a<br />
practitioner discovers areas of pain that their own senses failed to identify.<br />
Since trigger points of recent origin are easier to locate, acute trigger points<br />
often take less time to eliminate than chronic trigger points.<br />
Locating trigger points depends on the identification of certain<br />
characteristic signs. The most common signs are (1) pain when pressure is<br />
correctly applied, (2) thickening of subcutaneous tissue, (3) a jump sign, (4) a<br />
twitch response, and (5) ropiness or hardness within a muscle.<br />
The simplest test for trigger points is the appearance of pain when pressure<br />
is correctly applied. Light pressure can be applied by using the fingers or<br />
thumb to compress suspect tissues or pinching can be used when testing<br />
muscles that are small enough to grasp between the thumb and fingers.<br />
If a patient recoils while pressure is being applied, the jump sign is<br />
positive. If the trigger point is in a muscle, slight pressure will sometimes<br />
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cause spontaneous contraction of the entire muscle. This contraction may or<br />
may not be strong enough to move the affected body part. A positive jump<br />
sign combined with simultaneous radiation of pain to other parts of the body is<br />
strong evidence of trigger point involvement.<br />
Cutaneous tissue responses and a positive twitch response can be used for<br />
additional verification. If skin that is pinched and pulled away from the body<br />
feels coarse, granular, and inelastic, cutaneous tissue responses are positive. If<br />
taut bands of indurated tissue within the muscle respond elastically by<br />
snapping back into place when tension from transverse stretching is released,<br />
the twitch response is positive.<br />
The amount of pressure used during palpation is critical because too much<br />
pressure can obscure physical signs. Responses produced by light pressure are<br />
sometimes canceled by heavy pressure that restricts tissue movement and<br />
deadens pain. Light pressure is also more sensitive to differences in tissue<br />
consistency than heavy pressure. In some cases, heavy pressure will change<br />
tissue consistency before a difference in tissue compliance can be felt. In<br />
trigger point therapy, it is not uncommon for evaluation and treatment to occur<br />
simultaneously. Even light palpation will at times neutralize trigger points.<br />
When locating trigger points in thick muscles or trigger points covered by<br />
several layers of tissue, heavy pressure can be applied by using the elbow.<br />
Although light pressure is normally more discriminating than heavy pressure,<br />
light pressure does not always penetrate far enough to locate or treat trigger<br />
points in deep tissue. Another method is using light pressure for longer<br />
periods of time to penetrate thick flesh and reach deep trigger points. It is<br />
often safer to start with light pressure applied for a long period of time than to<br />
start with heavy pressure applied for a short period of time.<br />
Muscle weakness and resistance to passive stretch are consistent with<br />
trigger point activity, but not definitive because spasm, contracture, and<br />
various neurologic conditions produce similar conditions. If taut bands of<br />
muscle tissue are compressing a nerve, the physical signs are similar to those<br />
caused by fibrous or osteofibrous entrapment: nerve conductivity may be<br />
reduced and patients may feel weakness, aching pain, or paresthesia. If the<br />
taut bands of muscle tissue are being caused by trigger points, trigger point<br />
therapy and stretching should free the nerve and relieve the symptoms.<br />
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78<br />
Three factors seem to explain why trigger point therapy reduces pain:<br />
Digital pressure disperses pain-producing chemicals.<br />
Digital pressure stimulates production of endogenous opioids.<br />
Trigger points activated by pressure act as a counterirritant.<br />
• First, when digital pressure disperses blood and pain-producing<br />
chemicals away from trigger points, surrounding tissues become ischemic, as<br />
indicated by blanching (whiteness) of the skin. A decrease in electrical<br />
conductivity after treatment indicates that pressure has dissipated painproducing<br />
electrolytes such as potassium ions. Immediately upon release of<br />
pressure, blood reacts to a lowered hydrostatic pressure by reentering ischemic<br />
areas, as indicated by flushing (redness) of the skin. The redness is caused by<br />
hyperemia. The net effect of ischemic pressure and reactive hyperemia is a<br />
lower concentration of pain-producing chemicals such as histamine,<br />
bradykinin, and prostaglandin, and a higher concentration of oxygen. Since<br />
pain-producing chemicals stimulate nociceptors and cause pain, lower<br />
concentrations should reduce pain. The mechanical effects produced by<br />
injecting trigger points are similar to those produced by using digital pressure.<br />
Fortunately for the patient, a single application of digital pressure produces the<br />
same amount of fluid exchange that it would take multiple injections to<br />
produce.<br />
• Second, trigger point therapy relieves pain by stimulating the body to<br />
produce endogenous opioids such as endorphins that affect the limbic system<br />
and brain stem, enkephalins that affect the central nervous system, and<br />
dynorphins that are active in the brain and pituitary. Endogenous opioids<br />
produce analgesia by binding to opiate receptor sites involved in pain<br />
perception. Not only do opioids produce a type of analgesia similar to that<br />
produced by opiates, but also the effects of both substances are canceled by a<br />
drug called naloxone that prevents or reverses the effects of morphine and<br />
other opioid drugs. When patients receive naloxone, the pain-relieving effects<br />
of trigger point therapy and acupuncture are greatly reduced.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
• Third, trigger point therapy relieves pain by acting as a counterirritant.<br />
According to Melzack and Wall's gate-control theory of pain, the large<br />
diameter A-beta nerve fibers that transmit superficial pain can inhibit the small<br />
diameter A-delta and C nerve fibers that transmit deep pain. Since most<br />
people find superficial pain more tolerable than deep aching pain,<br />
counterirritants such as trigger point therapy and chemical irritants are often<br />
useful. Some people refer to superficial pain as a "good hurt." The most<br />
common chemical irritants are those that feel hot or cold when applied to the<br />
skin. Contrary to popular advertisements, these ointments do not penetrate<br />
deeply into muscles. Like most counterirritants, they relieve pain by acting on<br />
superficial tissue.<br />
Although trigger points seldom follow segmental distribution patterns such<br />
as dermatomes, myotomes, or sclerotomes, patterns of distribution tend to be<br />
similar for most people, and similar trigger points seem to produce a similar<br />
pain-distribution pattern. If trigger points are found in one muscle, it is<br />
common to find other trigger points in adjacent muscles, opposing muscles, or<br />
synergistic muscles. It is also common to find that trigger points often<br />
correspond with motor points, neurovascular points, and acupuncture points.<br />
Satellite trigger points are trigger points activated by another trigger point<br />
in the same reference zone. When left untreated, satellite trigger points can<br />
become primary trigger points and develop their own satellite patterns of<br />
distribution. Untreated satellite trigger points can also reactivate primary<br />
trigger points that became clinically quiescent after treatment.<br />
Secondary trigger points develop in a synergist or antagonist because of<br />
overload. When active trigger points debilitate a muscle and make it more<br />
resistant to range-of-motion stretching, synergistic muscles try to compensate<br />
for the loss by substitution, while antagonistic muscles are forced to work<br />
harder because the agonist is more difficult to stretch. This creates an overload<br />
that encourages secondary trigger points to form. Since muscles normally<br />
work in cooperation with other muscles, when treating the agonist, always<br />
check antagonistic and synergistic muscles for trigger points.<br />
Muscles at or slightly beyond resting length produce the strongest<br />
contractions. Within this range, the myofilaments of the muscle are aligned in<br />
ways that produce optimal overlap and maximal force. Too far below resting<br />
length, there is too much overlap and muscles exert less force. Too far beyond<br />
resting length, there is too little overlap and they also exert less force.<br />
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Since strength measures a muscle's ability to contract and exert force,<br />
strength and resistance to active or passive stretch are not the same. Even<br />
though a muscle may appear taut and give the appearance of being strong, the<br />
muscle's ability to contract and exert force may be less than normal.<br />
Abnormal shortness of an antagonist because of trigger point activity may<br />
cause abnormal stretching of the agonist and weakness in both muscles.<br />
Trigger point therapy that helps a muscle achieve its optimal length for<br />
contraction will produce an increase in strength. In addition to helping<br />
muscles achieve their optimal length, trigger point therapy can increase<br />
strength by reducing pain and consequently reducing pain inhibition.<br />
Unlike active trigger points that refer pain at rest or in motion, latent<br />
trigger points are painful only when palpated or compressed. Latent trigger<br />
points can lie dormant for years until stimulated by some form of stress. After<br />
long periods of quiescence, painful attacks may result from stretching,<br />
compressing, chilling, or fatiguing the tissue afflicted by latent trigger points.<br />
Other causes of activation include disease or emotional stress.<br />
After trigger points are located by palpation, moderate to heavy digital<br />
pressure can often be used to neutralize a trigger point. Just as some trigger<br />
points cannot be located when the muscle is relaxed, some trigger points are<br />
difficult to treat when the muscle is relaxed. It is often easier to feel a trigger<br />
point change from hard to soft when the affected muscle is contracted or<br />
stretched during treatment. Muscles under tension may also lengthen during<br />
treatment if the muscles were abnormally short before treatment.<br />
Even though digital pressure is normally effective in treating trigger<br />
points, the amount of pressure needed varies from case to case. Moderate to<br />
heavy pressure is normally more effective than light pressure. Trigger points<br />
in large deep muscles or muscles that overlay soft-tissue often require more<br />
pressure than trigger points in small superficial muscles or muscles that<br />
overlay bone.<br />
Compared with moderate to heavy pressure, light pressure is more likely to<br />
cause facilitation than inhibition. When trigger points in muscles are<br />
stimulated by light pressure, hypertonia and spasm may increase as the muscle<br />
attempts to guard itself against the insult. With light pressure, pain tends to<br />
increase and then remain constant. This differs from moderate to heavy<br />
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pressure that normally causes pain to intensify and then diminish as the<br />
pressure continues and the muscle starts to relax.<br />
When moderate to heavy pressure is used, pressure should be applied<br />
slowly and released slowly. Slowly applied pressure causes less trauma<br />
because tissues have more time to absorb force and accommodate the changes<br />
caused by pressure. Slowly released pressure lessens the recoil effect that<br />
normally occurs after pressure is removed. Both measures will increase the<br />
patient's comfort and improve the probabilities that treatments will have a<br />
longer-lasting effect.<br />
Though treatment times for trigger points are sometimes given as ten to<br />
twenty seconds, there is no way to give a definite time that applies to all<br />
situations. The best method is continuing pressure until the therapist feels an<br />
obvious reduction in tissue consistency or turgor (fullness). At this point,<br />
tissue will give the appearance of "melting away" or "melting down." In a<br />
large, indurated muscle, changes in tissue consistency may take one or more<br />
minutes to occur. The gluteus maximus can take five or more minutes.<br />
The normal sequence is a sharp increase in pain followed by a gradual<br />
decrease in pain. Just before a trigger point is neutralized, many patients<br />
report a feeling of pressure but not pain. If the patient reports no reduction in<br />
pain after one minute of pressure, stop the pressure and look for signs or<br />
symptoms that indicate a trigger point is not causing the pain or the trigger<br />
point being treated is not causing the pain. If the pain is being referred from<br />
another trigger point, find and treat the origin of pain. If the pain is being<br />
caused by inflammation, edema, acute traumatic injury, or nerve entrapment<br />
by osseous tissue, trigger point therapy will not be effective.<br />
If pain continues to decrease as pressure is being applied, continue<br />
pressure until the affected tissues become less resistant to pressure. A<br />
decrease in tissue consistency normally coincides with pain relief. If trigger<br />
point therapy is successful, the patient will experience less pain and greater<br />
mobility within minutes after treatment.<br />
If a patient cannot tolerate digital pressure, it may be possible to pinch the<br />
skin directly over the trigger point and partially desensitize the area by reflex<br />
effect. Once the skin is desensitized, trigger points are normally less sensitive<br />
to pressure. It is not uncommon to find that skin pinching will sometimes<br />
neutralize trigger points in a muscle without further treatment.<br />
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A question periodically arises concerning the advisability of using hard<br />
implements such as wooden or plastic dowels (T-bars) to compress trigger<br />
points. These instruments can generate great pressure, but lack the sensitivity<br />
of hands or elbows and are more likely to cause injury than pressure applied<br />
by human touch. A practitioner who constantly finds a need to apply pressure<br />
with a T-bar may be using too much pressure.<br />
The final phase of trigger point therapy is stretching. If tissues are not<br />
stretched to a normal length, trigger points are likely to recur. Low-velocity<br />
stretching helps to restore normal length without causing a stretch reflex or<br />
tearing tissues. Another way to avoid the stretching reflex is to have the<br />
patient actively stretch the affected muscle at the same time passive stretching<br />
is being used. Even though range-of-motion stretching may eliminate some<br />
trigger points without trigger point therapy, it can also irritate trigger points<br />
and cause spasm. Stretching is normally safer and much less painful if trigger<br />
points are neutralized before range-of-motion stretching.<br />
As a rule, extensive trauma and long-standing chronicity will increase the<br />
number of treatments needed to neutralize all the existing trigger points.<br />
Another factor to consider is quality of treatment. When injured body parts are<br />
mobilized early, trigger points are often less numerous. Prolonged<br />
immobilization or bed rest seems to encourage trigger points. Lifestyle can<br />
also be a factor. Smoking, lack of sleep, and poor nutrition can make trigger<br />
point therapy more difficult. The most common nutritional deficiencies that<br />
affect trigger points are a lack of vitamin C, vitamin B-complex, and iron.<br />
It is common to treat identifiable trigger points during one session and<br />
have the patient return for the next session with entirely different trigger<br />
points. Apparently the elimination of primary points during the first session<br />
can make secondary trigger points more discernible during the second session.<br />
Treatment should always be continued until all trigger points are eliminated.<br />
Great improvements may occur after just one treatment.<br />
Trigger point therapy can be palliative or curative. If the trigger points<br />
being treated are only symptoms of a problem, relief can be expected but not a<br />
cure. If the trigger points being treated are causing the pain, neutralizing the<br />
trigger points should effect a cure. When trigger points are the origins of pain,<br />
light pressure should reproduce the signs and symptoms and heavy pressure<br />
should eliminate the signs and symptoms.<br />
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83<br />
TRIGGER POINT <strong>THERAPY</strong> VS. CROSS-FIBER FRICTION<br />
Trigger point therapy can often be used to supplement or replace crossfiber<br />
friction. Trigger point therapy is faster, less painful, and produces many<br />
effects that are similar to those produced by cross-fiber friction. When used<br />
together, trigger point therapy anesthetizes highly sensitive (hyperesthetic)<br />
tissue and cross-fiber friction stretches restricted tissue. Whether friction<br />
aligns connective tissue as sometimes suggested is open to debate.<br />
Based on Wolff's law, collagen fibers develop a structure most suited to<br />
resist the forces acting on them. It appears that lines of stress produce<br />
piezoelectric forces that align fibroblasts and reorganize collagen fibers in a<br />
matrix composed of intercellular material. The factors determining the<br />
strength of piezoelectric currents are the (1) intensity, (2) frequency, and (3)<br />
duration of the forces acting on the collagen fibers.<br />
Compared to the forces generated by daily activity, the intensity of crossfiber<br />
friction is high, but frequency and duration are low. In terms of intensity,<br />
frequency, and duration, it appears that mobilization, range-of-motion<br />
stretching, and exercise would have a greater effect on the alignment of<br />
collagen fibers than cross-fiber friction.<br />
What cross fiber-friction may do more effectively than trigger point<br />
therapy is shear the inappropriate cross-links that form between collagen fibers<br />
during the early stages of wound healing. Too many cross-links or poorly<br />
placed cross-links reduce tissue extensibility and range-of-motion. Improving<br />
the distribution of cross-links would allow injured tissues to lengthen properly<br />
as the body resumes its normal activities. Even so, the question of whether<br />
cross-fiber friction is the best way to improve the distribution of cross-links is<br />
also open to debate, since early mobilization and range-of-motion stretching<br />
will also improve the distribution of cross-links.<br />
Early mobilization is another way to reduce cross-links. Whenever<br />
possible, injured parts should be mobilized several times per day as collagen<br />
fibers proliferate and realign. Failure to do this often results in long-standing<br />
disability that requires extensive soft-tissue therapy to correct.<br />
The major problem with cross-fiber friction is probably the pain. After<br />
one or two sessions, many patients never return. There is also a chance that<br />
cross-fiber friction will traumatize tissue and cause trigger points.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
84<br />
NEUROMUSCULAR <strong>THERAPY</strong><br />
Neuromuscular therapy is characterized by manual techniques that inhibit<br />
or facilitate muscle fibers. The primary tissues acted upon are nerve and<br />
muscle tissue. Facilitation is the enhancement or reinforcement of a reflex and<br />
inhibition is depression or arrest of a reflex. Inhibition encourages elongation<br />
and facilitation encourages shortening.<br />
Extensibility is the ability of muscle fibers to lengthen and contractility is<br />
the ability of muscle fibers to shorten. Muscles can lengthen to 50 percent<br />
more than resting length and shorten to about 50 percent less than resting<br />
length. Inhibition helps to lengthen hypertonic muscles by relaxation and<br />
facilitation helps to shorten hypotonic muscles by contraction.<br />
Neuromuscular techniques strengthen a muscle by eliminating the factors<br />
that cause weakness. This allows a patient to attain the greatest amount of<br />
strength possible without using exercise to change the upper limit of strength.<br />
By using inhibition and facilitation to balance opposing muscles in terms of<br />
length and strength, neuromuscular therapy restores function and prepares a<br />
patient for the next stage of therapy, which is normally exercise.<br />
Inhibition encourages relaxation by decreasing reflex activity and<br />
facilitation encourages contraction by increasing reflex activity. The two basic<br />
