EXCERPTS
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THE SCIENCE AND PRACTICE OF MANUAL THERAPY |
FOREWORDS BY
Gregory D. Cramer DC PhD
Professor and Dean of Research, National University of Health Sciences, Lombard, IL, USA
Robert Donatelli PhD PT OCS
National Director of Sports Rehabilitation, Physiotherapy Associates, Las Vegas, NV, USA
Frank H. Willard PhD
Professor, Department of Anatomy, University of New England, College of Osteopathic Medicine, Biddeford, ME, USA
CONTENTS (see detailed contents at end of document)
Chiropractic foreword VII
Osteopathic foreword IX
Physical therapy foreword XI
Preface XIII
Acknowledgement XV
1. Introduction 1
SECTION 1 The effect of manual therapy techniques in the tissue dimension 7
2. Manual therapy in the tissue dimension 9
3. Assisting repair with manual therapy 13
4. Affecting fluid flow with manual therapy 31
5. Assisting adaptation: manual stretching 47
6. Pain relief by manual therapy: the local tissue dimension 67
7. Overview and summary of Section 1 71
References 75
SECTION 2: Manual therapy in the neurological dimension 89
8. Manual therapy in the neurological dimension 89
9. The motor system 91
10. Proprioceptive stimulation by manual therapy techniques 101
11. Affecting the lower motor system with manual therapy 113
12. The adaptive code for neuromuscular re-abilitation 125
13. Abilities, inability and re-abilitation 141
14. Treating psychomotor and behavioural conditions 159
15. Treating the neuromuscular system in musculoskeletal damage 167
16. Re-abilitating the damaged motor system 181
17. Pain relief by manual therapy: neurological mechanisms 189
18. Muscle tone 197
19. Overview and summary of Section 2 203
References 207
SECTION 3 Psychological and psychophysiological processes in manualtherapy 225
20. Manual therapy in the psychological/ psychophysiological dimension 227
21. Origins of the therapeutic potential of touch 229
22. Psychological influences of manual therapy 237
23. Psychophysiology of manual therapy 249
24. Manual therapy in the psychosomatic field 259
25. Touch as a therapeutic intervention 269
26. Pain relief through manual therapy: psychological processes 277
27. Overview and summary of Section 3 283
References 285
SECTION 4 Overview and clinical application 295
28. Overview and clinical applications of the science 297
Index 309
CHIROPRACTIC FOREWORD
Clear writing, excellent organization and the effective use of line drawings, flow charts, boxes, tables and graphs have allowed Dr. Lederman to succeed in producing an outstanding text covering the basic science and clinical application of all forms of manual therapy. Dr. Lederman describes himself as a centralist, stressing therapies that actively involve the patient's cognition and motor involvement, as opposed to a peripheralist, a clinician who stresses therapies directed at peripheral joints and related tissues; therefore the emphasis of the book is on active therapies. The text is organized into sections that discuss manual treatments (including thorough discussions of the science underlying the treatments) of three essential 'domains' of neuromusculoskeletal injury and repair: these are the tissue, neurologic and psychologic domains.
The section covering the tissue domain includes discussions of the effects of different forms of biomechanical loading (including the safe loading during manual therapies) on connective, muscle and vascular tissues. Injury and repair of these same tissues are also covered, and this section provides a well-reasoned timeline for the introduction of various forms of manual therapies at each stage of injury and repair (including the amount of force thought to be most effective at each stage). When and when not to apply certain types of manual therapies and their risk versus benefit at different stages of injury and repair are also presented. The text provides science-based guidance on choosing manual techniques during each phase of repair for each type of tissue in order to provide an optimum environment for healing and adaptation of the injured tissues.
The section on the neurologic domain provides detailed descriptions of the influence of numerous forms of manual and active therapies on the motor system and also provides comprehensive analyses of the influence of manual therapies on proprioceptive stimulation and the role such stimulation may or may not play in the recovery of injured patients. The full range of active and passive therapies and their potential effects on the nervous system are covered in detail in this large section, and fascinating presentations of the neurophysiologic rationale for each therapeutic approach are provided.
The section on the psychologic domain discusses the psychologic component of health and injury and the relationship of this component to manual therapies. The effects of manual therapy on the proprioceptive and vestibular systems are described and the therapeutic effects of health-directed touch on body image and on the psychologic components of injury and healing are covered. Clinical boundaries, psychosomatic conditions, and other aspects of the psychologic domain and the relationship of these topics to manual therapies are described in detail.
The text concludes with a very practical 'Overview and clinical application' section that unifies the theories and therapeutic procedures discussed throughout the book.
Dr. Lederman's text is a masterful and fascinating presentation of the science of manual therapies. He is gifted with an extraordinary ability to clearly and logically organize very difficult concepts. The result of his efforts allows the reader to develop a new and profound understanding of the therapeutic effects of all forms of manual therapy and provides a rationale for selectively choosing different forms of active and passive manual therapies for different tissues at their various stages of injury and repair. Dr. Lederman is to be commended on an extraordinary accomplishment with the publication of this important text.
Prof. Gregory D. Cramer, Chiropractician, 2004
OSTEOPATHIC FOREWORD
Manual therapy has a long history of use in the healing of body ailments. Manual techniques predate the organized pharmaceutical industry by centuries, having been in medical literature since Greek and Roman writings. Images of the ancients using levers and ropes to 'adjust' body position and posture can be found in historical texts. Given the long history of this modality, the benefit of manipulative medicine in assisting healing should not be taken lightly. Although 'evidenced-based methods' for proving the efficacy of this form of medicine have generally been difficult to apply to manual medicine techniques, studies are emerging that provide the long-needed support for the practice.
Although manual medicine has been much used to address local ailments, the realization of how these approaches could alter psychological problems as well as improve the general health of the individual, was not appreciated until a better understanding of the emotional (limbic) system and its relationship to the neuroendocrine immune system developed in the scientific literature. The complex connections of the limbic forebrain extending from such areas as the prefrontal, insula and anterior cingulate cortex to the amygdala and hypothalamus, provide a major avenue whereby emotions can influence body function. Amygdaloid and hypothalamic responses rapidly involve both the autonomic nervous system with its wide-spread release of the catecholamines and the hypothalamic-pituitary-adrenal axis with its release of the glucocorticoids and mineralocorticoids. The resulting chemical change in internal milieu in the body has a marked effect on the production of cytokines from immune cells. The resultant alterations in the normal homeostasis of the body, secondary to the elevation of catecholamines, adrenal cortical steroids and cytokines, has been termed allostasis or 'stability through change'. Although allostatic changes are very beneficial and life-saving in the short run, the long-term pathological effect of allostasis on the general health of the body is profound and has been much studied recently.
Pathways are now understood through which information concerning the quality of the tissue in body can be relayed into the limbic system. Ascending spinal cord projections through posterior thalamus to insula, as well as directly to the amygdala, provide an avenue over which somatic and visceral tissue quality can directly influence emotional states and thereby, through the induction of allostasic mechanisms, affect the general state of health in the body. Manual therapy techniques that address tissue quality as well as neural and mechanical functions, thereby decreasing the drive on the allostatic mechanisms, are well positioned to exert a positive effect on the emotional state as well as general well-being of the body. This concept forms the basis for osteopathic interventions that address both the somatic and the emotional state of the individual when attempting to help the person's body handle its diseased condition.
The field of manual therapy has numerous practitioners throughout the world. An examination of the myriad of training programmes reveals various levels of background and rigour. Consistent with this wide range of training modalities are the many theories of how manual medicine may be working. Many texts exist that attempt to describe a particular method of therapy and purvey its virtues. What is needed is a clearly written book that develops the basic science fundamentals for a wide-ranging audience and then applies those principles to the clinical practice of manual therapy. Eyal Lederman has produced just such a work.
In the early chapters, Dr. Lederman develops a simplified concept of biological tissue and its normal and pathological behaviour, after which he explores the mechanical, fluid and neural models commonly used in explaining manual therapy. With this background, he carefully builds an argument for the role of manual therapy in the healing process. In the latter chapters, he expands his exploration to address the psychophysiology of manual therapy and its use in addressing psychosomatic problems.
The material in each chapter builds logically to the main point, which he defends with numerous references that will be of use to the student and skilled practitioner alike. Throughout the book, Dr. Lederman hammers away at numerous common misconceptions concerning the mechanism of action of manual therapy and replaces these outdated views with more recent, well-referenced theories of function. Examples include the much- abused description of the use of the stretch reflex by practitioners as well as the role of proprioception in the guidance of movement.
Importantly, throughout the book, Dr. Lederman uses the word 'suggests' or 'may' when he is speculating on the effect of a treatment paradigm or on a model. This helps the reader distinguish between the well-documented observation and the author's speculations - one wishes more authors would use this straightforward convention.
This book will be especially useful for students in the osteopathic schools. Beyond providing insight into the 'mechanisms of action' for manual techniques, Dr. Lederman's text is written in such a way that it will facilitate the formulation of research problems that can be organized into reasonable experimental studies. It is my pleasure to recommend this text as a starting point for gaining an understanding of manual therapy for all students of body function and dysfunction.
Prof. Frank H. Willard, Osteopath, 2004
PHYSICAL THERAPY FOREWORD
The second edition of Dr. Lederman's The Science and Practice of Manual Therapy arrives at a time when evidence-based practice is evolving as the state of the art in clinical practice. Practical application combined with scientific research and an understanding of anatomy and histology is the strong point of any treatment approach. The foundation of this book is built upon the above principles. At a time when pressures to increase productivity are prevalent, it is important to select techniques that have reliability and have proven to be successful in patient care.
Dr. Lederman has provided us with a wealth of information designed to enhance our clinical decision making and technical skills. The text expands the definition of manual therapy to a wealth of techniques which allows the clinician greater flexibility in treating a broad array of conditions. The most successful clinician is capable of being selective, matching up the appropriate technique to the patient's condition. This will help the clinician have a more effective treatment approach, which is safer and speeds up the patient's recovery. In order to make an effective clinical decision as to the appropriate treatment technique, the clinician must have a good understanding of how to make permanent changes in the musculoskeletal system. In Section 1, 'The effect of manual therapy techniques on the tissue dimension', the author does an excellent job of describing the effects of manual therapy on tissue homeostasis. Section 1 covers the effects of manual therapy on collagen realignment, increasing tensile strength, preventing adhesion formation, adaptation of tissue to manual stretching, describing the synovial pump, manual lymph drainage and the effects on muscle regeneration. One of my favourite chapters is Chapter 5 'Assisting adaptation: manual stretching'; stretching is described at the cellular level and the difference in stretching muscle and tendon is reviewed. Biomechanical terms such as creep deformation, viscoelasticity, toe-region, plastic and elastic range are defined and described using clinical examples. The diagrams of the tissue properties help the clinician visualize the changes resulting from manual therapy techniques.
