Leon Chaitow
Introduction
The symptoms of musculoskeletal pain and restricted range of motion – the shorthand for which is somatic dysfunction – seldom arise in joints themselves, unless there is frank pathology or traumatic damage. Instead, such pain and restriction are largely imposed and maintained by muscles and fascial structures that traverse or attach to such joints.
Features of somatic dysfunction often include abnormal proprioceptive activity, involving muscle spindles that appear unable to reset after strain (chronic or acute) – so helping to maintain joint dysfunction.
The term ‘
positional release techniques’
(PRT) describes a range of methods that have one common feature in their methodology – the disengagement of dysfunctional tissues from their restriction barriers – involving a movement of the affected structures towards comfort or ‘ease’, rather than towards restriction or ‘bind’ – a process that allows spindles to rest and reduces nociceptor sensitivity (Bailey & Dick 1992).
Muscle spindles are located between muscle fibers, and are extremely sensitive to position, load, and motion, potentially at least giving a partial explanation as to why a period of relative absence of stimuli – while being positioned and held at ‘ease’ – allows a reduction in hypertonicity.
PRT methods therefore involve
indirect
approaches that aim to restore tissue to normal physiological function, using two or three planes of movement in order to place tissues into a ‘
position of ease’
or comfort.
NOTE:
•
The barrier phenomenon is discussed in
Chapter 1
, and in other chapters, particularly
Chapters 12
(Muscle energy techniques) and
18
(Scars)
•
Examples of PRT approaches that are covered in detail in separate chapters include:
Chapter 10
, Functional fascial treatment – outlining both
fascial unwinding
and
balanced ligamentous tension
Chapter 13
, Myofascial induction (release) therapy – some aspects of this approach are indirect, disengaging from restriction barriers, while some are direct.
In this chapter, three further PRT related modalities – each with a different fascial connection – are outlined:
•
Strain–counterstrain (SCS), also known simply as
counterstrain
•
Facilitated positional release (FPR)
•
Functional positional release (FuPR).
SCS definition
Strain–counterstrain is a soft tissue manipulation technique in which the practitioner seeks to locate and alleviate nonradiating tender points in the patient’s myofascial structures. The practitioner positions dysfunctional tissue at a point of balance, in a direction away from the restriction barrier. The position of ease is held for 90 seconds, after which the patient is gently returned to the original position where the tender point is rechecked
(Mosby’s Dictionary of Complementary and Alternative Medicine 2005).
Barnes study
It is suggested that you revisit
Chapter 2
for the description of the Barnes (2013) hysteresis research.
This was the study in which several hundred individuals with neck pain were treated, using one of four methods:
•
High velocity manipulation – discussed briefly in
Chapters 2
and
5
•
Counterstrain (SCS) – as outlined in this chapter.
Soft tissue ‘stiffness’ in the dysfunctional regions, involving muscle and fascia, was measured before and after treatment, using a durometer. The levels of changes in stiffness – defined as hysteresis, as explained in
Chapter 5
– were recorded. All treatment methods (but not sham) produced significant benefits, with the greatest change being noted following SCS/positional release.
Strain–counterstrain
Strain–counterstrain (SCS), also known simply as ‘counterstrain’, is a treatment method developed in the USA by osteopathic physician Lawrence Jones (1997).
The method requires identification of a localized area in dysfunctional tissues that is painful on light pressure – known in SCS methodology as a
‘tender point’
. For those familiar with traditional Chinese medicine these equate with so-called ‘ah shi’ (spontaneously tender) points.
Tender points have been defined and described as small (between 3 mm and 10 mm in diameter), tense, tender, and edematous zones, located deep in muscle, tendon, ligament, or fascia (Jones 1997). They are considered to be sensory manifestations of neuromuscular or musculoskeletal dysfunction (Korr 1975).
Tender points are not necessarily trigger points
, although at times they may manifest characteristics of both, being both sensitive as well as producing referred or radiating pain.
