Trigger Points and Muscle Chains E-Book

Philipp Richter

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2019

Seitenzahl: 425

Beschreibung

Relief for your patients with musculoskeletal pain...

This unique guide takes an in-depth look at trigger point therapy. Divided into two sections – Functional Muscle Chains and Trigger Points and Their Treatment – this book combines detailed theory with tried and practical techniques.

The text covers the basics of functional muscle chains and the origin of myofascial pain arising from the musculoskeletal system, for example, due to poor posture. The reader will learn how various stretching exercises augment the myofascial therapy methods.

Anatomic drawings and liberal use of photographs in this book will help the reader to localize the trigger points and the associated pain areas.

Praise for the first edition:

"The information is brief but to the point; there is little wasted space so that the book is packed with information that can immediately be put into action." Doody's Review

Key Features:

• Various models of muscle chains introduced and described
• Detailed explanations of trigger points and their treatment
• New chapters about posture and influence of gravity, as well 46 new and redrawn illustrations, now totaling approximately 300, included in this new edition
• "Ticklish" and erogenous zones mapped out to help prevent unintended side effects of treatment

Trigger Points and Muscle Chains, second edition, is an essential tool for osteopaths, physical therapists, and all practitioners involved in pain therapy.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Trigger Points and Muscle Chains

Second Edition

Philipp Richter, DO

Institute of Applied OsteopathyBurg Reuland, Belgium

Eric Hebgen DO, MRO

Founder of the Vinxel Institute of OsteopathyKönigswinter, Germany

363 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 4th German edition published and copyrighted 2015 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Triggerpunkte und Muskelfunktionsketten in der Osteopathie und Manuellen Medizin

Translator: Johanna Cummings-Pertl, Hopland/CA, USA

Illustrator: Malgorzata and Piotr Gusta, Champigny sur Marne, France;

Christiane and Michael von Solodkoff, Neckargemünd, Germany

1st Finnish edition 2007

1st French edition 2008

1st Korean edition 2008

1st Japanese edition 2009

1st Italian edition 2010

1st Spanish edition 2010

1st Czech edition 2011

1st Chinese edition (simplified characters) 2011

2nd French edition 2013

2nd Spanish edition 2014

1st Polish edition 2014

1st Russian edition 2016

© 2019 Georg Thieme Verlag KG

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ISBN 978-3-13-241351-1

Also available as an e-book:eISBN 978-3-13-241352-8

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

For Anja and Heike–

without whose patience and support

this book would not have been possible.

Thank you!

Preface to the Second Edition

This book was first published in German in 2006. The book’s great success, also internationally, was surprising and showed us how important and necessary it was to write it. The first English-language edition of this book was published in 2008.

This second English-language edition is based on the fourth German edition, which contains two additions:

• We substantially expanded the chapter on posture. Posture problems are often overlooked as potential causes for functional problems of the locomotor system, especially of the spine. A.T. Still was convinced that locomotor system problems and especially problems involving the spine are the cause of all physical ailments. We trust that the additions to this chapter address the significance of this topic.

• We added stretching exercises to the sections on trigger points. Stretching represents the actual treatment of trigger points and provides excellent opportunities for patients to participate in their treatment by performing simple stretching exer cises as “homework.” One important aspect of these exercises is that they are easy to learn. This increases patient compliance with their “homework” and, with quick results, also helps patients accept the necessity to participate in their treatment success.

In this edition, we standardized the anatomical descriptions and nomenclature, which again improved the structure of the book. We extend our gratitude to Dr. Stephanie von Pfeil for editing the entire text.

Eric HebgenPhilipp Richter

Preface to the First Edition

The idea for this book originated many years ago. Practical experiences, readings in specialized literature, attendance at seminars, and conversations with colleagues and specialists from other disciplines showed us time and again the significance of the locomotor system.

Daily clinical routine showed us in the course of years that the same lesion patterns tended to occur over and over. Years of intensive observation and investigation as well as thorough literature research confirmed that our observations agree with reality and are not just wishful thinking.

Not only osteopaths, but also posturologists and manual therapists speak of motor patterns, using different explanatory models for the development of these patterns. In a course on muscle energy techniques, both Dr. F.L. Mitchell jr. and Dr. Ph. Greenman made reference to a universal pattern. Both agree on the existence of a universal pattern, because in the case of dysfunction in the motor system other body parts always adapt with identical patterns. Similarly, the entire organism follows certain patterns in physiology; examples are processes like walking or breathing. The common embryologic origin of all tissues, the connections of the connective tissue, and the organism as a hydropneumatic system all support this theory. The endocrine system is a good example for holistic behavior as well.

The holistic principle, highly prized by the osteopath, as well as embryologic, physiologic, and neurologic axioms offer explanations for the origin of certain patterns.

In our opinion, the nervous system and the myofascial structures play key roles in this process as organizer and as executing organ respectively.

We have compared different models of muscle chains and different osteopathic working models, looking for commonalities. Consequently, we have realized that all these models share a basic premise, but from different perspectives.

In this book, we present a model of muscle chains that is based on the two motor patterns of cranial osteopathy, namely flexion and extension. Because the organism consists of two halves, it has two corresponding chains of flexion and extension.

Littlejohn’s model of the “mechanics of the vertebral column” and the “Zink patterns” of the American osteopath Gordon Zink, DO have inspired us to divide the torso skeleton into units of movement. Much to our surprise, we realized that this division into units of movement correlated closely with the division of neurologic supply of certain organs and muscles.

We provided both chains with muscles, understanding that this can only be incomplete and theoretical. We ask the reader to keep this in mind. Nevertheless, because the organism only recognizes motor patterns, but not individual muscles, this is somewhat irrelevant.

In the second part of the book, we present a number of treatment methods for the myofascial structures.

For this purpose, we describe trigger point therapy in great detail because it is invaluable in clinic.

We have purposely limited this presentation to the mechanical aspect of osteopathy because it is significant for posture and can therefore be applied in diagnosis.