Dr. Lederman continues his detailed analysis of the physiological effects of manual therapy in Section 2 'The effect of manual therapy techniques on the neurological dimension'. Reviewing with the same depth and clinical application, he expands the use of manual therapy techniques to include proprioceptive stimulation, lower motor system facilitation and neuromuscular rehabilitation. The last section, 'Psychological and psychophysiological approaches', once again goes beyond the expectations of the reader and describes the psychological influences of manual therapy. In this section, the miracle of human touch is described as a therapeutic intervention.
In my opinion, understanding a treatment approach from the cellular level sets the highly skilled clinician apart. A successful treatment approach is initiated because of an understanding of the soft tissue properties of the damaged tissues, and their ability to regenerate or remodel. The healing effect of manual therapy techniques can be as or more successful than the surgeon's techniques of tissue repair. Furthermore, without the use of manual therapy techniques, the healing properties of the body may be slowed down or hindered. Throughout my entire career as a physical therapist I have fostered the use of manual therapy in my teaching and in my practice. The clinician will become a better manual therapist through reading Dr. Lederman's book. It is an astonishing extrapolation of information that is translated into clinically applicable terminology, allowing the clinician to become more proficient in selecting techniques that will enhance the level of care for the patient. Lederman's book is an excellent resource for the clinician/instructor.
Prof. Robert Donatell, Physiotherapist, 2004
PREFACE
When I started my professional life as a manual therapist (an osteopath), I was struck by the therapeutic power and the positive impact that the treatment had on my patients. It occurred to me that something that I had learned as an art had profound healing influences on my patients. I was curious to understand how my manual therapy technique could bring such changes. It was obvious that there was a science at the basis of my therapy. Unfortunately, 20 years ago, there were no theoretical models for manual therapy and this area was not well researched. There was no information available to teach me how my techniques worked, how they influenced my patients or how to match techniques to patients' conditions. I had many questions and no answers. This situation was clinically disabling: how could I decide which technique to use at any particular time? How could I develop my therapy and techniques any further? Were all my techniques equally effective? Are all manual therapy techniques clinically useful? Are there some techniques that have no effect yet are traditionally taught? Why was I successful with one patient's condition but was unable to reproduce the result with another? These were some of the questions that troubled me at that time.
It was this sense of curiosity that led me to research how manual therapy works. I undertook a doctoral thesis studying the effects of manual therapy techniques on the nervous system. This was one of the first collaborative research projects between osteopathy (British School of Osteopathy) and physiotherapy (King's College, London) in the UK. To make my life even harder, I decided at the same time to write a book that would examine the effects of manual therapy on the body: Fundamentals of Manual Therapy. In that book the basic theoretical/scientific/academic models of manual therapy were introduced. At the heart of the book was a fundamental model: the 'physiological model of manual therapy'. This model provided the framework for analysing how manual therapy works. The physiological model has been a consistent model that has developed over the years since its conception to become the 'dimensional model of manual therapy' in this book (see Ch. 2). That model forms the skeleton structure of this new edition.
It is with great pleasure and satisfaction that I have written this new edition. Twelve years have passed since I began researching and writing the first edition. Since then, manual therapy, in its many forms, has grown and matured, with extensive research being carried out and its introduction to various universities throughout the world. It has finally become a science. It is beginning to give some answers to the questions posed above; but, most importantly, the science of manual therapy serves one ultimate goal: it allows us to provide our patients with the most effective and safe treatment possible. Much of this research can be found throughout this book.
My personal input into this book is derived from several sources: my clinical experience over 20 years, my own research into manual therapy, teaching manual therapy for 15 years at undergraduate and graduate/professional level, and most recently, by providing supervision groups for practising therapists. It is through these encounters with students and professional therapists that I have become aware of the general needs of manual therapists. I hope to fulfil those needs in this current edition. I have also illustrated some of the research and theories with my own clinical experiences. These are not treatment formulas but instead serve to demonstrate how this information can be made clinically practical.
I would like to acknowledge Tsafi Lederman's special contribution to Section 3 of both editions of the book. Tsafi is a body-psychotherapist who has helped shape my thinking and work within the psychological dimension of manual therapy. Many of the working principles discussed in Section 3 are developments of her work.
I hope that The Science and Practice of Manual Therapy will meet several aims: that it will provide practitioners of manual therapy with a deeper understanding of how their techniques work; that it will help them provide more successful, effective and safer treatments; and that it will convey not only the extent and potential of manual therapy but also its boundaries and limitations. Finally, I hope that this book will raise awareness of the therapeutic value of manual therapy and elevate its standing with both the public and our colleagues in the allied health professions.
London 2004 Eyal Lederman
ACKNOWLEDGEMENT
I would like to thank Tsafi Lederman for her contribution in co-writing Section 3 of the book.
CHAPTER 1
CHAPTER CONTENTS
Overall therapeutic aims 2
The 'dimensional model of manual therapy' 3
Tissue dimension 3
Neurological dimension 4
Psychological dimension 4
Clinical examples of the dimensional model 4
Affective signals - breaking the code 5
Other dimensional levels 6
Pain relief and pain management in manual therapy 6
Summary 6
This book is about how manual therapy works and how it can be developed to be therapeutically effective. Manual therapy is broadly defined here as the use of the hands in a curative and healing manner, or as the use of 'hands-on' techniques with therapeutic intent. A wide range of disciplines extensively use manual techniques as a therapeutic method. This may be used as the primary therapeutic tool or secondary to other therapeutic modalities. Prominent users of this modality are physiotherapists, osteopaths, chiropractors and massage therapists as well as professionals such as nurses, who use touch in nurturing premature infants or massage in supporting the terminally ill. It also includes body-psychotherapists, who may use touch as a therapeutic modality in encouraging client self-exploration or initiating emotional processes, and social workers or counsellors, who may use touch as support for the bereaved. Manual techniques are the therapeutic tools of the manual therapist. A wealth of techniques with an understanding of their effects allows for greater flexibility in treating a wide range of conditions. Understanding the mechanisms that underlie the body's physiological response to manual therapy will help the practitioner to match the most suitable and effective technique to the patient's condition. This will provide a more effective and safer treatment as well as reducing the overall duration of treatment. The purpose of this book is to discuss the physiological, neurological and psychophysiological mechanisms underlying manual therapy. The book is divided along these lines into four main sections:
Section 1 relates to the direct effects of manual therapy techniques on local tissues.
Section 2 examines the neurophysiological aspects of manual techniques.
Section 3 describes the psychology of touch and manual therapy techniques and the consequent psychophysiological/psychosomatic responses.
Section 4 is an overview and summary of the previous three sections.
Whereas in Sections 1-3 the whole person is compartmentalized and fragmented, Section 4 aims to 'remedy' this by integrating the contents of the previous three sections and discussing their possible clinical application.
OVERALL THERAPEUTIC AIMS
The place to start our journey into understanding the therapeutic potential of manual therapy is to identify its overall therapeutic aims. Generally it can be said that our ultimate aim is to assist two major body processes (Fig. 1.1):
repair process
adaptation process.
When our patients present to us with conditions such as swollen knees, 'pulled' painful muscles or with disc pain, we are essentially treating an active repair process in these tissues. The overall aim of our treatment is to assist and direct this process with the different manual techniques. A patient who presents with joint stiffness and reduced range of movement or a patient who has had a frozen shoulder and is subsequently unable to raise the arm due to adhesion, is essentially presenting with an adaptation process in the tissues, albeit a dysfunctional one. The aim of our treatment is to provide the stimuli to encourage a more functional adaptation to take place in these tissues. In the examples given above, these processes are shown to occur within the symptomatic tissues themselves. However, they may not end there. A patient with a frozen shoulder may also have muscle wasting and dysfunctional motor control of the shoulder. Similarly, the chronic back patient may display a similar wasting of back muscle and loss of postural control of the trunk. A patient who has had an inversion sprain of the ankle may now exhibit postural instability when balancing on the now, non-painful, healed leg. What we are seeing here is an adaptation process occurring within the neuromuscular system - a neurological adaptation to injury. Here, too, the aim of our treatment would be to redirect these dysfunctional motor patterns to a functional one - an adaptation process as well. A more complex example of repair and adaptation is chronic trapezius myalgia. Often the cause for this condition can be traced to a sequence starting as a behavioural response, a psychomotor adaptation to psychological stress. This often feeds somatically, via the motor system, in the form of altered motor patterns, culminating in an overuse state in the muscles. In time, the chronic lack of relaxation in the muscle will lead to muscle damage and to adaptive tissue changes. What we are observing here are the processes of repair and adaptation occurring within three different dimensions in the individual. They occur locally within the tissue dimension as a cycle of damage and repair, as adaptive motor changes in the neurological/neuromuscular dimension and as adaptive behavioural responses in the psychological/psychomotor dimension. These examples serve to highlight the fact that repair and adaptation are multi-dimensional processes. The signals that affect these processes change dramatically from one dimension to another. The implication for manual therapy is that each dimension requires a distinct therapeutic approach and completely different forms of manual techniques. The 'dimensional model of manual therapy', described below, is a clinical model that enables us to do just that.
THE 'DIMENSIONAL MODEL OF MANUALTHERAPY'
The 'dimensional model of manual therapy' is a useful clinical tool that allows us to put together two important clinical processes. It provides us with a model for understanding in which dimension the patient's condition predominantly (but not exclusively) resides. It also provides us with a model to understand in which dimension we are working with our manual therapy techniques. Putting these two aspects together we have a powerful clinical tool - we can effectively match the most suitable manual therapy techniques to the patient's presenting condition. In this model, manual therapy techniques and their effects can be described in three dimensions within the individual (Fig. 1.2):
tissue dimension
neurological dimension
psychological dimension.
TISSUE DIMENSION
The local tissue dimension is where the direct physical effects of manual therapy take place. It is the dimension directly under the therapist's hands - skin, muscles, tendons, ligaments, joint structures and different fluid systems, such as vascular, lymphatic and synovial (these will be collectively termed 'soft tissues'). In this dimension we can expect the mechanical forces transmitted by the manual techniques to influence the tissues in three principal ways:
assist tissue repair
assist fluid flow
assist tissue adaptation.
Section 1 of the book will examine how specific forms of manual techniques can influence each of these local processes. It will also examine the possible role of manual techniques in affecting tissue pain processes.