Jones (1997) postulated that in most situations of somatic dysfunction, what is being treated involves tissues experiencing persistent neuromuscular noxious stimulus, and that use of SCS decreases or modifies this barrage, and allows self-regulating mechanisms to operate more effectively.
Key Point
Refer to the notes in
Chapter 1
on the research of Dittmore et al., in relation to collagen homeostasis. This offers insights into the benefits of methods that aim to ‘balance tissue tensions’, i.e. an objective beyond immediate symptom relief but with clear fascial implications.
•
Just sufficient pressure should be applied to a local area of tenderness (tender point) in order to create moderate discomfort – at which time the patient is instructed to ascribe to the degree of sensitivity being experienced, a value of ‘10’.
•
The patient, or the area involved, should then be moved into a position of ease, where the palpated discomfort reduces by at least 70% – and where it is held for up to 90 seconds, before slowly being returned to a neutral position.
•
The so-called
‘position of ease’
has been frequently identified as being a position that exaggerates any perceived tissue distortion; for example, shortened soft tissues would be placed into an even shorter position, to painlessly exaggerate their shortness, a process that appears to allow neurological ‘resetting’ (see discussion of mechanisms, below).
•
Another observation of possible clinical interest is that the
‘position of ease’
may replicate the position in which an initial strain occurred.
•
The essence of SCS, therefore, is the model in which tissues affected by dysfunction will have been taken to a position where 70% or more reduction in palpated pain – in a monitored tender point – has been achieved. The position of comfort/ease would then be maintained for approximately 90 seconds, before being gently released (D’Ambrogio & Roth 1997).
•
Importantly:
after identifying and compressing the tender point in order to achieve a
‘position of ease’
, light digital contact should be maintained throughout the 90-second holding time, without pressure, apart from periodic checking for the response to pressure, to ensure the
ease position
has not been lost. After 90 seconds, and passively and slowly taking the tissues back to their neutral position, the point may be rechecked, at which time it should feel less tense and less tender, and functional improvement should be evident in the affected tissues (such as an increased painless range of motion).
•
The patient should be warned to avoid active use of the area for a day or so, and that it is normal to experience increased soreness for 24 to 48 hours.
Box 15.1 Modified strain–counterstrain (SCS) protocol (D’Ambrogio & Roth 1997)
The SCS protocol described here relates to elbow pain:
1.
After completing a visual analog scale (VAS) for pain intensity on digital pressure applied to the predetermined tender point (TeP) site, pressure is applied (fingertip or thumb) to evaluate tissue tension. At the same time the patient is asked to confirm tenderness. The patient is asked to remain passive and relaxed throughout the process.
2.
The practitioner introduces movements of the arm in several planes, while monitoring with the contact digit the primary TeP site for relaxation of the myofascial tissues.
3.
The range of movements employed to influence the elbow joint in this example should involve a selection from: compression and distraction; flexion and extension; supination and pronation; translation (anterior and posterior); and wrist flexion and wrist extension. The practitioner asks for verbal confirmation of a reduction in pain intensity when applying approximately 3 kg/cm
2
pressure with either the fingertip or the thumb to the TeP.
4.
With minimal movements in all directions the practitioner refines the patient’s positioning to maximize the reported reduction of pain at the TeP,
as well as the palpated sense of tension or stiffness.
The subject’s arm is then held in the combined ease position for approximately 90 seconds.
5.
The subject is then instructed to ‘remain relaxed and not to try to help’ as the practitioner slowly returns the upper limb to a neutral position.
6.
After the process as described, the subject completes another VAS for pain intensity at the TeP before post-intervention outcomes are assessed.
SCS as a prescriptive approach
Over a period of many years, Jones and his associates (1995, 1997) compiled lists of specific tender point locations relating to almost every possible strain that might affect most joints, and many muscles. The accuracy of the locations were ‘proved’ by clinical experience, as well as an increasing amount of research evidence (see below).