For physiologic cranial dysfunctions, we have chosen a mechanical model to attempt an explanation. We have, however, refrained from presenting visceral dysfunctions in detail, in spite of the fact that they quite clearly follow the same patterns. Structural disturbances manifest in malposture through direct fascial trains and particularly through viscerosomatic reflexes. Following the holistic principle, the organs adapt to the “container,” the motor system, in the same way that static disturbances affect the location and function of the organs (adaptation of function to structure).

Our model of muscle chains is only a working model, just like many others; we do not lay claim to completeness. We were able to realize in clinic, however, that diagnosis as well as treatment of patients can become much more rational and effective when they originate in this perspective. This applies in particular to chronic and therapy-resistant cases.

Thommen and Königswinter, spring of 2006

Philipp RichterEric Hebgen

Table of Contents

Preface

Preface to the 1st Edition

AMuscle Chains

Philipp Richter

1Introduction

2Models for Myofascial Chains

2.1 Herman Kabat (1950): Proprioceptive Neuromuscular Facilitation

Motion Patterns

Application Modalities

Observations

2.2 Godelieve Denys-Struyf

Classification of the Five Muscle Chains

2.3 Thomas W. Myers

“Anatomy Trains” (Myofascial Meridians)

Myofascial Chains According to T. Myers

2.4 Leopold Busquet

Muscle Chains

Myofascial Chains According to Busquet

Functions of the Myofascial Muscle Chain

2.5 Paul Chauffour: Mechanical Link in Osteopathy

Paul Chauffour’s Biomechanical Chains

2.6 Summary of Myofascial Chain Models

3Physiology

3.1 Connective Tissue

Cells

Intercellular Substance

Connective Tissue Supply

“Creep” Phenomenon

3.2 Muscles

3.3 Fasciae

Functions of Fasciae

Manifestations of Fascial Disorders

Evaluation of Fascial Tensions

Causes of Musculoskeletal Dysfunctions

Genesis of Myofascial Disorders

Pain Patterns

3.4 Vegetative Innervation of Organs

3.5 Irvin M. Korr

Significance of Somatic Dysfunctions of the Spine for the Entire Organism

Role of the Spinal Cord

Role of the Autonomic Nervous System

Significance of Nerves for Trophism

3.6 Sir Charles Sherrington

Inhibition of Antagonists or Reciprocal Innervation (or Inhibition)

Postisometric Relaxation

Temporal and Spatial Summation

Successive Induction

3.7 Harrison H. Fryette

Lovett’s Laws

Fryette’s Laws

Gait as a Global Functional Motion Pattern

Gait Analysis

Muscle Activity while Walking

Conclusion

4The Craniosacral Model

4.1 William G. Sutherland

4.2 Biomechanics of the Craniosacral System

4.3 Motions and Dysfunctions of the Craniosacral Mechanism

Flexion–Extension

Torsion

Sidebending–Rotation

Vertical and Lateral Strain

Compression Dysfunction in the Sphenobasilar Synchondrosis

Intraossal Dysfunctions

Sacrum Dysfunctions

4.4 Impact of Cranial Dysfunctions and Malpositions on the Periphery

5The Biomechanical Model of John Martin Littlejohn: Mechanics of the Spine

5.1 History

5.2 “Mechanics of the Spine” and the Body’s Lines of Force

Central Gravity Line

Anterior Body Line

Anteroposterior Line

Two Posteroanterior Lines

5.3 Polygon of Forces

5.4 Arches, Pivots, and Double Arches

Arches

Pivots

Double Arches

5.5 Specific Adjusting Technique as per Dummer

History

Procedure

Three Units

6Postural Muscles, Phasic Muscles, and Crossed Syndrome: Vladimir Janda’s Contributions to Myofascial Treatment Methods

6.1 Posture

6.2 Motor Function

6.3 Postural Muscle Fibers (Red Fibers)

6.4 Phasic Muscle Fibers (White Fibers)

6.5 Muscles That Tend toward Contraction

6.6 Muscles That Tend toward Weakening

6.7 Crossed Syndrome

Upper Crossed Syndrome

Lower Crossed Syndrome

6.8 Practical Implications

7Zink Patterns

7.1 The Composition of Zink Patterns

Occipitoatlantoaxial Complex

Superior Thorax Aperture

Inferior Thoracic Aperture

Pelvis

7.2 Practical Applications of the Zink Pattern

Occipitoatlantal Axis

Superior Thorax Aperture

Inferior Thorax Aperture

Pelvis

8Myofascial Chains: A Model

8.1 Muscle Chains

Flexion Chain

Extension Chain

8.2 Summary and Conclusion about Flexion and Extension Chains

Flexion Chain

Extension Chain

8.3 Torsion

8.4 Special Characteristics of Some Muscles and Muscle Chains

Sternocleidomastoid

Scalene Muscles

Diaphragm

Iliopsoas Muscle

Hip Rotators

Summary

9Posture

9.1 Factors Impacting Posture

9.2 Impact of Gravity on the Locomotor System

9.3 Hinge Zones

9.4 Maintaining Equilibrium

Practical Relevance

Posture Receptors

Summary: Maintaining Equilibrium

9.5 Examination

Method

Posture Analysis

Differentiation: Parietal–Visceral–Cranial

Examination of Posture Receptors

Conclusion

9.6 Leg Length Differences

Leg Length Differences and Posture Changes of Pelvis and Spine

Symptoms of Leg Length Differences and Impact on Musculoskeletal System

Diagnosing Leg Length Differences

Should Leg Length Differences be Corrected?