NEUROLOGICAL DIMENSION
Although the therapist's hands are placed on distinct anatomical sites, manual techniques may have more remote influences on different neurological processes. There are three areas of neurology that the manual therapist aims to influence, the most frequently considered being the neuromuscular (motor) system and pain mechanisms. The commonly held belief that manual techniques can alter activity in the autonomic system at the spinal reflex level is another area of interest for manual therapy, particularly in osteopathy and chiropractice. Section 2 of the book will examine the neurological dimension and how manual therapy can effect diverse neurological/neuromuscular conditions such as:
treatment of neuromuscular deficits following musculoskeletal injury
rehabilitation of central nervous damage
postural and movement guidance
pain management.
PSYCHOLOGICAL DIMENSION
The effects of manual techniques and touch on mind and emotion play an important but often forgotten part in the overall therapeutic process. Touch is a potent stimulus for psychological processes that may result in a wide spectrum of physiological responses affecting every system in the body. This may manifest itself as:
psychological and behavioural responses
psychomotor responses
psychophysiological (including neuroendocrine and autonomic) responses
change in pain perception/levels.
Many treatment outcomes in manual therapy can be attributed to responses at this level. As will be discussed in Section 3, some of these responses can be surprisingly profound.
CLINICAL EXAMPLES OF THE DIMENSIONAL MODEL
Let us look at the dimensional model by using a few presentations from my experience in the clinic. The first example is a patient who had just had a fall, twisted a leg and then presented with a swollen painful knee. This is a straightforward injury that predominantly takes place in the tissue dimension (although there are repercussions for any injury in the neurological dimension, see Section 2 for further discussion). It is a process that will require 'repair assisting' manual techniques. In the next example, a patient had had an injury in the hamstrings muscle several months before presentation. The muscle was no longer painful but felt very tight when walking or bending. Again this is a condition occurring predominantly in the local tissue dimension. The repair has been completed, but there is residual dysfunctional adaptation in the form of muscle shortening. This condition will benefit from manual techniques that assist tissue elongation. Making the scenario a little more complex, the next example is a patient who presented with a frozen shoulder. This condition is still in the local tissue dimension although not exclusively. Starting in the local tissue dimension we have to assist two processes - repair (the pain and the swelling) and adaptation (the restricted movement due to adhesions). However, we are still left with the problem of muscle wasting which is occurring in the neurological dimension. The next scenario is a patient who had had a joint injury in the past but subsequently complained that often when walking, the foot suddenly 'gave' into inversion. He had no other symptoms such as pain or restrictions in the movement. This patient has functional instability where the motor programme for muscle synergism has been altered by an injury that has fully resolved. The tissues have repaired but the motor system still 'remembers'. In the frozen shoulder example, we saw that certain clinical manifestation of the condition occur in the neurological dimension and in the instability condition it occurs exclusively in the neuromuscular dimension. We now have to move dimensions with our manual therapy techniques and work with neuromuscular adaptation. As we will see later, we have to radically change our manual therapy techniques and clinical approach to treat in this dimension. Let us move further into clinical complexity. A female patient presented in my clinic complaining of severe neck and shoulder pain, suboccipital pain and tension headaches. Her symptoms had started 2 years before during divorce proceedings. She had three children, had had no support from the children's father and had to work 7 days a week in a highly stressful job. This is an example of a patient suffering from severe stress and exhaustion. Using the dimensional model we can analyse her condition as a sequence that started in the psychological dimension in response (adaptation?) to a particular stressful event and that is maintained by ongoing stress. The next stage in the sequence is the abnormal and subconscious increased neuromuscular activity (inability to motor relax) to the now painful muscle. This phenomenon is taking place in the neuromuscular dimension. This process culminates in the local tissue dimension as overuse damage to the muscle fibres. We now have to work within three different dimensions. Each of the dimensions requires a different therapeutic approach and specific manual therapy techniques. Throughout the book we will be examining such clinical presentations, identifying the dimension in which we are treating and matching the most effective technique and treatment strategies to treat these conditions. This book aims to clarify and offer practical models that will enhance this matching process. The clinical examples above raise an important question - how do we identify which manual therapy technique to use in each of the three dimensions? It is likely that certain groups of techniques are inherently more effective than others at a particular dimension. This inherent effectiveness has a very important clinical implication when the practitioner has to match the most effective manual therapy technique with the patient's condition. For example, manual therapy techniques aimed at restoring the range of movement of a joint (local tissue dimension) are substantially different from those aimed at promoting general body relaxation (psychophysiological dimension). Techniques used for relaxation may not be effective for improving the range of movement, and vice versa. If all techniques were equally effective at all levels, it would not be necessary to have a variety of techniques: in theory, one form of manual therapy technique would treat all conditions. Usually (but not always), most practitioners have a wide variety of techniques, and the question arises of how these are selected and matched to the patient's complaint. The way to achieve this is to consider manual therapy techniques as signals that activate different body processes - affective signals.
AFFECTIVE SIGNALS - BREAKING THE CODE
As therapists we have a basic question that underlies our work: what are the mechanisms of change and what are the signals that activate them? Imagine that each dimension in the dimensional model has a door with a combination lock. The doors are the natural buffers of the body against unwanted external influences. In our daily life, these buffers allow only particular events to influence our system while others are deflected (Fig. 1.3). For example, the neuromuscular system adapts to certain events such as repetitive exercise but not to single motor events, consequently 'forgetting' many insignificant daily actions. The signals that do activate the processes and behaviour of the system are the code elements in the combination lock. Each of the three dimensions has a door with its own particular (and highly specific) combination code. Events that contain a large number of the code elements will be more successful in bypassing these buffers. Essentially, manual therapy is an external influence. Being such, we need to make sure that our techniques will have a lasting effect and not be discarded by the system. Therefore our manual therapy techniques should contain these code elements, and in some way 'mimic' natural processes associated with repair and adaptation, i.e. identify the natural signals needed for repair and adaptation and incorporate them into our manual therapy techniques. Probably one of the most important tasks in manual therapy is to identify these code elements or signals. Once identified, we can add these signals to our manual therapy techniques. This would provide us with more accurate and dimension-specific manual therapy techniques. As we will see throughout the book, each dimension requires different signals and therefore will only respond to specific forms of manual therapy techniques. For example, a manual therapy technique that is effective for assisting repair (tissue dimension) may be ineffective for rehabilitating balance (neurological dimension). This book will aim to identify the most affective signals for each dimension and the manual therapy techniques that contain these signals for change.
OTHER DIMENSIONAL LEVELS
It is worth considering that there may be other dimensions and related physiological responses that are affected by manual therapy techniques. These dimensions may be affected in ways that currently cannot be described or explained in scientific or physiological terms (see Fig. 1.2). For example, the concept of meridians and bioenergy forms an important part of several manual disciplines such as shiatsu and Do-In. These dimension are outside the scope of this book and their exclusion does not refute their existence or clinical use.
PAIN RELIEF AND PAIN MANAGEMENT IN MANUAL THERAPY
Every manual therapist is a pain management unit. One of the most common motivating factors for patients to take up manual therapy is for pain relief. Manual therapy, in its many forms, is probably the major method, after medication, for the relief of musculoskeletal pain. This book will examine why manual therapy has such a potent positive influence on pain processes and how we can develop our techniques to be therapeutically more effective. The dimensional model of manual therapy will be used to explore the mechanisms by which manual therapy may affect pain. Manual pain relief can be seen to occur in the three dimensions: on a local tissue level by direct mechanical stimulation of the damaged area, in the neurological dimension by the activation of gating mechanisms, and in the psychological dimension by the psychodynamic emotive influences of touch. Pain is not a system on its own but is profoundly intertwined with repair and behavioural processes in the body/individual. Therefore, the effects of manual therapy on pain processes are discussed throughout the book. However, some of the chapters relate directly to manual pain relief:
Tissue dimension - the effects of manual therapy on pain processes in the tissue dimension are discussed in Section 1, Chapter 6, in context with tissue repair.
Neurological dimension - in Section 2, manual pain relief is discussed in conjunction with behavioural motor processes and motor reorganization in response to injury. In Chapter 17, the direct neurological gating effects of manual therapy on pain are discussed.
Psychological dimension - the psychological effects of manual therapy on pain perception are discussed in Section 3. In Chapter 26, there is a review of the psychological mechanisms associated with manual pain relief.
Section 4 of the book provides an overview and a summary of manual pain relief.
This book will examine the processes of pain relief in musculoskeletal structures only. It will concentrate on pain that arises from tissue injury and damage. This will exclude pain processes that are visceral tissue (the introspective sensory system) or pain that arises from pathologies of the pain system itself. The book will focus on the possible mechanisms that underlie manual pain relief. Specifically, it will look at the functionality of pain and its relief rather than histochemical and anatomical aspects of pain. It will attempt to identify natural pain subduing processes in the body and how manual therapy can be used to amplify them.
SUMMARY
This chapter introduced the three main themes underlying this book:
The role of manual therapy in assisting repair and adaptation
That repair and adaptation are multi-dimensional processes (occurring at tissue, neurological and psychological dimensions)
At each dimension different signals are required to activate these processes. Identifying the signals for repair and adaptation will enable us to match the most suitable ma
nual therapy techniques to the patient's condition.
Figure 1.1 The overall therapeutic aims of manual therapy.
Figure 1.2 The dimensional model of manual therapy.
Figure 1.3 All experiences, including manual therapy events, need to contain certain signals in order to activate different processes at each dimension.