principles are (1) deactivating any facilitating mechanism tends to inhibit a<br />
facilitated muscle and (2) deactivating any inhibitory mechanism tends to<br />
facilitate an inhibited muscle.<br />
As the opposite of inhibition, facilitation enhances reflex activity that<br />
causes contraction. The least amount of stimulus needed to produce a motor<br />
response is called the absolute threshold. When stimulation exceeds the<br />
absolute threshold, muscles contract and produce force.<br />
If a muscle produces enough force to overcome resistance, the muscle<br />
contracts isotonically and shortens. If a muscle does not produce enough force<br />
to overcome resistance, the muscle contracts isometrically and remains the<br />
same length. Isotonic contractions are used for locomotion or moving objects.<br />
Isometric contractions are used for holding objects stationary.<br />
Removing any factors that cause inhibition will not always cause<br />
contraction. Even without inhibition, if the existing level of stimulation is not<br />
greater than the absolute threshold, a muscle will not contract.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
The immediate goal of neuromuscular therapy is muscular balance. This<br />
means balancing and normalizing opposing muscles or muscle groups in terms<br />
of length and strength. The effects of muscular imbalance are pain and limited<br />
range of motion. Pain results when muscles and joints are abnormally stressed<br />
by asymmetrical forces. Limited range of motion is caused by agonistic<br />
muscles that are too weak to initiate movement or antagonistic muscles that<br />
are too short to allow movement.<br />
Although pathologic joints can produce pain and limit range of motion,<br />
dislocations, loose bodies, and menisci tears are less common than muscular<br />
imbalance. Even when joints are implicated, muscular imbalance may have<br />
caused the joint to become dysfunctional. First, asymmetrical forces acting on<br />
the joint may cause one side of the joint to wear more rapidly than the other<br />
and cause irritation. Second, when both muscle pairs are too short, excessive<br />
tension reduces joint space and limits range of motion. If restoring muscular<br />
balance normalizes the joint, muscles are more likely than joints to be the<br />
cause of disability.<br />
Even if joints are the initial cause of disability, splinting often occurs<br />
almost immediately to protect the joint. This makes it difficult to tell which<br />
came first: a joint problem that causes excessive muscle tension or a muscle<br />
problem that reduces joint space and irritates the joint. Regardless of which<br />
condition occurred first, normal joints should not be hot or swollen and normal<br />
muscles should not be indurated or painful when relaxed.<br />
Meltzer's law of contrary innervation states that all living functions are<br />
controlled by two opposing forces. This law relates to the Chinese concept of<br />
yin-yang, which states that opposing and complementary forces control all of<br />
nature. In neuromuscular therapy, the opposing forces are inhibition and<br />
facilitation. Inhibition restrains an action or process and facilitation promotes<br />
an action or process. When neuromuscular techniques are used to balance<br />
muscles, inhibition and facilitation produce the following results:<br />
(1) Inhibition:<br />
• Lengthen hypertonic muscles;<br />
• Strengthen weak muscles.<br />
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86<br />
(2) Facilitation:<br />
• Shorten stretched muscles;<br />
• Strengthen weak muscles.<br />
By causing relaxation, inhibition can help to lengthen short muscles and<br />
strengthen weak muscles. If a muscle is abnormally short because of spasm<br />
(hypertonia), inhibition can make it easier to lengthen the muscle by<br />
decreasing the muscle's internal resistance to active or passive stretch. Even<br />
though inhibition may cause a transitory weakness when applied to a normal<br />
muscle, inhibition applied to a hypertonic muscle may cause an increase in<br />
strength. This runs contrary to the popular belief that inhibition always<br />
weakens a muscle and facilitation always strengthens a muscle.<br />
Inhibition strengthens a muscle by (1) allowing muscle fibers to assume<br />
their optimal length before contraction, and (2) by reducing pain inhibition. In<br />
terms of achieving maximum strength, muscles that are capable of being<br />
stretched to at least resting length are potentially stronger than muscles that are<br />
not capable of being stretched to at least resting length.<br />
If spasm causes a muscle to be shorter than resting length, the muscle will<br />
be unable to exert maximum force. If relaxation allows the muscle to reach at<br />
least resting length, inhibition will increase, not decrease, strength. This occurs<br />
because muscles cannot produce maximum force when actin and myosin<br />
myofilaments are excessively overlapped. Since muscles produce the greatest<br />
amount of force when contraction begins at a length equal to or slightly<br />
beyond resting length, inhibition techniques can strengthen a muscle by<br />
reversing the adverse effects that are caused by too much facilitation.<br />
Second, when treating a cramp, inhibition and relaxation may increase a<br />
muscle's ability to exert force more than facilitation. A cramp is a painful<br />
spasm caused by a prolonged tetanic contraction. When a cramp is present,<br />
one of the main factors limiting strength is pain inhibition. Since inhibition<br />
techniques are more likely to stop a cramp and relieve pain than facilitation<br />
techniques, inhibition will sometimes increase strength more than facilitation.<br />
Facilitation can shorten stretched muscles and strengthen weak muscles.<br />
A muscle that is stretched for extended periods of time has a tendency to<br />
remain stretched and become weak. This condition is called stretch weakness.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
Facilitation techniques can reverse the effects of stretch weakness in two<br />
ways: (1) shorten the muscle by encouraging muscle fibers to contract and<br />
maintain normal tonus, and (2) strengthen the muscle by reversing the effects<br />
of inhibition. When facilitation techniques are used to reeducate muscle<br />
fibers, strength tends to increase because of greater neurologic efficiency<br />
within the muscle. If muscles are stretched far beyond their resting length,<br />
facilitation will improve strength by allowing muscles to reach a length near<br />
resting length, which is more conducive to exerting force.<br />
The standard protocol for using neuromuscular therapy to lengthen<br />
hypertonic muscles, strengthen weak muscles, shorten stretched muscles, and<br />
balance muscles or muscle groups is:<br />
Test for active, passive, or passive-assisted range of motion.<br />
Use inhibition to lengthen and strengthen short tissues.<br />
Test for strength by using resisted range-of-motion testing.<br />
Use facilitation to strengthen and shorten weak muscles.<br />
Retest for length and strength.<br />
Treat again if necessary.<br />
The underlying principle that applies to almost any method of soft-tissue<br />
therapy is lengthen first and strengthen second. Rarely would it be advisable<br />
to strengthen a muscle with a limited range of motion.<br />
When dealing with two opposing muscles, the same principle can<br />
normally be applied. If (1) the agonist is short, (2) the antagonist is long, and<br />
(3) both muscles are weak, the first step would be using inhibition to lengthen<br />
the agonist. This will decrease tension on the antagonist and make it more<br />
difficult for the antagonist to remain stretched. The next step would be using<br />
facilitation to strengthen and shorten the antagonist. This will increase tension<br />
on the agonist and make it more difficult for the agonist to remain short. If this<br />
approach fails, use the antagonist to stretch the agonist by strengthening the<br />
antagonist first and then passively stretching the agonist.<br />
If opposing muscles test long and weak, which is not likely, strengthen<br />
both muscles first and monitor length to ensure that all muscles shorten at the<br />
same rate. Care should be taken not to overstretch either muscle.<br />
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88<br />
KEY POINT: LENGTHEN FIRST and STRENGTHEN SECOND<br />
Another sequence that applies to most forms of therapy is test, treat,<br />
retest, and treat again if necessary. Testing gives therapy direction and<br />
allows both practitioner and patient a chance to monitor progress. It is often<br />
difficult for a patient to comprehend progress unless the practitioner points<br />
out benchmarks and measurable objectives.<br />
Do not replace testing with the assumption that stretched muscles are<br />
always weak and contracted muscles are always strong. Strength measures<br />
the ability of muscle to exert force as opposed to the ability of muscle to<br />
resist active or passive stretch. Although "short" muscles will normally test<br />
stronger than "long" muscles, hypertonic muscles can be highly resistant to<br />
passive stretch but test weak. That one muscle is too long and the opposing<br />
muscle is too short does not mean that both muscles are not weak.<br />
Inhibition and facilitation are not substitutes for exercise. Using<br />
neuromuscular therapy to normalize a muscle is different from using<br />
exercise to strengthen a muscle. The two main factors affecting strength are<br />
neurologic efficiency and muscle mass. Neuromuscular techniques and<br />
exercise both affect neurologic efficiency, but only exercise increases mass.<br />
When muscles are repeatedly forced to develop maximal or near<br />
maximal tension, individual muscle fibers may increase in size because of<br />
hypertrophy. When all other factors (such as motivation and neurologic<br />
efficiency) are equal, hypertrophy is the only way muscles become stronger.<br />
Though not a replacement for exercise, inhibition and facilitation can be<br />
used to prepare muscles for exercise. If muscles are not properly balanced,<br />
exercise may prolong or exacerbate any existing imbalance.<br />
Muscle imbalance contributes to many disabilities. When opposing<br />
muscles are not symmetrical in terms of length or strength, the tension on<br />
joints is not symmetrical and stronger muscles may stretch or tear weaker<br />
muscles. Activities that favor one opposing movement over another may<br />
cause a muscle imbalance that results in poor posture. Activities that<br />
strengthen the pectoral muscles but not the rhomboid muscles may cause the<br />
shoulders to be drawn forward and a forward head posture. The solution is<br />
(1) lengthen the pectorals, and (2) strengthen and shorten the rhomboids.<br />
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89<br />
<br />
<br />
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FOUR WAYS <strong>TO</strong> INHIBIT A MUSCLE<br />
Activation of Golgi tendon organs<br />
Deactivation of muscle spindles<br />
Reciprocal inhibition (RI)<br />
Post-isometric relaxation (PIR)<br />
<br />
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FOUR WAYS <strong>TO</strong> FACILITATE A MUSCLE<br />
Activation of stretch reflex<br />
Activation of muscle spindles<br />
Repeated contractions<br />
Successive induction<br />
Of all the different methods used to inhibit and facilitate muscles, the<br />
most common are those involving sensory end organs called proprioceptors<br />
that respond to stimulus originating within the body, such as pressure,<br />
equilibrium, or stretch. Proprioceptors give information concerning<br />
movements and positions of the body. In terms of neuromuscular therapy,<br />
the two most important proprioceptors are (1) Golgi tendon organs (G<strong>TO</strong>s)<br />
that measure the amount of tension being applied to a tendon, and (2) muscle<br />
spindles (MSs) that measure how rapidly and to what extent muscles are<br />
changing in length.<br />
Based on the premise that inhibition is the opposite of facilitation: (1)<br />
activating G<strong>TO</strong>s inhibits a muscle, (2) deactivating G<strong>TO</strong>s facilitates a<br />
muscle, (3) activating MSs facilitates a muscle, and (4) deactivating MSs<br />
inhibits a muscle. Of these four methods, deactivating G<strong>TO</strong>s is the least<br />
useful in clinical practice. First, other than slacking in a muscle, there is no<br />
practical way to deactivate G<strong>TO</strong>s. Second, if the existing level of stimulation<br />
is not greater than the absolute threshold, removing inhibition will not cause a<br />
muscle to contract. Contraction requires adequate stimulation.<br />
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90<br />
INHIBI<strong>TO</strong>RS<br />
Activation of Golgi Tendon Organs (Inhibition)<br />
If stretching a tendon produces enough tension, the Golgi tendon organs<br />
generate electrical impulses that relax muscle fibers. G<strong>TO</strong>s can be activated<br />
by active or passive tension and appear to be a protective mechanism that<br />
protects muscles from being torn and tendons from being ruptured or torn<br />
away from the bone (avulsed).<br />
To activate the G<strong>TO</strong>s, tendons are commonly stretched in three ways:<br />
(1) direct stretching by contracting the agonist, (2) active stretching by<br />
contracting the antagonist, and (3) passive stretching by using external force.<br />
When stretched by contracting the agonist, isometric contractions generate<br />
more tension than isotonic contractions. When actively stretched by the<br />
antagonist or passively stretched by external force, the tension is greatest<br />
when the muscle being stretched is abnormally short because of contraction<br />
or contracture.<br />
Three cautions using tension to activate the Golgi tendon organs:<br />
(1) Contracting a muscle when the insertions are not far enough apart to<br />
apply tension on the muscle may cause cramping. This can be demonstrated<br />
by flexing the elbow joint until the hand touches the shoulder and then<br />
slowly and carefully contracting the biceps brachii. Pain and cramping are<br />
normally felt as muscles start to shorten.<br />
(2) G<strong>TO</strong> inhibition can be overridden by training or motivation. When<br />
G<strong>TO</strong>s are activated by tension, descending impulses from the brain can<br />
mediate the reflex. Athletes often injure muscles and tendons despite the<br />
protection provided by Golgi tendon organs.<br />
(3) Actively or passively stretching a normal muscle far enough to cause<br />
inhibition by the Golgi tendon organs may traumatize the joint. In most<br />
cases, pain receptors in ligaments and joint capsules react faster than G<strong>TO</strong>s<br />
to protect the joint and tissues surrounding the joint (periarticular tissue). If<br />
these warnings are ignored, the joint may be damaged.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
In situations where muscles are shortened by contraction or contracture,<br />
the Golgi tendon organs are normally activated before the pain receptors in<br />
ligaments or joints. If a muscle is hypertonic, it is also possible that active<br />
or passive stretching may relax the muscle by decreasing the number of<br />
cross-bridges between actin and myosin myofilaments. The effect would be<br />
similar to that produced by Golgi tendon organ inhibition.<br />
Theoretically, muscles can be inhibited or facilitated by increasing or<br />
decreasing the tension on a tendon. Since the concentration of G<strong>TO</strong>s is<br />
greater at the musculotendinous juncture than at the periosteal-tendinous<br />
juncture, pulling a tendon away from the musculotendinous juncture should<br />
cause inhibition and pushing a tendon toward the juncture should cause<br />
facilitation or stop inhibition.<br />
In practice, locating the musculotendinous juncture is difficult and being<br />
able to apply enough force to activate or deactivate the G<strong>TO</strong>s is even more<br />
unlikely. The amount of force needed to activate or deactivate G<strong>TO</strong>s is<br />
much higher than the amount of force needed to activate or deactivate<br />
muscle spindles. To cause inhibition, a better approach is using direct<br />
pressure on tendons to relax hypertonic muscles.<br />
For reasons not entirely understood, direct pressure on tendons may<br />
cause inhibition and reduce spasm. Whether the process involves the Golgi<br />
tendon organs or another mechanism is unknown. If pressure causes pain,<br />
endogenous opiates could be involved. Since many patients report local<br />
numbness, inhibitory pressure may cause some degree of nerve disruption<br />
similar to neuropraxia, a condition where nerve conduction stops because of<br />
trauma. Whatever the cause, direct pressure on a tendon is more practical<br />
than proprioceptive techniques that involve pulling or pushing a tendon.<br />
Deactivation of Muscle Spindles (Inhibition)<br />
Muscle spindles are proprioceptors located throughout a muscle and<br />
highly concentrated within the belly of a muscle. Where the Golgi tendon<br />
organs respond to changes in tension, muscle spindle cells respond to<br />
changes in length or velocity of movement. Extrafusal fibers are muscle<br />
fibers that are inside the muscle but outside the muscle spindle. Intrafusal<br />
fibers are muscle fibers within the muscle spindle.<br />
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When intrafusal fiber tension is less than extrafusal fiber tension, the<br />
muscle relaxes (inhibition).<br />
When intrafusal fiber tension is less than extrafusal fiber tension, muscle<br />
spindles cause inhibition and the muscle relaxes. Heat and gentle massage<br />
may cause a reflex action that encourages intrafusal fibers to relax.<br />
Another way to cause inhibition is compressing the belly of a muscle<br />
toward the center to relax intrafusal fibers. This can be done by grasping the<br />
muscle near the musculotendinous junctures and using convergent force to<br />
compress the belly until both hands meet in the center. Force is applied<br />
parallel and slightly perpendicular to the muscle. The rate of movement<br />
should be slow to very slow and tissues should be allowed to "thin out,"<br />
"melt down," or "dissolve" as the hands move toward the center of the belly.<br />
The need for anything more than moderate force may indicate that<br />
movements are too fast. This method should relax hypertonic muscles.<br />
Reciprocal Inhibition (Inhibition)<br />
When muscles work in pairs, facilitation of the agonist causes reciprocal<br />
inhibition of the antagonist. As the agonist contracts, the antagonist relaxes<br />
to allow stretching by the agonist. If the antagonist fails to relax, the agonist<br />
may test weak despite normal strength. Coordinated movement is possible<br />
because one muscle relaxes when the opposing muscle contracts. Anything<br />
less than total relaxation of the antagonist restricts shortening of the agonist.<br />
If a flexor muscle is hypertonic, contracting the extensor muscles will<br />
cause the flexor muscles to relax. If a flexor muscle such as the biceps<br />
brachii is in spasm, contracting the opposing extensor muscle, the triceps<br />
brachii, should cause the biceps brachii to relax. The more completely the<br />
extensor muscles relax, the easier it is for the flexor muscle to generate<br />
movement. After relaxing a muscle using reciprocal inhibition, the final step<br />
is stretching the muscle to prolong the effects.<br />
While the methods for using reciprocal inhibition (RI) are extremely<br />
varied, most methods have one sequence in common: (1) contract the<br />
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antagonist, (2) relax the antagonist, and (3) stretch the agonist. Among the<br />
variables that may affect the way reciprocal inhibition is applied are:<br />
1. Starting and ending length of muscle<br />
2. Type and strength of resistance and counterforce<br />
3. Length of hold during contraction<br />
4. Type of stretch applied after contraction<br />
5. Breathing patterns<br />
6. Repetitions<br />
Based on clinical experience, the method below appears to be one of the<br />
most effective ways to use RI. The muscle being contracted is called the<br />
antagonist, and the muscle being stretched is called the agonist.<br />
1 The patient should start with the antagonist (1) at midrange, a length<br />
about halfway between fully contracted and fully stretched or (2) at a point<br />
just short of where the muscle starts to resist stretching (resistance barrier).<br />
2 The patient applies isometric resistance and the practitioner applies an<br />
equal amount of isometric counterforce. The strength of contraction for the<br />
antagonist should be about 25 percent of maximum strength.<br />
3 The patient should hold the isometric contraction for about 10 seconds.<br />
4 Shortly after the patient stops contracting the antagonist (about 3<br />
seconds), the practitioner should stretch the agonist. Slow stretching with<br />
moderate force will be more effective than rapid stretching with heavy force.<br />