Jones also provided prescriptive guidelines for achieving ‘ease’ for any tender points – usually involving a ‘folding’ or crowding of the tissues in which the tender point had been identified. The benefits noted (see studies below) included a rapidly achieved – and usually lasting – reduction of pain and inflammation, as well as increased mobility and strength.
A reduction in the time required before clinical effects are perceived when using SCS – from the recommended 90 seconds, to less than 20 – has been shown to result from the addition of a facilitating load into the tissues, based on the methods of facilitated positional release, which is described below (Chaitow 2009, Schiowitz 1990).
Facilitated positional release
Facilitated positional release (FPR) is an indirect myofascial release method where the tender point, or area of dysfunction, is gradually maneuvered (‘fine-tuned’) until a relatively pain-free neutral position is achieved, on all planes.
At this time, a further painless facilitating influence (for example torsion, distraction, shear force or compression) is introduced, in order to release joint or soft-tissue restriction further, reducing tissue tension, lowering perceived discomfort – without any increase in discomfort being reported elsewhere (Schiowitz 1990, Jonas 2005).
The addition of facilitation offers a major clinical benefit in that the holding time in the ease position reduces markedly, from 90 seconds to under 20.
•
Locate and palpate an appropriate tender point – usually located in shortened structures that would be active in producing the opposite movement to one that is either painful or restricted
Figure 15.1
A tender point in gluteus medius is monitored as the ipsilateral leg is used to achieve reduction in tender point sensitivity. The facilitating force involves long-axis compression towards the hip – reducing tender-point discomfort to below 30%, without creating additional discomfort.
•
Use minimal monitoring pressure on the tender point, and request the ‘patient’ to value the resulting discomfort as a ‘10’
•
Reposition tissues using minimal force to achieve maximum ease/comfort as reported ‘pain scores’ reduce
•
Add a facilitating compressive, distracting, or other force that:
decreases discomfort in the palpated point further – ideally to less than 30% of initial sensitivity, and
does not create any additional discomfort
•
Release after 20 seconds and return slowly to a neutral position
•
Recheck the tender point after you return to neutral, it should feel less tense and should be less tender
•
Warn the patient they may experience increased soreness for 24 hours as tissues adapt to the change.
Goodheart’s SCS guidelines
Modifications to the prescriptive model designed and developed by Jones and his colleagues have evolved in recent years. One such modification is that described by Goodheart (1984).
Goodheart suggested that instead of relying on charted maps of points, as compiled by Jones and colleagues, therapists should seek – via palpation (see
Chs 4 & 14
) – tender points in muscles antagonistic to those that are active when pain or restriction is identified or reported. If pain or restriction occurs during movement, the muscles antagonistic to those active at the time will most likely be those housing tender point(s).
Example:
•
If someone is locked in painful forward bending, pain will be experienced during extension when trying to stand upright.
•
Irrespective of where the pain is felt on extension,
tender points will be found in the muscles antagonistic to those working when the pain is experienced, i.e. a tender point will be located in the flexor muscles (probably in the abdominal muscles or in psoas) in this example (see
Fig. 15.1
).
•
A number of local tender areas may be identified on palpation of the target muscles, with one of these, usually the most tender, being selected to act as a monitor during application of SCS. If there is uniformity of discomfort in a number of possible tender points, it is suggested (based on clinical experience) that the most medial and most proximal of these should be chosen as a monitoring point.
•
The selected tender point is then used as a monitor to guide the practitioner, as tissues are positioned and fine-tuned, until initial tenderness (on digital pressure) reduces from the starting pain score of 10 to 3 or less (
Fig. 15.2
).
•
This is then maintained, as described above, for 90 seconds, with the palpating finger in touch but not compressing the point, before slowly reverting to the starting position.
•
In other words, the prescriptive Jones model has been modified by Goodheart’s insights as to where to locate suitably tender ‘points’ – avoiding the need for relying on a virtual cookbook of tender-point charts.