Conclusion

10Diagnostics

10.1 Anamnesis

10.2 Examination

Observation

Palpation

Motion Tests

11Therapy

11.1 Muscle Energy Techniques

Definition

Indications and Contraindications

Prerequisites for Optimal Muscle Energy Technique Application

Technical Prerequisites and Enhancers for Muscle Energy Techniques

Muscle Energy Technique Variants

Physiologic Principles

11.2 Myofascial Release Techniques

11.3 Neuromuscular Technique

11.4 Myofascial Release Technique with Ischemic Compression

BTrigger Points: Diagnosis and Treatment

Eric Hebgen

12Definition

13Classification of Trigger Points

14Pathophysiology of Trigger Points

15Diagnosing Trigger Points

16Trigger Point Therapy

17Trigger Point Perpetuating Factors

18Facilitated Segments

19Trigger Points

19.1 Head and Neck Pain: Related Muscles

Trapezius Muscle

Sternocleidomastoid Muscle

Masseter Muscle

Temporal Muscle

Lateral Pterygoid Muscle

Medial Pterygoid Muscle

Digastric Muscle

Orbicular Muscle of Eye, Greater Zygomatic Muscle, Platysma Muscle

Occipitofrontal Muscle

Splenius Muscle of Head and Splenius Muscle of Neck

Semispinal Muscle of Head, Semispinal Muscle of Neck, Multifidus Muscles

Rectus Capitis Posterior Major and Minor Muscles, Inferior and Superior Oblique Muscles of Head

Stretching the Lateral Cervical and Nuchal Muscles

19.2 Upper Thorax, Shoulder, and Arm Pain: Related Muscles

Levator Muscle of Scapula

Scalene Muscles

Supraspinous Muscle

Infraspinous Muscle

Teres Minor Muscle

Stretching the External Shoulder Rotators

Teres Major Muscle

Latissimus Dorsi Muscle

Stretching the Lateral Side of the Trunk

Subscapular Muscle

Rhomboid Muscles

Deltoid Muscle

Coracobrachial Muscle

Biceps Muscle of Arm

Stretching the Biceps Muscle of Arm

Brachial Muscle

Triceps Muscle of Arm

Anconeus Muscle

19.3 Elbow and Finger Pain: Related Muscles

Brachioradial Muscle

Long Radial Extensor Muscle of Wrist

Short Radial Extensor Muscle of Wrist

Ulnar Extensor Muscle of Wrist

Extensor Muscle of Fingers

Extensor Muscle of Index Finger

Supinator Muscle

Stretching the Lower Arm Extensors

Long Palmar Muscle

Radial Flexor Muscle of the Wrist

Ulnar Flexor Muscle of Wrist

Superficial Flexor Muscle of Fingers

Deep Flexor Muscle of Fingers

Long Flexor Muscle of Thumb

Pronator Teres Muscle

Stretching the Lower Arm Flexors

Adductor Muscle of Thumb

Opposing Muscle of Thumb

Abductor Muscle of Little Finger

Interosseous Muscles of Hand

19.4 Upper Trunk Pain: Related Muscles

Greater Pectoral Muscle

Smaller Pectoral Muscle

Subclavius Muscle

Stretching the Pectoral Muscles

Sternal Muscle

Superior Posterior Serratus Muscle

Inferior Posterior Serratus Muscle

Anterior Serratus Muscle

Erector Muscle of Spine

Stretching the Autochthonous Back Muscles

Rectus Abdominis Muscle, Internal and External Oblique Muscles of Abdomen, Transverse Abdominal Muscle, Pyramidal Muscle

Stretching the Abdominal Muscles

19.5 Lower Trunk Pain: Related Muscles

Quadratus Lumborum Muscle

Stretching the Lateral Side of the Trunk

Iliopsoas Muscle

Stretching the Hip Flexors and Gluteal Muscles

Muscles of the Pelvic Floor

Gluteus Maximus Muscle

Gluteus Medius Muscle

Gluteus Minimus Muscle

Piriform Muscle

Stretching the Piriform Muscle

19.6 Hip, Upper Leg, and Knee Pain: Related Muscles

Tensor Fasciae Latae Muscle

Sartorius Muscle

Pectineal Muscle

Quadriceps Muscle of Thigh

Stretching the Quadriceps Muscle of Thigh

Gracilis Muscle

Long Adductor Muscle

Short Adductor Muscle

Great Adductor Muscle

Stretching the Short Hip Adductors

Stretching the Long Hip Adductors

Biceps Muscle of Thigh

Semitendinous Muscle

Semimembranous Muscle

Stretching the Ischiocrural Muscles

Popliteal Muscle

19.7 Lower Leg, Ankle, and Foot Pain: Related Muscles

Anterior Tibial Muscle

Posterior Tibial Muscle

Long Peroneal Muscle

Short Peroneal Muscle

Third Peroneal Muscle

Gastrocnemius Muscle

Soleus Muscle

Plantar Muscle

Stretching the Calf Muscles

Long Extensor Muscle of Toes

Long Extensor Muscle of Great Toe

Long Flexor Muscle of Toes

Long Flexor Muscle of Great Toe

Short Extensor Muscle of Toes

Short Extensor Muscle of Great Toe

Abductor Muscle of Great Toe

Short Flexor Muscle of Toes

Abductor Muscle of Little Toe

Quadratus Plantae Muscle

Dorsal Interosseous Muscles of Foot

Plantar Interosseous Muscles

Adductor Muscle of Great Toe

Short Flexor Muscle of Great Toe

20Bibliography

21Illustration Credits

22List of Abbreviations

Index

A

Muscle Chains

Philipp Richter

1 Introduction

Role of Muscle Chains in the Body

The musculoskeletal system and muscle chains are the primary focus of this book. Myofascial structures participate in all somatic functions: Emotional states present as muscle tension. Physical labor requires muscle activity. Circulation, breathing, and digestion depend on an intact locomotor system.

Manual therapists—physical therapists, chiropractors, osteopaths, or Rolfing practitioners—examine and treat the locomotor system differently and with different motivations. Physical therapists and Rolfing practitioners treat the musculoskeletal system primarily to resolve discomfort (pain, tension, etc.) in the area being treated. Chiropractors and especially osteopaths view the myofascial system as a component of the body that can cause or result from dysfunction or pathology in other body systems. Another group of professionals—podologists or posturologists—are aware of the negative impact on the whole body that can result from minor shifts in weight or foot misalignments.