DETAILED CONTENTS
Chiropractic foreword VII
Osteopathic foreword IX
Physical therapy foreword XI
Preface XIII
Acknowledgement XV
1. Introduction 1
Overall therapeutic aims 2
The 'dimensional model of manual therapy' 3
Tissue dimension 3
Neurological dimension 4
Psychological dimension 4
Clinical examples of the dimensional model 4
Affective signals - breaking the code 5
Other dimensional levels 6
Pain relief and pain management in manual therapy 6
Summary 6
SECTION 1 The effect of manual therapy
techniques in the tissue dimension 7
2. Manual therapy in the tissue dimension 9
The wonders of mechanotransduction: breaking the code 10
Manual loading of tissues 10
Tension loading 11
Compression loading 11
Combined loading 12
3. Assisting repair with manual therapy 13
Connective tissue 13
Physiology of connective tissue 13
Collagen and elastin 14
Proteoglycans and water 15
Fibroblasts and chondrocytes 15
Connective tissue changes following injury 15
Connective tissue in immobilization 18
Connective tissue: the importance of movement 19
Importance of movement to joints 21
General considerations 21
Trans-synovial pump 21
Cartilage nutrition 22
Joint injuries and immobilization 22
Joints: the importance of movement 23
Range of movement/joint stiffness 24
Quality of repair 24
Pain levels and pain medication 25
Return to normal activity 25
Manual therapy techniques influencing joint repair 25
Muscle tissue 26
Repair in muscle 26
Muscle in immobilization 27
Effects of movement on muscle 28
The code for assisting repair 28
Provide adequate stress 29
Dynamic/cyclical 29
Repetition 29
Summary: movement, the blueprint for repair 30
4. Affecting fluid flow with manual therapy 31
General physiological considerations 32
Impediments to flow 33
Intrinsic factors impeding flow 33
Extrinsic impediments to flow 34
The mechanical signals for manual pumping 34
Manual therapy techniques for assisting fluid flow 35
Passive pump techniques 35
Interstitial and lymph flow 35
Manual lymph drainage techniques 37
Pattern of drainage 37
Intermittent external compression 38
External compression force 39
Pattern of drainage 40
Frequency of drainage 40
Passive movement 40
Static and rhythmic stretching 41
Traditional massage techniques 41
Active pump techniques 41
Muscle contraction and blood flow 42
Principles of the techniques 43
Frequency and force 44
Pattern of contraction 44
Summary 44
5. Assisting adaptation: manual stretching 47
Mechanisms in tissue elongation 48
Mechanical elongation 48
Viscoelasticity 48
The stress-strain curve 48
Toe region 49
Elastic region 50
Plastic region 50
Creep deformation 51
Force relaxation 52
The code for stretching 52
Adaptive elongation 53
Competition in adaptation 55
Manual stretching 57
Passive stretching 57
Rate of stretching 57
Force of loading 58
Duration of stretch 58
Repetitive stretching 59
Oscillatory stretches 60
Active muscle stretching 60
Functional stretching 61
Differences between active and passive stretching 61
Contraindications to active stretching 64
Pain tolerance 64
The adverse reaction 65
Restoring full-range movement: long-term mechanisms 65
Summary 66
6. Pain relief by manual therapy: the local tissue dimension 67
Tissue mechanisms of pain 67
Manual pain relief techniques 68
7. Overview and summary of Section 1 71
Technique choice in the different phases of repair 71
Treatment strategies: soft and solid conditions 73
Providing an environment for repair 73
Providing an environment for adaptation 74
References 75
SECTION 2 The effect of manual therapy techniques in the neurological dimension 87
8. Manual therapy in the neurological dimension 89
Breaking the neurological code for neuromuscular work 90
9. The motor system 91
Functional organization of the motor system 92
The executive stage 92
The effector stage 93
The motor programme 93
The comparator centre 94
The motor stage 94
Sensory feedback 96
Role of proprioception 98
Proprioceptors: feedback or control 98
Suborganization of the motor system: the lower motor system 99
Summary 100
10. Proprioceptive stimulation by manual therapy techniques 101
General considerations 102
Peripheral to central communication 102
Threshold 102
Slow- and fast-adapting receptors 102
Dynamic and static behaviour 102
Classification of techniques 103
Muscle spindle stimulation by manual therapy 104
Active and passive techniques 104
Dynamic and static techniques 105
Golgi stimulation by manual therapy 106
Active versus passive technique 106
Dynamic versus static technique 107
Joint afferent stimulation by manual therapy 108
Dynamic versus static, and active versus passive technique 108
Manual stimulation of skin mechanoreceptors 108
Dynamic versus static technique 109
Size and pattern of afferent feedback 109
Temporal volley 109
Spatial volley 109
Summary: afferent recruitment by manual therapy 110
11. Affecting the lower motor system with manual therapy 113
General considerations 113
Segmental influences of spindle afferents 115
What is the stretch reflex and can it be used clinically? 115
Can reciprocal inhibition be used clinically? 116
Segmental influences of the Golgi tendon organ 116
Segmental influences of skin afferents 118
Segmental influences of joint afferents 118
Task-dependent reflexes 119
Manual influences on the lower motor system and motorneuron excitability 119
Continuous and intermittent manual pressure on tendons 120
Manual tapping of muscle belly 120
Massage 120
Muscle stretching 120
Postcontraction inhibition 120
Manual effleurage 120
Effects of spinal manipulation 120
Effects of active, passive, dynamic and static manual therapy techniques 121
Manual limitation in controlling the motor system from the periphery 121
Summary: manual therapy techniques cannot be used reflexively to control motor activity 121
12. The adaptive code for neuromuscular re-abilitation 125
The adaptive code for neuromuscular adaptation 126
Adaptive code 1: importance of cognition 126
Cognitive phase 126
Automatic phase 126
Energy conservation in motor learning 127
Focusing attention: internal and external focusing 127
Adaptive code 2: importance of being active 129
Afferent recruitment 129
Proprioceptive acuity 130
Learning and motor output 130
Active cognition and passive cognition 130
Manual implications 131
Adaptive code 3: importance of feedback 131
From manual feedback to manual guidance 131
Adaptive code 4: the importance of repetition 132
Short-term sensory store 132
Short-term memory 133
Long-term memory 133
Adaptive code 5: the similarity (transfer) principle 133
Facilitating motor learning with mental practice 134
Plasticity in the motor system 135
Studies of plasticity in the motor system 135
Peripheral plasticity: muscle - the acrobat of adaptation 137
Summary: from learning to plasticity 138
13. Abilities, inability and re-abilitation 141
Sensory-motor inability 142
Motor abilities 143
Contraction abilities 143
Force control 143
Length control 144
Velocity/speed control 145
Synergistic abilities 145
Cocontraction and reciprocal activation 145
Composite abilities 147
Reaction time 147
Fine control (control precision) 148
Coordination 148
Balance and postural instability 148
Motor relaxation 149
Transition rate 150
Clinical notes on testing motor abilities 150
The fractal nature of abilities 150
Sensory ability 154
Position and movement sense 154
Spatial orientation 155
Treating the feedback 155
Enhancing proprioception by afferent stimulation 155
Enhancing proprioception by reducing visual feedback 155
Re-abilitation: inability to skill 156
Specificity of re-abilitation 157
Summary 157
14. Treating psychomotor and behavioural conditions 159
From emotion and behaviour to pain 160
Treating motor dysfunction 162
Psychomotor dimension 162
Neuromuscular dimension 162
Relaxation ability in motor dysfunction 163
Clinical use of relaxation ability 163
Active approach in motor dysfunction 164
Clinical notes on passive and active approaches 165
Behaviour and movement guidance 165 Unlearning 165
Treatment in the wrong dimension 166
Summary 166
15. Treating the neuromuscular system in musculoskeletal damage 167
Change in motor abilities 168
Force control 169
Length control 171
Velocity control 172
Cocontraction and reciprocal activation 172
Changes in timing and duration 172
Can inability be re-abilitated? 173
Proprioceptive changes following injury 173
Mechanisms of reduced proprioception 174
Local chemical changes at the receptor site 174
Damage to the receptor or its axon 174
Damage and structural changes in the tissue in which the receptor is embedded 174
Can proprioceptive losses be improved? 175
Manual re-abilitation in musculoskeletal damage 175
Testing to re-abilitating 175
Example: lower back damage 175
Creating an adaptation environment 178
To treat or not to treat 178
Summary 178
16. Re-abilitating the damaged motor system 181
Changes to the functional organization 181
Abilities affected 183
Re-abilitation in central damage 183
Cognition 184
Being active 184
Feedback 184
Repetition 185
Similarity principle 185
Working in the tissue and psychological dimensions 185
17. Pain relief by manual therapy: neurological mechanisms 189
Good pain - bad pain 190
Neurological pain mechanisms: implications for manual therapy 191
Manual therapy-induced analgesia 191
Manual gating of pain 192