General SCS guidelines for achieving tender-point ease
•
For tender points on the front of the body, flexion, side-bending and rotation should usually be towards the palpated point, followed by fine-tuning, in order to reduce sensitivity by at least 70%
•
For tender points on the back of the body, extension, side-bending and rotation should usually be away from the palpated point, followed by fine-tuning in order to reduce sensitivity by 70%
•
The closer the tender point is to the midline the less side-bending and rotation should be required, and the further from the midline the more side-bending and rotation should be required, to achieve an ideal ease position
•
Additional facilitating forces, such as compression or distraction, should not create new discomfort, and should enhance ‘ease/comfort’ – which should be reflected in the reported reduction in pain ‘score’.
Figure 15.2
A tender point being monitored in the lower abdominal muscles as part of a counterstrain treatment for low back pain in which extension of the spine is painful or restricted. The tissues holding the tender point, are ‘folded, and positioned until a significant reduction is reported in the palpated point’. This mirrors Goodheart’s guidelines for use of SCS. AIIS: anterior inferior iliac spine; ASIS: anterior superior iliac spine.
If these guidelines are not effective in reducing tender-point sensitivity, try other variations in positioning – in other words, these are not absolute rules, merely suggestions.
Mechanisms that may explain SCS effects
A number of explanations have been offered and described that, either individually or in combination, may account for the clinical results obtained using SCS (see a selection of studies later in the chapter). Some of the more fascia-related explanations are expanded on below:
•
Neurological changes
involving muscle, fascial and joint mechanoreceptors including Ruffini corpuscles, Golgi tendon organs, muscle spindles etc. (Jones 1995) and pain receptors (Howell et al. 2006). See
Chapter 5
for discussion of neural influences deriving from load variations on tissues, under the subheading:
Neural influences and fascial structures
, as well as
Box 1.3
in
Chapter 1
.
•
Proprioceptive theory:
this is the most commonly discussed explanation for the efficacy of SCS. It suggests that a disturbed relationship between muscles and their antagonists may emerge following strain (see quote from Wong 2012, below).
•
Altered fibroblast responses
– involving the shape and architecture of cells, i.e. mechanotransduction effects – leading to reduced inflammation (Standley & Meltzer 2008) influenced by fluid dynamics (see below).
•
Ligamentous reflexes
(Solomonow 2009, Chaitow 2009; see below).
•
And possibly others?
Proprioceptive theory
Wong (2012) has summarized the hypothesized process as follows:
According to the Proprioceptive Theory rapid stretching injury stimulates muscle spindles causing reflexive agonist muscle contraction that resists further stretching. However, a reflexive counter-contraction resulting from pain induced withdrawal quickly reverses the aggravating movement thereby exciting antagonist muscle spindles. The resulting neuromuscular imbalance, perpetuated by opposing muscle spasms each unable to release due to ongoing muscle spindle excitation (Korr 1975), can affect myofascial mobility and force transmission around neighboring joints and muscles (Kreulen et al. 2003, Huijing & Baar 2008). Underlying muscle imbalance can persist long after the strain heals (Goering 1995) with lasting motor impairment evident long after pain symptoms subside (Sterling et al. 2003).
It is suggested that the position of ease/comfort in SCS procedures then allows overactive agonist muscle spindle activity to reset, after which antagonist muscle spindle activity also returns to normal, restoring function (Bailey & Dick 1992).
Fibroblast (and fluid dynamic) responses to SCS
Explanations are offered in
Chapter 1
regarding mechanotransduction and associated processes, in which a variety of cellular effects are noted in response to mechanical load applications. Of particular interest are the effects of altered degrees and types of strain and load on fibroblasts – plentifully present in fascial structures.
•
Dodd et al. (2006) report that:
‘Human fibroblasts respond to strain by secreting inflammatory cytokines, undergoing hyperplasia, and altering cell shape and alignment … and that biophysical
[tissue changes]
– whether resulting from injury, somatic dysfunction, or
[soft-tissue manipulation, such as SCS]
– affects range of motion, pain, and local inflammation.’