Stretching should stop at the first sign of resistance or pain.<br />
5 The patient should breathe slowly out during contraction, breathe in<br />
during relaxation, and breathe slowly out during stretching.<br />
6 While up to 5 repetitions are acceptable, RI should be stopped if (1) the<br />
technique is too painful, (2) the patient's range of motion stops increasing, or<br />
(3) the patient's range of motion becomes normal.<br />
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Reciprocal inhibition is considered more gentle than inhibition<br />
techniques that compress or contract the agonist before stretching the<br />
agonist. Provided the isometric contraction of the antagonist does not<br />
become a contest of strength between the patient and the practitioner,<br />
isometric contractions are less likely to cause tissue damage than isotonic or<br />
isolytic contractions. During an isotonic contraction, the antagonist contracts<br />
and shortens because the counterforce is less than resistance. During an<br />
isolytic contraction, the antagonist contracts and lengthens because the<br />
counterforce is greater than resistance.<br />
Cocontraction is the opposite of reciprocal inhibition. Cocontraction<br />
means the simultaneous activation of two opposing muscles. Movement is<br />
not possible if both the agonist and the antagonist contract at the same time.<br />
Cocontraction increases the stability and decreases mobility. An example of<br />
cocontraction is holding a limb rigid. Reciprocal inhibition, on the other<br />
hand, increases mobility and decreases stability.<br />
Where limited range of motion is a problem, cocontraction is not<br />
beneficial. When opposing muscles such as flexors and extensors<br />
cocontract, the strength in both directions decreases because the extensors<br />
are working against flexors and flexors are working against extensors.<br />
Flexion would be stronger if the extensors relaxed and extension would be<br />
stronger if the flexors relaxed. This explains why some athletes practice<br />
relaxation to increase strength. Anxiety and tension weaken muscles and<br />
cause fatigue by encouraging cocontraction.<br />
Post-Isometric Relaxation (Inhibition)<br />
If hypertonic muscles are causing a restriction, fatigue can be used to<br />
inhibit contraction. Isometric contractions are the easiest way to fatigue a<br />
muscle without causing undue pain. If a hypertonic muscle contracts<br />
isometrically for about 5 to 10 seconds and then relaxes, the relaxation phase<br />
and latency period that follow the contraction phase decrease neurologic<br />
efficiency. Because of this decrease in neurologic efficiency, a muscle<br />
becomes more relaxed than it was before the contraction phase. During the<br />
relaxation phase and latency period, muscles become hypotonic and easier to<br />
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stretch. The technique of stretching an agonist after contracting the agonist<br />
isometrically is called post-isometric relaxation.<br />
While post-isometric relaxation (PIR), like reciprocal inhibition (RI), is<br />
subject to many variations, most methods have one sequence in common: (1)<br />
contract the agonist, (2) relax the agonist, and (3) stretch the agonist. Based<br />
on clinical experience, the method below appears to be one of the most<br />
effective ways to use PIR. The muscle being contracted and stretched is the<br />
agonist.<br />
1 The patient should start with the agonist (1) at midrange or (2) at a point<br />
just short of where the muscle starts to resist stretching (resistance barrier).<br />
2 The patient applies isometric resistance and the practitioner applies an<br />
equal amount of isometric counterforce. The strength of contraction for the<br />
agonist should be about 50 percent of maximum strength.<br />
3 The patient should hold the isometric contraction for about 10 seconds.<br />
4 Shortly after the patient stops contracting the agonist (about 3 seconds),<br />
the practitioner should stretch the agonist. Slow stretching with moderate<br />
force will be more effective than rapid stretching with heavy force.<br />
5 The patient should breathe slowly out during contraction, breathe in<br />
during relaxation, and breathe slowly out during stretching.<br />
6 While up to 5 repetitions are acceptable, PIR should be stopped if (1) the<br />
technique is too painful, (2) the patient's range of motion stops increasing, or<br />
(3) the patient's range of motion becomes normal.<br />
PIR is considered less gentle than RI because it contracts and stretches<br />
the same muscle. RI contracts the antagonist and stretches the agonist. If<br />
contracting the agonist causes extreme pain, PIR may not be safe to use.<br />
PIR should not be allowed to become a contest of strength, and any<br />
counterforces used against resistance should be slowly applied and slowly<br />
removed. While most therapeutic stretching is passive, having the patient<br />
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contract the antagonist while the agonist is being stretched (passive-assisted<br />
stretching) may help to relax the agonist by reciprocal inhibition.<br />
When PIR is used, breathing cycles should correspond correctly with<br />
periods of exertion and periods of relaxation. The best method is having the<br />
patient exhale during exertion, inhale during relaxation, and exhale while the<br />
muscle is being stretched. The following commands may help the patient<br />
understand the sequence:<br />
• Exhale slowly as you feel the muscle contract.<br />
• Inhale slowly as you feel the muscle relax.<br />
• Exhale slowly as you feel the muscle stretch.<br />
Exhaling during contraction reduces intrathoracic pressure and exhaling<br />
while muscles are being stretched makes it easier for patients to relax. Some<br />
patients appear to be less sensitive to pain when exhaling.<br />
If the elbow joint is normal and the patient is having difficulty extending<br />
the forearm, the two most likely problems are: (1) the extensor muscles are<br />
weak, and (2) the flexor muscles are restricted. To determine if these<br />
conditions exist, resisted range-of-motion testing can be used to evaluate the<br />
strength of extensor muscles and passive range-of-motion testing can be<br />
used to evaluate the extensibility of the flexor muscles.<br />
If the extensor muscles are normal and the flexor muscles are restricted,<br />
PIR may be a good choice for relaxing and lengthening the flexor muscles.<br />
Other possibilities would include activation of G<strong>TO</strong>s, deactivation of MSs,<br />
and RI. (In most cases, if the flexor muscles are restricted, the extensor<br />
muscles will be stretched and weak, and synergistic or fixator muscles will<br />
somehow be involved.)<br />
Physiological contractures are one exception to the principle that fatigue<br />
causes inhibition. Unlike normal fatigue, extreme fatigue depletes highenergy<br />
phosphate reserves (creatine phosphate) and causes muscle fibers to<br />
shorten. Creatine phosphate is needed to produce ATP, and muscle fibers<br />
cannot lengthen without energy input from ATP. Induced by heat, drugs, or<br />
acids, most physiological contractures, except for rigor mortis, are<br />
reversible. Rigor mortis is a stiffening of the body that occurs after death<br />
because of acids accumulating in protoplasm and coagulation of proteins.<br />
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97<br />
FACILITA<strong>TO</strong>RS<br />
Activation of Stretch Reflex (Facilitation)<br />
Muscle spindles (MSs) react to sudden stretching by reflex contraction.<br />
Long, rapid stretches are more detectable to a muscle than short, gradual<br />
stretches. A reflex contraction is called a stretch reflex or myotactic reflex.<br />
What is commonly called a tendon reflex is actually a stretch reflex.<br />
Sharply striking the patellar tendon rapidly stretches the quadriceps muscle<br />
and causes a "knee jerk" reaction.<br />
Throwing activities, such as pitching, make use of the stretch reflex by<br />
using a windup to put the throwing muscles on stretch before a pitch. The<br />
windup increases muscular power because the force from reflex contraction<br />
(stretch reflex) is added to the force from voluntary contraction. Because of<br />
viscoelastic properties of a muscle, elastic rebound from the stretch will also<br />
contribute to the power.<br />
A stretch reflex and reciprocal inhibition produce opposite effects. As<br />
stretching facilitates contraction, reciprocal inhibition relaxes opposing<br />
muscles. Once the agonist shortens, the muscle spindles reduce afferent<br />
discharge and the agonist relaxes. Using pitching as an example, throwing<br />
muscles are facilitated by the windup. As the ball is thrown, throwing<br />
muscles contract because of the stretch reflex and opposing muscles relax<br />
because of reciprocal inhibition. When the pitch is complete, the throwing<br />
muscles enter a resting state and relax also.<br />
The stretch reflex can be triggered in two ways: (1) increasing the<br />
distance between distal and proximal insertions or (2) physically stretching<br />
the muscle itself. Range-of-motion stretching increases the distance<br />
between insertions and cross-fiber stretching stretches a muscle at the point<br />
of contact. Cross-fiber stretching is applied at angles perpendicular to the<br />
muscle. Even a quick tap causes cross-fiber stretching.<br />
Since rapid stretching is more likely to trigger a stretch reflex than slow<br />
stretching, most forms of therapeutic stretching to lengthen a muscle are<br />
done slowly. The safest stretches are those that minimize force and<br />
maximize time. Facilitation techniques, on the other hand, are done quickly<br />
to encourage contraction. Rapid stretching, tapping, or shaking facilitate<br />
muscle contraction.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
98<br />
Activation of Muscle Spindles (Facilitation)<br />
A second method of facilitation involves relative changes in tension<br />
between intrafusal muscle fibers that are inside the muscle spindle cell and<br />
extrafusal muscle fibers that are outside the muscle spindle cell.<br />
When intrafusal fiber tension is greater than extrafusal fiber tension, the<br />
muscle contracts (facilitation).<br />
The two main factors affecting intrafusal and extrafusal fiber tension are<br />
(1) contraction or relaxation of intrafusal fibers, and (2) stretching or<br />
compressing extrafusal fibers. When intrafusal fiber tension is greater than<br />
extrafusal fiber tension, the muscle contracts (facilitation), and when<br />
intrafusal fiber tension is less than extrafusal fiber tension, the muscle<br />
relaxes (inhibition).<br />
The gamma system neurologically connects muscle spindles with the<br />
spinal cord and regulates intrafusal fiber tension. For various reasons,<br />
including injury or stress, intrafusal fibers contract because of innervation by<br />
the gamma system. This makes intrafusal fiber tension greater than<br />
extrafusal fiber tension and muscles contract. When a muscle is injured,<br />
reflex spasm and protective muscle shortening, as in splinting or guarding,<br />
may be caused by nerve impulses that travel from the spinal cord to muscle<br />
spindles. Spasm originating from the spinal cord is difficult to treat.<br />
When extrafusal fibers shorten by voluntary contraction, they initially<br />
generate more tension than intrafusal fibers. This would normally cause<br />
inhibition were it not for the gamma motor system stimulating intrafusal<br />
fibers to contract. This allows intrafusal fibers to adjust for gains in tension<br />
by extrafusal fibers. By adjusting to the shortening of extrafusal fibers, the<br />
gamma motor system acts as a positive servomechanism for the muscle.<br />
Without this mechanism, voluntary contractions would cause inhibition.<br />
Because of the gamma system, muscles can be facilitated or inhibited by<br />
using manual force to manipulate the belly of a muscle where the<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
concentration of muscle spindle cells is greatest. If stretching the belly of a<br />
muscle causes intrafusal fiber tension to become greater than extrafusal fiber<br />
tension, the muscle contracts. This can be done by grasping the belly of a<br />
muscle near the center and using divergent force to stretch the muscle in<br />
opposite directions away from the starting point. The lines of force are<br />
parallel to the muscle and the rate of movement is faster than stretching to<br />
lengthen connective tissue but not fast enough to cause pain. Weak muscles<br />
will normally test stronger after facilitation.<br />
Facilitating a muscle by activating the MSs requires less force than<br />
inhibiting a muscle by activating the G<strong>TO</strong>s. Although tapping a tendon can<br />
stimulate muscle spindle cells enough to cause facilitation, the same amount<br />
of tapping will not stimulate G<strong>TO</strong>s enough to cause inhibition.<br />
It should also be apparent that compressing or "stripping" a muscle from<br />
one end to the other inhibits a muscle by compressing the belly during the<br />
first part of the movement and then facilitates the muscle by stretching the<br />
belly during the last part of the movement. Movements compressing the<br />
muscle toward the midpoint inhibit, while movements stretching the muscle<br />
beyond the midpoint facilitate.<br />
If the purpose of stripping a muscle is inhibition, strip the muscle from<br />
insertion to midpoint in one direction, and then strip the same muscle from<br />
insertion to midpoint in the opposite direction. A more effective way to<br />
inhibit a muscle is to use both hands, start from opposite insertions, and<br />
work toward the belly of the muscle until both hands meet in the center. If<br />
the purpose is facilitation, the most effective way is to use both hands, start<br />
at the midpoint, and stretch the muscle away from the midpoint.<br />
Repeated Contractions (Facilitation)<br />
Another facilitation technique is repeated contractions. Based on the<br />
treppe phenomena, muscles contract more strongly after the first contraction.<br />
It is possible that increases in tissue temperature after the first contraction<br />
are great enough to increase metabolic efficiency and reduce tissue viscosity.<br />
Repeated contractions may also increase gain from the gamma neurons (thus<br />
discouraging inhibition by the muscle spindles), and maximize both the<br />
number of muscle fibers activated and the rate of firing.<br />
99<br />
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100<br />
In the absence of fatigue, muscles can be facilitated by using repeated<br />
contractions. If a patient's range of motion is restricted, repeated<br />
contractions in the direction of the barrier may facilitate muscles enough to<br />
overcome resistance and regain full range of motion. Once fatigue sets in,<br />
the strength of contraction becomes less and muscles become less efficient.<br />
Successive Induction (Facilitation)<br />
Successive induction refers to the principle that once facilitation of the<br />
agonist is completed, it takes less than normal stimulation to facilitate the<br />
antagonist. Muscles have an absolute threshold that determines how much<br />
stimulation is needed to cause contraction. According to the principle of<br />
successive induction, contracting and then relaxing the agonist lowers the<br />
threshold for stimulation of the antagonist and allows the antagonist to<br />
contract with less than normal stimulus. If shortening the agonist stretches<br />
the antagonist quickly enough, stretching may also facilitate the antagonist.<br />
Techniques that move in the direction of greatest freedom first are called<br />
indirect techniques. Successive induction is one factor that explains why<br />
range of motion can sometimes be increased by using techniques that move<br />
in the direction of greatest freedom first. If elbow extension is limited, but<br />
flexion is normal, flexing the elbow first facilitates the elbow extensors.<br />
Strengthening the extensors by flexion will make it easier to extend the<br />
elbow. A second factor relates to interstitial fluid pressure. If flexing the<br />
elbow reduces flexor muscle edema, elbow flexors will be less resistant to<br />
active or passive stretch by elbow extensors.<br />
SUMMARY<br />
Neuromuscular techniques can be used singly or in combination with<br />
each other to correct muscular dysfunction by facilitating or inhibiting<br />
specific muscles. If the patient's condition is correctly evaluated, the<br />
practitioner will know which muscles to facilitate and which muscles to<br />
inhibit. Hypertonic muscles need to be inhibited and stretched, while<br />
hypotonic muscles need to be facilitated and strengthened. If two opposing<br />
muscles are dysfunctional, synergistics or fixators are probably affected.<br />
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CONNECTIVE <strong>TISSUE</strong> <strong>THERAPY</strong><br />
Of all the tissues in the human body, connective tissue is the most<br />
abundant. Examples of dense fibrous connective tissue include tendons,<br />
ligaments, aponeuroses, deep fascia, and dermis. Other forms of connective<br />
tissue are bone, adipose tissue, and cartilage. The four main goals of<br />
connective tissue therapy are:<br />
<br />
<br />
<br />
<br />
Increase tissue mobility<br />
Break adhesions<br />
Improve fluid exchange<br />
Realign torn fibers<br />
The main types of connective tissue affected by manipulation are deep<br />
fascia, ligaments, aponeuroses, and tendons. While some varieties of<br />
connective tissue therapy work specifically to produce reflex effects or<br />
improve symmetry, the <strong>HEMME</strong> <strong>APPROACH</strong> emphasizes the physical effects of<br />
connective tissue therapy more than the reflex effects and concentrates on<br />
symmetry only when a lack of symmetry causes clinical problems.<br />
Connective tissues have three main components: cells, fibers, and matrix<br />
or ground substance. The most common mechanical properties of all<br />
connective tissues except bone are elasticity and plasticity. Elastic materials<br />
yield to stress and then resume normal shape. Plastic materials yield to stress<br />
and remain permanently deformed.<br />
Of the six basic cell types in connective tissue (fibroblasts, macrophages,<br />
plasma cells, mast cells, fat cells, and pigment cells), two in particular relate to<br />
connective tissue therapy: fibroblasts that synthesize fibers and matrix and<br />
mast cells that release histamine and serotonin. Besides mediating pain,<br />
histamines cause vasodilation and edema.<br />
The two most important extracellular fibers imbedded in the matrix or<br />
ground substance of connective tissue are collagen, which is white, and elastin,<br />
which is yellow. Collagen fibers, which form in bundles or sheets, have high<br />
tensile strength but low elasticity. Elastin fibers, which form dendritically,<br />
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102<br />
have low tensile strength but high elasticity. Collagen and elastin are both<br />
major connective tissue proteins.<br />
Although ligaments and tendons are both considered dense connective<br />
tissue, tendons have greater tensile strength because of collagen and ligaments<br />
exhibit higher degrees of extensibility because of elastin. Deep fascia has<br />
more collagen fibers than superficial fascia (loose connective tissue), but<br />
collagen fibers in deep fascia are less organized than collagen fibers in<br />
tendons, ligaments, or aponeuroses.<br />
Immobilization after an injury increases the density of collagen and the<br />
frequency of cross-bridging between fibers. The cross-bridging makes<br />
collagen fibers more resistant to passive stretch and less mobile. Stretching<br />
and exercise increase flexibility by reducing the number of cross-links.<br />
Proteoglycans form the intercellular matrix or ground substance that<br />
constitutes the bulk of connective tissue. Proteoglycans are composed of<br />
glycosaminoglycans (mucopolysaccharides) bound to protein chains.<br />
Proteoglycans form a viscous gel-like substance when combined with<br />
extracellular tissue fluid that contains water, metabolites, crystalloids, and<br />
gases. When intercellular viscosity is not too high, this gel-like substance<br />
reduces friction by acting as a lubricant between collagen fibers.<br />
The ability of ground substance to hold water allows for diffusion of<br />
metabolites between capillaries and cells. The presence of hyaluronic acid in<br />
ground substance reduces friction by increasing water retention. Hyaluronic<br />
acid molecules form large random chains that are filled with water.<br />
Proteoglycans such as hyaluronic acid give tissues elasticity and resistance to<br />
compression.<br />
Excessive water retention produces higher tissue tension and greater resistance<br />
to pressure. Tissue tension is a palpable sign that frequently occurs<br />
during inflammation or after trauma. High degrees of edema reduce mobility<br />