All somatic functions depend on well-functioning myofascial structures. The nervous system takes on the role of coordinator and controller. To avoid overloading the cortex, many activities are managed by subcortical reflexes and behavior patterns. Viscerosomatic and somaticovisceral reflexes have also been scientifically proven, which emphasize the special significance of muscle imbalances, especially of the paravertebral muscles.79,112

Motor and posture patterns of the human body involve the entire organism, in the same way that all physical activity results from interactions of all body systems. Osteopaths and chiropractors employ this fact in their diagnosis and therapy.

Segmental innervation of all body structures and adaptation mechanism patterns provide indications for structural involvement. Many sports injuries or musculoskeletal pain result from dysfunctions in parts of the myofascial chains. Understanding myofascial connections enables diagnosis and appropriate treatment. The osteopathic mindset provides a thought-provoking explanation for the mechanisms involved in the development and treatment of disorders.

Dr. Still’s Osteopathy

When Dr. Andrew Taylor Still presented his philosophy of healing, during a phase when he rejected the medicine practiced at the time, he called it osteopathy. He knew full well that this term had a different meaning in the medical world at the time. His desire was to help medicine return to its origins by placing humans at the center and natural laws in the foreground. Osteopathy was the most appropriate term to illustrate that disease (pathos) results from dysfunctions in the body. Dr. Still viewed the musculoskeletal system and especially the spine as playing a central role. He recognized that all diseases and functional disorders involved mobility limitations of the spine. Osteopathy is derived from the Greek words “osteon” for bone and “pathos” for disease.140

Dr. Still knew from experience that treating symptoms did not bring about healing. Successful healing required expert treatment of the causes of disease. He had no doubt that disease started with circulatory disorders and that the cause was to be found in the connective tissue.140 Therefore, this is where disease needed to be examined and treated. Myofascial tissue is of special importance in this process82,140 because of its ability to serve as the following:

• Connector (co nnective tissue).

• Pathway for veins, lymphatics, arteries, and nerves.

• Supporting tissue (stroma, matrix) for organs and bones.

• Protective structure.

For Still, the nervous system and its surrounding fluids (cerebrospinal fluid [CSF]) are possibly even more significant than connective tissue. The nervous system serves as a control center and regulating organ and is responsible for all adaptation mechanisms between individual body systems. It initiates and coordinates all functions in the entire body and is responsible for all adaptation and compensation mechanisms.

Still refers to CSF as possibly “the highest known element” in the entire organism. Its composition is similar to blood and lymph serum. CSF is connected to blood via the choroid plexuses and with lymph via the peripheral nerves of the interstitium. In addition to its protective and nourishing functions for the central nervous system, Still and especially his student William Garner Sutherland attributed a special function to the CSF:54,140,142,143 it carries the “breath of life” into all cells of the body.

Still’s experience in his early years likely gave rise to the development of osteopathy. As a physician, religious believer, and son of a Methodist preacher, Still had a close connection to religion and to God. This is reflected in all his writings: God gave humans health and disease is abnormal. Still believed that the osteopath’s task is to search for health in the body of patients.

In his search for true medicine, Still was inspired by two opposing directions: spirit healers and bone setters. In his view, spirit healers embody therapists who believe in God. They tune into tissues and, through their hands, focus energy into a pathologic area. The “breath of life” (Sutherland) then performs the healing. Bone setters, on the other hand, also achieve great success through physical manipulation (adjustments).

Still combined both directions in his osteopathic treatments. His special talents as a therapist derived from his precise understanding of anatomy and his excellent sense of touch, combined with his belief in the power of self-healing and his intention to help. His anatomical and physical knowledge enabled him to precisely visualize structures. His sense of touch allowed him to feel tension in tissues and apply targeted, appropriate techniques in each individual case.

As an osteopath, Still embodied both the spirit healer and the bone setter. He compared the human body to a machine and the osteopath to a mechanic who repairs the mechanics of the machine.140

One characteristic of Still’s osteopathy was that he combined biodynamics with biomechanics. Nowadays, it seems that some of his successors have divided this duality. Some osteopaths are pure “mechanics” who emphasize the laws of anatomy and physiology and manipulate the whole body using gentle and less gentle techniques. They represent the biomechanical direction of osteopathy.

Others are more biodynamically oriented. They place less importance on biomechanics and more emphasis on their sense of touch and the body’s power of self-healing. Like spirit healers, they attempt to activate the self-healing powers in tissues, with the difference being that they employ the body’s rhythms in diagnosis and therapy.8,9,72

Of interest in this context is a statement by Viola Frymann (continuing education 2000). She says that (Sutherland’s) primary respiratory mechanism (PRM) clearly manifests in healthy tissue. However, with dysfunctions, the PRM’s power of expression is impeded. This means that the PRM can be employed in diagnosis and therapy. Biodynamic therapists take advantage of this phenomenon by using their hands to establish a fulcrum in the tissue.8,72,135 After a certain period of time, the PRM expresses itself in its various rhythms, which is an indicator that the tissue is regaining its function.

The difference between classic cranial osteopathy and biodynamics is that classical cranial osteopathy examines the tissue for motion and motion limitations and then guides the structure to be treated into unrestricted motion and holds it there. This allows the PRM to develop freely without tension and carry out its therapeutic effect.

The motions of the sphenobasilar synchondrosis (SBS) palpated and described by Sutherland correspond to motions of the head in the three planes of space, plus translations in the sagittal plane (up and down strain) and in the horizontal plane (lateral strain) . Functional techniques applied to the locomotor system work according to the same principle. Therapists search for a balance point in all planes (stacking) and maintain the tissue in a relaxed position until automatic relaxation takes place. This shows that the principles employed in cranial osteo pathy are identical to those that apply to the rest of the body.