•
In 2007 Standley and Meltzer observed that:
‘Data suggests that fibroblast proliferation and expression/secretion of pro-inflammatory and anti-inflammatory interleukins may contribute to the clinical efficacy of indirect osteopathic manipulative techniques.’
•
Standley and Meltzer (2008) report on various clinically applied fascial methods (counterstrain, as well as myofascial release, see
Ch. 13
) used to treat somatic dysfunctions. These methods produced positive clinical outcomes such as reduced pain, reduced analgesic use, and improved range of motion. They note that
‘it is clear that strain direction, frequency and duration, impact important fibroblast physiological functions known to mediate pain, inflammation and range of motion.’
•
Meltzer et al. (2010) note that traumatized fascia disrupts normal biomechanics of the body, increasing tension exerted on the system and causing myofascial pain and reduced range of motion. They found that resulting inflammatory responses by fibroblast cells can be reversed by changes in load on the tissues, delivered either by counterstrain or myofascial release (see
Ch. 13
) and that such changes may take only 60 seconds to manifest.
•
Wong (2012) highlights the possible fluid dynamic nature of the effects of SCS:
‘decreased interleukin (IL-6) levels, important for mediating inflammatory healing after acute injury (Kopf et al. 1994), suggest SCS may affect local circulation (Standley & Meltzer 2007). Clinically, Achilles tendonitis patients reported decreased swelling after SCS (Howell et al. 2006) but research is needed to understand potential circulatory effects of SCS.’
Ligamentous reflexes
Solomonow (2009) spent many years researching the functions of ligaments. He identified their sensory potential and major ligamentomuscular reflexes that have inhibitory effects on associated muscles, and states: ‘If you apply only 60–90 seconds of relaxing compression on a joint … an hour plus of relaxation of muscles may result. This may come not only from ligaments, but also from capsules and tendon’
(personal communication 2009).
A possible clinical application of this ligamentous feature may be seen when joint crowding is induced as part of facilitated positional release and/or strain–counterstrain protocols. Such effects would be temporary – 30 to 60 minutes – but this would be sufficient to allow enhanced ability to mobilize or exercise previously restricted structures.
Coincidently, crowding (compression) of soft tissues would have an effect on the fluid content of fascia, leading to temporary (20–30 minutes) of reduced stiffness of fascial structures – with similar enhanced mobility during that period. See
Water, stretching and fascia
discussion in
Chapter 5
.
Wong (2012) summarizes current thinking regarding ligamento-muscular reflexes and SCS:
‘Ligamentous strain inhibits muscle contractions that increase strain, or stimulates muscles that reduce strain, to protect the ligament (Krogsgaard et al. 2002). For instance, anterior cruciate ligament strain inhibits quadriceps and stimulates hamstring contractions to reduce anterior tibial distraction (Dyhre-Poulsen & Krogsgaard 2000). Ligamentous reflex activation also elicits regional muscle responses that indirectly influence joints (Solomonow & Lewis 2002). Research is needed to explore whether SCS may alter the protective ligamento-muscular reflex and thus reduce dysfunction by shortening joint ligaments or synergistic muscles (Chaitow 2009).’
Cautions
SCS usage should be avoided in cases involving:
•
Open wounds
•
Recent sutures
•
Healing fractures
•
Hematoma
•
Hypersensitivity of the skin
•
Systemic localized infection.
SCS studies
Wong (2012) has reviewed and evaluated current research into SCS:
‘Descriptive cases HAVE documented SCS applications for foot (Jones 1973), knee (Pedowitz 2005), lower back (Lewis & Flynn 2001), shoulder (Jacobson et al. 1990), and myofascial disorders (Dardzinski et al. 2000). Some studies combined SCS with other treatments for disorders including complex regional pain syndrome (Collins 2007), cervicothoracic pain (Nagrale et al. 2010), lateral epicondylalgia (Benjamin et al. 1999), and cavus foot (Wong et al. 2010).’