by increasing tissue tension and causing spasm.<br />
Reduced water retention, on the other hand, increases friction between<br />
fibers and causes cross-bridging. Friction and cross-bridging irritate tissues<br />
and reduce mobility. Without water retention, tissues lose elasticity.<br />
The "gel-sol" theory proposes that aqueous solutions within connective<br />
tissue become highly viscous and produce a sticky gelatinous or gluelike<br />
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103<br />
substance that limits tissue mobility. Connective tissue manipulation is<br />
thought to liquefy and disperse viscous gel and restore free movement.<br />
Three factors explain why slow stretching produces more permanent<br />
changes in the length of connective tissue than rapid stretching:<br />
<br />
<br />
<br />
Thixotropy<br />
Hysteresis<br />
Creep<br />
Thixotropy and hysteresis explains why semisolid ground substance in<br />
connective tissues changes from gel to liquid when acted upon by force. Creep<br />
explains why connective tissues such as deep fascia are permanently<br />
lengthened by slow, steady, continuous tension.<br />
Thixotropy<br />
According to the concept of thixotropy, gels liquefy when agitated by any<br />
force that puts energy into the system. The energy input from deep stroking<br />
(compression and shear) is friction and heat. Changing from gel to liquid<br />
increases tissue mobility by decreasing tissue tension caused by edema. Tissue<br />
tension stimulates reflex activity that facilitates muscle contraction. When<br />
treating connective tissue, time is critical. To avoid trauma, wait for tissues to<br />
accommodate penetration by "thinning out" before advancing. Thixotropy<br />
also applies to trigger point therapy (compression), where slow digital pressure<br />
causes a "meltdown" and tissues become more compliant.<br />
Hysteresis<br />
According to the concept of hysteresis, stress and slow cyclic loading<br />
cause tissues to soften as energy is lost in the form of internal friction or heat.<br />
Cyclic loading refers to cycles of loading and unloading. Hysteresis plays a<br />
major role when the same tissues are treated multiple times by a sequence of<br />
slow steady pressure, slow release, and reapplication of slow steady pressure.<br />
Cyclic loading relieves tissue congestion by improving vascular flow and<br />
lymphatic drainage.<br />
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104<br />
The white fibrous proteins found in deep fascia are collagen fibers. Unlike<br />
colloids such as matrix or ground substance, collagen fibers are highly<br />
resistant to heat and pressure. Although range-of-motion stretching is more<br />
efficient with heat than without heat, proprioceptive inhibition and changes in<br />
tissue viscosity account for this difference more than changes in collagen fiber<br />
extensibility. Collagen fibers do not liquefy under pressure or weaken<br />
measurably because of cyclic loading.<br />
Creep<br />
Creep is defined as a slow permanent deformation of viscoelastic materials<br />
when placed under a constant load for long periods of time. The principle of<br />
creep can be applied directly to myofascial release, as found in osteopathy.<br />
Tissues are stretched carefully until solid resistance is felt. Small amounts of<br />
tension are then applied slowly for long periods of time until the tissues start to<br />
relax and lengthen. The point at which tissues start to lengthen is sometimes<br />
called a meltdown or release. Constant tension is continued until the tissues<br />
are fully elongated or no further stretching is possible. The keys to using creep<br />
effectively are (1) minimize force, and (2) maximize time.<br />
Viscoelastic materials like deep fascia are viscous materials with some<br />
degree of elasticity. Deep fascia is viscous because of ground substance and<br />
elastic because of elastin fibers and crisscrossing collagen fibers. Although<br />
tendons and deep fascia are both composed chiefly of collagen fibers, in<br />
tendons, which are less elastic than deep fascia, most fibers are parallel.<br />
Viscoelastic materials are sensitive to rates of loading. When rates of<br />
loading are normal, deep fascia retains its original shape because of molecular<br />
cohesion and elasticity. When rates of loading are slow and constant,<br />
viscoelastic materials deform plastically with minimal force and changes in<br />
length are permanent. Except for spasm, deep fascia has a greater effect on the<br />
length of a muscle than muscle tissue.<br />
If tissues heated before stretching are held in extension until they cool,<br />
increases in length are more likely to be permanent than temporary and tissues<br />
are less likely to be weakened. A similar characteristic is found in<br />
thermosetting plastics that soften when heated and set into a permanent shape<br />
when they cool.<br />
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105<br />
Range-of-motion stretching and topical stretching will sometimes break<br />
the adhesions that form during the wound-healing process. Adhesions are<br />
abnormal fibrous bands that connect tissues that are normally separate.<br />
Adhesions that form between the dermis and superficial fascia in response to<br />
inflammation or trauma are fairly common. Depending on how the<br />
attachments form, adhesions may or may not be symptomatic. Adhesions that<br />
irritate nerves or restrict mobility are symptomatic.<br />
Adhesions are common between the dermis and superficial fascia. The<br />
dermis has two layers: a superficial layer called the papillary layer and the<br />
deeper layer called the reticular layer. The papillary layer is relatively thin<br />
and projections from it produce fingerprints. The reticular layer is thicker and<br />
contains densely interwoven connective tissue and white collagenous bands.<br />
Forming below the dermis, superficial fascia minimizes resistance between<br />
the dermis and most underlying structures. Even though points of attachment<br />
do exist such as the soles of the feet, the palms of the hands, and skin folds,<br />
normal skin, for the most part, is loose.<br />
If abnormal attachments form that prevent the dermis from sliding freely<br />
over the top of underlying structures, loss of mobility and pain are likely.<br />
When adhesions break, relief from pain is almost immediate and the skin starts<br />
to move freely again.<br />
Like muscles, connective tissues form in layers. When attempting deep<br />
penetration through multiple layers of tissue, start with the uppermost layer of<br />
tissue first and work downward. As superficial layers "melt away" and<br />
become more compliant to pressure, proceed slowly to the next layer.<br />
Releasing superficial layers first makes it easier to work the deeper layers with<br />
less force. This approach is safer than using high degrees of physical force or<br />
hand-held devices such as wooden "T-bars" to increase pressure.<br />
In connective-tissue work, the direction of force can also be a factor in<br />
minimizing tissue damage. Connective tissue fibers that run parallel to each<br />
other form patterns called cleavage lines or Langer's lines. These lines follow<br />
about the same direction as normal skin folds. Except for cross-fiber friction<br />
to align tendon fibers after an injury and the use of torque or skin- rolling<br />
techniques to break adhesions, stretching in connective-tissue work is<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
106<br />
normally done in the same direction as cleavage lines. This encourages<br />
connective tissue to lengthen as a group without causing fibers that run in the<br />
same direction to separate from each other.<br />
The angle of force can be a factor in connective-tissue work. The closer<br />
the angle of application approaches 90 degrees, the greater the penetrating<br />
force. Angles of 45 degrees divide force equally between penetration and<br />
forward movement. Angles less than 45 degrees reduce penetration and favor<br />
forward movement. For most purposes, the most effective angle in<br />
connective-tissue work is 45 degrees.<br />
Topical methods of stretching adhesions are torquing forces applied to<br />
superficial scars and skin rolling. Tendons are stretched by cross-fiber friction<br />
and fascia is normally stretched by parallel stretching. Factors that affect the<br />
quality of stretching are (1) intensity of force applied, (2) duration of force, (3)<br />
direction of force, and (4) tissue temperature. Large forces applied rapidly at<br />
low temperatures are more likely to cause a rupture than small forces applied<br />
slowly at high temperatures (105F° to 110°F).<br />
SUPERFICIAL <strong>TO</strong>RQUE<br />
Superficial torquing forces are normally applied by using a force couple.<br />
This means that two equal, opposite, and parallel forces are applied to a body<br />
simultaneously. If the thumbs are placed on superficial scar tissue and<br />
separated about two inches, pushing one thumb forward while pulling the<br />
other thumb back creates a force couple. The two forces moving in opposite<br />
directions make an impression or wrinkle resembling the letter S on the skin.<br />
The combination of shear, compression, and tension produced by this<br />
movement is normally sufficient to rupture adhesions. When superficial<br />
adhesions break, it is not uncommon to hear a snap and feel a sudden release.<br />
The dimples or depressions caused by attachments will suddenly disappear.<br />
SKIN ROLLING<br />
Skin rolling is a particular sequence of forces (tension, compression, and<br />
then bending) applied to skin and subcutaneous fascia. Using both hands<br />
together, the balls of the thumb and forefingers of each hand are used to pull<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
107<br />
the skin away from the patient's body using tension and compression, and then<br />
create a fold by bending the skin over the tips of the forefingers. Once created,<br />
the fold can be rolled in a wavelike motion by using the balls of the thumb to<br />
push the wave forward while the fingers feed new skin over the top of the fold.<br />
If adhesions are detected in areas of the body where the skin is normally loose,<br />
skin rolling, with or without additional tension, should generate enough force<br />
to cause rupture.<br />
CROSS-FIBER FRICTION<br />
Cross-fiber friction is another variety of connective tissue therapy.<br />
Tendons are composed of collagen fibers, elongated tendon cells, and ground<br />
substance. When lesions form on a tendon, cross-fiber friction may help to<br />
align the torn fibers and hasten the wound-healing process. The digital<br />
compression that accompanies cross-fiber friction is similar to the digital<br />
pressure in trigger point therapy. It serves to reduce pain and disperse fluids<br />
that accumulate around lesions. If cross-fiber friction is too painful and timeconsuming<br />
for the patient to endure, trigger point therapy with mobilization or<br />
range-of-motion stretching is a good substitute.<br />
When dealing with tendons, tendinitis may be the effect and hypertonic<br />
muscles the cause. The muscles controlling the tendons need to be examined<br />
for spasm and treated accordingly. Generally, if the agonistic muscles<br />
controlling a tendon are hypertonic, antagonistic muscles are stretched and<br />
weak. To correct this problem, use neuromuscular therapy to inhibit the<br />
agonist and facilitate the antagonist. Range-of-motion stretching is normally<br />
used after trigger point therapy or neuromuscular therapy.<br />
PARALLEL OR PERPENDICULAR STRETCHING<br />
Fascia is normally stretched in directions parallel to cleavage lines. The<br />
terms parallel stretching and longitudinal stretching mean the same.<br />
Perpendicular or lateral stretching is more common in neuromuscular therapy<br />
than connective tissue therapy. In neuromuscular therapy, muscles are<br />
stretched at right angles to inhibit or facilitate contraction. In connective tissue<br />
therapy, perpendicular stretching is used to separate bundles of muscle fibers<br />
or break adhesions.<br />
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108<br />
Parallel stretching uses deep pressure to stretch fascia and restore fascial<br />
balance. As in most forms of connective tissue stretching, when pressure is<br />
slow and steady, fascia deforms plastically instead of elastically because of<br />
thixotropy, hysteresis, and creep. Hysteresis will have the greatest effect if the<br />
same tissues are stretched repeatedly.<br />
Although parallel stretching is often painful and may cause burning pain<br />
because of fascial tearing, initial treatments of an area are normally more<br />
painful than subsequent treatments of the same area. Most patients find<br />
multiple treatments of low intensity more tolerable than single treatments of<br />
higher intensity. Once again, increasing application time and decreasing force<br />
will decrease trauma.<br />
LYMPHATIC DRAINAGE<br />
Since lymphatic tissue and lymph are considered to be connective tissue,<br />
techniques to improve lymphatic function are considered connective tissue<br />
techniques. Even though the lymphatic system is normally passive, it can be<br />
affected by manipulation.<br />
The three main parts of the lymphatic system are lymphatic tissue, lymph<br />
fluid, and collecting ducts. The lymphatic system is sometimes known as the<br />
second circulatory system of the body, and the two main functions of the<br />
system are maintenance of fluid balance in the body and immunity.<br />
Lymph from the entire body, except the upper right quadrant of the body,<br />
drains into the thoracic duct. Lymph from the upper right quadrant drains into<br />
the right lymphatic duct. A decrease in drainage can result in massive edema,<br />
retention of toxic metabolic waste, infection, or cancer.<br />
Lymphatic techniques, in general, have two main goals: increase or<br />
maintain lymphatic flow. One basic approach is to elevate an arm or leg and<br />
use effleurage or petrissage to increase lymphatic flow. Lymph from the arm<br />
is directed toward the axilla and thorax, and lymph from the leg is directed<br />
toward the abdomen. The stroking to improve lymphatic flow should be slow<br />
and steady, and normally proceeds from distal to proximal. The pressure<br />
should not cause pain and the patient should breathe normally.<br />
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STRETCHING<br />
Unlike the stretching in connective tissue therapy that is largely topical,<br />
stretching as used here refers to range-of-motion (ROM) stretching. This<br />
means increasing the distance between muscle attachments (origin and<br />
insertion) to the greatest extent possible without causing tissue damage or<br />
jeopardizing stability.<br />
If an affected body part is hypomobile, ROM stretching may help to<br />
restore normal mobility. In some cases, range-of-motion stretching can<br />
minimize the effects of deep formed scar tissue, break adhesions, reduce<br />
spasm, decrease pain, and retard joint degeneration by increasing joint space. It<br />
may also improve coordination by increasing the range, velocity, and force of<br />
movement. ROM stretching increases velocity and force by allowing<br />
movements to accelerate over a longer distance with less internal resistance.<br />
Passive stretching covers a greater range of motion than active stretching.<br />
Physiologic barriers are the points to which a patient can actively move a<br />
joint. Anatomic barriers are the points to which a practitioner can passively<br />
move a joint beyond physiologic barriers. The space between the two barriers<br />
acts as a shock absorber for the joint. Restrictions that exist beyond<br />
physiologic barriers cannot be treated by active range-of-motion stretching.<br />
Only passive range-of-motion stretching can reach restrictions that exist<br />
between physiologic and anatomic barriers. Movements beyond the anatomic<br />
barrier disrupt tissue and may cause tissue damage or instability.<br />
The three main causes for restricted movement are:<br />
<br />
<br />
<br />
Pain<br />
Spasm<br />
Contracture<br />
These causes may occur separately or in combination with each other. The<br />
normal sequence for treatment is (1) control pain, (2) reduce spasm, and (3)<br />
lengthen connective tissue.<br />
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Even though range-of-motion stretching will have an impact on all three<br />
conditions, most patients are more tolerant of therapeutic stretching if pain and<br />
spasm are treated first. If the patient's range of motion changes radically after<br />
less than one minute of treatment, the probable cause of restriction is pain or<br />
spasm, not connective tissue shortening.<br />
In the absence of pain or spasm, the most significant restriction on range of<br />
motion is connective tissue involvement. Though many types of connective<br />
tissue such as ligaments, tendons, and joint capsules can restrict movement,<br />
the most likely is deep fascia, the fibrous membrane that covers, supports, and<br />
separates a muscle. The three varieties of deep fascia common to skeletal<br />
muscle are (1) epimysium (the outermost sheath), (2) perimysium (the<br />
covering that envelops each primary bundle of muscle fibers), and (3)<br />
endomysium (the covering that invests each striated muscle fiber and binds the<br />
fibers together). If shrinkage of deep fascia causes contracture, the main<br />
course of therapy is range-of-motion stretching.<br />
The correct rate for slow therapeutic stretching depends on how quickly<br />
the affected tissues release. During the initial stages of stretching, lengthening<br />
by stages may indicate that various bundles of muscle fibers are relaxing at a<br />
different rate. This may give the appearance that tissues are "unwinding."<br />
Connective tissues deforming elastically are more likely to stretch at a constant<br />
rate than muscle fibers. During the final stages of stretching, most muscle<br />
fibers are relaxed and connective tissues deform plastically at a uniform rate<br />
till body parts reach their limit. If these changes are not palpable, the rate of<br />
stretching may be too fast.<br />
If a sudden release occurs after tissues have reached their apparent limit,<br />
this may indicate that too much force was applied and tissues are starting to<br />
rupture. Based on Hooke's law, changes in length are proportional to force<br />
until tissues exceed the elastic limit. Once past the elastic limit, tissues may<br />
continue to lengthen and then rupture even if the amount of force being<br />
applied is reduced.<br />
As a caution, flexibility and stability are trade-offs. Too much flexibility<br />
causes instability and too much stability causes inflexibility. By not trying to<br />
go beyond a joint's normal range of motion, practitioners can use range-ofmotion<br />
stretching to achieve a balance between flexibility and stability in ways<br />
that maximize function and minimize the risk of injury.<br />
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111<br />
Although measurements can be taken with a goniometer to determine if<br />
the patient's range of motion is normal, variations from one patient to another<br />
can be expected. Despite the convenience of using numeric goals, the patient's<br />
ability to function is more important than readings on a scale. Even if a patient<br />
falls short of "normal," it is safer to discontinue stretching too soon than to<br />
cause joint damage and hypermobility. Lengthening restricted connective<br />
tissue can be done with range-of-motion stretching, but repairing overly<br />
stretched connective tissue may require medication or surgery.<br />
To maximize flexibility, active range-of-motion stretching should be done<br />
in all directions of movement that are normal for the affected body part. To<br />
improve flexibility of the low back, a combination of flexion and extension<br />
exercises will be more effective than using just one or the other. Extension<br />
exercises are very effective in reducing low back stiffness when shortening of<br />
the gluteal or hamstring groups reduces lumbar lordosis.<br />
Therapeutic stretching is not always confined to normal directions and<br />
planes of movement. Treating the gluteals or hamstrings may require passive<br />
stretching in directions that combine flexion, abduction, and internal rotation<br />
into one movement. Stretching confined to standard directions such as flexion<br />
and extension or to standard planes such as sagittal, coronal, or transverse,<br />
may not be varied enough to reach affected tissues.<br />
Even though most of the standard directions and planes are based on 90-<br />
degree angles, a large percentage of movements made by the human body use<br />
other angles. Once a body part is working normally through standard<br />
directions and planes, movements along other planes or directions should be<br />
evaluated. A patient who is able to perform standard movement reasonably<br />