Opinions vary about which mechanisms are ultimately responsible for tissue relaxation. Practitioners of biomechanics maintain that it involves a reflexive response originating in the tissue receptors. Biodynamic practitioners believe in the effect of the PRM.

In his therapy, Still employed a combination of so-called direct and indirect techniques. Direct techniques manipulate the segment to be treated in the corrective direction. Indirect techniques move the segment in the direction of dysfunction.

Richard Van Buskirk23 conducted research into Still’s treatment methods by asking older patients, who were treated by osteopaths in their childhood or youth, to recall the techniques used in their treatment. Some of these patients were still able to describe those techniques and Van Buskirk was surprised to find that they resembled the few techniques described by Still himself.

A short video clip still exists in which Still can be observed treating a rib. This video along with statements of patients and the limited documentation written by Still about his techniques show the following: After thorough diagnosis, the segment to be treated is placed into the lesion position until the contracted muscles relax. Then the segment is moved into the corrective position using slight pressure that is focused on the blocked joint throughout the motion.

Scientific Evidence

As has been mentioned, the nervous system plays a central role for Still. It forms the link between the visceral, parietal, and cranial systems. The importance of the central nervous system and especially of the spinal cord in the genesis of dysfunction and pathology has been scientifically documented in research by Korr, Sato, Patterson and others.79,81,112

These scientists experimentally verified the significance that Still and other manual therapists placed on the spine in the development and maintenance of pathological states. They confirmed the central, regulating role of the spinal cord. Korr79 was able to provide scientific explanations for generally accepted phenomena observed in experiments. He referred to the locomotor system as “the primary machinery of life” and maintained that the other systems (digestion, endocrine, heart, and circulatory systems) serve the locomotor system.

The autonomic nervous system (ANS) plays a special role in this context. Both parts of the ANS are complimentary rather than antagonistic. Roughly speaking, the parasympathetic (craniosacral) nervous system (PNS) regenerates the organism. It also plays a regulating role in processes of longer duration. The sympathetic nervous system (SNS), on the other hand, adapts body system functions to current needs. It intervenes in the regulation of blood supply to active muscles, for example, by reducing blood flow to the digestive system to benefit muscles during physical activity. At the same time, the SNS increases respiration and pulse rates. The SNS enables the body to spontaneously adjust to immediate requirements.

Korr supplied neurophysiological explanations for many phenomena observed by clinicians. He coined terms such as facilitated segment and neurologic lens. A facilitated segment is a segment of the spinal cord where the stimulus threshold of all nuclei is lowered by repeated stimulation or by dysfunction of the segment due to chronic stimulation. In this condition, subliminal stimulation of the facilitated segments suffices to cause disproportional reactions. One example is acute torticollis resulting from exposure to drafts.

The term neurologic lens describes the following phenomena: If a spinal cord segment is chronically irritated, it becomes susceptible to stimuli that should normally only be able to stimulate other, more distant segments. The irritated segment is said to “attract stimuli.”

In their experiments, the research team led by Korr produced other interesting results:

• Increasing the sympathetic tone (locally or generally) lowers the stimulus threshold of the segments involved and increases muscle tone for the muscles supplied by those segments.

• Blocking of vertebrae increases the sympathetic tone of the segments involved and lowers the stimulus threshold.

• Stress of all types increases muscle tone, especially in facilitated segments.

• Posture imbalances impact the muscle tone of paravertebral muscles and of muscles supplied by facilitated segments.

• Reducing the muscle tone of paravertebral muscles lowers sympathetic tone in those segments.

Taken together, research results in this area clearly illustrate two facts:

• The musculoskeletal system is one of the main agents involved in the development and maintenance of somatic dysfunctions.

• The spinal cord plays an important role as a control element and organizer in the genesis of pathological states.

Korr’s characterization of the locomotor system as the “primary machinery of life” is therefore by no means an exaggeration.

Myofascial structures play a main role in all important bodily functions, from respiration (thoracic as well as cell respiration), circulation (diaphragm and muscles as venolymphatic pump), and digestion (as mobilizer of organs) to being a means to express emotions. The locomotor system enables motion, communication with others, food intake, etc.

The fact that more than 80% of all afferents originate from the locomotor system further underscores the importance of the musculoskeletal system.79,112,158 The extreme sensitivity of muscle spindles (1 g of traction and a stretch of 1 mm cause a reaction of the muscle spindle79) makes the locomotor system a highly sensitive organ. This enables quick reactions, but at the same time, it increases susceptibility to dysfunctions. This results in contractions, malpositions, and coordination disorders.

Irvin [in155] and Kuchera and Kuchera82 describe how a 1- to 1.5-mm tilt of the base of the sacrum suffices to change the muscle tone of the paravertebral muscles. Korr described the resulting impact on the SNS and on the entire body. However, the spinal cord as a controlling and organizing center is not influenced by only peripheral stimuli.

The emotional state of a person is a significant factor in the genesis of dysfunctions and pathologies. The limbic system plays a decisive role in this process.158 As the body’s memory, it evaluates all stimuli and impressions as either positive or negative for the person, depending on previous experience. If a stimulus is experienced as pleasant, it provides positive feedback. If the stimulus is perceived as harmful, it provides negative feedback.

The hypothalamic–pituitary–adrenal (HPA) axis controls the neuroendocrine system, which regulates hormone balance as well as the neurovegetative system. Facilitated segments are especially impacted by positive and negative emotional stimuli (e.g., weekend migraine or stress ulcers). Segments with lower stimuli thresholds remain “chronically irritated” after a certain amount of time when they are subjected to persistent stimulation.112Therapy for this condition requires treatment of the entire lesion pattern to erase the imprinting of the pathological pattern at the level of the central nervous system. In this context, Korr talked about the spinal cord as organizer of disease processes.79

The embryologically determined metamerism of the spinal cord leads to segmental affiliations of certain muscles, organs, vessels, skin area, bones, and joints. Stimulating one of these structures influences the functions of all other structures associated with this segment.