'Pain starvation' therapy 194
Nociceptors do not adapt to, or fatigue after, noxious mechanical stimuli 195
Summary 196
18. Muscle tone 197
Passive muscle tone 197
Active muscle tone 198
Changes in muscle tone 199
Dysfunctional passive tone 199
Transient and chronic fluid accumulation 199
Structural changes 199
Dysfunctional active tone 200
Protective muscle activity following injury 200
Psychological stress 200
Damage to the motor system 200
Treating the cause 200
19. Overview and summary of Section 2 203
The therapeutic drive in the neurological dimension 203
Re-abilitation 204
Creating an environment for neuromuscular adaptation 204
Why manual re-abilitation? 204
Centralists and peripheralists 205
Section 2 References 207
SECTION 3 Psychological and psychophysiological processes in manualtherapy 225
20. Manual therapy in the psychological/ psychophysiological dimension 227
21. Origins of the therapeutic potential of touch 229
Biological needs 229
Proprioceptive-vestibular stimulation 231
Association 232
Development of the self, body-self and body image 233
Touch in the development of communication 234
Touch needs throughout life 234
Summary 235
22. Psychological influences of manual therapy 237
The body-self and body image in manual therapy 239
Body image and symbolism in the body 239
Touching the symbolic body 241
The body-self and body image: disunity, fragmentation and distortion 241
Nurturing and re-integration of the body-self by manual therapy 243
Tactile contact: erotic or therapeutic? 246
Taboo areas of the body 246
Summary 247
23. Psychophysiology of manual therapy 249
The limbic system: where emotion meets the soma 250
Pathways to the soma 252
Motor pathway 252
Effects of manual therapy on the motor pathway 252
Neuroendocrine and autonomic pathways 253
Effects of manual therapy on neuroendocrine and autonomic activity 253
Clinical note on limbic responses 255
Psychophysiological versus somatovisceral reflexes 255
Summary 257
24. Manual therapy in the psychosomatic field 259
Therapeutic intent 270
Instrumental and expressive intent 270
Forms and contents of expressive touch 271
Touch as communication 273
Interpretation of touch 273
Feedback and communication from the patient 274
Summary 275
25. Touch as a therapeutic intervention 269
Therapeutic intent 270
Instrumental and expressive intent 270
Forms and contents of expressive touch 271
Touch as communication 273
Interpretation of touch 273
Feedback and communication from the patient 274
Summary 275
26. Pain relief through manual therapy: psychological processes 277
Pleasure and pain in manual therapy 279
Manual therapy and touch as a source of pleasure 280
Tactile pleasure and re-integration 280
Pain, pleasure and pleasurable/therapeutic pain 280
Aversion to touch pleasure 281
Summary 281
27. Overview and summary of Section 3 283
Manual therapy in psychosomatic conditions 284
'Procebo' 284
Section 3 References 285
SECTION 4 Overview and clinical application 295
28. Overview and clinical applications of the science 297
Tissue dimension 298
Affective signals in the tissue dimension 299
Neurological dimension 299
Affective code in the neurological dimension 299
Psychophysiological dimension 300
Affective code in the psychological dimension 301
Imitating nature's way 301
Manual therapy: creating an environment for repair and adaptation 301
Manual tools 302
Pain relief through manual therapy 302
Matching technique with the patient's condition 303
Index 309
INDEX
A
Abilities
cognitive, 142, 142, 182
fractal nature of, 150-4
inability and re-abilitation, 141-58
motor, 143-50, 143, 147, 182, 186
change in, 168-73, 168-71, 180
composite, 147-50, 152, 187, 299
contraction, 143-5, 150-1, 151, 165, 186, 299
synergistic, 145-7, 151-2, 185-6, 299
testing, 150
motor system damage and, 183
sensory system, 153, 154-6, 154, 182-3, 187, 299
motor, 141, 151-3, 156, 204
Abuse
physical, 238
sexual, 238, 265, 273
Actin-myosin cross-bridges, 62
Active oscillatory stretching (AOS), 61
Active techniques see Techniques
Adaptation, 57-65, 71, 156, 194, 267, 302
adaptive elongation, 53-7
at the tissue dimension, 3, 72
competition in, 55-7, 56, 166
of dysfunctional motor system, 159
environment for, 74, 178
hypertrophic (lateral), 137
length, 137, 299
manual stretching, 47-66, 52, 54, 66
mechanical elongation, 48-53, 54
neuromuscular, 156
processes, 2, 10, 10, 298-9
restoring full range movement, 65-6
self-regulation, 230-1
Adaptive code
elements, 163
for neuromuscular re-abilitation, 125-39, 137-8, 204-5
being active, 129-31
active and passive cognition, 130-1
afferent recruitment, 129, 129
learning and motor output, 130
manual implications, 131
proprioceptive acuity, 130
cognition, 126-9
feedback, 131-2
motor learning and mental practice, 134-5
plasticity in motor system, 135-8
repetition, 132-3
similarity principle, 133-4
Adhesions, 17, 19, 24, 48, 58, 174
Adhesive capsulitis, 305
Adrenal gland, 263
hormone release and, 253
Affective code
in neurological dimension, 299-300
in psychophysiological dimension, 301
Affective signals
breaking the code, 5-6, 5
in tissue dimension, 299
Afferents
feedback, 98, 109-10
fibres, 99, 113
Golgi, 109, 118
joint, 108, 118-19, 118, 171
muscle, 174
non-nociceptor, 192
pathway, 194
recruitment, 110, 111, 129, 129
signals, 279
skin, 118, 121
spindle, 104-5, 111, 114-16, 174
stimulation, 155
Agonistic muscles, wasting of, 170
Aims, therapeutic, 2, 2
Anger, 260, 277
Angiogenesis, 137, 184
Ankle injuries, 149, 172-5, 178, 271
joint mobility, 38
Anorexia, 243
Anterior cruciate repair, 172
Anxiety, 175, 238
AOS (active oscillatory stretching), 61
Aromatherapy, 237
Arousal, 253, 264-5, 264, 274
Arthritis, 23
Arthrogenic inhibition, 169-70, 173, 200
Articular cartilage, 21-4
Articulation, joint, 71-2, 104, 122, 193, 264
Association, 232-3
Attachment behaviour, 230-2, 235
Autism, child, 233
Autonomic nervous system, 190, 228, 230, 251-2, 261, 278
pathways, 263, 266-7, 283, 300
to soma, 253-5, 260
responses, 4, 249, 254-7
dysfunctional, 263
Aversion to touch pleasure, 281
B
Back, 171-3, 175, 190, 198, 277
neck and, 166, 259, 278
Back injuries, 173
Back pain, 164, 190-1, 198, 259, 277-8
lower, 172-3, 175, 195
Balance, 134, 137, 142, 148-9, 152
Baroreceptors, 257
Behaviour, 251, 265
as an adaptive process, 262
attachment, 230-2, 235
change, 266, 300
dynamic and static receptor, 102-3
effect of touch and, 238
evasive to pain, 162, 164
movement guidance and, 165-6
Behaviour (contd)
physiological, 250
problems, 238
processes and pain, 190
psychomotor conditions and, 4, 159-66, 200
responses, 4, 180, 189-90
therapy, 265-7, 278, 278, 300
Biceps tendon, 114
Bioenergy forms, 6
Biofeedback, 131-2, 163, 266
Biological needs, 229-31, 230, 238
Blood flow, 41, 43, 164, 198
Body
armouring (Reich), 261-2
boundaries, 239, 243
healing, 271
rocking, 232, 264
space, 239, 243
Body image, 185, 233, 274, 278
body-self and, 227, 233, 239, 242, 300
pain or discomfort and, 242, 244-5
symbolism and, 239-41
Body-self
body image and, 227, 233, 239, 242, 300
re-integration of, 243-6, 244-5
Braille, 136
Breast cancer, 249
Broken heart syndrome, 261
Bruxism, 164
Bulimia, 243
Burns, touch and, 238
C
Cancer patients, touch and, 238
Capsulitis, 22, 26, 305
Cardiac surgery, touch and, 238
Cardiovascular system, 255, 257
effect of touch on, 254
Carpal tunnel syndrome, 32, 34
Cartilage, 21-4
Central motor damage, 304
Central sensitization, 194-5
Centralist approach, 205
Centre mass of body, perception of, 240
Cerebral palsy, 200
Chemoreceptors, 257
Chondrocytes, 15, 21-2, 23, 24
Cinderella fibres, 161
Cinderella Units, 161
Clinical applications, 295-307
Clinical examples of dimensional model, 4-5
Cocontraction, 151-2, 157, 164-5, 169-70, 172, 185-6
reciprocal activation and, 145-7, 172-3
Cognition, 126-31, 184
automatic phase, 126-7, 126
energy conservation, 127, 128
focusing attention, 127-9
motor learning and, 204
Cognitive
abilities, 142, 142, 182
behavioural therapy, 278, 278
characteristics, 299, 301
Collagen, 16-18, 20-1, 28, 35, 55
elastin and, 14-15, 15, 50
Comfort, 232, 234
Communication and touch, 234, 274
interpretation, 273-5
see also Signalsv Comparator centre, 94
Compartment syndrome, 201, 304
Composite abilities, 147-50, 152, 187, 299
Compression, 11, 26
adequate, 35
intermittent, 35, 38-40, 39, 72, 199
loading and, 10-12, 23
rhythmic and repetitive, 35
Connective tissue, 55, 200, 301
build up, 54
changes in, 15-17, 28-9, 63
in immobilization, 18-19, 18
matrix, 19-20, 53
movement and, 19-21, 20
physiology of, 13-15, 14
repair, 13-21, 24, 26
Contract and relax method, 163
Contraction
abilities, 143-5, 150-1, 151, 165, 186, 299
force and, 28, 96, 116
isometric, 121-2
pain and, 194
rhythmic, 41-4
of wounds, 19
Control
fine, 187
force, 143-4, 169-71, 170-1
length, 144-5, 171-2, 183
limitation in, 121
precision, 148
synergistic, 145-7
velocity, 145, 145, 172
Coordination, 137, 148, 152, 187
Counselling, 162, 238
Cramp, writer's, 252
Cranial technique, 104
Creep formation, 50-2, 51
Cross-fibre soft-tissue stretching, 199
Cross-links, 19-20
abnormal, 20
excessive, 17, 58
intermolecular, 14, 15
Cutaneous mechanoreceptors, 103
D
Deep friction (technique), 104
Deep sensory abilities, 187
Deoxyribonucleic acid (DNA), 21
Depression, 175, 243, 259-61, 277
Developmental failure in children, 231
Direct periodic stresses, 37
Disc prolapse, 178