well during clinical evaluation may not function as well in the real world,<br />
where movements are not structured along 90-degree angles. Many of the best<br />
planes for therapeutic stretching are diagonal, as opposed to 90 degrees.<br />
The best directions for stretching are sometimes difficult. Body parts may<br />
try to move in directions that avoid restrictions or follow the path of least<br />
resistance. Patients will normally indicate directions of movement that are<br />
painful by showing signs of pain or trying to avoid painful movements. The<br />
directions of movement that patients avoid are often the same directions of<br />
movement that need to be improved.<br />
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112<br />
If stretching is successful, some patients may report feelings of greater<br />
sensitivity or heat. Sensitivity will increase if stretching relieves pressure that<br />
traps a nerve and stops nerve conduction. Unless tearing occurs, heat is often<br />
caused by an increased profusion of blood within the muscle. Feeling a warm<br />
sensation is not the same as feeling a burning sensation. The three main<br />
causes for a burning sensation are fascial tearing, exercise to the point of<br />
fatigue, and stingers. Also called a burner syndrome, stingers are caused by<br />
forceful blows to the head or shoulders that irritate the brachial plexus.<br />
The main causes for feelings of pressure or tension are spasms,<br />
contractures, adhesions, or edema. Piriformis and scalenus anticus syndrome<br />
are caused by muscles trapping nerves that penetrate the muscle. When<br />
muscle tension reduces joint space, joint pressure can trap nerves that penetrate<br />
the joint. If a decrease in joint space is causing nerve entrapment, distracting<br />
the joint may relieve nerve signs and compressing the joint may intensify the<br />
signs. The most common nerve signs are shooting pain, numbness, or<br />
paresthesia (a prickling or tingling sensation).<br />
Until the patient can execute coordinated, full range-of-motion movements<br />
without pain or restriction, recovery is not complete. Range-of- motion<br />
stretching works to achieve the range of motion a patient can be expected to<br />
have if therapy is successful. Although therapeutic stretching is not always<br />
painless, excessive pain during or after a stretch may indicate tissue damage<br />
and a need for less force or a different technique.<br />
Despite the tendency to think all stretching should be slow, one reason for<br />
rapid stretching is preparing athletes for competition, where most of the<br />
movements require ballistic power. If range of motion is normal, ballistic<br />
movements can improve performance by improving the quality of movement.<br />
Rapid stretching is not recommended where the athlete's range of motion<br />
is limited. Since tissues have more time to absorb energy, slow stretching is<br />
safer. Boxers "roll with a punch" to give their bodies more time to absorb<br />
energy. Sudden force is more likely to exceed a tissue's plastic limit and cause<br />
rupture than slowly applied force.<br />
Even patients with full ROM will benefit from regular stretching. Without<br />
stretching, muscles and connective tissue have a tendency to shorten because<br />
of age or inactivity. Stretching combined with exercises for strength and<br />
endurance contribute to a patient's general fitness. Regular stretching helps<br />
patients preserve their normal range of motion and may prevent the occurrence<br />
or recurrence of injury.<br />
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The recommendations for regular stretching can range from 2 days a week<br />
to 7 days a week. In the absence of injury or spasm, stretching is fairly<br />
painless and sometimes even relaxing. It is always better to start a moderate<br />
stretching program and continue with the program than to start a strenuous<br />
program and stop because the program is too difficult or because of an injury.<br />
The long-term benefits of stretching will often depend on a patient's<br />
willingness to continue stretching on a regular basis without supervision.<br />
Patients should use overstretching (stretching a tissue beyond its present<br />
length) to increase range of motion until they have a normal pain-free range of<br />
motion. Since muscles have a tendency to shorten during sleep, one of the<br />
best times for stretching is shortly after rising. Stretching just before bedtime<br />
may help to relax the body and make it easier to sleep.<br />
For all the benefits, stretching alone is not the final answer. In our zeal as<br />
practitioners to find the best methods for treating soft-tissue impairments, there<br />
seems to be a tendency to champion one or more techniques to the exclusion<br />
of all others. In reality, no one technique is ever the best or only technique for<br />
all situations. Techniques are best that work best for a given situation. For all<br />
its versatility, stretching is normally the most effective when used in<br />
combination with modalities and other forms of manipulation.<br />
Even so, range-of-motion stretching affects more types of tissue directly<br />
than any other form of manipulation. The four types of tissue in the human<br />
body are nerve tissue, muscle tissue, connective tissue, and epithelial tissue.<br />
Whereas neuromuscular therapy focuses on nerve and muscle tissue and<br />
connective tissue therapy focuses on connective and epithelial tissue, range-ofmotion<br />
stretching affects all four types of tissue and duplicates many of the<br />
effects produced by neuromuscular and connective tissue therapy.<br />
Like neuromuscular therapy, stretching is capable of causing inhibition or<br />
facilitation. Static stretching, holding a stretch for extended periods of time,<br />
may cause inhibition, and rapid stretching, because of the stretch reflex, may<br />
cause facilitation. Where the effects of connective tissue therapy are normally<br />
superficial, the effects of ROM stretching can be superficial or deep. When<br />
treating scar tissue or contractures that form deep within a muscle, range-ofmotion<br />
stretching is more effective than connective tissue therapy.<br />
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Range-of-motion stretching may also duplicate many of the effects<br />
produced by trigger point therapy, such as neutralizing trigger points, reducing<br />
pain, and relieving spasm. By improving circulation, stretching may help to<br />
remove pain-producing chemicals, improve tissue metabolism, and increase<br />
the concentration of oxygen. Range-of-motion stretching should be used after<br />
trigger point therapy to normalize muscle tonus and make the effects of trigger<br />
point therapy longer-lasting or permanent.<br />
Range-of-motion stretching can be used alone or in combination with<br />
modalities or other forms of manipulation such as trigger point therapy,<br />
neuromuscular therapy, and connective tissue therapy. Even the effects from<br />
high-velocity manipulation are less likely to be short-term if high-velocity<br />
treatments are concluded by low-velocity range-of-motion stretching.<br />
MODALITIES AND STRETCHING<br />
While stretching can be done with or without modalities, heating and<br />
cooling modalities facilitate stretching by relieving pain and reducing spasm.<br />
In addition to these benefits, heat reduces tissue viscosity and cold produces<br />
analgesia. The choice of heat or cold depends on which effects are more<br />
important: heat-induced reduction of viscosity or cold-induced analgesia.<br />
Heat is preferred in the absence of swelling and serious pain, while cold is<br />
preferred when the patient is guarding the affected part because of pain. Cold<br />
can also be used after stretching or exercise to control edema and reduce pain.<br />
The application of ice for 15 to 20 minutes is probably the most effective way<br />
to control pain prior to stretching or exercise, and ice applied after stretching<br />
or exercise helps to control pain and reduce edema.<br />
A patient psychologically aroused and apprehensive of pain will be more<br />
resistant to passive stretching than someone relaxed and calm. The attitude of<br />
the practitioner and modalities such as heat or vibration can be used to induce<br />
relaxation. The practitioner being calm and collected seems to help the patient<br />
relax. If a patient prefers heat and dislikes cold, or vice versa, the patient's<br />
inclination should be followed whenever possible.<br />
Some people find various sounds, aromas, or colors relaxing. Slow<br />
traction and mild percussion are more likely to sedate a muscle than rapid<br />
traction and strong percussion. Most patients relax more during exhalation<br />
than inhalation and slow breathing is more relaxing than rapid breathing.<br />
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Whenever heat is used to facilitate stretching, stretching should begin<br />
while tissue temperatures are still elevated and the stretch should be held until<br />
tissue temperatures return to normal. Like thermoplastics, the shape or length<br />
that tissues have at the time of their cooling tends to become permanent.<br />
(When thermoplastics harden because of cooling, the term used is set.)<br />
TRIGGER POINTS AND STRETCHING<br />
If pain is causing a psychological or physical resistance to passive<br />
stretching, neutralizing trigger points may be helpful. Digital ischemic<br />
pressure, compressing the belly of the muscle, or pinching hypersensitive skin<br />
are various trigger-point methods that work well in combination with<br />
stretching. Chemical counterirritants, ice, or vapocoolant sprays can also be<br />
used to desensitize skin and reduce pain or spasm prior to stretching.<br />
Although vapocoolant sprays such as ethyl chloride and Fluori-Methane<br />
are popular (spray and stretch), ice massage can produce the same results.<br />
Besides cryogenic effects, ice produces ischemic pressure when used on<br />
trigger points. Other factors that favor ice are availability, cost, and safety.<br />
The risk of causing an allergic reaction or frostbite is greater with ethyl<br />
chloride spray than ice. Ethyl chloride is also flammable and potentially<br />
explosive when the vapor is mixed with air, while Fluori-Methane is a mixture<br />
of chlorofluorocarbons that may cause damage to the ozone layer.<br />
Piriformis syndrome is caused by entrapment of the sciatic nerve as it<br />
emerges from under the piriformis muscle. Pain is reproduced when the<br />
extended leg is tested with external rotation or resisted external rotation. If<br />
trigger points and muscle spasm are causing the entrapment, trigger point<br />
therapy and stretching may produce dramatic relief. With the patient prone, a<br />
practitioner can lean over the piriformis muscle and use the elbow to apply<br />
ischemic pressure. If trigger point therapy is effective, the piriformis muscle<br />
should be stretched by using medial rotation of the thigh with the hip straight.<br />
Regardless of how trigger points are treated, stretching is always the final<br />
step. ROM stretching can be effective without trigger point therapy, but<br />
trigger point therapy is seldom effective without ROM stretching.<br />
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NEUROMUSCULAR AND STRETCHING<br />
Neuromuscular techniques are often used in combination with active or<br />
passive range-of-motion stretching. In post-isometric relaxation, isometric<br />
contractions are used to prepare muscles for passive stretching or passiveassisted<br />
stretching. In reciprocal inhibition, contracting the opposing muscle<br />
(antagonist) is used to prepare the agonist for stretching. Any neuromuscular<br />
technique that inhibits contraction of the muscle being stretched or facilitates<br />
contraction of the opposing muscle can be used with ROM stretching.<br />
CONNECTIVE <strong>TISSUE</strong> AND STRETCHING<br />
If joints are normal and surrounding muscles are not hypertonic,<br />
connective tissue restrictions are more likely to prevent passive stretch than<br />
tissue viscosity or shrinkage of the epidermis. Connective tissues have a<br />
tendency to shorten when irritated or inflamed. Since muscles are more likely<br />
to relax progressively than all at once, lengthening may occur by stages. As<br />
portions of the muscle relax, slack can be taken up by stretching connective<br />
tissues until muscle fibers provide the next barrier. As other groups of muscle<br />
fibers relax, slack can be taken up again. This explains why patients are more<br />
likely to experience stretching as a series of small releases rather than one<br />
continuous release. These releases should not be confused with fibrillations<br />
that sometimes occur if stretching is painful.<br />
Following the principles of stretching and safety, stretch connective tissue<br />
with slow and steady pressure. Although stretching requires enough force to<br />
exceed the tissue's elastic limit, tissues can accommodate great stress without<br />
injury when forces are applied slowly. Loading applied slowly allows<br />
realignment of collagen molecules and redistribution of ground substance that<br />
encourages tissues to deform plastically without tearing. Because of creep,<br />
small forces applied slowly for long periods of time produce higher degrees of<br />
permanent deformation than larger forces applied quickly. When loading is<br />
rapid, molecular disorientation encourages rupture.<br />
Thixotropy and hysteresis are also factors. Loading is the application of<br />
force and cyclic loading causes fascia to lose energy. Thixotropy reduces<br />
friction by causing gels to liquefy when agitated by loading. Not only should<br />
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stretching be done slowly because of creep, but it should also be done in stages<br />
because of thixotropy and hysteresis. Small amounts of continuous force<br />
applied slowly and then repeated after the tissues relax may increase the<br />
patient's range of motion faster than single forces applied continuously.<br />
When multiple repetitions of stretching are used, the basic sequence is (1)<br />
stretch, (2) return to starting position, (3) allow the tissue enough time to relax,<br />
and (4) repeat the stretch. Patients should exhale during the stretching stage<br />
and inhale during the relaxation stage. The holding period for multiplerepetition<br />
stretching is normally less than 15 seconds and repetitions normally<br />
range from 3 to 12. A holding period of 2 seconds or less is less likely to<br />
trigger a stretch reflex than a holding period that is longer than 2 seconds.<br />
Permanent changes in tissue length occur when tissues exceed the elastic<br />
limit and start to deform plastically. Although stretching may at times cause<br />
rupture if the levels of force are too high, the stresses within a muscle are<br />
normally well below the rupture point and tissues deform plastically without<br />
tearing. High resistance to passive stretch followed by sudden release would<br />
indicate a rupture. A rupture is more likely to occur at the musculotendinous<br />
juncture than in the belly of a muscle.<br />
BALLISTIC STRETCHING<br />
Ballistic stretching is not recommended for most patients, especially when<br />
tissues are edematous or muscles are in spasm. Rapid stretching may trigger a<br />
stretch reflex that causes contraction and makes the muscle more resistant to<br />
active stretching. Slow stretching does not trigger a stretch reflex. In<br />
terms of specificity, on the other hand, athletes may need to consider ballistic<br />
stretching as a necessary part of their training. The principle of specificity<br />
states that practice activities should be as close as possible to actual<br />
performance. In other words, athletes should practice whatever it is they<br />
intend to do. If athletes participate in a sport that requires high-powered<br />
ballistic movements, they should practice the same movements during<br />
training. One form of conditioning, plyometric training, even uses ballistic<br />
movement to increase power. To minimize the risk of injury during training,<br />
warm-ups and static stretching should be done first and ballistic stretching<br />
with a cool-down done last.<br />
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INDIRECT TECHNIQUES<br />
Indirect techniques involve moving in the direction of greatest freedom<br />
before moving into the barrier. Since the muscles used when moving away<br />
from the barrier are probably the same muscles that are causing a limited<br />
ROM, contracting these muscles may in some way diminish their ability to<br />
restrict movement. The principles involved here may relate to successive<br />
induction and post-isometric relaxation: moving away from the barrier may<br />
facilitate the antagonist (successive induction) and inhibit the restricted agonist<br />
(post-isometric relaxation). Using the indirect approach, if elbow extension is<br />
limited, move in the direction of freedom (flexion) and then move into the<br />
barrier (extension). If successful, extension will increase.<br />
PROGRESSIVE MOVEMENT<br />
Progressive movement begins by having the patient stretch as far as<br />
possible into the barrier and then have the practitioner hold the body part in<br />
place until the pain stops and tissues relax. If possible, the patient should<br />
repeat the stretch. Each time the patient repeats the stretch, passive resistance<br />
should be used to hold the body part in place. This process should be<br />
continued until the patient achieves the fullest range of motion possible.<br />
Patients who resist passive stretching may find this method more acceptable<br />
because the patients control their own movements.<br />
Once the affected part reaches its final range of motion, the final step is<br />
having the patient return to starting position and repeat the entire movement<br />
several times without the body part being held in place at the end of the<br />
movement by the practitioner. The final movements by the patient should<br />
move into the barrier slowly to avoid a stretch reflex and back to the starting<br />
position slowly to avoid stressing the muscle being stretched. A typical<br />
movement would be (1) slowly move into the barrier, (2) hold the stretch for 2<br />
seconds or less without assistance, and (3) slowly return to starting position.<br />
The movements into the barrier and back to starting position should take about<br />
equal time. Since progressive movement cannot increase the patient's ROM<br />
beyond the physiologic ROM, passive stretching (overstretching) may be<br />
needed to reach the anatomic range of motion.<br />
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CHAPTER SUMMARY<br />
THREE <strong>HEMME</strong> LAWS<br />
• <strong>HEMME</strong>’s 1st law: Most conditions treatable by soft-tissue therapy<br />
are characterized by pain, limited range of motion, or weakness.<br />
• <strong>HEMME</strong>’s 2nd law: Most conditions treatable by soft-tissue<br />
therapy can be identified and treated by using five basic steps:<br />
History, Evaluation, Modalities, Manipulation, and Exercise.<br />
• <strong>HEMME</strong>’s 3rd law: Always be ready, willing, and able to disregard<br />
any law, principle, axiom, or belief that proves to be incorrect.<br />
TEN LAWS OR PRINCIPLES OF <strong>SOFT</strong>-<strong>TISSUE</strong> <strong>THERAPY</strong><br />
• Beevor's axiom: The brain knows nothing of individual muscles,<br />
but thinks only in terms of movement.<br />
• Creep: Deformation of viscoelastic materials when exposed to a<br />
slow, constant, low-level force for long periods of time.<br />
• Facilitation-Inhibition:<br />
A. When a nerve impulse passes once through a set of neurons to the<br />
exclusion of other neurons, it usually takes the same path in the future<br />
and resistance to the impulse becomes less.<br />
B. As opposites, facilitation encourages a process and inhibition<br />
restrains a process.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
• Head's law: If painful stimulus is applied to areas of low sensibility<br />
in close central connection with areas of high sensibility, pain may be<br />
felt where sensibility is high.<br />
120<br />
• Hilton's law: The nerve trunk that supplies a joint also supplies the<br />
muscles that move the joint and the skin that covers the insertions of<br />
the muscles that move the joint.<br />
• Hysteresis: Energy loss in viscoelastic materials subjected to<br />
or to cycles of loading and unloading.<br />
stress<br />
• Sherrington's laws:<br />
A. Every posterior spinal root nerve supplies one particular region<br />
on the skin, although fibers from segments above and below<br />
can invade this region.<br />
B. Reciprocal Inhibition: when the agonist receives an impulse to<br />
contract, the antagonist relaxes.<br />
C. Irradiation: nerve impulses spread from a common center<br />
and disperse beyond the normal path of conduction.<br />
Dispersion tends to increase as the intensity of stimulus<br />
becomes greater.<br />
• Sherrington's reflex: A muscle contracts in response to passive<br />