Examples:
•
‘
49 volunteers aged 19–38 years, with hip weakness and corresponding tender points (TP)
… [after four SCS treatments over 2 weeks] …
all groups reported reduced pain and increased strength 2–4 weeks following the intervention
’ (Speicher et al. 2004)
•
Lewis and Flynn (2001) used strain–counterstrain to successfully treat patients with low back pain:
‘The SCS intervention phase for each case took approximately one week and consisted of 2 to 3 treatment sessions to resolve perceived ‘aberrant neuromuscular activity.’
•
In treatment of Achilles tendonitis, Howell et al. (2006) noted that following treatment
incorporating SCS:
‘subjects indicated significant clinical improvement in soreness, stiffness, and swelling … Because subjects’ soreness ratings also declined immediately after treatment, decreased nociceptor activity may play an additional role in somatic dysfunction, perhaps by altering stretch reflex amplitude’.
•
Dardzinski et al. (2000) reported:
‘SCS techniques should be considered and evaluated further as adjunctive therapy for patients previously unresponsive to standard treatment for myofascial pain syndrome’.
•
Wynne et al. (2006) found that:
‘Clinical improvement occurs in subjects with plantar fasciitis in response to counterstrain treatment
[SCS]
. The clinical response is accompanied by mechanical, but not electrical, changes in the reflex responses of the calf muscles’.
See notes on SCS and plantar fasciosis in
Chapter 5
and
Figure 5.4
.
•
‘Symptoms of a 30-year-old distance runner with ITBFS
[iliotibial band friction syndrome]
were reduced with the help of OMT
[osteopathic manipulation treatment]
, specifically SCS. This technique allows for relief of pain at a tender point by moving the affected body part into its position of greatest comfort, aiding in the reduction of receptor activity. The tender point was located from 2 cm proximal to the lateral femoral epicondyle. There is no prior documentation of the osteopathic manipulation of this specific tender point. Thus, this case report reflects an initial identification of a distal iliotibial band tender point, and a new therapeutic modality for ITBFS’
(Pedowitz 2005).
Functional positional release (FuPR)
Functional positional release (FuPR) technique has the same clinical objective as counterstrain and FPR – identification of a position of ease in relation to pain or restriction, acute or chronic, irrespective of whether dysfunction involves muscles, fascia or joint complexes.
However, unlike counterstrain, FuPR does not use pain reduction as a guide to finding the desired position of ease – instead it relies on a reduction in palpated tone in stressed (hypertonicity/spasm) tissues, as the body (or part) is being positioned or fine-tuned, using/testing all available directions of movement. Hoover (1969), the osteopathic developer of functional technique, used the term
‘dynamic neutral’
to describe what was being achieved as disturbed tissues were positioned in a state of ‘ease’.
FuPR methodology (Bowles 1981)
The practitioner’s hand palpates the affected tissues (molded to them, without invasive pressure), in order to ‘listen’ to, and assess changes in tone, as the other hand guides the patient, or part, through a sequence of positions aimed at increasing the sense of palpated ‘ease’ as ‘bind’ is reduced.
A sequence of evaluations is carried out, each involving different directions of movement (flexion/extension, rotation right and left, side-bending right and left, etc.), with each evaluation starting at the point of maximum ease discovered during the previous evaluation, or at the combined position of ease of a number of previous evaluations.
In this way one position of ease is ‘stacked’ on to another until all directions of movement have been assessed for ease. The precise sequence in which the various directions of movement are evaluated is not relevant, as long as all possibilities are included (
Fig. 15.3
).
Only very limited ranges of motion might be available in some directions during this assessment, and the whole procedure should be performed very slowly. When a position of maximum ease – involving the combined ‘positions of ease’ in multiple directions – is arrived at, this is held for up to 90 seconds, to allow a process of self-regulation and resetting to reduce hypertonicity and pain to start.