Discomfort and body image, 244-5
Distress, chronic, 259-60, 277
Do-In, 6
Dopamine system, 238
Drainage techniques, 104
Dynamic
ability, 143
position sense, 153
receptors, 102-3
E
Effector stage in motor processes, 93-6
Effleurage, 26, 69, 104, 109, 120, 122, 272
Effusion of joints, 23, 170, 298, 304
Elastin, 14-15, 50
Elderly and bereavement, 261
Electric shock, 256
Electromyogram (EMG), 52, 161, 171, 184, 198
biofeedback, 131-2
lower motor system and, 116, 117, 119-20
re-abilitation and, 127, 134
Elevation of limbs, 26
Elongation of tissue, 48-57, 54, 56
code for stretching, 52-3
competition in adaptation, 55-7
viscoelasticity, 48-52
Emotion, 230, 274, 277, 283
mood change and, 300
pain and, 160-2
responses, 256
soma and, 250-2
End-organ vulnerability, 263, 263
Endothelium, 36-7
Energy conservation, 127, 198
Enteric receptors, 257
Eroticism, 246, 281
Excitability, 169
hyperexcitability, 149, 169, 171, 179-80
motorneurons, 119-21, 122
Executive stage in motor processes, 92-3, 251
Exercise, 164, 178, 184
balance, 149
introspective, 240
lumbar extension, 173
physical, 240, 243
postexercise pain, 42
proprioceptive, 173
remedial, 156
rhythmic, 106
Exhaustion, 251
Exteroceptors, 96-7
Extracellular compartments, 32
F
Fatigue, 150, 166, 169, 199, 238
Feedback, 121, 184-5, 267, 273, 280, 300-1
afferent, 98, 109-10
biofeedback, 131-2, 163, 266
communication and, 274
during treatment, 205
electromyogram (EMG), 131-2
guidance and, 131-2, 163
movement, 98, 109, 165, 173
re-abilitation and, 130-2, 142, 149-50, 154-6
sensory, 96-9, 135, 173, 174, 189, 190, 240
Feldenkrais method, 156
Fibres, 164
afferents and, 99, 113
Cinderella, 161
extrafusal, 174
fibrotic tone, 200
Fibroblasts, 10, 14, 15, 55, 301
Fine control, 148, 152, 187
Fluid accumulation, 199
Fluid flow, 3, 31-45, 71, 72, 301-2
active pump techniques, 41-4, 44
dynamics, 298-9
impediments to, 31-4
manual pumping signals, 34-5
passive pump techniques, 35-41, 44, 199
physiology, 9-10, 10, 32-3
Focusing attention, 127-9
Force, 150-1, 183, 185-6
contraction and, 28, 96, 116
control, 143-4, 169-71, 170-1
of loading, 58
loss of, 65
pump techniques and, 44
re-abilitation, 157
relaxation, 51, 52
tensile, 73
tensional, 29, 53
Frequency modulation of receptors, 102
G
Gating
manual, 192-4, 193
sensory, 25, 191-3, 193
Glycosaminoglycans (GAGs), 14-15, 18, 20, 23, 35
Golgi afferents, 109, 118
Golgi tendon organs, 96, 104-7, 105, 111, 116-19
active versus passive technique, 106-8, 107
dynamic versus static technique, 107-8
inhibitory/reflexive influences, 118
Grief, 260-1, 265
Guidance, 134, 156, 163, 267
definition, 131-2
movement, 4, 165-6
H
Hacking (technique), 104
Haemartherosis, 24
Hamstrings, 55, 59, 61-2, 120, 172
Hand injury, 154
Harmonic pump techniques, 39, 41, 68-9, 72
Headaches, 159-61, 163, 252
Heart beat, 233
Heart and vascular pump, 34
High velocity
manipulation, 104, 107
thrust (HVT), 58, 69, 264
Hips, 57, 61-2, 113, 121-2, 167
Holding techniques, 104, 238, 264, 272
Hormone release, 253
Human growth factor (HGF), 54
Human immunodeficiency virus (HIV), 238, 249-50
Hydrokinetic transport, 33-4, 36
Hydrostatic pressure, 33
Hyper-arousal, 230
Hyperaemia, 41-4
Hyperalgesia, 195
Hyperexcitability, 149, 169, 171, 179-80
Hyperirritation, 195
Hypertonicity, 169, 199, 252, 263
muscles and, 56, 113, 149, 183-4
Hypertrophy, 28, 53, 60, 137, 161
Hypo-arousal, 230
Hypochondriasis, 246
Hypoperfusion, 32, 42
Hypothalamus, 240, 252-3, 263
Hypotonic muscles, 113, 183
Hypoxia, 199
I
Imaging studies, 137
Immobilization
connective tissue, 18-19, 18
joints and, 19, 22-5, 108, 173
in muscle tissue, 27-8
tendons and, 18-19
Immune responses, 255
Impediments to flow conditions, 31-4
Inflammation, 298, 304v neurological dimension and, 102, 108, 170, 194-5, 200
tissue dimension and, 10, 16-42 passim, 50-8 passim, 66-73 passim
Inhibition, 104, 120-1, 123, 171, 252
arthrogenic, 169-70, 173, 200
connectivity and, 149
Golgi tendon organs and, 118
inhibitory system, 184, 195
reciprocal, 116
Instability, 173
Intact motor system, 203, 299
Intent, therapeutic, 270-3, 271, 301
Intermolecular cross-links, 14, 15
Interstitial and lymph flow, 35-7, 36
Intra-articular pressure, 22, 23
Introspective exercise, 240
Irritability, 252
Irritable bowel syndrome, 261, 263, 266
Irritation
chemical, 68
mechanical, 68, 194-5
nerve root, 32, 34, 305
thermal, 68
Ischaemia, 67, 304
conditions of, 31-2
Isometric contractions, 121-2
J
Jaw pain, 159-61, 164, 252
Joint
afferents, 108, 118-19, 118, 171
articulation techniques, 71-2, 104, 122, 193, 264
disease, 98
effusion, 23, 170, 298, 304
inflammation, 108, 304
injuries, 23-5, 108, 148, 170, 305
movement, 21-5, 22, 25, 26
nociceptors, 102
oscillation, passive, 104, 193
receptors, 102-3, 108, 108, 118
repair and technique, 25-6
stability, 146
Joints
immobilised, 19, 22-5, 108, 173
sprained, 9, 15, 26
see also Ankle injuries; Hips; Knees
K
Knees, 27, 61-2, 113, 121-2, 170-5 passim
chronic pain in, 241-2
osteoarthritis in, 23, 173, 195
L
Learned responses, 261-3
Learning, motor, 126-8, 149, 184, 204
mental practice and, 134-5, 135, 184
output, 130
principles of, 149, 156, 160, 301
Leg muscles, 118
Length, 151, 185-6
adaptation, 137, 299
control, 144-5, 171-2, 183
Ligaments, 18, 20, 20
Limbic system, 230, 250-2, 250-1, 255, 258, 260, 266, 283
Loading
compressive, 10-12, 23
external and spindle activity, 106
force of, 58
mechanical, 21
of tissues, 10-12, 11
Longitudinal
mechanical tension, 28
stretching, 199
Lower back
damage, 175-8, 176-7
pain, 159-61, 190
Lower motor system, 99-100, 113-23, 137
general considerations, 113-14
Golgi tendon organ, 116-18
joint afferents, 118-19
Lower motor system (contd)
limitation in control, 121
motorneuron excitability, 119-21, 122
skin afferents, 118
spindle afferents, 115-16
task-dependent reflexes, 119
Lumbar extension exercise, 173
Lymph flow, 35-7
lymphatic drainage, 32, 35-9, 36, 38, 72
Lymphoedema, 9, 42
M
Magnetic resonance imaging (MRI), 190
Manipulation, 122
high velocity, 104, 107
pain-free, 40
Manual
approaches in treatment, 265-7, 265-6, 284
gating, 192-4, 193
loading, 10-12, 11
lymph drainage, 37-8
pressure, 120
pump techniques, 32, 34-5, 39, 68-9
re-abilitation, 175-8, 204-5
stretching, 47-66, 52, 54, 66
tensile force, 73
therapy
affective signals, 5-6, 5
behavioural, 265-6
definition, 1
dimensional model, 2-4, 3, 297, 298
clinical examples of, 4-5
see also Techniques
tools, 302, 302
Massage, 28, 109, 120-2
fluid flow and, 37, 40-1
pain relief and, 69, 72, 193-4
psychology and, 237-8, 243, 245, 249
psychophysiology and, 252-5, 264, 272
Maternal movement and fetus, 233
Maximum voluntary contraction (MVC), 116, 161
Mechanical signals, 10, 29
for fluid flow, 44
for manual pumping, 34-5
for repair, 72
Mechanisms for pain relief, 189-96
Mechanogrowth factor (MGF), 27, 27, 53
Mechanoreceptors, 98, 103, 131, 171, 257
lower motor system and, 113, 114, 118-19, 121, 123
pain relief and, 190, 193-4
proprioceptive stimulation and, 101-3, 103, 108-11, 108
Mechanotransduction, 10, 55
Medication for pain, 25
Memory stores, 132, 133, 149
Mental practice, 134-5, 135
Meridians, 6
MET (muscle energy technique), 60, 104, 116, 299
MGF (Mechano Growth Factor), 27, 27
Migraine, 238
Mitochondria, 161
Mood change, 300
Motor abilities, 143-50, 143, 147, 182, 186
change in, 168-73, 168-71, 180
cocontraction and reciprocal activation, 172-3
force control, 169-71, 170-1
inability and re-abilitation, 173
length control, 171-2
velocity control, 172
composite abilities, 147-50, 152, 187, 299
contraction abilities, 143-5, 150-1, 151, 165, 186, 299
synergistic control, 145-7, 151-2, 185-6, 299
testing, 150
Motor dysfunction, 92, 121, 159, 160, 168, 183
active approach, 164-5
behaviour and movement guidance, 165-6
neuromuscular dimension, 162
psychomotor dimension, 162
relaxation ability, 163
clinical use of, 163-4
treatment in wrong dimension, 166
Motor learning, 126-8, 130, 204
mental practice and, 134-5, 135, 184
principles, 149, 156, 160, 301
Motor organization, protective, 179-80
Motor pathways, 263, 267, 283, 300
to soma, 252-3, 252, 260
Motor relaxation, 149-50, 152, 163, 184, 187
re-abilitation and, 169
Motor system, 63, 90-100, 95, 228
damage and re-abilitation, 181-7, 182
abilities affected, 183
central damage, 182-3, 183-5, 185-7, 200
tissue and psychological dimension, 185
effects of touch on, 254
functional organization, 92-6, 92-3, 181-3
effector stage, 93-6, 251
executive stage, 92-3, 251
intact, 203, 299
and movement, 130
relaxation, 149-50
sensory feedback, 96-9, 173, 190
see also Lower motor system
Motor tone, abnormal, 305
Motor transition rate, 150, 187
Motorneurons, 114-15, 118, 134, 170, 252
excitability, 119-21, 122
Movement
active, 184
active and dynamic, 106
blueprint for repair, 30, 30
dynamic and cyclical, 29
dysfunctional patterns, 305
feedback, 98, 109, 165, 173
guidance, 4, 165-6
hydrokinetic flow and, 34
of joints, 21-5, 22, 25, 26
motor process and, 130
muscle tissue repair and, 28
passive, 40-1, 69, 130, 245
patterns, 160
position sense and, 154-5
re-education, 165-6
restoring full range, 65-6, 65
techniques, 40-1, 72, 106, 184
MRI (magnetic resonance imaging), 190
Multiple sclerosis, 243
Muscle, 10, 301
activation, 170
active/passive range, 171
activity, 176-7
synergistic, 145, 164, 173
adaptation and, 137-8
afferents, 174
changes in fibre type, 137
fatigue, 198