longitudinal stretch. (also called stretch reflex or myotatic reflex)<br />
• Thixotropy: Certain gels liquefy when agitated and revert to gel<br />
upon standing.<br />
• Wolff's law: Bone and collagen fibers develop a structure most suited<br />
to resist the forces acting upon them.<br />
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FOUR TYPES OF FORCE USED IN <strong>SOFT</strong> <strong>TISSUE</strong> <strong>THERAPY</strong><br />
• Tension: A force that pulls objects apart (stretch).<br />
• Compression: A force that pushes objects together (press).<br />
• Shear: A force that causes parallel but opposite movement (slide).<br />
• Torque: A force that causes rotation about an axis (twist).<br />
FIVE SIGNS CHARACTERISTIC OF TRIGGER POINTS<br />
• Pain when pressure is correctly applied<br />
• Thickening of subcutaneous tissue<br />
• A jump sign<br />
• A twitch response<br />
• Ropiness or hardness within a muscle<br />
THREE REASONS WHY TRIGGER POINTS REDUCE PAIN<br />
• Digital pressure disperses pain-producing chemicals.<br />
• Digital pressure stimulates production of endogenous opioids.<br />
• Trigger points activated by pressure act as a counterirritant.<br />
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FOUR GOALS OF NEUROMUSCULAR <strong>THERAPY</strong><br />
• Inhibition: lengthen hypertonic muscles.<br />
• Inhibition: strengthen weak muscles.<br />
• Facilitation: shorten stretched muscles.<br />
• Facilitation: strengthen weak muscles.<br />
FOUR WAYS <strong>TO</strong> INHIBIT A MUSCLE<br />
• Activation of Golgi tendon organs<br />
• Deactivation of muscle spindles<br />
• Reciprocal inhibition (RI)<br />
• Post-isometric relaxation (PIR)<br />
FOUR WAYS <strong>TO</strong> FACILITATE A MUSCLE<br />
• Activation of stretch reflex<br />
• Activation of muscle spindles<br />
• Repeated contractions<br />
• Successive induction<br />
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FOUR GOALS OF CONNECTIVE <strong>TISSUE</strong> <strong>THERAPY</strong><br />
• Increase tissue mobility<br />
• Break adhesions<br />
• Improve fluid exchange<br />
• Realign torn fibers<br />
THREE FAC<strong>TO</strong>RS THAT EXPLAIN SLOW STRETCHING<br />
• Thixotropy<br />
• Hysteresis<br />
• Creep<br />
THREE CAUSES FOR RESTRICTED RANGE OF MOTION<br />
• Pain<br />
• Spasm<br />
• Contracture<br />
ONE MANIPULATION THAT AFFECTS FOUR MAJOR <strong>TISSUE</strong>S<br />
• Range-of-motion stretching affects the four major tissues: nerve<br />
tissue, muscle tissue, connective tissue, and epithelial tissue.<br />
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EXERCISE<br />
An exercise program is often the difference between full recovery, partial<br />
recovery, or no recovery at all. Although exercise programs without<br />
manipulations are seldom productive, the value of exercise cannot be<br />
overstated. The results of inactivity are deconditioning of the body as<br />
characterized by atrophy, fibrosis, circulatory insufficiency, loss of bone mass,<br />
and chronic fatigue. Patients who are unwilling to exercise on a regular basis<br />
can expect continuous dependency on treatment, exacerbation of symptoms,<br />
and progressive loss of function. Even if soft-tissue therapy is successful,<br />
exercises are needed to maintain fitness and decrease the risk of re-injury. If<br />
injuries recur, physical fitness has a positive effect on controlling the severity<br />
of injuries and rehabilitation time.<br />
After eliminating the activities that aggravate a patient's condition, the<br />
general goals of an exercise program are to lengthen areas of shortness and<br />
strengthen areas of weakness. Normal movement stops when muscles are not<br />
long enough to permit a full range of motion or strong enough to overcome<br />
internal resistance. Lengthening and strengthening also make it easier for<br />
muscles to overcome external resistance and move objects.<br />
Stretching to increase flexibility is normally the first stage of any exercise<br />
program. Once a full, pain-free range of motion is possible, the second stage<br />
is muscular strength and muscular endurance training to strengthen and<br />
condition muscles that need improvement. Most programs should end with<br />
full range-of-motion stretching exercises to help the patient maintain<br />
flexibility. In most clinical programs, stretching can be used before strenuous<br />
activity to warm up and after strenuous exercise to cool down.<br />
During the early stages of an exercise program, movements should not be<br />
extremely painful or cause fatigue. Perspiration, shortness of breath, difficulty<br />
talking, rapid pulse, and slow recovery times may indicate the exercises are too<br />
intense. Too much exercise causes overuse injuries and slows the patient's<br />
progress. If exercise programs are too difficult, many patients will not<br />
continue.<br />
Once pain is reduced and the patient feels stronger, some people seem to<br />
forget that injuries take time to heal and continue performing the same<br />
activities that caused the original injury. For these patients, caution cannot be<br />
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overstressed. Even though an early return to exercise is normally desirable, it<br />
may exacerbate the existing condition or cause new injuries. Everyone<br />
responsible for the patient's care, including practitioners, trainers, or physical<br />
fitness instructors, should carefully monitor the effects of exercise on the<br />
patient's condition. Any sign of reversal in the patient's condition may indicate<br />
the exercise program needs to be modified.<br />
Even after a full recovery, patients should be instructed to eliminate any<br />
activities that may have caused the original injury. Though some injuries such<br />
as traffic accidents are difficult to predict or prevent, participation in<br />
recreational activities should be controllable by the patient. If the activity is<br />
vital to the patient's self-interest, such as work-related duties, the alternatives<br />
are (1) conditioning the body to accept the added stress by using exercises to<br />
improve strength, endurance, flexibility, or coordination, and (2) using the<br />
body in ways that minimize the effects of stress. Patients are more prone to<br />
injury when tired or fatigued, weak muscles decrease joint stability, and some<br />
injuries could be avoided if patients used better body mechanics when lifting.<br />
Exercise programs should always be structured by someone with<br />
appropriate training in therapeutic exercise. The two groups that seem to use<br />
therapeutic exercise the most are athletic trainers and physical therapists.<br />
Because of special requirements involving space and equipment, exercise<br />
programs and manual therapy may not be available at the same location.<br />
The basic components of a physical fitness program are (1) flexibility, (2)<br />
muscular strength, (3) muscular endurance, (4) aerobic endurance, and (5)<br />
coordination. In terms of therapeutic exercise, the two main goals are<br />
flexibility and muscular strength. Until patients have enough flexibility to<br />
achieve a normal range of motion and enough strength to perform at least one<br />
repetition of the intended movement, muscular endurance, aerobic endurance<br />
(cardiorespiratory endurance), and coordination are secondary.<br />
Physical fitness can only be achieved by following five basic principles.<br />
Everyone connected with a patient's therapy, as well as anyone interested in<br />
their own welfare, should be familiar with these principles. All too often,<br />
practitioners are quick to apply these principles to a patient but slow to apply<br />
the same principles to themselves. These five principles are (1) the overload<br />
principle, (2) the intensity principle, (3) the frequency and duration principle,<br />
(4) the specificity principle, and (5) the training principle.<br />
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<br />
<br />
<br />
<br />
<br />
PRINCIPLES OF PHYSICAL FITNESS<br />
The Overload Principle<br />
The Intensity Principle<br />
The Frequency and Duration Principle<br />
The Specificity Principle<br />
The Training Principle<br />
THE OVERLOAD PRINCIPLE<br />
The overload principle refers to exercising at levels of stress that are<br />
greater than normal. When functioning at normal levels of stress, fitness<br />
remains about the same. The body responds to levels of stress above normal<br />
by making physiologic changes called adaptations or training effects that<br />
improve the body's ability to deal with future stress. These changes affect<br />
flexibility, strength, muscular endurance, and cardiorespiratory fitness. Once<br />
new levels of stress become standard, higher levels of stress are needed for<br />
improvement.<br />
In therapy, overload can be accomplished by using various forms of<br />
resistance such as gravity, weights, weight machines, opposing muscles, or<br />
resistance provided by the therapist. Progressive resistance exercises are based<br />
on the principle that resistance should be increased incrementally after the<br />
body adapts to each new level of stress. Adaptations to overload will continue<br />
until the body reaches its own limit.<br />
Single sessions of an exercise produce temporary changes that are called<br />
responses. These changes become more permanent after repeated bouts of the<br />
same exercise. It is not the exercise itself, but the changes because of exercise<br />
that improve biologic efficiency.<br />
The overload principle can be applied by using both isometric and isotonic<br />
exercises. Isometric contractions do not produce movement because internal<br />
forces are not great enough to overcome external resistance. Muscles<br />
contracting isometrically develop tension without changing length. Isotonic<br />
contractions, on the other hand, produce movement because internal forces are<br />
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great enough to overcome external resistance. Muscles contracting<br />
isotonically develop tension and become shorter. Isometric contractions<br />
improve static strength such as gripping or holding an object, whereas isotonic<br />
contractions improve dynamic strength such as pushing or pulling an object. It<br />
is normally easier to hold an object than to move an object.<br />
Although both types of contraction are used in normal living, from a<br />
therapeutic standpoint, isometric contractions generate less friction and are less<br />
likely to aggravate joints and periarticular tissues. Because there is no<br />
movement during contraction, isometric exercises can sometimes be used<br />
where isotonic exercises would cause tissue damage.<br />
Although not commonly considered, the overload principle can be applied<br />
to flexibility exercises. Flexibility refers to the mobility or range of motion of<br />
a given joint. The structural factors limiting flexibility are muscles, tendons,<br />
ligaments, fascia, body fat, skin, joint capsules, and sometimes the joint.<br />
Contrary to popular belief, flexibility is joint-specific. Flexibility in one joint<br />
does not guarantee flexibility in other joints. Flexibility patterns develop that<br />
are typical for a given activity.<br />
To use the overload principle in flexibility exercises (1) stop the stretch at<br />
the first sign of resistance, (2) hold the stretch until the tissues relax, (3) stretch<br />
slowly until the patient starts to feel pain, (3) hold the stretch until the tissues<br />
relax again, and (4) continue the sequence until stretching becomes too painful<br />
or no further increase in range of motion is needed.<br />
Two other approaches that use overload are (1) stop at the first sign of<br />
resistance, hold the stretch for less than 2 seconds, release the tension, return to<br />
starting position, and then repeat the sequence if needed; or (2) stop at the first<br />
sign of resistance, hold the stretch for 15 seconds or more, release the tension,<br />
return to starting position, and then repeat the sequence if needed.<br />
Regardless of which method is used, patients should normally exhale<br />
during the stretching stage and inhale during the relaxation stage. Since<br />
flexibility and stability are tradeoffs, increasing the patient's range of motion<br />
beyond normal may adversely affect joint function by decreasing stability.<br />
Like exercise programs in general, stretching programs should be<br />
constructed and supervised by someone familiar with training principles, softtissue<br />
therapy, and rehabilitation since too much exercise or inappropriate<br />
exercise can be just as damaging as no exercise or too little exercise.<br />
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THE INTENSITY PRINCIPLE<br />
Related to the overload principle, the intensity principle is probably the<br />
most important single factor in conditioning. Where overload measures the<br />
amount of energy expended to overcome resistance, intensity measures the<br />
rate of expenditure.<br />
Every tissue of the body has a threshold for improvement. Intensity below<br />
this level will not cause improvement. Strength training and, to a lesser extent,<br />
muscular endurance training require higher levels of intensity for improvement<br />
than either flexibility or cardiovascular fitness training.<br />
In sports training, the best measure of intensity is fatigue. Muscles are<br />
fatigued when they lose their ability to contract and momentarily fail. What<br />
causes fatigue is not always clear. Possible causes are depletion of glycogen in<br />
the muscle, accumulation of metabolic waste, depletion of oxygen, and failure<br />
of the body to regulate temperature.<br />
In therapy, a muscle may fatigue after one attempt to move a body part<br />
against gravity. Although fatigue is a good indicator that muscles are being<br />
used to the fullest extent possible, this level of intensity is normally too high<br />
for most patients. Muscle fatigue is inversely related to contractile force.<br />
High-intensity exercises that use near-maximum strength fatigue muscles<br />
rapidly and low-intensity exercises that use 30 percent or less of maximum<br />
strength fatigue muscles slowly. In terms of rehabilitation, low-intensity<br />
exercises are normally safer and more effective than high-intensity exercises.<br />
Even though it is not exactly clear what causes muscle soreness, intensity<br />
of exercise appears to be a factor. Microtrauma, spasm, and edema are several<br />
of the main factors that may cause muscle soreness. According to one theory,<br />
muscle soreness occurs when the byproducts of metabolism, such as lactic<br />
acid, accumulate in the tissues and cause edema. As the fluids shift back into<br />
blood plasma from the tissues, hydrostatic pressure decreases and pain<br />
subsides. Even though the accumulation of metabolites is probably a major<br />
factor in causing muscle soreness, the role of lactic acid is less certain for three<br />
reasons. One, lactic acid levels are not elevated in the muscles long enough to<br />
explain muscle soreness. Two, eccentric exercises produce more muscle<br />
soreness but less lactic acid than concentric exercises. And three, some people<br />
who experience muscle soreness are unable to produce lactic acid because of<br />
hereditary defects or disease (McArdle's disease).<br />
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The most recent theories now suggest that microtraumas are the main<br />
cause for muscle soreness. During intense exercise, microtraumas trigger the<br />
release of pain-producing chemicals such as histamines, bradykinin, serotonin,<br />
potassium ions, and prostaglandins. These chemicals are followed by pain,<br />
spasm, edema, and secondary tissue damage because of edema. The<br />
combination of spasm and edema may also restrict blood vessels and reduce<br />
circulation at a time when metabolic demands are high. Circulatory<br />
insufficiency may then cause metabolites to accumulate and tissues to become<br />
ischemic. Both metabolites and ischemia cause pain.<br />
In many respects, a sequence of muscle soreness resembles a pain cycle.<br />
The differences appear to be onset and resolution. In muscle soreness the<br />
onsets are sudden because of exercise; in pain cycles the onsets are insidious<br />
because the immediate causes are difficult to identify. Muscle soreness is<br />
normally self-limiting and resolves without treatment. Pain cycles are<br />
normally self-perpetuating and seldom resolve without treatment.<br />
It appears that exercise intensity has a direct effect on microtraumas. As<br />
the intensity of exercise increases, microtraumas increase. Though highintensity<br />
exercises favor rapid gain, they increase the risk of muscle soreness,<br />
torn muscles, ruptured tendons, fractured bones, and dislocated joints. Lowintensity<br />
exercises favor long-term improvements but slower progress. Since<br />
for many patients even small amounts of exertion may cause some degree of<br />
improvement, it is normally safer to exchange rapid gains for long-term<br />
progress. An effort of about 60 percent of maximum strength is normally<br />
sufficient to produce an increase in muscle size (hypertrophy).<br />
When muscles increase in size because of hypertrophy, part of this<br />
increase results from an increase in the diameter of muscle fibers and part<br />
results from an increase in the volume of connective tissue. Most skeletal<br />
muscles are about 85 percent muscle fiber and 15 percent connective tissue. If<br />
all other factors are equal (which is seldom the case), a muscle's maximum<br />
force potential is proportional to the cross-sectional area of the muscle.<br />
In addition to intensity, two other factors that affect progressive overload<br />
are frequency and duration. Frequency is the number of times an exercise is<br />
repeated and duration is the amount of time an exercise continues.<br />
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THE FREQUENCY AND DURATION PRINCIPLE<br />
Therapy sessions should be spaced far enough apart to allow sufficient<br />
time for rest. As tissues break down (catabolism) from exercise, rest periods<br />
are needed for growth and repair (anabolism) of injured tissue. High- intensity<br />
exercises require longer periods of rest than low-intensity exercises. Although<br />
flexibility training can often be done more times per week than strength<br />
training, the desired frequency requires a case-by-case assessment.<br />
While 2 or 3 treatments per week may be reasonable, some patients require<br />
more and others less. Since the majority of exercise training in soft-tissue<br />
therapy is done outside the clinic, the patient's motivation and schedule can be<br />
a factor in determining how many sessions are appropriate.<br />
The duration of exercise can also vary. Thirty minutes per patient is about<br />
the average, with 15 minutes the lower limit and 50 minutes the upper limit.<br />
High-intensity exercise requires less time than low-intensity exercise and<br />
strength training requires less time than aerobic training. Poorly conditioned<br />
patients often need shorter sessions than physically fit patients.<br />
THE SPECIFICITY PRINCIPLE<br />
Specific exercises produce specific adaptations. Each exercise has its own<br />
characteristics in terms of muscle groups, rates of energy expenditure, and<br />
patterns of movement. These patterns include velocities, accelerations,<br />
distances, amounts of force, and directions of movements.<br />
The value of training depends on what type of transfer occurs between<br />
practice exercises and final performance (the reason for training). The transfer<br />
is positive if training is beneficial and negative if training is detrimental.<br />
Positive transfer is greatest when the practice exercise and final performance<br />
are nearly identical. To increase positive transfer, a marathon runner should<br />
spend more time running than riding a bicycle or swimming.<br />
In physical fitness testing, the best way to ensure a positive transfer is to<br />
use the testing device for both training and testing. If a stationary bicycle is<br />
used to measure aerobic fitness, a stationary bicycle should be used as the<br />
training device. If the test involves swimming, cycling, or jogging, the<br />
practice should also involve swimming, cycling, or jogging. If the test<br />
involves push-ups, the practice should involve push-ups or possibly bench<br />
presses, since push-ups and bench presses use similar muscles.<br />
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Complete positive transfer is not always possible. In cases of extreme<br />
deficiency, strength training may be the only way to improve muscular<br />
endurance. Without enough strength for even a single repetition, endurance<br />
training would not be possible. Where strength is the limiting factor, strength<br />
training is needed to improve muscular endurance.<br />
Different exercises are needed for each factor that needs to be improved.<br />
A well-rounded exercise program should include exercises to improve<br />