Figure 15.3
The palpating hand assesses tissue responses to movement in different planes and directions, and ‘stacks’ positions of ease onto each other, as all options are assessed for ‘ease’ (flexion, extension, side-flexion, rotation, translation antero-posterior and lateral). One position of ease is stacked on the combined previously identified positions. The final position of ease is held for 90 seconds during which circulatory, proprioceptive and viscoelastic effects are thought to induce a self-regulating process.
The final position of palpated maximum ease (reduced tone) in the distressed tissues should correspond with the position that would have been found if pain was being used as a guide, as in counterstrain methodology. Despite the gentleness of the methods there is almost always a reaction involving stiffness and possibly discomfort on the day following treatment, as adaptation processes accommodate to changes.
Examples of FuPR
NOTE:
Both facial unwinding (
Ch. 10
) and balanced ligamentous tension (
Ch. 10
) are examples of functional technique.
Post-surgical use of FuPR
In order to determine the effects on cardiac hemodynamics, O-Yurvati et al. (2005) documented the effects of FuPR applied to traumatized thoracic tissues, as part of a broader osteopathic intervention, following coronary artery bypass graft (CABG):
•
10 subjects undergoing CABG were compared, pre-treatment versus post-treatment, involving measurements of thoracic impedance, mixed venous oxygen saturation and cardiac index.
•
Immediately following CABG surgery, FuPR was provided to
anesthetized and pharmacologically paralyzed patients
to alleviate anatomic dysfunction of the rib cage, caused by
median sternotomy, and to improve respiratory function.
As shown in
Figure 15.4
, this FuPR treatment approach involved the practitioner placing one hand under the supine patient, to rest/palpate tissues between the scapulae. Simultaneously, the other hand was placed anteriorly, directly over the surgically traumatized tissues. Just sufficient pressure was exerted to allow the superficial skin and fascia to be moved in the directions being tested:
•
Each hand independently evaluated tissue preference directions – superior/inferior?
•
Lateral to the left/lateral to the right?
•
Clockwise/anticlockwise?
Each evaluation commenced from the ‘ease’ position of the previous evaluation(s).
Once the final ease position was identified by each hand independently, the tissues were maintained in those positions for 90 seconds before a slow return to the starting position. Results suggested improved peripheral circulation and increased mixed venous oxygen saturation after the treatment. These increases were accompanied by a significant improvement in cardiac index.
FuPR variation: integrated neuromuscular release
Integrated neuromuscular release is a form of FuPR involving a segmental, anteroposterior approach that aims to correct muscular, fascial and neural imbalances. ‘Osteopathic manipulative treatment has been concerned, purposefully or not, with manipulation of the fascia’
(Danto 2003).
•
With the patient seated, the practitioner’s hands are placed anteriorly and posteriorly. Independently, they perform evaluations of tissue direction preferences, in the same way described above in the post-surgical example (
Fig. 15.4
).
•
Each direction sequence is asking the same question – in which direction do the tissues move most freely – with each change in direction
commencing from the position(s) of ease previously identified?
Figure 15.4
With one hand on the anterior and one on the posterior surface, each hand – independently – stacks perceived positions of ease onto each other, as all directions are assessed for ‘ease’. The final combined position of ease is held for 90 seconds during which circulatory, proprioceptive and viscoelastic effects encourage self-regulating processes.
Superior/inferior?
Lateral to the left/lateral to the right?
Clockwise/anticlockwise?
•
In this way the palpated tissues are taken into their preferred directions of motion towards a combined ‘ease’ position, at which time compression is added – a feature of facilitated positional release (FPR). This is held for 60–90 seconds, or longer if changes in the tissues are being sensed – pulsation, rhythmic motion, etc. – before a slow release.
Conclusion
Positional release methods are safe, easy to apply and have been validated clinically. They clearly have a fascial connection whether via fibroblast influences or ligamentous reflexes and they combine efficiently with most other manual modalities.
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