hyperexcitability, 171, 179-80
hypertonic, 56, 113, 149, 183-4
hypotonic, 113, 183
injuries, 9
ischaemia, 304
as pump mechanism, 34, 42
relaxation, 164, 198-9, 252
shortening, 56, 64, 194
spasticity, 149, 184, 200, 253, 263
spindles, 174
stimulation, 104-6, 105-7
splinting, protective, 170, 195
stiffness, 58, 198
strain and inflammation, 304
stretching, 28, 104-6, 116, 118, 120, 194, 280
active, 60-4
passive, 122
tendon unit, 60, 103
tension, 199-200, 266
tissue, 26-7
wasting, 26, 28, 169-71, 179-80, 305
Muscle contraction, 28, 96, 145
blood flow and, 42-4
involuntary, 199
rhythmic, 41, 194
technique, 193
Muscle energy technique (MET), 60, 104, 116, 299
Muscle groups
antagonistic, 146
co-contraction, 96
reciprocal activation and, 96
synergistic, 96, 172
Muscle tone, 197-201, 249, 253, 306
active, 198-9, 198
changes in, 199-200, 199, 201
dysfunctional (defined), 199
passive, 197-8, 198
treating the cause, 200-1, 201
Musculoskeletal
conditions, 159-60, 283
soft, 73, 73, 298-9
solid, 73, 73, 299
damage, 167-80, 183, 185
injuries, 4, 101, 127, 238, 257, 263, 271
re-abilitation and, 142, 146, 148-9, 156
pain, 160, 179-80, 259
structures, 9, 193
MVC (maximum voluntary contraction), 116, 161
Myalgia, 42, 161, 163
trapezius, 159, 164, 199, 252
Myocytes, 301
Myofascia, 61, 254
Myofibril, 53
N
Nature's way, 301
Neck pain, 159-66 passim, 173, 259, 271, 277-8
Nerve root irritation, 32, 34, 305
Neuroendocrine system, 190, 228, 230, 251-2, 278
effects of touch on, 254
pathways, 263, 267, 283, 300
to soma, 253-5, 260
responses, 4, 253, 255
Neurological dimension, 4, 6, 87-224
abilities, inability and re-abilitation, 141-58
adaptive code for re-abilitation, 125-39
affective code in, 299-300
damaged motor system re-abilitation, 181-7
lower motor system, 113-23
mechanisms for pain relief, 189-96, 190
motor system, 91-100
muscle tone, 197-201
neuromuscular system, 167-80
proprioceptive stimulation, 101-11
psychomotor and behavioural conditions, 159-66
sensitization and, 108
therapeutic drive and, 203-4
Neuromuscular system, 4, 26
adaptation, 156
drive, chronic hypertonic, 56
dysfunction, 162, 203
in musculoskeletal damage, 167-80, 168
manual re-abilitation, 175-8
motor ability change, 168-73
proprioceptive changes, 104, 173-5
treatment decisions, 178
plasticity of, 138
re-abilitation, 99, 109, 129, 131, 156
see also Adaptive code for neuromuscular re-abilitation
relaxation, reflex, 52
therapeutic principles, 90
Neuropeptides, 162
Neuroplasticity, 183-4
Neurore-abilitation, 127
Neurosis, 246, 261, 277
Nociceptors, 102, 170-1, 190, 192-4, 195, 278
O
Oedema, 20, 24, 28, 199, 298
fluid flow and, 34, 37, 40, 41-2
inflammatory, 68-9
Oscillatory techniques, 26, 60-1, 72, 104, 193, 232
Osteoarthritis, 9, 22, 170
hip, 25, 28
knees, 23, 173, 195
P
Pain, 26, 89, 199-200, 241-2
behaviour and, 160-2, 164, 168
body image and, 242, 244-5
development sequence, 162
dimension of, 52
gain, 144
gating, 25, 191-4, 193
learning, 194
levels, 25, 165, 238
lower motor system, 115, 118-19
management, 4
musculoskeletal, 160, 179-80, 259
pattern, 73
perception, 192, 249, 300
phantom, 191
postexercise, 42
psychophysiology and, 238, 251, 260, 275
receptors, 108
repair timeline and, 179-80
strategies, 164
tolerance, 60, 64-5
see also Back pain; Knees; Neck pain; Shoulder pain
Pain relief, 108, 168, 178, 185, 302-3, 303
after manipulation, 279
local tissue dimension, 67-9, 68, 69
manual techniques, 68-9
tissue mechanisms, 67-8
management, 6
massage, 69, 72, 193-4
medication, 25
neurological mechanisms, 189-96, 190
good pain-bad pain, 190-1, 191
implications of, 191-4, 192
manual gating, 192-4, 193
starvation therapy, 194-5, 194
therapy-induced analgesia, 191-2, 192-3
psychological processes and, 277-81, 279
pleasure and pain, 279-80, 280
tactile pleasure and re-integration, 280-1
touch as source of pleasure, 280
Parasympathetic system, 254, 257
Parkinson's disease, 200
Passive motion, 24-6, 41, 60
Passive techniques see Techniques
Peripheralist approach, 205
Peristalsis, 233
Physical exercise, 240, 243
Physical therapy, 267, 300
Physiological
affects of pleasure and pain, 280
behaviour, 250
needs, 240
responses, 263, 283
Pituitary gland, 263
and hormone release, 253
Plastic range, 50-1, 50, 55
Plasticity, 66, 135, 138
autonomic, 267
in motor system, 135-8
peripheral, 137-8, 137
studies of, 135-7, 136
Pleasure and pain, 279-80, 280
PNF (proprioceptive neuromuscular facilitation), 57, 60-1, 106, 299
Position sense, 153, 154-5, 299
Postcontraction inhibition, 120
Posttraumatic stress, 243
Posture
dysfunctional patterns, 305
instability, 148-9
Potentiation, long-term, 194
Pressure
hydrostatic, 33
intermittent on skin, 109
intra-articular, 22, 23
manual, 120
'Procebos', 284
Proprioception, 233
changes, 104, 173-5, 173-4
depth, 272
enhancement, 155-6
musculoskeletal damage and, 168, 177
re-abilitation, 148-9, 154-5
role of, 98-9
sensory map, 97
Proprioceptive
acuity, 129-30
exercise, 173
feedback, 98-9, 119, 131, 251
loss, 182, 185
neuromuscular rehabilitation (PNF), 57, 60-1, 106, 299
stimulation, 101-11
afferent recruitment, 110, 111, 129, 129
general considerations, 102-3
dynamic and static behaviour, 102-3
receptors, 102, 102
Proprioceptive (contd)
Golgi tendon organs, 106-8
joint afferents, 108
muscle spindle stimulation, 104-6
skin mechanoreceptors, 108-10
technique classification, 103-4
-vestibular, 231-2, 233
Proprioceptors, 96-7, 114-21 passim, 192, 255-7, 280
Protective
functions of pain, 191
motor organization, 179-80
muscle activity, 200
responses, 168
strategies, 168, 170-1
Proteoglycans and water, 15
Psychiatric illness, 261
Psychological and psychophysiological processes, 185, 225-93, 249
dimensions, 4, 6, 185, 227-8, 300-1
psychological influences, 237-48
body image and symbolism, 239-40, 239-40
body-self and body image, 239
disunity, fragmentation and distortion, 241-4, 241-2
effects of pleasure and pain, 280
erotic or therapeutic touch, 246-7, 247
factors and traits, 261-3, 262
nurturing and re-integration of the body-self, 243-6, 244-5
pain relief and, 277-81, 279
techniques and, 168, 272
touching the symbolic body, 241
psychophysiology, 4, 249-58
limbic system, 250-2, 250-1, 258
pathway to the soma, 252-3
psychosomatic field, 259-67
responses, 251, 256, 260, 269, 301
to touch, 228-9, 250
stress, 159-61, 164, 200, 205
therapeutic potential of touch, 227, 229-35, 237, 269-75, 283
Psychomotor dimension, 168
behavioural conditions and, 4, 159-66, 200
emotion and pain, 160-2
motor dysfunction, 162-6
problems, 146
protective organization, 168
relaxation, 253
responses, 169, 180
Psychophysiology see Psychological and psychophysiological processes
Psychosis, 243
Psychosomatic field, 259-67
conditions, 232, 251, 271
illness, 230
symbolic model for, 262
manual approaches in treatment, 265-7, 265-6, 284
behavioural therapy, 265-7
physical therapy, 267
supportive therapy, 265
pathways/systems, 263
psychophysiological to, 260-5, 260-1
responses, 260-1, 263-6
arousal, 264-5, 264
relaxation, 263-5
Psychotherapy, 162
Pump
heart and vascular, 34
mechanisms, 34, 42
sequence for oedema, 40
system, 301
Pump techniques, 298
active, 41-4, 42-4
frequency and force, 44
muscle contraction and blood flow, 42-3
pattern of contraction, 44
principles of, 43-4
rhythmic, 69, 199
harmonic, 39, 41, 68-9, 72
manual, 32, 34-5, 39, 68-9
passive, 35-41, 199
intermittent external compression, 38-40
interstitial and lymph flow, 35-7
manual lymph drainage, 37-8
movement, 40-1
static and rhythmic stretching, 41
traditional massage, 41
R
Re-abilitation, 141-58, 177-8, 204
adaptive code for, 125-39
damaged motor system, 181-7, 182
fractal nature of abilities, 150-4
inability to skill, 156-7, 173
manual, 175-8, 204
motor abilities and, 143-50, 143, 147, 169
neuromuscular system, 99, 109, 129, 131, 156
sensory ability, 154-6, 154
-motor inability, 142-3
specificity of, 157
tests, 175-8, 176-7
Reaction time, 147, 152
Receptors, 190, 234, 256
baroreceptors, 257
chemical changes in site, 174
chemoreceptors, 257
damage, 174-5
dynamic, 102-3
enteric, 257
exteroceptors, 96-7
frequency modulation of, 102
groups, 109
joint, 102-3, 108, 108, 118
non-mechanical, 257
skin, 243
static, 102-3
types, 111
see also Mechanoreceptors; Nociceptors; Proprioceptors
Reciprocal
activation, 96, 164-5, 172-3
re-abilitation and, 145-7, 152, 185-6
inhibition, 116
Reflex responses, 119, 121-3
abnormal, 183
mass, 256
mechanisms, 121
neuromuscular, 52, 180
protective, 168, 170-1
somatovisceral, 255-7
stimulation, 258
stretch, 115-16, 121-2
task-dependent, 115, 119
Reflexology, 237
Regeneration cycles, 161
Rehabilitation, 90, 173
see also Re-abilitation
Reiki, 237
Relaxation
ability, 163-4
force, 51, 52
motor, 149-50, 152, 163, 169, 184, 187
muscle, 164, 198-9, 252
pain relief and, 278
psychomotor, 253
reflex, 52
responses, 185, 232, 263-5, 264
to touch, 229, 238, 252-3
techniques, 162, 184
Remedial exercise, 156
Repair assistance, 13-30, 71
code for, 28-30, 29
connective tissue, 13-21, 28-9
environment for, 73-4, 301-2, 301-2
joint injuries and immobilization, 22-5, 25
joint repair and technique, 25-6
movement: blueprint for, 30
movement to joints, 21-2
muscle tissue, 26-7, 27
musculoskeletal injuries, 178, 200
phases in, 16
process, 2, 9, 10, 298-9
quality in, 24-5
repair timeline, 179-80
technique choice, 71-3, 73
tissue, 3, 47
Repetition, 132-3, 133