flexibility, strength, muscular endurance, and cardiovascular fitness. In softtissue<br />
therapy, flexibility and strength are normally given more attention than<br />
muscular endurance and cardiovascular fitness.<br />
THE TRAINING PRINCIPLE<br />
The training principle states that patients normally make the greatest gains<br />
during the early stages of an exercise program. Patients in poor condition<br />
seem to improve faster than patients in good condition. The most common<br />
reasons for early improvement are better use of body mechanics and reduction<br />
of counterproductive movements. Neural changes that improve neurologic<br />
efficiency often precede morphologic changes that alter the mass or chemical<br />
composition of a muscle. As patients develop more self-confidence and relax,<br />
general performance seems to improve.<br />
As the program continues, progress is normally slower and some patients<br />
become frustrated, lose interest in the program, and quit training. Explaining<br />
the training principle can make it easier for patients to understand the nature of<br />
progress and continue with the program.<br />
Some people will resist exercise and refuse to participate in their own cure.<br />
Despite the benefits of exercise and the consequences of inactivity, some<br />
patients lack self-discipline. The best approach is try to find methods of<br />
exercise that are both enjoyable and beneficial. In most cases, a patient's<br />
willingness to exercise at home without direct supervision will have a greater<br />
long-term effect on recovery than supervised exercise. In many respects, the<br />
practitioner's role is making the patient capable of tolerating exercise and then<br />
turning responsibility for the patient's welfare back over to the patient.<br />
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CHAPTER SUMMARY<br />
FIVE PRINCIPLES OF PHYSICAL FITNESS<br />
• The overload principle<br />
• The intensity principle<br />
• The frequency and duration principle<br />
• The specificity principle<br />
• The training principle<br />
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OBJECTIVES SATISFIED OR NOT SATISFIED<br />
OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED are the final two steps<br />
in the <strong>HEMME</strong> <strong>APPROACH</strong>. Objectives are satisfied when the patient regains<br />
normal function or achieves lesser goals if restoration of normal function is not<br />
possible. Lesser goals may include less pain, a greater range of motion, or<br />
more strength. If the same problems continue to occur despite therapy, a lesser<br />
goal could be fewer occurrences of the same problem or less disability when<br />
the same problem recurs.<br />
If the patient's problem is not solved, the objectives are not satisfied.<br />
Reasons for not solving a problem are many. Some patients will not cooperate<br />
and some conditions are not treatable by soft-tissue therapy. For many of<br />
these conditions, the only alternatives are medication, surgery, or<br />
psychological counseling.<br />
In rare cases, high-velocity manipulations are more effective than lowvelocity<br />
manipulations. Fragments of bone or cartilage (joint mice) that cause<br />
knees to lock and joint dislocations may respond better to high-velocity<br />
manipulations than low-velocity manipulations. High-velocity manipulations<br />
are normally performed by chiropractors, osteopaths, or medical doctors.<br />
Some problems are not solved because patients refuse to change their<br />
lifestyle or eliminate factors that contribute to the problem. If patients<br />
continue pursuing activities that cause overuse injuries, therapy will not be<br />
effective. Patients with low intakes of vitamin C and B complex are more<br />
prone to soft-tissue impairments and overuse injuries than patients with<br />
healthy diets. Refusal to exercise or change eating habits can adversely affect<br />
the outcomes of therapy.<br />
In any event, only two alternatives are possible, either the objectives are<br />
satisfied or they are not satisfied. Objectives are satisfied when soft-tissue<br />
impairments are corrected to a satisfactory degree. The five main goals of<br />
soft-tissue therapy are normally (1) reduce pain, (2) increase or maintain a<br />
pain-free range of motion, (3) increase or maintain strength, (4) improve the<br />
quality of movement, and (5) restore normal function.<br />
If the objectives are satisfied, verifiable evidence of improvement such as<br />
an increased range of motion by degrees or increased strength based on muscle<br />
testing should be recorded as part of the patient's medical history. Retesting to<br />
determine if the objectives are satisfied or not satisfied normally resembles<br />
step number two in the <strong>HEMME</strong> <strong>APPROACH</strong> titled EVALUATION.<br />
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Objectives are not satisfied when the patient's condition remains the same<br />
or becomes worse. If the original objectives are not satisfied, therapy can be<br />
continued or discontinued. If therapy is continued, the original goals can be<br />
reattempted or new goals can be set. If a realistic appraisal of the patient's<br />
condition shows the original goals are not feasible, new goals can be set using<br />
modified standards. For some patients, any improvement at all is a realistic<br />
goal.<br />
When making final evaluations, statements by the patient are not always<br />
reliable. If the patient and practitioner have good rapport, the patient may<br />
claim improvement just to please the practitioner. On the other hand, if good<br />
rapport is lacking, patients may deny improvement to frustrate the practitioner.<br />
Some patients may deny improvement to justify withholding payment or not<br />
making a complete payment.<br />
While patients concerned about losing their employment or being passed<br />
over for promotion may overstate the recovery, patients anticipating secondary<br />
gain from litigation or sympathy may overstate the disability. Insurance<br />
benefits and job dissatisfaction seem to encourage malingering. To avoid<br />
being overly influenced by the patient, rely on physical signs more than<br />
statements or complaints by the patient.<br />
Therapy is a never-ending learning process and failures are going to occur.<br />
You sometimes learn more from failure than success. Each learning<br />
experience offers new information that makes it easier to find solutions in the<br />
future. By learning from mistakes, a practitioner becomes more adaptable and<br />
patients derive the benefit.<br />
Above all else, always bear in mind a statement made by the Greek Father<br />
of Medicine, Hippocrates, 460-400 BC: "Whenever a doctor cannot do good,<br />
he must be kept from doing harm." In other words, whether a doctor or<br />
therapist, the first and highest duties to perform are:<br />
• PROVIDE THE BEST CARE POSSIBLE<br />
• DO THE PATIENT NO HARM<br />
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MacConaill, M.A., and J.V. Basmajian. 1977. Muscles and movement. 2d<br />
ed. Huntington, New York: Robert E. Krieger Publishing Company.<br />
Magee, David J. 1987. Orthopedic physical assessment. Philadelphia: W.B.<br />
Saunders Company.<br />
Magoun, Harold I., ed. 1978. Practical osteopathic procedures. Kirksville,<br />
Missouri: The Journal Printing Company.<br />
Maigne, Robert. 1996. Diagnosis and treatment of pain of a vertebral origin.<br />
Baltimore: Williams & Wilkins.<br />
Manheim, Carol J., and Diane K. Lavett. 1989. The myofascial release<br />
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Mannheimer, Jeffrey S. 1984. Clinical Transcutaneous Electrical Nerve<br />
Stimulation. Philadelphia: F.A. Davis Company.<br />
Mattes, Aaron L. 1995. Active isolated stretching. Sarasota, Florida: Aaron L.<br />
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Mayer, Tom G., and Robert J. Gatchel. 1988. Functional restoration for<br />
spinal disorders: The sports medicine approach. Philadelphia: Lea &<br />
Febiger.<br />
Mazzarelli, Joseph P., ed. 1983. Chiropractic interprofessional research.<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
McArdle, William D., Frank I. Katch, and Victor L. Katch. 1994. Essentials<br />
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McLatchie, Greg R. 1986. Essentials of sports medicine. Edinburgh:<br />
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Melzack, Ronald and Pat D. Wall, eds. 1994. Textbook of pain. 3d ed.<br />
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Melzack, Ronald and Patrick D. Wall. 1988. The challenge of pain. 2d ed.<br />
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Mennell, John McM. 1960. Back pain. Boston: Little, Brown and Company.<br />
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Michlovitz, Susan L. 1996. Thermal agents in rehabilitation. 3d ed.<br />
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Murray, Chas H. 1912. Practice of osteopathy. 3d ed. Elgin, Illinois: The<br />
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Nestle, Marion. 1985. Nutrition in clinical practice. Greenbrae, California:<br />
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Neumann, Heinz-Dieter. 1989. Introduction to manual medicine. Translated<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
145<br />
Noback, Charles R., and Robert J. Demarest. 1981. The human nervous<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
146<br />
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
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<strong>HEMME</strong> Approach to Soft-Tissue Therapy
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149<br />
GLOSSARY<br />
acute Short duration, not chronic, rapid onset, severe.<br />
active trigger point Hyperirritable spots or zones that actively produce pain<br />
and may cause autonomic responses.<br />
adhesion<br />
separated.<br />
A tissue structure holding parts together that are normally<br />
adipose Pertaining to fat.<br />
agonist Muscle or muscle group primarily responsible for performing some<br />
movement (prime mover).<br />
anabolism The constructive phase of metabolism.<br />
analgesia Loss of sensitivity to pain.<br />
anesthesia Partial or complete loss of feeling, with or without loss of<br />
consciousness.<br />
ankylosis Fixation of a joint.<br />
anoxia Without oxygen.<br />
antagonist Muscle or muscle group that opposes the movement of the<br />
agonist and produces the opposite movement.<br />
antalgic A posture or gait that avoids pain.<br />
aponeurosis A flat fibrous sheet of connective tissue that attaches muscles<br />
to bone.<br />
approximate To bring close together.<br />
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apraxia Loss of ability to perform purposeful movement in the absence of<br />
paralysis.<br />
asthenia Loss of strength or energy.<br />
ataxia Loss of motor coordination.<br />
athetosis Snakelike movements.<br />
atonia Lack of tension or tone, flaccid.<br />
atrophy Decrease in size of an organ or tissue.<br />
auscultation Listening for sounds made by various body structures.<br />
ballistics A study of motion and trajectory.<br />
barrier An obstruction that tends to restrict free movement.<br />
blanch To become pale, white, or lose color.<br />
capsulitis Inflammation of a capsule.<br />
CAT SCAN Computerized (axial) tomography scan.<br />
catabolism Destructive phase of metabolism.<br />
causalgia Burning pain.<br />
chronic Long duration, normally more than six months.<br />
claudication Lameness resulting from inadequate circulation.<br />
clonus Uncontrolled spasmodic muscle jerking.<br />
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cocontraction Mutual contraction of antagonistic muscles for the purpose<br />
of stabilizing a body part.<br />
collagen A fibrous protein found in connective tissue.<br />
compensatory Making up or compensating for a defect, deficiency, or loss.<br />
concentric contraction A muscle shortens during contraction.<br />
contractility Having the ability to contract or shorten in response to<br />
stimulus.<br />
contraction Increased tension caused by physiologic shortening of a<br />
muscle.<br />
contracture A pathologic shortening of a muscle due to spasm or fibrosis that<br />
increases resistance to active or passive stretch.<br />
convergence The moving of two or more forces toward the same point.<br />
conversion Changing emotions such as hysteria into physical manifestations.<br />
counterirritation Superficial irritation that relieves another irritation or<br />
deep pain.<br />
cramp Strong and painful spasm.<br />
creep A slow permanent deformation of viscoelastic materials when placed<br />
under a constant load for long periods of time.<br />
crepitus The sound of bone rubbing against bone.<br />
cryotherapy Therapeutic application of cold.<br />
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cyanosis Bluish or gray discoloration of skin because of reduced hemoglobin<br />
in blood.<br />
cyst A closed sac or pouch containing fluid, semisolid, or solid material.<br />
diaphoresis Profuse sweating.<br />
disease A morbid or pathologic condition that deviates from normal<br />
function where agent, signs, and symptoms are identifiable.<br />
distract To separate.<br />
divergence The moving of two or more forces away from a common<br />
center.<br />
dysesthesia Unpleasant sensations produced by ordinary stimulus.<br />
eccentric contraction A muscle lengthens during contraction.<br />
EMG Acronym for electromyogram, the graphic record of muscle contraction<br />
that results from electrical stimulation.<br />
encephalitis Inflammation of the brain.<br />
endogenous Produced or developed from within the organism.<br />
entrapment syndrome Entrapment of a nerve by hard or soft tissue.<br />
etiology Scientific study involving the causes of disease.<br />
exacerbation Aggravating symptoms or increasing the severity of a disease.<br />
exostosis Bony growth arising from the surface of bone.<br />
extensibility The ability to lengthen.<br />
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exteroceptor A sense organ receiving stimuli from outside the body.<br />
extracellular Outside the cell.<br />
extravasation Fluids escaping from vessels into surrounding tissue.<br />
fascia A fibrous connective tissue membrane covering, supporting, and<br />
separating a muscle.<br />
fasciculation Spontaneous contraction or twitch of a group of muscle<br />
fibers.<br />
fascitis Inflammation of any fascia.<br />
fibrinolytic Dissolution or splitting up of fibrin.<br />
fibroblast A cell that produces connective tissue.<br />
fibroma A fibrous, connective tissue tumor.<br />
fibroplasia Development of fibrous tissue during wound healing.<br />
fibrositis Inflammation of fibrous tissue.<br />
FIRST Acronym for mechanism of injury:<br />
Severity, and Time.<br />
Force, Intensity, Regions,<br />
flail joint Excessive mobility of a joint, usually because of paralysis.<br />
force That which changes or tends to change a body's motion or shape.<br />
gamma motor neuron An efferent nerve cell that innervates the ends of<br />
intrafusal muscle fibers.<br />
ganglion Benign cystic tumors developing on a tendon or aponeurosis.<br />
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G<strong>TO</strong> Acronym for Golgi tendon organs.<br />
guarding Involuntary muscle contractions that limit range of motion to<br />
avoid pain.<br />
<strong>HEMME</strong> Acronym for History, Evaluation, Modalities, Manipulation, and<br />
Exercise.<br />
hypalgesia Decreased sensitivity to pain, opposite of hyperalgesia.<br />
hyper- Prefix meaning more than, excessive, above.<br />
hyperalgesia Increased sensitivity to pain, opposite of hypalgesia.<br />
hyperemia Increased quantity of blood in a body part shown by redness of<br />
skin.<br />
hyperesthesia Increased sensitivity to pain; hyperalgesia.<br />
hyperirritable Increased response to stimulus.<br />
hypermobility Excessive mobility of any joint.<br />
hypertonia Excessive tone of skeletal muscles that increases resistance to<br />
passive stretch.<br />
hypertonic A state of greater than normal tension in muscles.<br />
hypertrophy Increase in size of organ or tissue.<br />
hypo- A prefix meaning less than, deficient, beneath.<br />
hypoesthesia Decreased sensitivity to pain; hypalgesia.<br />
hypokinetic Decreased motor function.<br />
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hypomobility Decreased mobility of a joint or range of motion.<br />
hypotonia Diminished tone in skeletal muscles and decreased resistance to<br />
passive stretch.<br />
hypotonic A state of less than normal tension in muscles.<br />
hypoxia Deficiency of oxygen.<br />
hysteresis Energy loss in viscoelastic materials subjected to stress or cycles<br />
of loading and unloading.<br />
hysteria A neurotic condition presenting somatic symptoms in the absence<br />
of organic disease.<br />
iatrogenic An adverse state or condition induced by treatment.<br />
idiopathic A disease of spontaneous origin with unknown cause.<br />
induration Hardening of soft-tissue caused by extravasation of fluids.<br />
insidious A disease that appears slowly and progresses with few or no<br />
symptoms indicating the illness.<br />
inspection Examination by the eye.<br />
ischemia Insufficient blood supply to a tissue or organ.<br />
isometric contraction Contraction of a muscle with no change in length.<br />
isotonic contraction Contraction of a muscle with a decrease in length.<br />
joint mice Bits of bone or cartilage that are present in joint space.<br />
keloid scar A raised, red, smooth scar that is often painful.<br />
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kinetics A study of forces acting on a system.<br />
latent trigger point Trigger points that lie dormant except when palpated.<br />
ligament A band of fibrous connective tissue connecting the articular ends<br />
of bones.<br />
lipoma A fatty tumor that is not metastatic.<br />
malingering Pretending to be ill.<br />
manipulation Therapeutic use of hands with or without impulse.<br />
matrix The intercellular substance of a tissue.<br />
mechanism of injury The forces that caused the injury.<br />
metastasis Spread of malignant cells.<br />
mobilization Making a joint movable.<br />
modality A therapeutic or physical agent such as thermotherapy (heat),<br />
cryotherapy (cold), hydrotherapy (water), or vibration.<br />
MRI Acronym for magnetic resonance imaging.<br />
muscle hypertrophy An increase in the size of a muscle because of activity.<br />
muscle atrophy A decrease in the size of a muscle.<br />
myalgia Muscular pain.<br />
myofascial release An osteopathic technique that follows the principle of<br />
creep.<br />
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myofascial Involving muscles and fascia.<br />
myofibrosis Replacement of muscle tissue by fibrous connective tissue.<br />
myositis Inflammation of a voluntary muscle.<br />
myotenositis Inflammation of a muscle and its tendon.<br />
necrosis Death of a tissue.<br />
neuralgia Pain along the course of a nerve.<br />
neuritis Inflammation of a nerve.<br />
neuropraxia A traumatized nerve that no longer conducts even though<br />
anatomic structure appears to be intact.<br />
nociceptor A nerve for receiving and transmitting injurious or painful<br />
stimuli.<br />
opioid An opiate-like synthetic narcotic not derived from opium.<br />
osteoarthritis Chronic disease involving degeneration of joints.<br />
osteoblast A cell that produces bone.<br />
palliative Relieving symptoms but not a cure.<br />
Palmer, Daniel Self-educated manipulator (1845-1913) and founder of<br />
chiropractics.<br />
palpation Examining the body by application of hands or fingers to the<br />
surface of the body.<br />
paralysis Loss or impairment of voluntary muscle function.<br />
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paresis Incomplete loss of voluntary muscle function.<br />
paresthesia Abnormal sensation such as "pins and needles,"<br />
burning, tickling, or tingling.<br />
pathology Condition or manifestation produced by disease.<br />
percussion Tapping sharply on the body to determine position, size, and<br />
consistency of underlying structures.<br />
periosteum A fibrous connective tissue membrane that covers bone.<br />
physiatrist A doctor specializing in physical medicine.<br />
pilomotor Pertaining to the arrector muscles that cause hairs to move or<br />
stand erect (goose flesh).<br />
PNF Acronym for Proprioceptive Neuromuscular Facilitation.<br />
proprioceptor A receptor within the body that responds to pressure,<br />
position, or stretch.<br />
proteoglycans The extracellular matrix of connective tissue composed of<br />
glycosaminoglycans (GAG) bound to protein chains.<br />
psychogenic Created by the mind.<br />
radiculitis Inflammation at the origin of a nerve.<br />
range of motion The maximal span of a joint as measured by angular<br />
displacement between two adjacent segments.<br />
Raynaud's disease A peripheral vascular disorder characterized by<br />
abnormal vasoconstriction of the extremities when exposed to cold.<br />
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rebound tenderness Pain or discomfort when pressure is released.<br />