Since neighboring segments are connected by interneurons, facilitation usually impacts several segments. The plurisegmental supply of organs and muscles also supports this concept. In our opinion, it is wrong to associate an organ or function with a single spinal cord segment, especially since the brain knows only motion patterns, not individual muscles. Congenital and acquired patterns are of equal importance in this context.

The digestive system has considerable autonomy due to the enteric nervous system, but it is nevertheless subordinate to overall body function, with the endocrine and neurovegetative system also providing a regulating function.

It is safe to assume that both congenital and acquired behavior patterns are found in this system, just like with the locomotor system. These patterns likely correlate with posture and locomotor system patterns and create a certain type.151

Mobility and Stability

The locomotor system consists of muscles and bones. It needs to serve two contradictory functions simultaneously: provide stability and allow movement.

The cerebellum and the vestibular system enable both functions. They both receive their information from receptors that are primarily located in myofascial structures.

Both functions are carried out by muscles: adequate basal muscle tone, ability to react quickly, and well-coordinated muscle tension enable delicate, harmonious motions as well as subtle and appropriate adjustments to ensure balance in the most efficient manner.

In its wisdom, nature (or the Creator) has provided a simple solution for this problem. Centrifugal force (expanding force of the organs) is balanced by the imploding force (inherent muscle tension) of the musculature. The extraordinary sensitivity of muscles supported by the precise coordination provided by the nervous system enables optimal and efficient stabilization of the locomotor system.

To perform harmonious motions, muscles need stable support, a central organ that coordinates activity (nervous system) and structures that guarantee their supply (metabolism). These activities are controlled by the nervous system, which activates agonists and synergists and inhibits antagonists precisely to the extent needed to perform targeted, harmonious motions.

Most motions occur unconsciously with the help of several spinal reflexes. This is necessary for humans to act anticipatorily. The cerebrum needs decision autonomy.

The spinal cord acts as a control center for all physical activities. Dysfunctions can have disastrous consequences. All afferent signals from the locomotor system reach the spinal cord and efferent signals to the muscles originate there. This is where motor and posture patterns are processed.

In the 1950s, Sherrington described several reflex actions that explain these patterns [in21 and in160]. Muscles consist of different muscle fibers with different characteristics. White (fast-twitch) fibers are more suited to fast contractions, while red (slow-twitch) fibers support longer lasting tension. Both fibers exhibit different pathologic tendencies. White fibers tend toward weakness and atrophy, whereas red fibers tend toward contracture and shortening. These characteristics need to be addressed during treatment.40,41,86,87

The Organism as a Unit

At the beginning of this chapter, we pointed out that the organism always responds as a unit. We do not intend to reproduce the basic foundations of osteopathic thinking in this book, but only those concepts necessary for understanding the following chapters.

Our organism always acts as a unit, in physiologic as well as in pathologic states. The entire body participates in each physiologic process. Respiration, for example, involves all muscles. It not only activates the respiratory system muscles, but also mobilizes digestion in a certain pattern. Circulation is also supported by muscles. These activities always follow a specific process. During inspiration, the entire locomotor system, including the head, carries out a motion pattern that Sutherland called “flexion–external rotation–abduction”.101,102,142,143 Exhalation reverses this pattern: “extension–internal rotation–adduction.”

Walking follows a similar pattern. Gait is a harmonious sequence of motions from the tip of the big toe to the root of nose, in the same repeating patterns. We also find this holistic behavior in pathologic states.

The best indicator of holistic behavior can be found in the embryologic development of humans. When an ovum cell is fertilized by a sperm cell, the ovum cell divides into two cells that have the same genetic code. This division continues until the cells join into cell units to form organs, muscles, bones, nervous system, etc.

This shared origin of all cells in the body supports the conclusion that all cells also jointly react to a given situation. The nervous system seems to have a special function in this process as a control and coordination center.

Sutherland bases his explanation of the human body as a unit on the membrane system and on the fluctuation of liquor.101,102,142,143 He uses the term reciprocal tension membrane to describe that traction on the base of one membrane system influences all other bases. These reciprocal tension membranes consist of the cranial and spinal dura mater.

Sutherland describes the following attachment points for the dural system:

• Crista galli, in front.

• Clinoid process.

• Petrous part of temporal bone, left and right.

• Inion, in back.

• Foramen magnum.

• Cervical vertebra C2.

• Sacrum.

One practical consequence is that a position change of the sacrum, for example, automatically changes the positions of the occipitoatlantoaxial (OAA) complex and the cranial bones.

The dural system is filled with nerve tissue and fluid (CSF) and continues via the nerve sheaths to the interstitium, which is also filled with fluid. In other words, changes in the dural system exert pressure on the fluids in the dural sac. These pressure changes disperse throughout the interstitial fluid and therefore the entire body.

The PRM described by Sutherland and consisting of flexion and extension phases causes pressure changes in the entire dural system and intercellular tissue. These changes display a specific rhythmicality, and their direction and amplitude is tissue specific. The direction of movement correlates with thoracic respiration: cranial flexion corresponds to inspiration and cranial extension corresponds to expiration.

The anatomy of fasciae provides further proof of holism. Embryologically, all connective tissues originate in the mesoderm. Basically, the different layers form a single cover that divides the organism, envelopes organs and muscles, and forms the body’s skin. The body’s three fascia layers are connected. This continuity causes changes in one location, for example, tension or pressure, to manifest throughout all tissues. This reciprocity makes fasciae so extraordinarily important for posture, locomotion, and physical response to mechanical stress.111

The continuity of fasciae, the continuity of fluids, and their common origin are indicators of unity, especially since all cells share the same DNA.

The entire body will always respond as a unit, in physiology as well as in pathology. Any organ dysfunction will impact the muscles and joints that are segmentally connected to the organ. The continuity of myofascial tissue causes changes in tension and pressure ratios in the entire body and, via the dural system, in the cranium. Posture, cranium, and organs adapt in a specific pattern. The body endeavors to leave the functions of the entire organism undisturbed for as long as possible.