memory and, 132-3
motor learning and, 178, 300-1
relaxation and, 149, 163
of strain, 201
stretching, 59-60
in therapy, 29-30, 133, 185
Resisted joint oscillation, 104
Respiratory
pump, 34
rhythms, 233
Responses
behavioural, 4, 180, 189-90
latency of, 116
learned, 261-3
limbic, 255
patterned, 261
physiological, 263, 283
protective, 168
psychomotor, 4, 169, 180
psychophysiological, 4, 251, 256, 260, 269, 301
response-programming, 93
selection of, 92
somatic, 250, 260
stereotypic, 262
to touch, 228-9, 250, 252-3
visceral, 257
whole nervous system, 189
see also Autonomic nervous system; Reflex responses; Relaxation
Rhythmic
active pump techniques, 69, 199
compression, 35
contraction, 41-4, 194
cyclical tension, 28-9
exercise, 106
techniques, 72, 104, 232
Ribonucleic acid (RNA), 53
RICE (rest, ice, compression and elevation), 26
S
Sarcomeres, 28, 53, 54, 60
Scar tissue, 17, 19, 20, 32
Schizophrenia, 243
Search-and-relax procedure, 163-4
Selective attention, 132
Self, body-self and body image, 233
Self-regulation, 230-9 passim, 249, 251, 255, 260, 271
Sensory system, 148, 204, 278
abilities, 153-4, 154-6, 182-3, 187, 299
motor, 141, 151-3, 156
activity, 192
feedback, 96-9, 135, 173, 174, 189, 190, 240
role of proprioception, 98-9
gating, 25, 191-3, 193
loss, 131, 173
stimulation, 243
store, 132
Shiatsu, 6, 104
Shortening
of muscle, 56, 64, 194
of tissues, 47-8, 60, 73
Shoulder pain, 57, 159-60, 163, 166, 173, 252
Signals
affective, 5-6, 5
afferent, 279
communication and, 234
for manual pumping, 34-5
mechanical, 10, 29, 45
Similarity principle, 133-4, 133, 142, 156, 163, 185, 300-1
Skills, 133, 141, 154, 156-7, 187
Skin, 21
afferents, 118, 121
lymphatics, 39
massage, 40
mechanoreceptors, 108-11
afferent feedback, 109-10
dynamic versus static technique, 109
excitation, 118
receptors, 243
Soft musculoskeletal conditions, 73, 73, 298-9
Soft tissues, 10
cross-fibre stretching, 199
massage, 28, 72
shortening, 304
techniques, 104, 272
Solid musculoskeletal conditions, 73, 73, 299
Soma, 250-3, 250-1, 260
motor pathway to, 252-3, 252
neuroendocrine and autonomic pathways to, 253-5, 253-4
psychophysiological versus somatovisceral reflexes, 255-7
Spasms, 169
Spasticity, 149, 184, 200, 253, 263
Spatial orientation, 153, 155, 187, 299
Spatial volley, 109-10
Speed see Velocity
Spinal
conditions, 9
injuries, 25, 304
joints, 173
manipulation, 120-1
reflex mechanism, 255-6
sensitization, 170
Spinal cord, 102, 108, 136-7, 256
motor system and, 93-4, 99
lower, 113-14, 118
pain relief and, 189, 192, 194-5
Spindle afferents, 104-5, 111, 114-16, 174
reciprocal inhibition, 116
stretch reflexes, 115-16
Splinting, protective, 170, 195
Spondylolithesis, 178
Stability, 135, 146
Static
force ability, 143-4
position sense, 153
receptors, 102-3
and rhythmic stretching, 41
see also Techniques
Stereotypic responses, 262
Stiffness, 47-8, 56, 60, 64, 73, 164
of muscles, 58, 198
Stimulus identification, 92
Strain, 48-50, 57, 104, 304
joint, 73
repetitive, 201
Stress, 5, 159-66 passim, 175, 200, 205, 235, 249, 259-71 passim, 300-1
antidote to, 251-2, 263-4
de-stress periods, 40
levels, 162, 238
posttraumatic, 242-3
and stretching, 60
in techniques, 29
Stress-strain curve, 48-50, 49
Stresses
direct periodic, 37
mechanical, 30, 159, 165, 167, 199
physical, 191
Stretching, 28, 119, 280-1, 302
after injury, 14
amplitude of, 275
cross-fibre soft-tissue, 199
longitudinal, 199
manual, 47-66, 52, 54
active, 60-4, 61, 62, 64
adverse reaction to, 65
code for, 52-3
duration of, 58-9
pain tolerance, 64-5
passive, 57-9
repetitive, 59-60
muscle, 29, 104-6, 116, 118, 120, 194, 280
oscillatory, 60-1
pain free range, 25-6
passive, 57-9, 107, 122, 163, 272
principles of, 48
proprioceptive stimulation and, 104, 106
rate of, 57-8, 57
reflexes, 115-16, 121-2
repetitive, 53, 66
techniques, 41, 69, 72
Stroke patients, 154, 184, 200
case history, 185-7
Stroking, 238, 245, 253, 272
Supportive therapy, 265, 300
Surface of body, perception of, 240
Swelling, 68, 298
Symbolism, 262-3
symbolic body, 239-41
Sympathetic nervous system, 253
excitation of, 257
Synaptogenesis, 137, 183-4
Synergism
muscle, 96, 145, 172
synergistic
abilities, 146-7, 151-2, 185-6, 299
activity, 164, 173
control, 145-7
Synovial
blood flow, 23, 26
fluid, 21-4
joint receptors, 108
Synovitis, 22
Synovium, inflamed, 170
T
Taboo areas of the body, 246-7, 247, 274
Tai Chi, 156, 280
Tapping, of muscle belly, 122
Task performance, 142
Techniques, 68-9, 299-301
active, 131, 134, 193, 243, 245-6
dynamic, 104, 155
proprioceptive neuromuscular facilitation, 104
for motor dysfunction, 164-5
movement, 72, 106, 184
oscillatory stretching (AOS), 60-1
and passive, 104-8, 121, 129, 165, 272
pump, 41-4, 42-4, 72, 199
resisted, 104
static, 104
muscle energy, 104
stretching, 60-4
aromatherapy, 237
choice in repair, 71-3, 73
classification, 103-4, 104
communication and, 301
deep soft-tissue and massage, 272
dynamic and static, 105-9, 121
effects of
on neurological dimension, 87-205
on tissue dimension, 7-74
expression, 301
harmonic, 39, 41, 68-9, 72
high velocity thrust (HVT), 58, 69, 264
holding, 238, 264, 272
isometric contraction, 122
joint articulation, 71-2, 104, 122, 193, 264
knee and hip extension against resistance, 122
lymphatic drainage, 72
manipulation/hut, 122
manual for fluid flow, 35
manual tapping of muscle belly, 122
massage, 37, 40, 122, 193, 237-8, 245, 264, 272
matching with condition, 303-7, 304-7
modes and patterns, 110
motor relaxation, 184
muscle energy (MET), 60, 104, 116, 299
oscillatory, 26, 72, 104, 193, 232
passive, 106, 134-5, 185, 243
active and, 104-8, 121, 129, 165, 272
dynamic, 155
articulation, 104
functional, 104
high-velocity manipulation, 104, 107
longitudinal muscle stretching, 104
oscillatory, 104
rhythmic, 104
traction, 104
static, 30
cranial, 104
deep friction, 104
drainage, 104
effleurage, 26, 69, 104, 109, 120, 122, 272
hacking, 104
holding, 104
inhibition, 104
Shiatsu, 104
soft-tissue, 72, 104, 272
strain, 104
stretching, 104
transverse muscle, 104
stretching, 57-9, 107, 122, 163, 272
percussive, 193
potency of, 44
proprioceptive neuromuscular rehabilitation (PNF), 57, 60-1, 106, 299
proprioceptive stimulation, 101-11
psychological and behavioural, 168, 272
pump, 32, 35-43, 68-9, 72, 298
rhythmic active, 69, 199
reflexology, 237
Reiki, 237
relaxation, 162
stroking, 238, 245
therapeutic touch, 237
vibratory, 193
Temporal volley, 109-10
Temporomandibular joint, 173
Tendons, 21, 49, 114
immobilised, 18-19
pressure on, 120
repair, 26
as unit with muscle, 60, 103
Tensile strength, 11, 17-18
of collagen, 20
force, 73
of soft tissue, 17, 59
of tendons, 21
Tension
force, 29, 53
loading, 10-11
longitudinal, 28
muscle, 199-200, 266
rhythmic cyclical, 28-9
Testing
motor, 150
muscle activity, 175-7
in re-abilitation, 175-8, 176-7
Therapeutic
changes, 17
drive, 203-4
intent, 270-3, 271, 301
forms of expressive touch, 271-3, 271
instrumental and expressive, 270-1, 271
pain, 280-1
potential of touch, 227, 229-35, 237, 269-75, 283
principles, 90
Thrusts (HVT), high-velocity, 58, 69, 264
Time-line of repair, 307
Tissue dimension, 3, 6, 7-86, 298-9
affecting fluid flow, 31-45
affective signals in, 299
assisting adaptation, 47-66
assisting repair, 13-30
changes, 33
compression, intermittent, 72
elongation, 48-57, 54, 56
manual loading, 10-12, 11
matrix, connective, 53
mechanotransduction, 10, 10
pain relief and, 67-9
psychological dimensions and, 185
tensile strength, 17
see also Connective tissue
Toe region, 49-50, 50
Tools, manual, 302, 302
Touch, 162, 185, 252-3, 283
abusive, 233, 238
behavioural effect of, 238
comforting, 232, 234
deprivation, 231
during treatment, 237
effects, 227
on cardiovascular system, 254
integrative potential of, 244-5
on limbic system, 258
on mind and body, 250
neuroendocrine system and, 254
elderly and, 246
misinterpreted as sexual, 246
'negative', 238
negative response to, 274
pleasure and re-integration, 280-1
pleasurable/therapeutic pain, 280-1
psychodynamics of, 227
psychophysiological responses to, 228-9
symbolic body and, 241
taboo areas, 246-7, 274, 274
as therapeutic intervention, 269-75
communication and, 273-5, 274
therapeutic intent, 270-3, 271
forms of expressive, 271-3, 271
therapeutic potential of, 229-35, 237
association, 232-3
biological needs, 229-31, 230
communication and, 234
needs through life, 234-5, 234
proprioceptive-vestibular stimulation, 231-2, 233
self, body-self and body image, 233
treatment boundaries and, 246
Traction, 104
Training, 204
Trans-synovial pump, 21-2, 22, 24-5
Transfer see Similarity principle
Transitional
ability, 152
rate, 150, 187
Transverse muscle techniques, 104
Trapezius myalgia, 159, 164, 199, 252
Trauma, 47
Treatment strategies, 73
manual approaches, 265-7, 265-6, 284
V
Vascular pump and heart, 34
Vascular supply, 164
Vasodilators, chemical, 33
Velocity, 96, 105-6, 150, 151, 183, 185-6
control, 145, 145, 172
manipulation, 104, 107
thrust (HVT), 58, 69, 264
Ventral taboo, 246-7
Vestibular system, 96
apparatus, 148
sensations in fetus, 233
Vibration, 109, 191-3
Visceral responses, 257
Viscoelasticity, 48-52, 49
Visualization, 135
Voodoo, 261
W
Water, 15, 32, 35
Weight gain in infants, 255
Well-being, 229, 232, 237, 278-9
biochemistry of, 251
Whiplash injuries, 173, 195
Writer's cramp, 159
Y
Yoga, 156, 280
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