reflex An involuntary response to stimulus.<br />
rheumatoid arthritis A form of arthritis involving inflammation of joints,<br />
stiffness, and swelling.<br />
RICE Acronym for rest, ice, compression, and elevation.<br />
ROM Acronym for range of motion.<br />
salicylate Any salt of salicylic acid that is used in drugs such as aspirin to<br />
reduce pain and temperature.<br />
satellite trigger point A trigger point activated by another trigger point in<br />
the same reference zone.<br />
sciatica Severe pain along the sciatic nerve.<br />
secondary trigger points Trigger points that develop in a synergist or<br />
antagonist because of overload.<br />
self-limiting A condition that runs a definite course and then stops without<br />
treatment.<br />
sentient Capable of feeling sensation.<br />
servomechanism A control mechanism that operates by positive or negative<br />
feedback.<br />
sign Objective evidence of an illness.<br />
somatic dysfunction Altered or impaired function related to components<br />
of the body and treatable by manipulation.<br />
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spasm Involuntary contraction of a muscle beyond physiologic needs.<br />
spastic Inflicted by spasm.<br />
spondylolisthesis anterior displacement of lower lumbar vertebrae over the<br />
body of the sacrum.<br />
spondylosis Vertebral ankylosis that may involve osteoarthritis.<br />
spondylotherapy Spinal manipulation for treating disease.<br />
sprain Trauma to a joint causing injury to ligaments.<br />
stasis Stagnation of blood or other body fluids.<br />
statics A study of systems that do not move.<br />
stenosis Constriction or narrowing of a passage.<br />
Still, Andrew American physician (1828-1917), founder of osteopathy.<br />
strain Trauma to a muscle or musculotendinous unit.<br />
strength The ability to exert muscular force.<br />
stress The results produced when a structure is acted upon by force.<br />
subluxation A partial or incomplete dislocation.<br />
symptom Subjective evidence of an illness.<br />
syncope Loss of consciousness caused by inadequate blood flow to the<br />
brain, fainting.<br />
syndrome A group of signs and symptoms characterizing a disease.<br />
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synergist A muscle functioning in cooperation with another muscle.<br />
telepathy Communication between two people without physical or<br />
physiological explanation, a form of extrasensory perception.<br />
tendinitis Inflammation of a tendon.<br />
tendon A fibrous connective tissue attaching muscles to bones.<br />
TENS Acronym for Transcutaneous Nerve Stimulation.<br />
thermotherapy Therapeutic application of heat.<br />
thixotropy A property of certain gels that liquefy when agitated and become<br />
semisolid again when left standing.<br />
torque A turning caused by rotary force acting about a pivot point.<br />
traction Process of pulling apart.<br />
trigger point or zone A spot or zone of the body that produces sudden pain<br />
when stimulated by pressure.<br />
urticaria Eruption of skin characterized by severe itching.<br />
vasoconstriction Decrease in the caliber of blood vessels.<br />
vasodilation Increase in the caliber of a blood vessel.<br />
vertigo Sensation of whirling or rotating in space or being surrounded by<br />
objects that are whirling or rotating in space.<br />
viscoelastic A viscous material that is also elastic.<br />
viscosity Resistance to flow or shear caused by stickiness or cohesion.<br />
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<strong>HEMME</strong> <strong>APPROACH</strong> QUIZ<br />
1. Which sign or symptom does not characterize soft-tissue impairments?<br />
a. pain Hint: use the table of contents,<br />
b. limited range of motion<br />
index, and chapter summaries.<br />
c. poor quality movement<br />
d. subluxations<br />
2. Which factors cause soft-tissue impairments?<br />
a. trauma<br />
b. disease<br />
c. postural defects<br />
d. all of the above<br />
3. What is replacement of muscle tissue by fibrous tissue called?<br />
a. fibrositis<br />
b. myofibrosis<br />
c. myositis<br />
d. fascitis<br />
4. Which statement about pain cycles is false?<br />
a. Mechanisms that cause pain cycles are difficult to locate.<br />
b. Pain cycles are both chronic and acute at the same time.<br />
c. Muscular imbalance has no effect on pain cycles.<br />
d. Reflexogenic activity perpetuates pain cycles.<br />
5. Which sequence describes the basic steps in the <strong>HEMME</strong> <strong>APPROACH</strong>?<br />
a. Subjective, Objective, Appraisal, and Plan<br />
b. History, Evaluation, Modalities, Manipulation, and Exercise<br />
c. Problem, Theory, Testing, Solution<br />
d. None of the above<br />
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163<br />
6. What does the first letter of the acronym FIRST refer to?<br />
a. fibrosis<br />
b. fascia<br />
c. force<br />
d. fibroblast<br />
7. Which process is not a classical method of physical evaluation?<br />
a. inspection<br />
b. palpation<br />
c. telepathy<br />
d. auscultation<br />
8. Which classification defines range-of-motion testing where the force<br />
is provided by the examiner without assistance from the patient?<br />
a. active range-of-motion testing<br />
b. passive range-of-motion testing<br />
c. active-assisted range-of-motion testing<br />
d. resisted range-of-motion testing<br />
9. In muscle testing, what is the ability to hold against gravity with full<br />
resistance graded as?<br />
a. normal<br />
b. good<br />
c. fair<br />
d. zero<br />
10. In muscle testing, which procedure is potentially unsafe?<br />
a. apply resistance quickly<br />
b. apply resistance slowly<br />
c. do not break the patient's contraction<br />
d. remove resistance slowly<br />
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164<br />
11. Which condition is not commonly cited as a contraindication to softtissue<br />
therapy?<br />
a. malignancies<br />
b. hypertonic muscles<br />
c. cardiac or circulatory disease<br />
d. severe respiratory disease<br />
12. Which condition would normally contraindicate soft-tissue therapy?<br />
a. fibrosis<br />
b. myalgia<br />
c. encephalitis<br />
d. myofibrosis<br />
13. Specialized nerve endings that receive and transmit painful (nociceptive)<br />
stimulus are sensitive to what changes?<br />
a. temperature (thermosensitive)<br />
b. mechanical stress (mechanosensitive)<br />
c. noxious chemicals (chemosensitive)<br />
d. all of the above<br />
14. Which compound is not considered a pain-producing substance?<br />
a. salicylate<br />
b. histamine<br />
c. serotonin<br />
d. bradykinin<br />
15. Which phrase characterizes deep pain?<br />
a. sharp prickling pain<br />
b. dull aching pain<br />
c. well-defined pain<br />
d. tingling pain<br />
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165<br />
16. Which structures are least sensitive to pain?<br />
a. periosteum and joint capsule<br />
b. ligaments and tendons<br />
c. articular cartilage and fibrocartilage<br />
d. muscles<br />
17. Which method of manipulation is not used in the <strong>HEMME</strong> <strong>APPROACH</strong>?<br />
a. high-velocity spondylotherapy<br />
b. trigger point therapy<br />
c. neuromuscular therapy<br />
d. connective tissue therapy<br />
18. Which condition is not indicated for heat?<br />
a. muscle spasm<br />
b. pain<br />
c. contracture<br />
d. edema<br />
19. Which condition(s) contraindicate the use of heat?<br />
a. bleeding<br />
b. malignancy<br />
c. inflammation<br />
d. all of the above<br />
20. Which condition is not indicated for cold?<br />
a. muscle spasm<br />
b. pain<br />
c. vascular stasis<br />
d. edema<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
166<br />
21. Which condition(s) contraindicate the use of cold?<br />
a. Raynaud's disease<br />
b. cold sensitivities<br />
c. severe heart disease<br />
d. all of the above<br />
22. Which principle states the brain knows nothing of individual muscles<br />
but thinks only in terms of movement?<br />
a. Arndt-Schultz law<br />
b. Beevor's axiom<br />
c. Head's law<br />
d. Hilton's law<br />
23. How is soft-tissue therapy defined?<br />
a. manipulation of osseous tissue for therapeutic purposes<br />
b. manipulation of sensory tissue for therapeutic purposes<br />
c. manipulation of superficial or soft tissue for therapeutic purposes<br />
d. manipulation of visceral tissue for therapeutic purposes<br />
24. What is the force called that pushes objects together?<br />
a. creep<br />
b. cocontraction<br />
c. compression<br />
d. contracture<br />
25. Which principle states that all living functions are continually<br />
controlled by two opposing forces?<br />
a. Wolff's law<br />
b. Sherrington's reflex<br />
c. Meltzer's law<br />
d. Facilitation<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
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26. What is another name for stretching?<br />
a. tension<br />
b. compression<br />
c. shear<br />
d. torque<br />
27. Trigger points are indicated by what signs?<br />
a. thickening of subcutaneous tissue<br />
b. a jump response<br />
c. ropiness within a muscle<br />
d. all of the above<br />
28. Which factor does not explain why trigger point therapy reduces pain?<br />
a. production of heat by friction<br />
b. dispersion of pain-producing chemicals<br />
c. production of endogenous opioids<br />
d. counterirritation<br />
29. What are trigger points called that lie dormant for years?<br />
a. active trigger points<br />
b. satellite trigger points<br />
c. latent trigger points<br />
d. secondary trigger points<br />
30. Which method of therapy produces many effects that are similar to those<br />
produced by cross-fiber friction (connective tissue therapy)?<br />
a. trigger point therapy<br />
b. neuromuscular therapy<br />
c. range-of-motion stretching<br />
d. none of the above<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
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31. Which method of inhibition or facilitation is not used in neuromuscular<br />
therapy to balance muscles?<br />
a. lengthen hypertonic muscles<br />
b. strengthen weak muscles<br />
c. weaken strong muscles<br />
d. shorten stretched muscles<br />
32. Which neuromuscular principle is referred to as a key point?<br />
a. lengthen first, strengthen second<br />
b. strengthen first, lengthen second<br />
c. lengthen only<br />
d. strengthen only<br />
33. Which technique in neuromuscular therapy facilitates?<br />
a. activation of Golgi tendon organs<br />
b. activation of muscle spindles<br />
c. reciprocal inhibition<br />
d. fatigue (post-isometric inhibition)<br />
34. Which technique in neuromuscular therapy inhibits?<br />
a. activation of Golgi tendon organs<br />
b. activation of muscle spindle cells<br />
c. repeated contractions<br />
d. successive induction<br />
35. What are the aims of connective tissue therapy?<br />
a. break adhesions<br />
b. improve fluid exchange<br />
c. realign torn fibers<br />
d. all of the above<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
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36. Which concept explains why gels liquefy when agitated?<br />
a. thixotropy<br />
b. hysteresis<br />
c. creep<br />
d. none of the above<br />
37. Which concept explains why viscoelastic materials placed under a<br />
constant load for long periods of time deform with minimal force?<br />
a. thixotropy<br />
b. hysteresis<br />
c. creep<br />
d. none of the above<br />
38. Superficial torque, skin rolling, cross-fiber friction, and parallel or<br />
perpendicular stretching are found in what type of therapy?<br />
a. trigger point therapy<br />
b. neuromuscular therapy<br />
c. connective tissue therapy<br />
d. range-of-motion stretching<br />
39. Which factor(s) are likely to cause limited range of motion?<br />
a. pain<br />
b. spasm<br />
c. contracture<br />
d. all of the above<br />
40. What fibrous membrane covers, supports, and separates a muscle?<br />
a. superficial fascia<br />
b. deep fascia<br />
c. keloid tissue<br />
d. adipose tissue<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
170<br />
41. Which tissues are the focus of connective tissue therapy?<br />
a. nerve and muscle tissue<br />
b. connective tissue and epithelial tissue<br />
c. connective tissue and muscle tissue<br />
d. connective tissue and nerve tissue<br />
42. Which method of therapy targets the four major types of tissue?<br />
a. trigger point therapy<br />
b. neuromuscular therapy<br />
c. connective tissue therapy<br />
d. range-of-motion stretching<br />
43. Which technique moves in the direction of greatest freedom first?<br />
a. direct technique<br />
b. indirect technique<br />
c. linear technique<br />
d. circular technique<br />
44. Which principle of exercise refers to exercising at levels of stress that<br />
are greater than normal?<br />
a. overload principle<br />
b. intensity principle<br />
c. specificity principle<br />
d. training principle<br />
45. Which principle states that patients normally make the greatest gains<br />
during the early stages of an exercise program?<br />
a. overload principle<br />
b. intensity principle<br />
c. specificity principle<br />
d. training principle<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
171<br />
46. Which word defines loss of sensitivity to pain only?<br />
a. analgesia Hint: use the glossary.<br />
b. anesthesia<br />
c. asthenia<br />
d. ataxia<br />
47. Which term defines mutual contraction of antagonistic muscles?<br />
a. concentric contraction<br />
b. cocontraction<br />
c. eccentric contraction<br />
d. isometric contraction<br />
48. Which term defines involuntary muscle contractions that limit range of<br />
motion to avoid pain?<br />
a. atonia<br />
b. hypotonic<br />
c. guarding<br />
d. hypotonia<br />
49. Which term defines a disease of spontaneous origin with unknown cause?<br />
a. hysteria<br />
b. idiopathic<br />
c. iatrogenic<br />
d. insidious<br />
50. Which term defines a nerve for receiving and transmitting injurious or<br />
painful stimuli?<br />
a. exteroceptor Please return only the<br />
b. nociceptor<br />
one-page answer sheet.<br />
c. proprioceptor<br />
d. synergist<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
172<br />
INDEX<br />
active insufficiency 35<br />
active range-of-motion testing 30, 31<br />
active-assisted range-of-motion testing 30, 32<br />
auscultation 26, 28<br />
ballistic stretching 117<br />
Beevor's axiom 36, 64, 119<br />
connective tissue and stretching 116-117<br />
connective tissue therapy 49, 101-108<br />
contraindications to cold 59<br />
contraindications to heat 56<br />
contraindications to soft-tissue therapy 38-40<br />
contraindications to vibration 60<br />
contrast applications 53<br />
creep 64, 104-105<br />
cross-fiber friction 83, 107<br />
cryotherapy 56-59<br />
exercise 124-131<br />
facilitation 86, 89<br />
Facilitation-Inhibition 64<br />
fascia 1-3, 5, 27, 29, 41, 68, 101-108, 110, 112, 116, 127<br />
FIRST 22-23<br />
fixators 35<br />
forces 68-74<br />
frequency and duration principle 130<br />
Golgi tendon organs 90-91<br />
Head's law 45, 64<br />
heat vs. cold 59<br />
<strong>HEMME</strong>’s 1st law 63<br />
<strong>HEMME</strong>’s 2nd law 63<br />
<strong>HEMME</strong>’s 3rd law 64<br />
<strong>HEMME</strong> <strong>APPROACH</strong> 15-18<br />
<strong>HEMME</strong>GON 18<br />
high-velocity manipulation 1, 8, 10, 12, 38, 65-67<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
173<br />
Hilton's law 43, 64, 74<br />
Hooke's law 110<br />
hysteresis 64, 103-104<br />
indirect techniques 118<br />
inhibition 85, 89<br />
inspection 27-28<br />
intensity principle 128-129<br />
latent trigger points 80<br />
low-velocity manipulations 1, 10, 12, 74<br />
lymphatic drainage 108<br />
Meltzer's law 85<br />
modalities 53-60<br />
modalities and stretching 114-115<br />
muscle spindles 91-92, 98-99<br />
muscle testing 29-37<br />
muscle testing by grade 33<br />
muscle testing safety 36<br />
myofibrosis 2<br />
neuromuscular and stretching 116<br />
neuromuscular therapy 84-100<br />
nociceptors 41<br />
overload principle 126-127<br />
pain 41-46<br />
pain cycle 3-9, 42, 129<br />
pain-sensitive structures 45<br />
pain-producing substances 41<br />
painful stimulus 42<br />
palpation 26-28<br />
parallel or perpendicular stretching 107<br />
passive range-of-motion testing 30-32<br />
PDQ 22<br />
percussion 26, 28<br />
post-isometric relaxation 94-96<br />
principles of soft-tissue therapy 63-65<br />
reciprocal inhibition 92-94<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
174<br />
repeated contractions 99-100<br />
resisted range-of-motion testing 30, 33<br />
restrictions 27, 109, 111, 116<br />
salicylate 41<br />
satellite trigger points 76, 79<br />
secondary trigger points 79<br />
Sherrington's laws 64, 74<br />
Sherrington's reflex 65<br />
skin rolling 106<br />
soft-tissue impairments 1-3, 5, 9-10, 12, 27, 74, 113, 133<br />
soft-tissue therapy 1-2, 8-12, 16-17, 38, 53-54, 63-65, 68, 74<br />
SOS 50-51<br />
specificity principle 130-131<br />
stretch reflex 97-98<br />
stretching 109-118<br />
substitution 34<br />
successive induction 100<br />
superficial torque 106<br />
thermotherapy 54-56<br />
thixotropy 65, 103<br />
training principle 131<br />
trigger point therapy 75-83<br />
trigger points and stretching 115<br />
trigger point signs 76<br />
vibration 60<br />
Wolff's law 65, 83<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
I<br />
QUICK REFERENCE GUIDE FOR<br />
NEUROMUSCULAR <strong>THERAPY</strong><br />
INHIBIT<br />
FACILITATE<br />
BELLY<br />
BELLY<br />
Slow compression directed toward the belly of a muscle tends to inhibit.<br />
Rapid tension directed away from the belly of a muscle tends to facilitate.<br />
The belly is normally the wide, fleshy, or central portion of a muscle.<br />
Copyright, David H. Leflet, 1997<br />
<strong>HEMME</strong> Approach Publications<br />
3334 Spring Valley Lane, Bonifay, FL 32425<br />
850-547-9320<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
II<br />
INHIBITION AND FACILITATION<br />
Slow, progressive<br />
stretching tends<br />
to inhibit a<br />
muscle.<br />
slow stretch (pull)<br />
Rapid stretching<br />
tends to facilitate<br />
a muscle.<br />
rapid stretch (pull)<br />
tendons<br />
Pressure on a<br />
tendon tends<br />
to inhibit a<br />
muscle.<br />
Repeated<br />
contractions<br />
tend to facilitate<br />
a muscle.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
III<br />
RECIPROCAL INHIBITION (RI)<br />
Practitioner<br />
applies<br />
counterforce<br />
while patient<br />
contracts the<br />
antagonist.<br />
Practitioner<br />
stretches the<br />
agonist to<br />
increase ROM.<br />
slow stretch (pull)<br />
counterforce (hold)<br />
1 The patient should start with the antagonist at midrange, a length about halfway between<br />
fully contracted and fully stretched or at a point just short of where the muscle starts to resist<br />
stretching (resistance barrier).<br />
2 The patient applies isometric resistance and the practitioner applies an equal<br />
amount of isometric counterforce. The strength of contraction for the antagonist<br />
should be about 25 percent of maximum strength.<br />
3 The patient should hold the isometric contraction for about 10 seconds.<br />
4 Shortly after the patient stops contracting the antagonist (about 3 seconds), the<br />
practitioner should stretch the agonist. Slow stretching with moderate force will be<br />
more effective than rapid stretching with heavy force. Stretching should stop at the<br />
first sign of resistance or pain.<br />
5 The patient should breathe slowly out during contraction, breathe in during<br />
relaxation, and breathe slowly out during stretching.<br />
6 While up to 5 repetitions are acceptable, RI should be stopped if the technique is<br />
too painful, the patient's range of motion stops increasing, or the patient's range of<br />
motion becomes normal.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy
IV<br />
POST-ISOMETRIC RELAXATION (PIR)<br />
Practitioner<br />
applies<br />
counterforce<br />
while patient<br />
contracts the<br />
agonist.<br />
Practitioner<br />
stretches the<br />
agonist to<br />
increase ROM.<br />
slow stretch (pull)<br />
counterforce (hold)<br />
1 The patient should start with the agonist at midrange or at a point just short of<br />
where the muscle starts to resist stretching (resistance barrier).<br />
2 The patient applies isometric resistance and the practitioner applies an equal<br />
amount of isometric counterforce. The strength of contraction for the agonist should<br />
be about 50 percent of maximum strength.<br />
3 The patient should hold the isometric contraction for about 10 seconds.<br />
4 Shortly after the patient stops contracting the agonist (about 3 seconds), the<br />
practitioner should stretch the agonist. Slow stretching with moderate force will be<br />
more effective than rapid stretching with heavy force.<br />
5 The patient should breathe slowly out during contraction, breathe in during<br />
relaxation, and breathe slowly out during stretching.<br />
6 While up to 5 repetitions are acceptable, PIR should be stopped if the technique is<br />
too painful, the patient's range of motion stops increasing, or the patient's range of<br />
motion becomes normal.<br />
<strong>HEMME</strong> Approach to Soft-Tissue Therapy