Interrelation of Structure and Function

All osteopaths are familiar with the interrelation of structure and function. Structure depends on function and function impacts structure.

The most effective illustration of this concept is joint mobility. Joints need to remain mobile to prevent ankylosis. If the mobility of a joint is impaired, the synovial joint membrane produces less fluid. Lack of loading and unloading of weight on the cartilage reduces its supply. The joint capsule and the cartilage become brittle. This results in reduced joint mobility and may lead to arthrosis or ankylosis. Arthrosis results from joint dysfunction, whatever the cause.

The locomotor system provides an especially instructive example of this adaption of structure to function. Muscle dysfunctions lead to structural changes. This process happens surprisingly quickly,2,46 but fortunately, it is partially reversible. It takes about 30 days for functional problems to cause structural changes.41,82

At the same time, structure determines function. For example, certain joint changes cause gait changes and impact the normal functioning of other structures. Osteopaths who work in pediatrics are especially familiar with the impact of structure on function. Still writes about the significance of osteopathic treatments for newborns.140 Sutherland,142,143 Magoun,101,102 Frymann,57 and Arbuckle4 provide details about this topic.

Structural changes in the cranial base of newborns due to prenatal or perinatal complications are the starting point of dysfunctions in cranial nerves (X, XI, XII) and posture problems of the spine (scoliosis, kypholordosis). Magoun explains this as due to the craniosacral connection and growth impairment caused by membrane tension.101 Korr confirms his theory.79

Still stated the same view 50 years earlier when he posited that circulation disorders are the beginning of disease.140 For Still, circulation included venolymphatic and arterial circulation as well as the circulation of nerve impulses. Structural changes are subject to the laws of mechanics. The following are significant:

• Gravity.

• External forces.

• Shape and condition of joint surfaces.

• Impact of muscle traction.107

Biomechanics of the Spine and Locomotor System

No other researcher analyzed the biomechanics of the spine in as much detail as Littlejohn53,95,96,97,98,126 and Fryette56 [from a different perspective]. Littlejohn takes a holistic view of the spine and attempts to provide mechanical explanations for commonly found dysfunctions. Fryette describes the behavior of individual vertebra during motion and in the presence of certain dysfunctions. Littlejohn supplies mechanical explanations for the behavior of the spine (globality).

The behavior of the spine and of the locomotor system in general is directed by mechanical laws. The spine consists of anteroposterior arches. The movement of joints is dictated by ligaments, muscles, and joint surfaces. The spine and joints respond in their own patterns to strain (tension or pressure) and this causes the remaining locomotor system to adapt accordingly.

The spine consists of two anteriorly concave arches (thoracic spinal column [TSC] and sacrum) and two posteriorly concave arches (cervical spinal column [CSC] and lumbar spinal column [LSC]). Kypholordosis develops during growth due to forces impacting the body. Congenital and acquired emotional factors should not be underestimated in this context.25, 86,141 Perinatal microtrauma4,57,102,142,143 and childhood trauma (falling onto the buttocks) can influence this process and cause scoliosis as well as hyperkypholordosis.

Scoliosis usually develops into S-shaped curves.4, 82,145 It is as if the entire spine rotates around a vertical axis in a horizontal plane. Horizontality of the base of the sacrum plays a decisive role in this process. A tilt of 1 to 1.5 mm in the frontal plane can induce scoliosis of the spine due to the extreme sensitivity of muscle spindles.82,155

In the initial phase, the spine seems to adapt to a sudden tilt of the base of the sacrum by forming a global C-shaped scoliosis. However, postural factors then activate muscles to turn the C-shape into an S-shape as quickly as possible. Littlejohn’s model of the mechanics of the spine provides a mechanical explanation for this process.36,96,97 In addition to the anatomical condition of joints, muscles are the most important element as the implementers of these adaptation processes.

Scoliosis and kypholordosis impact not only the spine, but also the head, thorax, and extremities. The body as a whole participates in this process.101

This holistic behavior is ensured by myofascial continuity and the hydraulic system, which encompasses the CFS and interstitial fluid. Structure holistically adapts to function to ensure homeostasis.

Significance of Homeostasis

Homeostasis is the maintenance of a relatively constant internal milieu or balance in the organism with the help of feedback loops between the hypothalamus, the hormone system, and the nervous system.115

Homeostasis serves to optimize all bodily functions for the purpose of maintaining health. It is not a static state, but a constantly fluctuating process of adaptations to changing internal and external conditions. Body functions are controlled by mechanical, electrophysiological, and chemical processes. The body’s metabolism is maintained by pressure gradients, polarities, temperature differences, and concentration gradients.

These processes take place in the extracellular fluid within a framework provided by the connective tissue. Connective tissue plays a key role in homeostasis. Every cell participates in and simultaneously benefits from homeostasis.111 This reciprocity enables automatic regulation of all bodily functions.

When a dysfunction develops, the extracellular fluid responds to correct the problem. If this is not successful, more and more systems will be impacted. They are no longer able to contribute toward homeostasis. That is where disease begins.

The first signs of dysfunction are changes in myofascial tissue, because that is where the disease process takes place. Even minor organic disturbances cause viscerosomatic reflexes that lead to changes in myofascial structures, especially in the paravertebral muscles. This has been scientifically proven.112 These neuromusculoskeletal reflexes are based on embryological connections. The important consideration for therapy is that the body’s self-healing powers can reestablish homeostasis.

Somatovisceral reflexes as documented by Sato [in112,82] can be employed therapeutically to influence organ dysfunction. On the other hand, these reflexes also underscore the scope of muscle imbalances and posture disorders.

Paravertebral hypertonia is not only a sign of segmental facilitation but can also be its cause and therefore induce visceral disorders. The most frequent causes of paravertebral hypertonia are accidents (sports and work injuries), asymmetric physical activity, and differences in leg length.

The Nervous System as Control Center

The “primary machinery of life”79 is powered by muscles. The musculature is the organ of the locomotor system, and the nervous system is the control center. Muscles need to cooperate to carry out harmonious motions. They do so by working as chains where each unit of movement supports the next one.

Example: For the biceps muscle of arm to flex the elbow, the shoulder needs to be prevented from being pulled forward. This task is carried out by the shoulder extensors and the stabilizers of the scapula.

This creates loop-shaped chains, called lemniscates (lemnisci). Since most muscles run diagonally or are fan-shaped, these lemniscates occur in the sagittal as well as in the frontal planes.

The nervous system is tasked with recruiting muscles to carry out motions. Congenital reflexes facilitate this work for the organism. Receptors in muscles, tendons, fascia, and joints provide information about motions. Together with the centers of postural and directed motility, these receptors enable finely coordinated motions and adequate adjustments to changes in balance.

Different Muscle Chain Models

There are several different models of myofascial chains (see Chapter 8). Rolfing therapists, physical therapists, and osteopaths have all described muscle chains. Differences in these descriptions of muscle chains result from differences in opinions and from different treatment perspectives. Rolfing therapists may not emphasize the same treatment aspects as osteopaths or physical therapists.

The model we present in Chapter 8 is based on Sutherland’s theory that there are two motion patterns:

• Flexion–abduction–external rotation.

• Extension–adduction–internal rotation.

While Sutherland did not describe muscle chains, he did document the behavior of segments for both patterns. One interesting aspect of his model is that it corresponds to the motions of respiration and gait.

Since our work is based on a holistic principle of physiology and pathology, we are convinced that cranial patterns continue into the locomotor system and into the visceral domain and vice versa.

The factors described earlier (fluids, membranes, connective tissue continuity) ensure this process. In addition, physical and mechanical laws ensure that the joints of the locomotor system (including cranial sutures) carry these patterns into the entire musculoskeletal system. This is true regardless of whether the pattern was triggered by a vertebra, the ilium, an organ, or a cranial bone.

The entire organism adapts to dysfunctional and pathogenic elements to allow the body to function optimally and as free of pain as possible. This reduces tension, harmonizes pressure ratios, and maintains circulation. These factors are necessary for the body’s self-healing powers to accomplish their work. According to the theory of cranial osteopathy, this maintains the primary respiration mechanism and allows the “breath of life” to reach the cells.

In This Book

In the first part of this book, we briefly introduce several different models of myofascial chains (Chapter 2) and then describe the physiological principles for the behavior of the locomotor system (Chapter 3).

In Chapter 4, we present the biomechanical aspects of Sutherland’s cranial concept. We describe the physiologic motions of the SBS and its impact on the spine and locomotor system.

The position of the occiput above the atlas determines the location of the sacrum. This in turn determines the position of the spine, extremities, and thorax.

Chapter 5 presents the mechanics of the spine as viewed by Littlejohn. Littlejohn’s concept is a functional model he developed in his practice. It explains how the individual segments of the spine relate to each other. The specific adjusting technique (SAT) developed by Bradbury and further refined by Dummer51,52,53 represents a logical and clinically very valuable application of Littlejohn’s model.

In Chapter 6, we introduce some interesting discoveries and ideas by Janda that are primarily of clinical relevance.

Chapter 7 covers a very simple type of rational diagnosis: Zink’s common compensatory pattern (CCP). It examines the myofascial torsion patterns at the junctions of the spine. We employ this model to identify the dominant regions (see the “Practical Applications” section in Chapter 7). In this section, we also draw comparisons between the models of Littlejohn, Zink, and neurophysiological and anatomical facts. We show that Littlejohn’s and Zink’s models can be projected onto each other, and that there are neurophysiologic connections that help explain these findings. This underscores the functional and structural interrelations.

In Chapter 8, we introduce a muscle chain model that builds on Sutherland’s two patterns. We describe the behavior of the various locomotor units of the body, the development of kypholordosis and scoliosis, and the muscles involved in these processes. This model exhibits some key differences compared to other models.

In our opinion, all locomotor units behave like cogwheels, similar to the cranial bones in Sutherland’s cranial model. This causes counter-rotating motions between two successive locomotor units. It explains kypholordosis and scoliosis as well as counter-rotation between units (as in foot, knee, and hip position with genu valgus or genu varum).

We view flexors as the muscles in the concavities and extensors as the muscles in the convexities of the locomotor system. Dominant flexor chains automatically result in increased curvatures and dominant extensor chains result in stretching of the skeleton. Since the organism embryologically consists of two equal halves, each half of the body contains one flexor chain and one extensor chain. The nervous system directs coordination between both sides. In this book, we describe these muscle chains and explain the development of posture problems. We would like to emphasize that our model does not claim to be comprehensive and represents yet another attempt to explain phenomena found in our daily clinical practice. Our intensive research of professional literature and participation in seminars have provided us with answers to many questions and compelled us to write about this interesting topic.

The second part of this book covers practical applications. We present a diagnostic model and describe some treatment methods. We base our examination on the Zink patterns (see Chapter 7) and on simple traction tests that enable us to very quickly identify dominant structures. We focus on presenting treatments for myofascial structures. It goes without saying that organic and cranial dysfunctions must receive appropriate treatment. In this part of the book, we describe the diagnosis and treatment of trigger points in detail. This type of therapy provides rapid palliative pain relief for acute and chronic problems and normalizes structural changes in the myofascial unit.

2 Models for Myofascial Chains

2.1 Herman Kabat (1950): Proprioceptive Neuromuscular Facilitation

Dr. Herman Kabat developed the concept of proprioceptive neuromuscular facilitation (PNF) in the 1940s for treating poliomyelitis patients. Kabat was supported in his work by Margaret Knott and Dorothy Boss, who published the first book about PNF in 1956. Since then, this method has been developed further and applied successfully in patients with other disorders.